Was the policy of physician assistant development in America's best interest? Professor Moore questioned whether PAs were needed, hypothesizing that they may be cost effective in the short run but would negate their cost effectiveness in the long run.1 A number of studies on the utilization of PAs  have proven otherwise. However, the literature comes up short on whether the social policy of introducing yet another health care provider into the mix has produced a “social good” in a way that expansion of the physician workforce would not have achieved. The belief that if PAs were inefficient they would not be employed is the maxim that no bad news is essentially good news. However, it fails to answer if PAs are a social good.

The Health Professions Assistance Act of 1963 was designed to stimulate the growth of the PA profession through funding of Title VII, Section 747 of the Public Health Service Act. Policy planners wanted to supply providers for underserved populations through the use of nurses, allied health professionals, and assistants to doctors.2 The plight of the poor and underserved was a force to be reckoned with,  and it was addressed in creative ways. The concept of the PA was not part of American medicine's infrastructure.3 However, at the time social engineers believed the right social strategy could lift America from its impoverished roots. Title VII served as one mechanism for transformation of medical care delivery in unforeseen ways.

This 1963 US public policy has stood in place for decades with little analysis; the question of whether PAs provide some benefit to the community that more doctors would not produce has persisted. Why have a social policy if it cannot be shown to produce a public benefit? Public/social goods are commodities that are valuable socially but cannot be financed reliably by the private sector. One trait of social goods is that excluding people from its benefits is difficult or impossible. A classic example of a social good is a lighthouse, which indirectly improves the commerce of people. Keeping water-borne trade off the shoals benefits industry and improves the public through employment and taxation whether you live on the coast or inland. The leverage of its cost cannot be precisely figured, but its value is recognized.

PA education developed with Title VII. Many initiatives have arisen from this activity, including expansion of programs to address the rural and underserved.4 The little money committed to PA programs via Title VII has been leveraged into a sizeable pipeline. But what of the social mandate “to increase the quality and access to health care provid ed to US citizens”?2 Are PAs a social good that improves the welfare of a nation as a whole, or do they just serve their employers? Do PAs provide care to the underserved in compliance with the intent of the Act?

On the west coast, PAs and NPs provide primary care to the underserved in higher ratios than doctors.5 In a national study on seniors, PAs and NPs were more likely than doctors to be the providers of elder care to those without private insurance.6,7 A 2007 analysis demonstrated that patients who paid medical expenses out of pocket—the poor and uninsured—were visiting PAs more than patients with insurance (who were more likely to see doctors for their care). Furthermore, patients in rural areas were found to be more likely to visit PAs than those living in urban areas.8 Without PAs, one can suggest that a segment of the nation as a whole would be out of care because of cost or access. In the aggregate, the studies demonstrate that PAs are providing care where doctors are not, and the benefits are immeasurable.

PAs appear to be a public good. These and other studies should bring the question of the public benefit of PAs to the fore. Social analysts can now categorically show that the creators of Title VII achieved their objective: to produce goods that benefit the public by extending the reach of doctors through the deployment of PAs. With validated data growing, policy makers can now take stock of their bold initiative and be assured they made the right decision. Why do governments support public health, fund research, provide snow removal, and build lighthouses? Because these activities offer beneficial externalities, or public goods, through tax-dollar use that otherwise might not be undertaken by private services. We can now add PAs to that list. JAAPA

Roderick S. Hooker PhD, PA, is Director of Rheumatology Research, Medical Services, Department of Veterans Affairs, Dallas, Texas.

REFERENCES

1. Moore GT. Will the power of the marketplace produce the workforce we need? Inquiry. 1994; 31(3):276-282.

2. Cawley JF. Physician assistant and Title VII support. Acad Med. 2008;83(11):1049-1056.

3. Hooker RS, Cawley JF, Asprey DP. Physician Assistants: Policy & Practice. 3rd ed. Philadelphia, PA: FA Davis; in press.

4. Strand J, Carter R. Primary care training grants through title VII, section 747: The Duke experience. Perspect Physician Assistant Education. 2003;14(1):25-30.

5. Grumbach K, Hart LG, Mertz E, et al. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med. 2003;1(2):97-104.

6. Hooker RS, Cipher DJ, Sekscenski E. Patient satisfaction with physician assistant, nurse practitioner, and physician care: a national survey of Medicare beneficiaries. J Clin Outcomes Manag. 2005;12(2):88-92.

7. Hooker RS, Cipher DJ. Physician assistant and nurse practitioner prescribing: 1997-2002. J Rural Health. 2005;21(4):355-360.

8. Staton FS, Bhosle MJ, Camacho FT, et al. How PAs improve access to care for the underserved. JAAPA. 2007;20(6):32-40.