From the AAPA - December 2008

By Ashley Kent, publications manager

A recent study by Duke University Medical Center suggested that PAs provide an efficient way to fill the provider gap created by the physician shortage. The study, entitled “Impact of Physician Assistant Care on Office Visit Resource Use in the United States,” was published in the October 2008 issue of the journal Health Services Research, which had the theme “Efficiency and Value in Healthcare.”

The study's lead author, Perri Morgan, who is the director of PA research for the PA Division of Duke's Department of Community and Family Medicine, said, “Particularly among skeptics of the profession, there's been the concern that adding another type of provider into the mix might actually increase health services use. If that is true, and using PAs leads to extra patient visits, PA use could lead to higher health care costs even though they are less expensive to hire than physicians.”

“This [study] was designed to examine this question of whether use of PAs leads to increased use of health services. We used a nationwide sample of office-based visits to compare a group of patients who received care only from physicians with a group for whom a PA was the visit provider for at least 30% of visits. We asked whether inclusion of a PA in the provider mix for a patient was associated with an increase in number of visits used in 1 year.”

One of the questions Morgan investigated was whether PAs were serving as alternative providers to physicians or as additional providers. “Overall, [the study found that] PA care in the US seems to serve, on average, more as a substitute for physician care than as a supplement to physician care.”

“If PAs supplemented physician care, they might be providing services that the physician would not have normally provided, and we would expect to see more visits per year,” Morgan explained. “On the other hand, if PAs substitute for physician visits, we would expect that there would be about the same number of visits per year. And that's what we found.”

In addition, the study found that the number of office visits dropped when PAs provided a substantive amount of care. The patients who saw PAs for at least 30% of their visits within a year had about 16% percent fewer visits than the patients who only saw physicians, Morgan said. “Therefore we saw no increase in use when PAs were included in care.” Morgan noted, however, that the study did not go so far as to claim that PAs necessarily cut down on patient office visits. “My conclusion was that no more visits were required,” she said.

Morgan explained that the 16% drop may be a result of the fact that researchers were not able to completely control for how sick people were. “As we expected, the people who saw only physicians were a bit older and not quite as healthy as those who also saw PAs, so they would be expected to need more visits. We controlled statistically for many of these factors such as age, diagnosis, and socioeconomic status, but we may not have been able to completely correct for a difference in medical complexity between the two groups we compared.”

Although previous studies have focused on the efficiency of PAs in the United States, those were conducted using patients from small geographic areas or patients with minor diagnoses. “This is the first nationwide study that takes a sample of all types of people— meaning those who are very sick and those who are not very sick, no matter what their diagnosis is … so it's more representative of a national population than previous studies,” Morgan said. Researchers used national data collected by the Agency for Healthcare Research and Quality to monitor health care use.

Morgan said the study's findings are significant given the current doctor shortage and economic situation. “Other studies have shown that labor costs can be reduced by using PAs and that quality of care is maintained when PAs are added to the mix. Our study suggests that use of PAs does not increase the number of office visits required. If you take all those things together, it suggests that PAs may be a cost effective way to address the physician shortage,” Morgan said.

According to 2005 data from the National Center for Health Statistics, which was referenced in the study, there is 1 PA for every 10 physicians in clinical practice. Further, that number is expected to increase with the current trend of PAs entering the work force at a rate of 1 PA for every 6 physicians. “With spiraling health costs and the increased demand that we're going to have for health care due to the aging of the population, we'll be looking for ways to provide high quality health care at low cost. And PAs are an important piece of that solution,” Morgan said.

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