Physician assistants/associates in psychiatry: a workforce analysis.

BACKGROUND: Physician assistants/associates (PAs) provide services in diverse medical specialties globally, including psychiatry. While health professionals in psychiatry have been described for many years, little is known about PAs practicing in this discipline. METHODS: We describe US PAs practicing in psychiatry using robust national data from the National Commission on Certification of Physician Assistants (NCCPA). Analyses included descriptive and inferential statistics comparing PAs in psychiatry to PAs in all other medical and surgical specialties. RESULTS: The percentage of PAs practicing in psychiatry has increased from 1.1% (n = 630) in 2013 to 2.0% (n = 2 262) in 2021. PAs in psychiatry differed from PAs practicing in all other specialties in the following: they identified predominately as female (71.4% vs. 69.1%; p = 0.016), were more racially diverse (Asian [6.6% vs. 6.0%], Black/African American [5.5% vs. 3.4%], multi-race [2.8% vs. 2.1%], and other races [Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or other; 3.7% vs. 3.6%]; p < 0.001), and resided in the South (43.8% vs. 34.1%; p < 0.001). PAs in psychiatry vs. all other specialties were more likely to work in office-based private practice settings (41.6% vs. 37.3%; p < 0.001) and nearly twice as likely to provide telemedicine services for their patients (62.7% vs. 32.9%; p < 0.001). While one-third (31.9%) of PAs in psychiatry experienced one or more burnout symptoms, and 8.1% considered changing their current position, the vast majority of PAs in psychiatry (86.0%) were satisfied with their position. CONCLUSIONS: Understanding the attributes of PAs in psychiatry is essential in medical labor supply and demand research. Our findings suggest that the number of PAs working in psychiatry is steadily increasing. These PAs were predominantly female, exhibited greater racial diversity, and were primarily located in the South and Midwest regions of the US. A striking difference was that PAs in psychiatry were almost twice as likely to provide telemedicine services for their patients. Although nearly a third of PAs in psychiatry acknowledged having one or more symptoms of burnout, few were considering changing their employment, and the vast majority reported high job satisfaction.

Family Physicians as Proceduralists for Medicare Recipients.

PURPOSE: Procedures are manual technical skills clinicians perform for their patients. Family physicians (FPs) acquire these skills during residency; most are undertaken in outpatient settings. We performed a retrospective observational cohort study to describe the extent to which FPs perform the core procedures recommended by the Council of Academic Family Medicine (CAFM) and how this might have changed over time. METHODS: The CAFM recommended a list of procedures all FP residents should perform competently after graduation. We modified this list for Medicare beneficiaries to enable matching with Current Procedural Terminology codes. We probed Medicare Part B databases for modified CAFM procedure claims submitted by FPs in 2021 and how these claims changed from 2014 to 2021. RESULTS: In 2021, there were 904,278 modified CAFM procedures filed by 9,410 FPs in the outpatient setting. All procedures were clustered with respect to organ system (eg, musculoskeletal, skin, pulmonary). Beginning in 2014 and continuously through 2021, there was a 33% decrease in outpatient procedures filed and a 36% decrease in the number of FPs filing them. CONCLUSIONS: Office-based procedures are integral to a primary care physician's role, although the activity is rarely analyzed. At a time when the Medicare population is growing, the number of available FPs and the number of procedures they perform are not. This decrease might result from the changing scope of FP practice, new referral patterns, task shifting, and/or increased delegation to physician associates and nurse practitioners.

Office procedures for older adults by physician associates and nurse practitioners.

OBJECTIVE: We hypothesized that physician associate (PA) and nurse practitioner (NP) procedural roles are expanding. We sought to describe ambulatory procedures these professionals performed in 2021 for older adults. STUDY DESIGN: Retrospective observational cohort study of Medicare Part B data. US Bureau of Labor Statistics data were used to provide overall PA and NP employment context. METHODS: Medicare Part B databases were probed for outpatient events by PAs and NPs using a modified list of the Council of Academic Family Medicine's recommended clinical procedures that focused on 29 procedures organized into 9 categories called procedure clusters. These procedures were linked to Current Procedural Terminology codes and PA and NP National Provider Identifier codes in Medicare Part B and then tabulated and analyzed for 2021. The Bureau of Labor Statistics provided NP and PA employment trends for context. The trend of the procedures and providers spanning 2014-2021 was analyzed. RESULTS: In 2021, 23,581 NPs and PAs filed 9.6 million Medicare Part B enrollee procedure claims. Most procedures (96%) involved skin or the musculoskeletal system. PAs filed more than twice as many claims for skin and musculoskeletal procedures as NPs, and NPs filed 1.25 times as many as PAs for the eye, ear, nose, and throat; pulmonary; genitourinary; gastrointestinal-colorectal; and women's health categories. From 2014 through 2021, the number of PAs and NPs in clinical practice increased by 72%, and the number of those who filed procedure claims increased by 74%. CONCLUSIONS: Overall, PAs performed more skin and musculoskeletal procedures than NPs, and NPs performed more procedures in the other 7 procedure clusters than PAs. PA and NP employment growth does not fully explain these observations. We suggest that outpatient procedural task-shifting activity presents an area for further research.

