Physician assistants and nurse practitioners: rural-urban settings and reimbursement for services

Addressing the nursing shortage: a critical health care issue

This article explores factors that influence a nurse's choice between working in a rural and an urban area. Understanding how nurses make the choice of which type of environment is critical to addressing this shortage, especially in these hardest hit rural areas. A comprehensive literature review suggested a number of factors worthy of investigation. These factors were assessed through six focus groups and a survey. Results suggest that native geographic preferences dominate, but that value congruence, economics, work facilities and stress all play a significant role in the decision when choosing between an urban and rural work environment.

Pediatric physician assistants: distribution and scope of practice

BACKGROUND

Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited.

OBJECTIVE

To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice.

METHODS

Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties.

RESULTS

Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings.

CONCLUSIONS

PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.

The role of physician assistants in rural health care: a systematic review of the literature

PURPOSE

A literature review was performed to assess the role of physician assistants (PAs) in rural health care. Four categories were examined: scope of practice, physician perceptions, community perceptions, and retention/recruitment.

METHODS

A search of the literature from 1974 to 2008 was undertaken by probing the electronic bibliographic databases of English language literature. Criterion for inclusion was original data published on rural PAs. Each paper was assessed and assigned to the four categories.

FINDINGS

A total of 51 papers were identified; 28 papers had a primary focus on research and specified PAs in a rural setting. Generally, the literature suggests that PAs provide cost-efficient and supplemental medical services to underserved rural populations and that these services are valued. It also appears that rural PAs possess a larger scope of practice than urban PAs. This broad range of skills and procedures may be necessary to match the extensive health care needs of underserved rural populations. Over a 35-year period of examination, the literature improved in numbers of PAs studied and the quality of research. However, the lack of longitudinal studies was considered a shortcoming of rural health PA observational research.

CONCLUSIONS

Through this review, some insights about the role of PAs emerged. Overall, they seem well adapted to rural health. Important issues regarding the recruitment and retention of PAs to rural populations also emerged. Improvement in enabling legislation contributes to the utilization of PAs in America.

Factors in recruiting and retaining health professionals for rural practice

CONTEXT

Rural communities, often with complex health care issues, have difficulty creating and sustaining an adequate health professional workforce.

PURPOSE

To identify factors associated with rural recruitment and retention of graduates from a variety of health professional programs in the southwestern United States.

METHODS

A survey collecting longitudinal data was mailed to graduates from 12 health professional programs in New Mexico. First rural and any rural employment since graduation were outcomes for univariate analyses. Multivariate analysis that controlled for extraneous variables explored factors important to those who took a first rural position, stayed rural, or changed practice locations.

FINDINGS

Of 1,396 surveys delivered, response rate was 59%. Size of childhood town, rural practicum completion, discipline, and age at graduation were associated with rural practice choice (P < .05). Those who first practiced in rural versus urban areas were more likely to view the following factors as important to their practice decision: community need, financial aid, community size, return to hometown, and rural training program participation (P < .05). Those remaining rural versus moving away were more likely to consider community size and return to hometown as important (P < .05). Having enough work available, income potential, professional opportunity, and serving community health needs were important to all groups.

CONCLUSION

Rural background and preference for smaller sized communities are associated with both recruitment and retention. Loan forgiveness and rural training programs appear to support recruitment. Retention efforts must focus on financial incentives, professional opportunity, and desirability of rural locations.

International rural health needs and services research: a nursing and midwifery response

As the importance of evidence-based practice in global health care increases, the need for constant, accurate feedback from those in practice is critical, yet the requirement to rapidly obtain and disseminate data on a global basis is a challenge for all health professionals. The Internet allows for global participation in data collection that dramatically streamlines the traditional survey process. This new paradigm applies to surveys that are short, issue focused, and time sensitive. The Global Network of World Health Organization (WHO) Collaborating Centres for Nursing and Midwifery Development used a sample of international nurses in 70 countries to identify the worldwide rural health issues of WHO priority health needs, treatment modalities, health care interventions, and providers, as well as the current state of rural health research on a global level. This article presents the results of the survey regarding rural health needs and nursing and midwifery's response to them internationally, demonstrates Internet data collection, and shows how this research paradigm can help establish an evidence base for nursing practice.

