ABSTRACT
There is broad consensus among medical workforce analysts that the demand for physician assistants (PAs), physicians, nurses, allied health, and other medical providers has substantially increased since the late 1990s. While researchers tend to examine the deployment of various providers in private medical offices, they often overlook federally-employed PAs. Since the late 1980s, the Department of Veterans Affairs (VA) has been a major employer of PAs. The demand for services is projected to increase by 30% over the next decade as the VA undergoes expansion.
We examined the characteristics of PAs in the Veterans Health Administration (VHA), the medical arm of the VA. In 2010, 1,878 PAs were employed in 153 VA medical centers and many of the more than 900 community-based outpatient clinics. The majority work full time, and 49% are female. VHA PAs are distributed broadly across medical services (38%), surgery (47%), mental health (11%), and other services (4%). Thirty-one percent of PAs have prior military experience. The average years of VHA PA employment is 10.5, and the average age of a VHA PA is 49 years (range 23-74 years); one-third (34%) are within 5 years of retirement eligibility. Annual attrition for PAs is 9%, consistent with doctors, nurses, and pharmacists in the VHA. Projected demand for PA services in the VHA is expected to grow to 2,550 by 2018. Strategies are under way to improve the PA workforce in the VA.
Near the end of the last century, the Veterans Health Administration (VHA) in the Department of Veterans Affairs (VA) initiated a medical workforce re-engineering effort to improve its quality of care.1,2 The VHA is vertically integrated and comprehensive.3 Admired for its ability to deliver services in both urban and rural areas, it has also been a leader in advance medical record integration technology and safety.4 Additionally, the VHA is a major employer of physician assistants (PAs).
The VHA is notable for its commitment to primary care, and this specialty serves as the entry point for beneficiaries to access the health system. It is also a model of a managed health system that relies heavily on electronic record access to all aspects of care. Because of a commitment to improve all aspects of care to veterans, the VHA boosts its efforts to improve quality through performance measurement.5 However, an increasing transition of active duty military members to VA status and new policies on beneficiary enrollment over the past decade have created backlogs in access to medical care and processing claims.6 Furthermore, the VA takes care of a different population than the civilian sector; predominantly male, elderly, vulnerable, and burdened with significant chronic diseases. The profile of this beneficiary structure produces large differences in patterns of practice within the VA, and as a result, more care is inpatient-based and specialist-oriented with higher per capita expenditures than in private practices. These veterans, many with service-connected disabilities and without any other means of medical care, consume resources at different rates than a non-VA population. Nonetheless, the VA is challenged to make systematic improvements while at the same time implementing economy of scale measures of cost-effectiveness. Because the VA is vertically organized with most of the care produced under one roof, it serves as a model institution to study optimal delivery of health care services.
Since the late 1990s, the VHA has increasingly turned to PAs to improve access and maintain continuity of care. Employment criteria include graduation from an accredited PA program and a passing score on the PA National Certification Examination (VA policy). Each of the 153 VA medical centers or the more than 900 community-based outpatient centers employs providers according to its need. As a result, the utilization of PAs is irregular across the nation. Some locations have no PAs, and other regions make very high use of PAs.
Administration is hierarchical; each medical officer (MO) and PA reports to the service chief. The service chief reports to the medical director of the facility. A director of PA services reports to the chief patient care services officer. In turn, a VHA physician assistant field advisory committee advises the PA director on policy matters.
PAs employed in federal institutions often bypass state control of provider services. For example, state PA practice laws tend to have little bearing on whether a VA facility permits PAs to perform medical or surgical procedures. PAs practice under federal authority, and states do not have jurisdiction over federal health care facilities. If the facility approves a scope of practice that includes performing colonoscopy (or any other procedure), it can be granted by that facility under federal law.
The VA also supports PA education. For example, a VA Medical Center in Durham, North Carolina, has provided clinical education sites dating back to the first PA students at Duke University in the 1960s. The St. Louis University PA program was partially funded by the VA in 1971. In 1972, the VA standardized the role of PAs, defined the areas of the hospital in which PAs could be utilized, and specified the type and level of tasks assigned to them.
Implementing and using team delivered care has been a major goal of the VHA, and PAs are part of this effort. In one study of 32 VHA medical centers, 84% of operating room (OR) and 75% of intensive care units had implemented team concepts to improve care. As a result, efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event.7