Physician assistants: current status of the profession

In the two decades since the inception of the physician assistant concept in the United States, 52 physician assistant training programs have been established. Currently, approximately 16,000 physician assistants are employed by physicians and institutions throughout the country. Established to fill a perceived gap in primary health care delivery in the 1960s, the profession continues to serve mainly in primary care settings, with 43 percent of all physician assistants in family practice clinics. There is a trend, however, for physician assistants to fill health care gaps in other settings, such as long-term care institutions and correctional facilities. The clinical effectiveness of physician assistants has been demonstrated in terms of both quality of care and patient acceptance, and they are adept at adjusting to shifts in the health care marketplace. However, the real determinant of the future of the profession will be economic advantage. Recent changes in Medicare legislation now permit reimbursement for physician assistant services in nursing homes and hospitals, and payment under Medicaid has been approved in one half of the states. Given the cost effectiveness of physician assistants, their demonstrated competence and acceptability, and their adaptability to a variety of settings, the demand for their services is likely to continue.     

The effect of nurse practitioner scope of practice laws on primary care delivery

Nurse practitioners (NPs) are an increasingly integral part of the primary care workforce. NPs' authority to practice without physician oversight is regulated by state-level scope of practice (SOP) restrictions. To the extent that SOP restrictions prevent NPs from practicing to their full abilities and capacity, they could create inefficiencies and restrict access to health care. In this paper, I study what happens at primary care practices when states relax their SOP laws. Using a novel dataset of claims and electronic health records paired with a difference-in-differences research design, I quantify the effects of relaxing SOP laws on: (1) NPs' autonomy in their day-to-day jobs; (2) total workload and patient allocation between NPs and physicians; and (3) the provision of low-value services at primary care practices. I find some evidence that NPs practice more autonomously following SOP changes, but I find no evidence that relaxing SOP laws changes the volume nor allocation of patients to NPs, nor the provision of low-value services. Given the lower reimbursement that NPs typically receive, these findings suggest that allowing NPs to practice without physician oversight could reduce health care spending, without harming patients.     

Rural physician assistants: a survey of graduates of MEDEX Northwest.

Graduates of MEDEX Northwest, the physician assistant training program at the University of Washington, were surveyed to describe differences between physician assistants practicing in rural settings and those practicing in urban settings. Differences in demography, satisfaction with practice and community, practice history, and practice content were explored. Of the 341 traceable graduates, 295 (86.5 percent) responded to the mail survey. Although rural- and urban-practicing physician assistants are remarkably similar in most respects--income, hours worked, levels of practice satisfaction, for example--those in rural primary care reported performing a much wider range of medical and administrative tasks than those in urban practice. Half of the physician assistants who grew up in small towns were practicing in rural places compared with 18 percent of those from large towns. The broader scope of practice available to primary care physician assistants in rural areas may be of particular interest to those considering rural careers, to people who train physician assistants, and to rural communities trying to recruit and retain physician assistants. Results also suggest that recruitment of students for rural practice should focus on rural residents. Some problems that rural practitioners are more likely to face than urban ones, such as unreasonable night call schedules and lack of acknowledgement and respect for them as professionals, need to be addressed if rural communities are to be able to attract and retain physician assistants.     

How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants

Nurse practitioners (NPs) and physician assistants (PAs) now outnumber family practice doctors in the United States and are the principal providers of primary care to many communities. Recent growth of these professions has occurred amidst considerable cross-state variation in their regulation, with some states permitting autonomous practice and others mandating extensive physician oversight. I find that expanded NP and PA supply has had minimal impact on the office-based healthcare market overall, but utilization has been modestly more responsive to supply increases in states permitting greater autonomy. Results suggest the importance of laws impacting the division of labor, not just its quantity.     

Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act

BackgroundProvider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims.MethodsWe assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing.ResultsPharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination.ConclusionsAdult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.     

Assessing Medicaid patients' perceptions of the OB/GYN-patient relationship

OBJECTIVES: The objective of this study was to understand how the dynamics of the health care provider-patient relationship differ between Medicaid patients and private pay patients in the context of obstetric care. Various aspects of the patient-physician relationship were examined including trust, commitment, dependence, social content, service quality, and behavioral outcomes such as satisfaction, referral behavior, ease of voice, and retention. METHODS: Questionnaires were mailed to a sample of mothers who had recently given birth. MANOVA was used to compare the means of Medicaid patients with private pay patients for the variables of interest in the study. RESULTS: Medicaid patients had lower commitment to their primary physician. They trusted the practice, the primary physician, and the other physicians in the practice less. They perceived themselves as less similar to both the overall practice and their primary physician and also rated their health care service experience lower. They were less satisfied and less likely to use the same practice for future pregnancies or make referrals. They also felt less comfortable voicing complaints. CONCLUSIONS: The evidence clearly indicates that Medicaid obstetric patients perceived their service experience more negatively than private pay patients. Health care providers know they must provide clinical quality for their patients, however, in treating Medicaid patients they need to focus on patient driven-quality as well. The results indicate that health care providers, particularly OB/GYNs, need to do a better job of determining and delivering the key performance criteria that Medicaid patients use to make trust judgements.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