Prescribing by Physician Associates and Nurse Practitioners in Older Adults Is Outpacing Traditional Prescribers: Implications for Practice in American Medicine.

Prescribing is a significant activity undertaken by physicians, physician associates/assistants (PAs), and nurse practitioners (NPs). We analyzed prescribing data to understand better the growing presence of PAs and NPs in older adults. A trend in frequently prescribed medications was compared with other physicians. All prescriptions in Medicare Part D were grouped into broad categories of drugs and linked to each type of provider. The analysis spanned 9 years (2013-2021). The results revealed that all five providers similarly prescribed the top three main drug classes (antacids, antihypertensives, and statins). In addition, there was a decline in the number of unique prescribers and prescriptions for all three types of physicians (family medicine, internal medicine, and general practice physicians). Concurrently, the number and share of prescriptions for NPs and PAs increased yearly. The findings are consistent with data that PAs and NPs are backfilling physician shortages in treating older adults.

The PA profession in the 1990s.

ABSTRACT: History is rarely linear, and nowhere is this more evident than the US physician assistant/associate (PA) movement (1965-2021). The 1990s stand out as pivotal years for the PA profession, marked by advances that shaped the profession, experiments in primary care delivery, sex equity, the Balanced Budget Act, and national policy errors in predicting a physician surplus. Rapid growth followed program expansion, doubling from 57 in 1993 to 120 by 1999. By the end of the decade, all states had advanced PA-enabling legislation with broad-based prescribing. During this era, PA-focused research moved from descriptive to predictive, an official journal emerged in 1988, the Accreditation Review Commission on Education for the Physician Assistant became independent, and the American Academy of Physician Associates helped shape federal health policy. Also during this period, the profile of PAs shifted from older males to younger females with important sociological implications in leadership and career development. Notable milestones included national recognition of PAs as Medicare-eligible providers, direct commissioning in the military, and employment surges in the Veterans Health Administration and US Public Health Service. Not least of all this was a time of role shifts toward specialized medicine and surgery.

Financial analysis of PA lifetime earnings and debt.

ABSTRACT: This economic analysis of physician assistant/associate (PA) career earnings sought to assess the increasing effect of student debt, its potential effect on job selection, and whether such financial obligations may influence graduates to select higher-paying specialties. The model was a 30-year-old newly graduated PA who begins working in family medicine. A simulation included wages, student debt, national household expenditures, and real estate statistics. The scenario consisted of a high and middle cost of living in two geographic areas, a family of four, and an average life expectancy. Using a validated economic program, a series of calculations produced the financial effect on moderate-income levels and expenditures based on median PA earnings. On the deficit side is education debt, loan repayment, financing a house, college for children, retirement, and discretionary spending. Weighted variables were used to maximize the sensitivity effect of the simulation. A Monte Carlo probabilistic program predicted the likely outcome of income, expenses, inflation, and investments. Furthermore, the lifetime earnings of a PA who retires at age 67 years and lives to age 85 years falls in the 75th percentile of income of all Americans. The conclusion is that a full-time PA career in any clinical role is as economically rewarding as it is satisfying.

Financial analysis of PA lifetime earnings and debt.

ABSTRACT: This economic analysis of physician assistant/associate (PA) career earnings sought to assess the increasing effect of student debt, its potential effect on job selection, and whether such financial obligations may influence graduates to select higher-paying specialties. The model was a 30-year-old newly graduated PA who begins working in family medicine. A simulation included wages, student debt, national household expenditures, and real estate statistics. The scenario consisted of a high and middle cost of living in two geographic areas, a family of four, and an average life expectancy. Using a validated economic program, a series of calculations produced the financial effect on moderateincome levels and expenditures based on median PA earnings. On the deficit side is education debt, loan repayment, financing a house, college for children, retirement, and discretionary spending. Weighted variables were used to maximize the sensitivity effect of the simulation. A Monte Carlo probabilistic program predicted the likely outcome of income, expenses, inflation, and investments. Furthermore, the lifetime earnings of a PA who retires at age 67 years and lives to age 85 years falls in the 75th percentile of income of all Americans. The conclusion is that a full-time PA career in any clinical role is as economically rewarding as it is satisfying.

