Growth and Change in the U.S. Physician Assistant Workforce

Eric H. Larson, Ph.D.

MEDEX Northwest

University of Washington

November 11, 2008

Outline

• Origins of the PA professionOrigins of the PA profession• Growth of PA profession 1967-2005Growth of PA profession 1967-2005• National PA workforce characteristicsNational PA workforce characteristics• Issues in PA workforce researchIssues in PA workforce research

What’s a PA?

• A graduate of an accredited PA program authorized to practice medicine under the supervision of a licensed physician

• Physicians may delegate to PAs medical duties within the physician’s scope of practice and the PA’s training and experience, and in accordance with law

1967: Problems/Opportunities

• Rural Health Access

• Physician Burn-out

• Returning Military Medics

Founders of the PA Profession

Growth of the

PA profession

1967 - 2005

PA Graduates by gender 1967-2005

19

67

19

68

19

69

19

70

19

71

19

72

19

73

19

74

19

75

19

76

19

77

19

78

19

79

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Male

Female

Rural-Urban PA/Population ratios 1980-2003

1980 1991 2000 20030

5

10

15

20

PA

/Po

pu

lati

on

rat

io p

er 1

00,0

00 p

op

ula

tio

n

4.34.68

8.56

10.54

12.96

14.36 14.39

16.76

Rural

Urban

MD/PA Population Ratios 1980-2005

1980 1990 2000 20050

10

20

140

160

180

200

220

240

Pro

vid

er/

Po

pu

lati

on

ra

tio

per

100

,000

po

pu

lati

on

4.5

11

1416

167

188

227 230MD

PA

PAs in Primary/Specialty Care: 1974-2003

Source: AAPA, Pew Report

1974 1980 1990 2000 20030

10

20

30

40

50

60

70

80

90

100

70

30

61

39

46

54

4852

44

56

Primary care

Specialty care

Highest degrees granted by PA programs 1987-2006

1987 1990 1994 1998 2001 2006

% Masters -- 5.9 18.6 25.8 42.9 73.9

% BA/BS 71.4 64.7 61.0 52.8 42.9 18.7

% Assoc. 10.2 11.8 5.1 6.7 4.0 2.2

% Cert. 18.4 17.6 13.6 14.6 10.3 5.2

Number of programs

------

49

-----

51

-----

59

------

89

------

126

-----134

Selected Characteristics of the

Current PA Workforce

In 2005.......

• 71,216 PAs had been trained• 58,665 PAs were in clinical practice • 131 programs graduated 4,275 new PAs • 72% of new students were women• 22% of new students were non-white• Mean age of active PAs was 41 • 28% practicing family practice (down from 40% in 1996)

• 25% worked in surgery• PAs treated 221,000,000 patients (AAPA, 2005)

PA Pop. Ratios by area type, 2003

All Urban Rural PC-HPSA Pers. Poverty0

10

20

PA

/Po

pu

lati

on

ra

tio

pe

r 1

00

,00

0 p

op

ula

tio

n

16.4

6.1

16.7

5.6

14.4

8.2

11.8

7.1

10.3

6.3

All PAs

PC PAs

PA Employer Types, 2007

0

5

10

15

20

25

30

35

Pe

rce

nt

16

22.9

14.5

12.5

24.1

33.1

15.4

12.613.8

4.5

16.2

14.4

Rural

Urban

PA Primary work settings, 2007

0

5

10

15

20

25

30

35

40

45

Pe

rce

nt

22.8

39.4

17.1

1.2

14

11.8

18.8

23.4

11.4

9.1

22.8

15.1

Rural

Urban

Work settings of hospital-based PAs

0

5

10

15

20

25

30

35

40

45

50

Pe

rce

nt

2

6.3

12.8

28.6

22.2

18.6

46.2

24.9

14.1

18

2.73.6

Rural (22.8% of total)

Urban (39.4% of total)

Issues in PA Workforce Research

“Prediction is very difficult, especially about the future.” --Niels Bohr

Three Key Issues in PA Workforce Research

• Provider Supply & PA Contribution to Care

• Geographic Distribution

• Specialization

Provider Supply

• Who gets counted?

– Provider/population ratios

• How should we count?

– Headcounts, FTEs, visits

• How much do PAs do?

– Productivity and Contribution to care

Productivity - how much do PAs do? Nationally representative sample shows:

• Overall, 61 OP visits per week (74 for physicians)

• Specialty productivity is lower

• PC PAs compared to PC physicians = 81 visits vs 104 (FTE equivalent ~ .78)

• How you count providers matters (FTEs, not headcounts!)

