1. Rural Physician Assistants (PAs): History, Distribution, Scope and Retention Challenges Jennifer Coombs, PhD, PA-C Assistant Professor University of Utah PA Program

2. Objectives Overview of the rural workforce in US-what is the rural convergence of crises? Physician shortages Brief history and overview of PAs Current assessment of rural physician assistants (PAs), and their distribution in rural areas Discuss the scope of PA practice, and issues facing retention of the rural PA workforce.

3. Rural America is facing a convergence of crises a) Elderly b)Economic stagnation c)Towns without young people d)Sustainable chronic diseases need more care e)Native American populations f)Health profession shortages

4. PAs 84,064 licensed PAs in the US as of 2013 (Provider 360 Database) Program growth (191 programs accredited) Program growth primarily at private institutions Projections 125,000 PAs by 2026 Young, primarily white and female Median compensation~$90,000 Hooker, Roderick S Muchow, Ashley N JAAPA. 2014 Mar;27(3):39-45. doi: 10.1097/01.

5. PAs practicing in the rural west A brief history of PAs in rural areas PAs since inception designed to go into rural areas Most common practice for a rural PA is primary care Community health centers, migrant health centers, indian health centers and prison systems One study showed more than 50% of rural hospitals utilized PAs.

6. Rural Health Providers 62 million Americans, or 20% of the nation’s population, live in a rural area. (National Rural Health Association) Only 9% of the nation’s physicians practice in rural areas, and 77% of the 2,050 rural counties in America are designated as Health Professional Shortage Areas (HPSAs) PAs and NPs together now outnumber family medicine physicians

7. Physician Maldistribution Clinically Active Physicians per 100,000 Individuals by Hospital Referral Region (2010)215 to to316 (57) (57)200 to < to <215 (54) (54) 185 to < to <200 (63) (63) 170 to < to <185 (67) (67) 118 to < to <170 (65) (65) Not Populated Dartmouth Atlas of Healthcare Project

10. PA distribution Higher earnings potential in urban areas Affordable Care Act may benefit rural areas (some rural states like Utah still debating Medicaid expansion for example) Need a workforce to deliver that care Reimbursement of PAs by Medicaid and Medicare greater issue in rural areas (elderly populations as high as 45% in some rural areas)

11. Percentage of physicians working with PAs and NPs in rural area The percentage of primary care physicians working with PAs or NPs varied by the urbanicity of the physician's office location. PAs and NPs are more prevalent in rural and underserved areas, which have fewer primary care physicians. The supply and access to physicians increases as locations are more urban… and, the inclusion of a PA or NP in primary care physician practices increased as office locations became more rural Esther Hing, M.P.H., and Chun-Ju Hsiao, Ph.D State Variability in Supply of Office-based Primary Care Providers: United States, 2012 NCHS Data Brief

12. PA state laws American Academy of PAs (AAPA) “Six Key Elements” “Licensure” as the regulatory term (not certification) Scope of practice determined at the practice site Adaptable supervision requirements Full prescriptive authority Number of PAs a Physician May Supervise Determined at Practice Level Chart co-signature requirements determined at the practice American Academy of Physician Assistants, “Statutory and Regulatory Requirements for State Licensure” (February 2013), http://www.aapa.org/workarea/downloadasset.aspx?id=599http://www.aapa.org/workarea/downloadasset.aspx?id=599

13. Example of recent changes Kentucky Eliminated the 18 mo direct supervision requirement for new graduates Decreased co-signature for chart notes from 100% to 10% Maybe able to increase PA-physician supervision from 2 PAs to 4. Kentucky one of two states that cannot prescribe narcotics

15. Physician supervision and delegation 24 states require a physician’s signature on some percentage of the charts Most states specify how many PAs a physician may supervise-generally 2-6 PAs. Delegation restrictions with some prescribing limits exist in 14 states, and in 11 states there is legislation or board sets task

16. PAs, supervision and delegation Typically PAs work with physicians at the same site, but according to AAPA 3.4% of PAs report their supervising physician is off site. 25 states place restrictions on how often the physician must be on-site In some states those can change as the relationship matures and the PA gains experience

17. PA and NP regulation and supply Considerable cross state variability in NP and PA regulations Unpublished analysis by Dr. Everett, no correlation between more restrictive and less restrictive state practice environments and rurality Stange K. How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. J Health Econ. 2014;33:1-27

18. Which family physicians work with NPs PAs and CNMs? Study in Journal of Rural Health by Lars E. Peterson MD, PhD 2014 used a sample to determine 60% routinely working with NPs, PAs or CNMs Conclusion, PA, NPs and CNMs increased access to healthcare particularly in rural areas. Peterson LE, Blackburn B, Petterson S, Puffer JC, Bazemore A, Phillips RL. Which family physicians work routinely with nurse practitioners, physician assistants or certified nurse midwives. J Rural Health. 2014;30(3):227-234

19. Expansion Some state workforce commissions have recommended creation of new or expanded PA programs (Utah, Minnesota, New Mexico and Oklahoma) New programs expanding at private institutions resulting in higher debt loads for students Hanover Research, Demand for a Master of Physician Assistant Program (January 2011), http://www.hanoverresearch.com/wp- content/uploads/2012/02/Demand-for-a-Master-of-Physician-Assistant-Program-Redacted.pdfhttp://www.hanoverresearch.com/wp- content/uploads/2012/02/Demand-for-a-Master-of-Physician-Assistant-Program-Redacted.pdf

