PA job availability in primary care during 2014 and 2016.

OBJECTIVES: The objective of this project was to evaluate demand for PAs by examination of job postings. We compared proportions of PAs in primary care with proportions of job postings in primary care in 2014 and 2016 and described job postings for PAs by specialty in 2014 and 2016. METHODS: Internet job postings for PAs supplied by Burning Glass Technologies were evaluated for practice specialty. Job postings were compared with existing filled positions by specialty as reported by the National Commission for the Certification of Physician Assistants. RESULTS: In both years, more than 25% of PAs in practice were in primary care and fewer than 20% of job openings were in primary care. More than half of postings were in medical and surgical subspecialties. CONCLUSIONS: Our findings provide insights into which specialties have emerging high demand for PAs. The demand for PAs appears to remain much stronger for specialty jobs than for primary care jobs.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients.

Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.

Medication oversupply in patients with diabetes.

BACKGROUND: Studies in integrated health systems suggest that patients often accumulate oversupplies of prescribed medications, which is associated with higher costs and hospitalization risk. However, predictors of oversupply are poorly understood, with no studies in Medicare Part D. OBJECTIVE: The aim of this study was to describe prevalence and predictors of oversupply of antidiabetic, antihypertensive, and antihyperlipidemic medications in adults with diabetes managed by a large, multidisciplinary, academic physician group and enrolled in Medicare Part D or a local private health plan. METHODS: This was a retrospective cohort study. Electronic health record data were linked to medical and pharmacy claims and enrollment data from Medicare and a local private payer for 2006-2008 to construct a patient-quarter dataset for patients managed by the physician group. Patients' quarterly refill adherence was calculated using ReComp, a continuous, multiple-interval measure of medication acquisition (CMA), and categorized as <0.80 = Undersupply, 0.80-1.20 = Appropriate Supply, >1.20 = Oversupply. We examined associations of baseline and time-varying predisposing, enabling, and medical need factors to quarterly supply using multinomial logistic regression. RESULTS: The sample included 2519 adults with diabetes. Relative to patients with private insurance, higher odds of oversupply were observed in patients aged <65 in Medicare (OR = 3.36, 95% CI = 1.61-6.99), patients 65+ in Medicare (OR = 2.51, 95% CI = 1.37-4.60), patients <65 in Medicare/Medicaid (OR = 4.55, 95% CI = 2.33-8.92), and patients 65+ in Medicare/Medicaid (OR = 5.73, 95% CI = 2.89-11.33). Other factors associated with higher odds of oversupply included any 90-day refills during the quarter, psychotic disorder diagnosis, and moderate versus tight glycemic control. CONCLUSIONS: Oversupply was less prevalent than in previous studies of integrated systems, but Medicare Part D enrollees had greater odds of oversupply than privately insured individuals. Future research should examine utilization management practices of Part D versus private health plans that may affect oversupply.

Lipid testing in patients with rheumatoid arthritis and key cardiovascular-related comorbidities: a medicare analysis.

OBJECTIVE: For patients with rheumatoid arthritis (RA) and comorbid cardiovascular disease (CVD), diabetes, or hyperlipidemia, annual lipid testing is recommended to reduce morbidity and mortality from comorbidities. Given trends encouraging complex patients to receive care in "medical homes," we examined associations between regularly seeing a primary care provider (PCP) and lipid testing in RA patients with cardiovascular-related comorbidities. METHODS: We performed a retrospective cohort study examining a 5% random USA Medicare sample (2004-06) of beneficiaries over 65 years old with RA and concomitant CVD, diabetes, or hyperlipidemia (n = 16,893). We examined the relationship between receiving lipid testing in 2006 and having at least 1 PCP visit per year in 2004, 2005, and 2006 using multivariate regression. RESULTS: Ninety percent of patients had prevalent CVD; 46% had diabetes, and 64% had hyperlipidemia. However, annual lipid testing was only performed in 63% of these RA patients. Thirty percent of patients saw a PCP less than once per year, despite frequent visits (mean >9) with other providers. Patients without at least 1 annual PCP visit were 16% less likely to have lipid testing. Increased age, complexity scores, hospitalization, and large town residence predicted decreased lipid testing. CONCLUSIONS: Despite comorbid CVD, diabetes, or hyperlipidemia, 30% of Medicare RA patients saw a PCP less than once per year, and 1 in 3 lacked annual lipid testing. Findings support advocating primary care visits at least once per year. Remaining gaps in lipid testing suggest the need for additional strategies to improve lipid testing in at-risk RA patients.

Receipt of monitoring of diabetes mellitus in older adults with comorbid dementia.