Physician extender services in family planning agencies: issues in Medicaid reimbursement

The US Social Security Amendments of 1972 mandated the inclusion of family planning services in state Medicaid plans, authorized 90% of reimbursements for family planning care, and imposed financial penalties for failure to provide these services to Medicaid-eligible clients. On the other hand, many states have retrictive policies regarding Medicaid reimbursements to family planning agencies for services provided by physician extenders (e.g.s nurse practitioners and physician assistants). There is concern that such restrictions greatly reduce accessibility to family planning services. Reasons that hae been suggested as causes of such restrictive policies include physician concern over loss of income, the uncertain status of physician extenders in some states, a fear that this step will lead to a demand for reiimbursement for the services of other allied health care providers such as social workers, and concern that care for the indigent will lead to an expensive increase in state reimbursement for family planning services. However, a review of relevant federal law and regulations indicates that Medicaid reimbursement for services provided to eligible patients by physician extenders has never been prohibited or discouraged. Physician supervision is required in reimbursement cases, but this does not mean that a physician must be on the premises while services are delivered. The Medicaid program actually allows significant latitude in establishing administrative policies and procedures. Rather, problems faced by family planning agencies in receiving Medicaid reimbursements for physician extenders' services are due to restrictions in state laws and staff misinterpretations of policy. Research has demonstrated that physcian extenders can contribute significantly to cost effectiveness, while providing types of care in localities such as rural areas that physicians tend to avoid. Given the importance of family planning services to Medicaid-eligible clients, unwarranted policy restrictions contrary to congressional intent should be eliminated.     

Factors influencing the costs of workers' compensation

This article presents several factors believed to have shaped the costs of workers' compensation. Of these factors, the most notable influence on claims severity is related to the way medical care is delivered to treat occupational injuries and illnesses. Although medical care providers may have some influence on the other factors responsible for increased claims severity, such as attorney costs and differences in state workers' compensation laws, they have a tremendous impact on the way medical care is delivered and its resultant costs. This places physicians, nurse practitioners,physical therapists, chiropractors, nurses, and physician assistants in a unique role of being able to assist US business in improving productivity through a reduction in workers' compensation costs.     

The impact of S-CHIP enrollment on physician participation in Medicaid in Alabama and Georgia

OBJECTIVE: To assess whether increasing enrollment in State Children's Health Insurance Programs (S-CHIPs) has an impact on the number of office physicians participating in Medicaid and the extent of their participation. Effects are measured for a freestanding S-CHIP program with an open provider panel and an S-CHIP program that uses the state's Medicaid provider panel. DATA SOURCES: Children's Medicaid claims data for primary care services were used to measure physician participation in the program; census and enrollment data were used to describe market area characteristics. Study Design. This is a time series study of communities in two states, measuring physician Medicaid participation quarterly between 1998 and 2001, controlling for changes in community characteristics and children's program enrollment as well as other factors by quarter. DATA COLLECTION/EXTRACTION: Office physician participation is measured by practice site. Claims data are aggregated to the level of the community and reflect the number of limited practice sites, the ratio of Medicaid office sites to the number of primary care physicians in the community as reported by the American Medical Association (AMA), and the mean number of Medicaid office visits made to physician sites in the community in the quarter. FINDINGS: In Alabama, the state with a freestanding S-CHIP program, there is little association between increased S-CHIP enrollment and physician participation in Medicaid. In Georgia, where the same provider network serves both programs, increases in S-CHIP enrollment are associated with a decline in office-based physician participation in Medicaid in urban areas. CONCLUSION: Linkage of S-CHIP and Medicaid programs through the use of the same provider network, in the absence of market conditions that encourage the expansion of the network, can lead to a negative impact on access for Medicaid enrollees.     

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.     

Work-related complaints of dentists and dental assistants

Summary Occupational health problems of dental teams were investigated in 68 dentists and 90 dental assistants of Helsinki Health Centre. A pre-tested, self-administered questionnaire was used. Diagnosed diseases or discomforts of occupational origin were reported by 38% of the dentists and 12% of the dental assistants. Thirty-one percent of the dentists and 10% of the assistants reported having been on sick-leave during the 2 years prior to the survey because of some kind of occupational problem. As a consequence of years in the dental profession, musculoskeletal disorders of back and neck and stress were most frequently experienced by the dentists and rash or allergic reactions and respiratory infection by the assistants. Only 1% of both professional groups reported no aches while practising dentistry during the 6 months preceding the survey. The vast majority of subjects took regular physical exercise but practice of muscular relaxation or gymnastics at the place of work was unusual. The results indicate that dental teams need functionally designed dental equipment and proper training in ergonomic methods.     

