Ambulatory and Chronic Disease Care by Physician Assistants and Nurse Practitioners

Physician Associates/Assistants in Primary Care: Policy and Value

Since the new century, primary care physician supply has worsened. Analysts predict that health service demand in the United States will grow faster than physician supply. One strategy is the utilization of physician assistants/associates (PAs). Most PAs work full-time, and approximately one quarter are employed in family medicine/general medicine. PAs deliver primary care services in a team-oriented fashion in a wide variety of settings, including private health systems and community health centers. One fifth work in rural and medically underserved areas. Together PAs and nurse practitioners provide approximately one third of the medical services in family medicine, urgent care, and emergency medicine.

Care received by patients from nurse practitioners and physicians in U.S. primary care settings

OBJECTIVE

Nurse practitioners (NPs) and physicians serve in both usual source of care (USC) and supplement roles to each other in the provision of primary care to patients. Yet little is known about the care that patients receive from providers in these roles. This study examined the care individuals received when NPs and physicians served in USC and supplemental roles.

DATA SOURCES

Pooled data from the Household Component of the Medical Expenditure Panel Survey 2002-2013.

STUDY DESIGN

Cross-sectional, secondary data analysis using propensity score matching and multinomial logistic regression.

DATA COLLECTION

Data were collected from a national subsample of households.

PRINCIPAL FINDINGS

Regardless of provider role, patients reported receiving more therapeutic or preventive care from NPs but more diagnostic care and biomedical treatments from physicians. Patients reported having similar diagnoses when seen by NPs and physicians serving in USC roles, but different diagnoses when NPs and physicians served in supplemental roles.

CONCLUSIONS

NPs and physicians providing different care when serving in the same role. Findings can inform policy-makers as they develop policies for serving patients and utilizing the relevant expertise of NPs and physicians.

Collaborative practice trends in US physician office visits: an analysis of the National Ambulatory Medical Care Survey (NAMCS), 2007-2016

OBJECTIVE

Practice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing.

DESIGN

Temporal ecological study.

SETTING

Non-federal physician offices.

PARTICIPANTS

Patient visits to a physician, PA or NP, spanning years 2007-2016.

METHODS

A stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007-2011 and 2012-2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type.

RESULTS

Within years 2007-2011 and 2012-2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012-2016 compared with years 2007-2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012-2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers.

CONCLUSIONS

In non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery.

Disruptive innovation in rural American healthcare: the physician assistant practice

Purpose

This article proposes a new disruptive innovation in healthcare through the development of a physician assistant business model, which can be most readily applied in vulnerable rural health care settings.

Design/methodology/approach

This study reviews the current state of the health care system in terms of physician assistant utilization and primary care shortages in rural communities. The study proposes that the physician assistant-owned and -operated primary care business represents a disruptive innovation, via the application of the five principles of Clayton Christensen’s (1997) thesis on disruptive innovation.

Findings

Considering the current state of the health care industry, the study logically defends the proposed model as a disruptive innovation in that it: focuses on an underserved market, has lower costs, has few competitors, offers high quality and provides a sustainable competitive advantage.

Practical implications

The physician assistant business model is a viable solution for providing primary care for rural communities with educational, financial, transportation and other resource limitations.

Originality/value

This is a unique application of the theory of disruptive innovation, which illustrates how a new business model can solve a chronic shortage in primary care, especially in underserved populations.

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.

Nurse Practitioner Autonomy and Satisfaction in Rural Settings

Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice.

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.

Supply of physician assistants: 2013-2026

As part of healthcare reform, physician assistants (PAs) are needed to help mitigate the physician shortage in the United States. This requires understanding the population of clinically active PAs for accurate prediction purposes. An inventory projection model of PAs drew on historical trends, the PA stock, graduation estimates, retirement trends, and PA intent to retire data. A new source of licensed health professionals, Provider 360 Database, was obtained to augment association information. Program growth and graduate projections indicated an annual 4.7% trend in new entrants to the workforce, offset by annual attrition estimates of 2.9%. As of 2013, there were 84,064 licensed PAs in the United States. The stock and flow equation conservatively predicts the supply of PAs to be 125,847 by 2026. Although the number of clinically active PAs is projected to increase at least by half by 2026, substantial gaps remain in understanding career trends and early attrition influences. Furthermore, education production could be constrained by inadequate clinical training sites and scarcity of faculty.