A National Survey of postgraduate physician assistant fellowship and residency programs.

INTRODUCTION: The development of postgraduate programs for physician assistants (PAs) began in 1973 and by 2020 there were approximately 72 programs spread across a broad range of medical and surgical disciplines. PA Post-graduate education programs are voluntary and available to American licensed PAs. Therefore, an assessment of the characteristics of PA post-graduate fellowships and residencies programs was initiated. METHOD: A non-experimental, descriptive research study was designed to obtain information on the characteristics of PA postgraduate education programs in the US. The source of information was from surveyed members of the Association of Postgraduate Physician Assistant Programs (APPAP). Questions were drawn from consensus discussions. Directors of postgraduate programs that were operational in 2020 were eligible to participate. RESULTS: Seventy-two postgraduate program directors were invited to the survey and 34 program directors replied. These programs are geographically distributed across the US in 13 states. The respondents represent a wide range of medicine: surgery, emergency medicine, critical care, orthopaedics, hospitalist, psychiatry, oncology, primary care, pediatrics, and cardiology. Most programs are associated with an academic medical center and some institutions have more than one postgraduate specialty track. The curriculum includes bedside teaching, lectures, mentorship, assigned reading, procedures, simulation, and conferences. An average program length is 12 months and awards a certificate. Stipends for PA fellows are $50,000-80,000 (2020 dollars) and benefits include paid time off, health and liability insurance. About half of the programs bill for the services rendered by the PA. Over 90% of graduates are employed within 2 months of completing a PA postgraduate training program. CONCLUSION: A trend is underway in American medicine to include PAs in postgraduate education. PA postgraduate training occurs across a broad spectrum of medical and surgical areas, as well as diverse institutions and organizations overseeing these programs. Most PA postgraduate programs are in teaching hospitals where the PA resident or PA fellow also serves as a house officer alongside a categorical resident. This study sets the stage for more granular economic and social research on this growing phenomenon in American medicine.

Physician assistants in geriatric medical care.

BACKGROUND: The US population is maturing. As of 2020, over 52 million (16%) people are age 65 or older. With a citizenry that is increasingly "gray," the nation is short of medical providers who specialize in geriatric medical care. For example, the number of geriatrician physicians per 10,000 adults 65 years and older has decreased since 2000, with approximately 5300 in 2018. Nurse practitioners in geriatric medical care numbered 598 in 2018. Considering that the projected needs by 2030 will be over 30,000, the trajectory of geriatricians is becoming increasingly inadequate for the aging population. Physician assistants (PA) are another class of providers that are filling this geriatric medical care role, although little has been published. To address this role of PAs a study was undertaken. METHODS: The National Commission on Certification of Physician Assistants databank provided the number and characteristics of PAs in geriatric medicine and compared them to all other certified PAs. Analyses included descriptive statistics, Chi-Square, and Wilcoxon Rank Sum tests for comparisons between PAs practicing in geriatric medical care vs. all other PA specialties. Where a comparison between PAs in geriatrics and other specialties was made, a P value of .05 or less was considered statistically significant. RESULTS: As of 2018, there were 794 certified PAs, or 0.8% of the certified PA workforce, in geriatric medical care. This cadre has grown significantly since 2013, both in total number (increasing over 373%) and as a percentage of the PA workforce. The median age of certified PAs in geriatrics is 45 years, and 79% are female. Almost half (46%) of PAs in geriatric medicine work in extended care facilities or nursing homes, which differs from PAs in non-geriatric care. Another 8% work in government facilities and 8% in rehabilitation facilities. In 2018, the mean annual income for this PA group was $106,680. CONCLUSIONS: As the American population continues to age, the relative growth of PAs in geriatric medicine makes them a natural part of the solution to the projected physician geriatrician deficit. The role of PAs in geriatric medical care remains to be explored.

Observations on the Global Spread of Physician Assistant Education.