Recent changes in occupational medicine in The Netherlands

 In some respects, the Dutch seem to be forerunners in Europe. Occupational health care for all workers can be considered as a substantial progress. Nonetheless, The Netherlands has taken the lead in Europe regarding high work pressure, sickness absence and disability for work. The resulting focus on sickness absence management in many companies is associated with changes in the tasks and position of the occupational physician. Quality of occupational health care is not always as high as it should be, partly as a result of the commercial approach occupational health services have to adopt nowadays. However, the post-academic education programme, with special attention for training of skills, is increasingly adapted to occupational physicians working in a commercial environment. Moreover, a basis has been laid for a better infrastructure and occupational physicians show an increase in professional enthusiasm. Furthermore, co-operation between different professionals has become increasingly common, resulting in a more comprehensive support for companies. Efforts are being made for better co-operation with general practitioners and medical specialists. Finally, the priorities for future research have been clearly outlined by a programming study. Experts are in demand for studies regarding implementation and evaluation of interventions, especially cost-benefit analysis. Furthermore, work stress and musculoskeletal disorders remain on the research agenda. Received: 8 April 1999 / Accepted: 24 April 1999     

'They'll still get the bodily care'. Discourses of care and relationships between nurses and health care assistants in the NHS

This paper examines the impact of recent changes in work organisation in the NHS, drawing on research undertaken in two English hospital wards. Nurses' and health care assistants' responses to the introduction of a new skill mix are explored through qualitative interview data. The nurses' perceptions are explored in relation to theories of occupational closure. These suggest that claims to distinct knowledge and ownership of the process of care may be undermined by the reproduction of hierarchical models of work organisation. The data suggest that the nurses' ambivalence, recognised by managers, seems to limit their effectiveness in resisting fordist practices of routinisation and deskilling. It also impacts upon health care assistants, who seem to be excluded from nursing's occupational project and whose contribution to care may, as a consequence, be devalued.     

Do the Medicaid and Medicare programs compete for access to health care services? A longitudinal analysis of physician fees, 1998–2004

As the demand for publicly funded health care continues to rise in the U.S., there is increasing pressure on state governments to ensure patient access through adjustments in provider compensation policies. This paper longitudinally examines the fees that states paid physicians for services covered by the Medicaid program over the period 1998–2004. Controlling for an extensive set of economic and health care industry characteristics, the elasticity of states’ Medicaid fees, with respect to Medicare fees, is estimated to be in the range of 0.2–0.7 depending on the type of physician service examined. The findings indicate a significant degree of price competition between the Medicaid and Medicare programs for physician services that is more pronounced for cardiology and critical care, but not hospital care. The results also suggest several policy levers that work to either increase patient access or reduce total program costs through changes in fees.     

Use of nonphysician health care providers for skin cancer screening in the primary care setting

BACKGROUND: Nonphysician health care providers are in an optimal position to provide cancer prevention and screening services. METHODS: We conducted a survey of primary care physicians to determine physician use and amenability to use of nonphysician health care providers to perform skin cancer screening in comparison with other cancer screening examinations. RESULTS: A total of 1,363 eligible physicians completed the survey. Of these, 631 physicians (46%) reported a nurse practitioner or physician assistant performing at least one type of cancer screening examination on their patients. Twenty-nine and 22% of all physicians reported nurse practitioners or physician assistants performing skin cancer screening, respectively. Family physicians were more likely to use nurse practitioners and physician assistants to perform these cancer screening examinations than internists (chi(2) test, P = 0.001 for each examination). Skin examinations were performed less frequently by nurse practitioners and physician assistants than all other cancer screening examinations. A total of 73-79% of family physicians and 60-70% of internists were amenable to having a nonphysician health care provider perform one or more of these examinations. CONCLUSIONS: Primary care physicians are currently utilizing nonphysician health care providers to perform cancer screening examinations and the majority of those surveyed are amenable to the use of these providers for such examinations. This suggests that one possible strategy for increasing skin cancer screening is through an expanded role of nonphysician health care providers.     

A “Medical Mission” at Home: The Needs of Rural America in Terms of Otolaryngology Care

Objectives: Describe the population, Medicaid, uninsured, and otolaryngology practice demographics for 7 representative rural Southeastern states, and propose academic‐affiliated outreach clinics as a service to help meet the specialty care needs of an underserved rural population, based on the “medical mission” model employed in international outreach clinics. Methods: A needs assessment was conducted via review of medical licensing and practice location data from state medical licensing authorities, together with population, Medicaid, and uninsured data from state health/human services departments and the US Census Bureau. Results: In all states examined, there are significantly more practicing otolaryngologists per capita in urban areas compared to rural areas (P < .05), with the exception of West Virginia, where the difference was not statistically significant (P= .33). In the majority of the states examined, there were higher rates (expressed as a percentage of total county population) of both Medicaid recipients and uninsured patients in rural counties compared to urban counties. Notable exceptions include Louisiana and West Virginia, where there are higher percentages of Medicaid patients in urban areas, and Kentucky and Tennessee, where there are higher percentages of uninsured patients in the urban areas (P < .05 for each comparison). Conclusions: Borrowing design elements from the international outreach clinics, which involve many US otolaryngologists, a similar medical mission model could be of benefit domestically. There are rural areas of the Southeast where visiting outreach clinics could improve access to otolaryngology care and facilitate effective use of existing “safety net” health care resources.