OBJECTIVES: To examine the extent to which receipt of recommended monitoring of diabetes mellitus (DM) differed for participants with and without comorbid dementia, as well as the effect of other comorbidities on monitoring of DM in individuals with comorbid dementia. DESIGN: Retrospective cohort study. SETTING: Secondary analysis of 2005/2006 claims and enrollment data for a 5% national random sample of Medicare beneficiaries. PARTICIPANTS: Two hundred eighty-eight thousand eight hundred five Medicare fee-for-service beneficiaries with a diagnosis of DM before 2006, 44,717 (16%) of whom had evidence of comorbid dementia in claims. MEASUREMENTS: Established algorithms were used to determine whether patients received at least one glycosylated hemoglobin (HbA1c) test, one low-density lipoprotein cholesterol (LDL-C) test, and one annual eye examination in 2006 and to construct variables representing comorbidities common in DM, sociodemographic characteristics, and patterns of healthcare utilization. RESULTS: In unadjusted and fully adjusted models, the presence of dementia reduced the likelihood of receiving HbA1c tests, LDL-C tests, and eye examinations, with effects being smallest for HbA1c tests. The effects of other comorbidities on DM monitoring in participants with dementia varied according to the nature of the comorbidity and the specific test. CONCLUSION: Dementia reduces the likelihood that individuals with DM will receive recommended annual monitoring for DM. More research is needed to understand reasons for lower monitoring in this subgroup and how this affects functioning, adverse events, and quality of life.

The contributions of physician assistants in primary care systems.

Shortages of primary care doctors are occurring globally; one means of meeting this demand has been the use of physician assistants (PAs). Introduced in the United States in the late 1960s to address doctor shortages, the PA movement has grown to over 75,000 providers in 2011 and spread to Australia, Canada, Great Britain, the Netherlands, Germany, Ghana and South Africa. A purposeful literature review was undertaken to assess the contribution of PAs to primary care systems. Contemporary studies suggest that PAs can contribute to the successful attainment of primary care functions, particularly the provision of comprehensive care, accessibility and accountability. Employing PAs seems a reasonable strategy for providing primary care for diverse populations.

Predictive modeling the physician assistant supply: 2010-2025.

OBJECTIVE: A component of health-care reform in 2010 identified physician assistants (PAs) as needed to help mitigate the expected doctor shortage. We modeled their number to predict rational estimates for workforce planners. METHODS: The number of PAs in active clinical practice in 2010 formed the baseline. We used graduation rates and program expansion to project annual growth; attrition estimates offset these amounts. A simulation model incorporated historical trends, current supply, and graduation amounts. Sensitivity analyses were conducted to systematically adjust parameters in the model to determine the effects of such changes. RESULTS: As of 2010, there were 74,476 PAs in the active workforce. The mean age was 42 years and 65% were female. There were 154 accredited educational programs; 99% had a graduating class and produced an average of 44 graduates annually (total n=6,776). With a 7% increase in graduate entry rate and a 5% annual attrition rate, the supply of clinically active PAs will grow to 93,099 in 2015, 111,004 in 2020, and 127,821 in 2025. This model holds clinically active PAs in primary care at 34%. CONCLUSIONS: The number of clinically active PAs is projected to increase by almost 72% in 15 years. Attrition rates, especially retirement patterns, are not well understood for PAs, and variation could affect future supply. While the majority of PAs are in the medical specialties and subspecialties fields, new policy steps funding PA education and promoting primary care may add more PAs in primary care than the model predicts.

Effect of patient selection method on provider group performance estimates.

BACKGROUND: Performance measurement at the provider group level is increasingly advocated, but different methods for selecting patients when calculating provider group performance have received little evaluation. OBJECTIVE: We compared 2 currently used methods according to characteristics of the patients selected and impact on performance estimates. RESEARCH DESIGN, SUBJECTS, AND MEASURES: We analyzed Medicare claims data for fee-for-service beneficiaries with diabetes ever seen at an academic multispeciality physician group in 2003 to 2004. We examined sample size, sociodemographics, clinical characteristics, and receipt of recommended diabetes monitoring in 2004 for the groups of patients selected using 2 methods implemented in large-scale performance initiatives: the Plurality Provider Algorithm and the Diabetes Care Home method. We examined differences among discordantly assigned patients to determine evidence for differential selection regarding these measures. RESULTS: Fewer patients were selected under the Diabetes Care Home method (n=3558) than the Plurality Provider Algorithm (n=4859). Compared with the Plurality Provider Algorithm, the Diabetes Care Home method preferentially selected patients who were female, not entitled because of disability, older, more likely to have hypertension, and less likely to have kidney disease and peripheral vascular disease, and had lower levels of predicted utilization. Diabetes performance was higher under Diabetes Care Home method, with 67% versus 58% receiving >1 A1c tests, 70% versus 65% receiving ≥1 low-density lipoprotein (LDL) test, and 38% versus 37% receiving an eye examination. CONCLUSIONS: The method used to select patients when calculating provider group performance may affect patient case mix and estimated performance levels, and warrants careful consideration when comparing performance estimates.

Physician assistants and nurse practitioners as a usual source of care.

PURPOSE: To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. METHODS: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). FINDINGS: Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (beta=-0.22, 95% CI =-0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. CONCLUSIONS: Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.