(Larson, Hart, Ballweg 2001 Journal of Allied Health)

Headcount vs FTE - Washington generalist providers 1998-99 (1 FTE= 104 visits)

MD/DOs NPs PAs0

500

1000

1500

2000

2500

3000

3500

4000

45004189

2781

699

330

581411

Headcounts

FTEs

Geographic Distribution of PAs

• Rural/Urban

• Underserved Areas

• Regions and States

PA Pop. Ratios by area type, 2003

All Urban Rural PC-HPSA Pers. Poverty0

10

20

PA

/Po

pu

lati

on

ra

tio

pe

r 1

00

,00

0 p

op

ula

tio

n

16.4

6.1

16.7

5.6

14.4

8.2

11.8

7.1

10.3

6.3

All PAs

PC PAs

Number of active PAs - 2003

MississippiArkansas

HawaiiWyomingDelawareVermont

DCRhode IslandNorth Dakota

MontanaNew Hampshire

AlaskaNevada

AlabamaSouth Dakota

IdahoLouisiana

IndianaNew Mexico

MissouriUtah

MaineSouth Carolina

West VirginiaOregon

NebraskaKentucky

KansasIowa

TennesseeNew Jersey

OklahomaMinnesota

VirginaConnecticut

ArizonaWisconsin

MassachusettsColorado

IllinoisOhio

MarylandWashington

GeorgiaMichigan

North CarolinaFlorida

PennsylvaniaTexas

CaliforniaNew York

0 1000 2000 3000 4000 5000 6000

Number of active PAs per 100,000 - 2003

MississippiArkansasAlabama

IndianaMissouri

LouisianaHawaii

New JerseyIllinois

TennesseeSouth Carolina

VirginaOhio

NevadaCalifornia

TexasOregon

KentuckyMinnesota

FloridaMassachusetts

Rhode IslandArizonaGeorgia

UtahWisconsinDelaware

IowaNew Hampshire

OklahomaNew Mexico

MichiganKansas

WashingtonIdaho

PennsylvaniaMarylandColorado

WyomingMontanaVermont

West VirginiaConnecticut

North CarolinaDC

New YorkNebraska

North DakotaMaine

South DakotaAlaska

0 5 10 15 20 25 30 35 40

U.S. overall- 16.36 per 100,000 population

Number of active primary care PAs per 100,000 - 2003

ArkansasMississippi

AlabamaIndiana

LouisianaNew Jersey

MissouriOhio

South CarolinaHawaii

DelawareIllinois

VirginaTennessee

Rhode IslandFlorida

KentuckyMassachusetts

CaliforniaNevada

DCTexas

GeorgiaOregon

MarylandConnecticut

ArizonaPennsylvania

MinnesotaWisconsinNew YorkOklahomaMichigan

UtahNew Hampshire

KansasWashingtonNew Mexico

West VirginiaIowa

IdahoNorth Carolina

VermontMontanaColorado

MaineWyomingNebraska

North DakotaSouth Dakota

Alaska

0 5 10 15 20 25 30 35 40

U.S. Overall- 6.10 per100,000 population

Specialization• The frontier of PA workforce research in the US

• What’s the “correct” ratio of physicians and PAs/NPs? Depends on:

– Scope of practice

– Degree of autonomy

– Effects of PA “residency” training

– Emergence of roles in hospital and specialty practice

– Organization & economics of medical practice

Specialty practiced for primary PA employer, 2007

0

5

10

15

20

25

30

35

Pe

rce

nt

of

PA

s

20.7

7.9

28.9

12.8

9.1 9.510.7

10

6

16.3

8.4

10.6

16.2

32.9Rural

Urban

PAs in orthopedic practice: early results• Employers

– 58% Orthopedic group practices– 27% hospitals

• 42% take first call• 74% first assist regularly• 64% close independently• Very strong feelings about post-grad

training

Recent study of 400 rural hospital Emergency Depts.

• 33% staffed ED with PAs part of the time• 26% staffed ED with NPs part of the time• 14% staffed ED with both NPs and PAs• About 59% of NP/PAs in ED employed by

hospital• About 20% of NP/PAs in ED employed by local

physician group• Physician was off-site in 68% of hospitals when

ED staffed by NP/PA. (Casey et al, 2007)

More research themes

• Pedagogy

• Effects of increased PA use in teaching hospitals

• Effects of “degree creep” on the PA workforce and pipeline

• Feminization of the PA workforce

• PAs in the rural/underserved workforce

• Internationalization of the PA concept

Three Imponderables of Health Workforce Research or: Why there will always be work for health workforce researchers

• New Diseases (e.g. HIV/AIDS)

• New Technologies (e.g. laparoscopic surgery)

• Policy and Politics (e.g. AAMC 2006, National Health Insurance, CHCs, NHSC, Medicaid/Medicare policy)

Questions?

ehlarson@u.washington.edu