20. Debt Loan repayment programs, some state, but mostly federal (National Health Service Corps-NHSC) Few states offer debt relief or incentives for training (lack of clinical sites), incentives toward working in underserved areas are lacking Primary public funding is through HRSA (Title VII Health Professions Program) specifically looking for PA programs that have a mission to serve primary care and rural populations

21. Debt continued Median educational debt for physicians in 2012 was 170,000 and 86% of graduates carried some debt. (AAMC Physician Education Debt and the Cost to Attend Medical School 2012 Update) Recent Robert Graham Center report, “The Impact of Debt Load on Physician Assistants”, July 2014

23. More on Debt From the Graham Center report: Some surprising findings Students who received more than $25,000 in non-loan financial aid for their PA program were twice as likely as students who received no aid to express an interest in a rural or underserved area. Students at both ends of the debt spectrum—those owing some debt but less than $50,000 in total debt and those owing more than $150,000—were more likely to express interest in practicing in a rural area.

24. PAs who own their practices How does a PA employ their supervising physician? States individually determine if this is allowed Arizona, Idaho, Maryland, North Carolina, and Washington all may own their own practices American Academy of Physician Assistants, Physician Assistants and Practice Ownership (March 2011)

25. National Governors Association Recent IOM report called for nurse practitioners to be allowed to practice to the full extent of their training. (Institute of Medicine 2011) Similarly the National Governors Association (NGA) issued a report that called for states to institute better policies for PAs: “States can ensure that PAs are used efficiently by reviewing state laws and regulations—especially the definition of provider—for appropriateness and by facilitating educational and clinical training opportunities for PAs. Finally, states can consider creating financial incentives to encourage PAs to work in underserved communities.” (NGA paper 2014)

26. Rural PA PAs provide cost-efficient and supplemental medical services to underserved rural populations and that these services are valued. It is probable that rural PAs possess a larger scope of practice than urban PAs. Necessary to match the large scale health care needs of rural populations. Henry, Lisa R., Roderick S. Hooker, and Kathryn L. Yates. "The role of physician assistants in rural health care: a systematic review of the literature." The Journal of Rural Health 27.2 (2011): 220-229.

27. Critical Access Hospitals PAs and NPs in CAH Advantages to CAH in hiring NPs and PAs. Under the Medicare Conditions of Participation (CoP) hiring NPs or PAs may have advantages~ “A Critical Access Hospital must have at least one physician, but that person is not required to be on-site. Midlevel practitioners can be an independent part of the medical staff and can provide direct service to patients. CAHs are also required to provide guidance by a physician, but the provisions are very liberal. This can be useful in communities that have had difficulty recruiting physicians.”

28. Recruitment of PAs The National Rural Health Resource Center have many resources: Recruitment manual Contract and compensation reviews https://www.ruralcenter.org/recruitment/recruitment- services

29. References 1. Henry LR, Hooker RS. Caring for the disadvantaged: The role of physician assistants. JAAPA. Jan 2014;27(1):36-42. 2.Hooker RS. Working with the medically underserved. Can Fam Physician. Apr 2013;59(4):339-340. 3.Hooker RS. Physician assistants working with the medically underserved. JAAPA. Apr 2013;26(4):12. 4.Everett CM, Thorpe CT, Palta M, Carayon P, Gilchrist VJ, Smith MA. Division of primary care services between physicians, physician assistants, and nurse practitioners for older patients with diabetes. Med Care Res Rev. Oct 2013;70(5):531-541. 5.Everett C, Thorpe C, Palta M, Carayon P, Bartels C, Smith MA. Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes. Health Aff (Millwood). Nov 2013;32(11):1942-1948. 6.Dill MJ, Pankow S, Erikson C, Shipman S. Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Aff (Millwood). Jun 2013;32(6):1135-1142. 7.Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. Jan 2012;20(1):20-31. 8.Huckabee MJ, Wheeler DW. Physician assistants as servant leaders: meeting the needs of the underserved. J Physician Assist Educ. 2011;22(4):6-14. 9.Henry LR, Hooker RS, Yates KL. The role of physician assistants in rural health care: a systematic review of the literature. J Rural Health. Spring 2011;27(2):220-229. 10.Everett CM, Schumacher JR, Wright A, Smith MA. Physician assistants and nurse practitioners as a usual source of care. J Rural Health. Fall 2009;25(4):407-414. 11.O'Connor TM, Hooker RS. Extending rural and remote medicine with a new type of health worker: physician assistants. Aust J Rural Health. Dec 2007;15(6):346-351. 12.Henry LR, Hooker RS. Retention of physician assistants in rural health clinics. J Rural Health. Summer 2007;23(3):207- 214. 13.Grumbach K, Hart LG, Mertz E, Coffman J, Palazzo L. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med. Jul-Aug 2003;1(2):97-104. 14.Shi L, Samuels ME. Practice environment and the employment of nurse practitioners, physician assistants, and certified nurse midwives by community health centers. J Allied Health. Summer 1997;26(3):105-111. 15.Li LB, Williams SD, Scammon DL. Practicing with the urban underserved. A qualitative analysis of motivations, incentives, and disincentives. Arch Fam Med. Feb 1995;4(2):124-133; discussion 134.