What can rural agencies do to address the additional costs of rural services? A typology of rural service innovation

There is a national commitment to ensuring that, regardless of where patients live, they should be provided with an acceptable level of service in terms of quality, effectiveness and accessibility. Because of differences in the distributions of their populations, rural and urban areas present quite different challenges for the optimal design of health services and social care. However, this has not been fully acknowledged in the development of national policies to unify service standards. The problems of providing services in sparsely populated areas are not new. However, until the case for a rural premium in English health resource allocation is accepted, rural agencies must either tolerate lower levels of services (an option made difficult by the introduction of national service standards) or develop very different approaches to service delivery. To date, there has been little systematic knowledge about the extent of innovative rural practice, a paucity of evaluation of such initiatives and few opportunities to disseminate learning from one area to another. The present paper begins to address this deficit. Drawing upon a review of the formal literature and a comprehensive evaluation of projects developed within a rural Health Action Zone, it presents a typology of innovative responses at the health/social care interface. Examples of service innovations which fall into six broad categories are provided. These not only suggest possibilities for the transfer of good practice, but also the potential for future research.

Variations in nurse practitioner use in Veterans Affairs primary care practices

BACKGROUND

Increasingly, primary care practices include nurse practitioners (NPs) in their staffing mix to contain costs and expand primary care. To achieve these aims in U.S. Department of Veterans Affairs medical centers (VAMCs), national policy endorsed involvement of NPs as primary care (PC) providers.

OBJECTIVES

To evaluate the degree to which VAMCs incorporated NPs into PC practices between 1996 and 1999, and to identify the internal and external practice environment features associated with NP use.

STUDY DESIGN

We surveyed 131 PC directors of all VAMCs in 1996 and 1999 to ascertain the staffing and characteristics of the PC practice and parent organization (e.g., academic affiliation, level of physician staffing, use of managed care arrangements), and drew on previously published studies and HRSA State Health Workforce Profiles to characterize each practice's regional health care environment (e.g., geographic region, state NP practice laws, state managed care penetration). Using multivariate linear regression, we evaluate the contribution of these environmental and organizational factors on the number of NPs/10,000 PC patients in 1999, controlling for the rate of NP use in 1996.

PRINCIPAL FINDINGS

From 1996-1999, NP use increased from 75 percent to 90 percent in VA PC practices. The mean number of NPs per practice increased by about 60 percent (2.0 versus 3.2; p<.001), while the rate of NPs/10,000 PC patients trended upward (2.2 versus 2.7; p=.09). Staffing of other primary care clinicians (e.g., physicians and physician assistants per practice) remained stable, while the NP-per-physician rate increased (0.2 versus 0.4; p<.001). After multivariate adjustment, greater reliance on managed-care-oriented provider education programs (p=.02), the presence of NP training programs (p=.05), and more specialty-trained physicians/10,000 PC patients (p=.09) were associated with greater NP involvement in primary care.

CONCLUSIONS

Staffing models in VA PC practices have, in fact, changed, with NPs having a greater presence. However, we found substantial practice-based variations in their use, suggesting that more research is needed to better understand how they have been integrated into practice and what impact their involvement has had on the VA's ability to achieve its restructuring goals.