The physician assistant concept was developed in the 1960s as a response to the shortage and uneven distribution of generalist doctors. The goal was to increase the public's access to health care. After a half century of development and implementation, the PA model has become a global strategy to augment medical service delivery. In many instances the introduction of the PA was successful. Elsewhere it is in the early stages of development. The name may be modified depending on the country: "physician associate," "clinical assistant," "associate physician" are alternatives. While not all PA start-ups have been successful, where the PA model is thriving and growing, the concept provides rich examples of adaptation and evolution. The notion of including a PA is based on the concept of a medical team model and modified depending on the needs of the nation's health structure, regulation, and policy. Along the way, the education process undergoes modification, depending on the needs of the nation, but what emerges is a strategy for augmenting a stretched physician cadre. The reasons for success and failure are multifactorial, and the early implementation of a PA program can be a daunting task. This article examines the PA education experience in 15 countries. Successful use of PAs suggests that flexible adaptation to health care demand, generalist education, physician acceptance, and cost-effectiveness analysis may be keys that influence policy and their retention. In the end, success, adaptation, and failures are the lessons learned.

Physician Assistant and Nurse Practitioner Malpractice Trends.

Trends in malpractice awards and adverse actions (e.g., revocation of provider license) following an act or omission constituting medical error or negligence were examined. The National Practitioner Data Bank was used to compare rates of malpractice reports and adverse actions for physicians, physician assistants (PAs), and nurse practitioners (NPs). During 2005 through 2014, there ranged from 11.2 to 19.0 malpractice payment reports per 1,000 physicians, 1.4 to 2.4 per 1,000 PAs, and 1.1 to 1.4 per 1,000 NPs. Physician median payments ranged from 1.3 to 2.3 times higher than PAs or NPs. Diagnosis-related malpractice allegations varied by provider type, with physicians having significantly fewer reports (31.9%) than PAs (52.8%) or NPs (40.6%) over the observation period. Trends in malpractice payment reports may reflect policy enactments to decrease liability.

Future growth of physicians and non-physician providers within the U.S. Dermatology workforce.

Trends in the training, supply, availability, career decisions, and retirement of US dermatology physicians are not well delineated. The current study evaluates whether growth in the dermatology workforce will keep pace with population expansion in the United States. A dermatologist supply model was projected to 2030 drawing on data from the American Academy of Dermatology, American Medical Association, Bureau of Labor Statistics, American Association of Medical Colleges, and other associations. The clinically active dermatologist workforce in 2015 was 36 per capita (1,000,000); entry following postgraduate training was age 30 with career separation at age 65 on average. Added to the provider model are physician assistants and nurse practitioners in dermatology practices. A linear regression micro simulation model based on age cohorts produced a per capita supply of dermatology providers of 61 (±3) per 1,000,000 by 2030, up from 47 in 2016. The dermatology workforce is growing faster than population expansion. Workforce estimates could be affected by changing trends in retirement and training of dermatology providers. Investments in training of nurse practitioners and physician assistants, in addition to training more doctors, may be an effective strategy for increasing access to care in populations with low dermatologist density.

Modifying State Laws for Nurse Practitioners and Physician Assistants Can Reduce Cost Of Medical Services.

"Bending the cost curve" for health care services in the United States challenges policymakers. A cost analysis was undertaken based on what would occur if more physician assistants (PAs) and nurse practitioners (NPs) per capita were deployed over a 10-year period. The State of Alabama was used as a case study because it is one of a handful of U.S. states with restrictive legislation impacting the scope of practice of PAs and NPs. Changing PA and NP scope of practice legislation in Alabama to match states in the upper quartile of collaborative legislation such as Washington and Arizona would increase the employment and distribution of PAs and NPs. Even modest changes in legislation will result in a net savings of $729 million over the 10-year period. Underutilization of PAs and NPs by restrictive licensure inhibits the cost benefits of increasing the supply of PAs and NPs and reducing the reliance on a stagnant supply of primary care physicians in meeting the needs of its citizens.

Payment source and provider type in the US healthcare system.

Greater use of physician assistants (PAs) and nurse practitioners (NPs) to meet growing demand for healthcare in the United States is an increasingly common strategy to improve access to care and control costs. Evidence suggests that payment for services differs depending on the type of provider. This study sought to determine if the source of payment for a medical visit varies based on whether care is provided by a physician, PA, or NP. Data from the National Hospital Ambulatory Medical Care Survey (2006 through 2010) were analyzed. Physicians were proportionally more likely than NPs or PAs to provide care for medical visits compensated by private insurance or Medicare. Conversely, PAs and NPs were more likely to serve as providers of care for services with other payment sources such as Medicaid and out-of-pocket.