Rural health care providers in the United States

One of the most recalcitrant problems of the rural health landscape is the uneven distribution and relative shortage of medical care providers. Despite considerable efforts by federal and state governments over the past three decades to address these problems, rural provider distribution and shortage issues have persisted. The purpose of this article is to identify the challenges for rural health research and policy regarding health provider supply in the first decade of the 21st century. While the emphasis in this article is on physicians, workforce concerns pertaining to nurses, nurse practitioners, and physician assistants are briefly described. Physician supply, geographic and specialty distribution, age, gender, quality of care, recruitment and retention, training, productivity and income, reimbursement and managed care, federal and state ameliorative programs, safety net, and telehealth are discussed. Also highlighted are issues concerning rural health care workforce research, methods, and data as well as a series of policy-relevant questions. Solutions to rural health personnel problems can only be successfully addressed through multifaceted approaches. No vision of the future of rural health can come to fruition if it does not promote stable, rewarding, and fulfilling professional and personal lives for rural health care providers.

Utilization and scope of practice of Nurse Practitioners and physician assistants in Montana

PURPOSE

To explore the licensing, certification, governance and education requirements of nurse practitioners (NPs) and physician assistants (PAs) in the state of Montana. Services provided and privileges retained in employment were also analyzed.

DATA SOURCES

This was a descriptive study using a survey of rural hospital administrators (N = 34).

CONCLUSIONS

Survey results show that 92.5% of PAs in Montana meet their supervision requirement by a telephone contact provision outlined by the state board of medicine. In contrast, 54.2% of NPs, who are autonomous by legal definition, have a telephone supervision requirement imposed on them by their employers.

IMPLICATIONS FOR PRACTICE

These findings have implications for the current and prospective professionals and the businesses for which they work. Nurse practitioners and their professional organizations need to consider the implications these findings have on the professional image and marketability of all NPs.

Nurse practitioners and physician assistants revisited: do their practice patterns differ in ambulatory care?

The education and regulation of nurse practitioners and physician assistants would suggest unique role differentiations and practice functions between the professions. This study explored to what extent their practice patterns in primary care actually differ. It was hypothesized that the primary care services provided by nurse practitioners would tend to be women and family health services, health prevention and promotion oriented, provided to minority and socioeconomic disadvantaged patients, and less dependent on physician supervision. In contrast, the services provided by physician assistants would more likely be medical/surgical oriented; diagnostic, procedural, and technical in nature; likely to be in rural areas; and more dependent on physician supervision. The study used patient data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Although some differences emerged, the argument is not compelling to suggest strong, unique, practice differences across all ambulatory care settings between the two types of nonphysician providers. It is the specific type of ambulatory setting that influences the practice pattern for both provider groups. If practice patterns are less distinctive than previously believed, more opportunities for interdisciplinary education need to be explored, and health policies that promote a discipline-specific primary care workforce may need to be reexamined.

Critical access hospitals: rural nursing issues

Critical Access Hospitals (CAHs) are a recent federal initiative to address the fiscal concerns of small rural hospitals and improve access to healthcare for rural residents. A national effort exists to examine the outcomes of this federal initiative, but there is a paucity of information about nursing in CAHs. This pilot study, using survey techniques, examined rural nurses' perceptions of CAH conversion. The authors discuss the authorizing legislation, Medicare Rural Hospital Flexibility Program (MRHFP), and highlight survey findings on nurses' perceptions about hospitals that converted to CAH status. The information can be used by nursing administrators and educators to prepare nurses to work in CAHs that are located in more remote areas of the United States.

The changing nature of rural health care

The rural health care system has changed dramatically over the past decade because of a general transformation of health care financing, the introduction of new technologies, and the clustering of health services into systems and networks. Despite these changes, resources for rural health systems remain relatively insufficient. Many rural communities continue to experience shortages of physicians, and the proportion of rural hospitals under financial stress is much greater than that of urban hospitals. The health care conditions of selected rural areas compare unfavorably with the rest of the nation. The market and governmental policies have attempted to address some of these disparities by encouraging network development and telemedicine and by changing the rules for Medicare payments to providers. The public health infrastructure in rural America is not well understood but is potentially the most fragile aspect of the rural health care continuum.