Chapter 3 ('Physician Assistants')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. "Many aspects of PA's current clinical practice activities have not been addressed, and the number of PA's that would be needed to meet future health professions workforce requirements has not been calculated." (p22)
   
   
2. "Data on PA productivity and physician substitutionality in inpatient settings and accurate information describing PA activities and potential in Graduate Medical Education programs are generally lacking." (p22)
   
   
3. "No one has directly measured PA clinical productivity rates and PA's capacity to substitute for physicians in inpatient roles." (p23)
   
   
4. "More recent utilization patterns reveal a steady trend toward practice in non-primary care specialties and urban settings." 'The number of PA's working in primary care specialties has fallen over 15 years' (although the total number has gone up tremendously). "Only 32 percent are in family practice... The percentage of PA's employed in hospital settings increased from 14 to nearly 30 percent." (p24,25)
   
   
5. 'In 1981, 27% of PA's were in practice in communities of less than 10,000 population. In 1992, the percentage was 16 percent. PA utilization patterns over the last decade have closely mirrored those of physicians.' (p27)
   
   
6. "Hospitals that have employed PA's to augment physician and resident services in GME programs have compensated for the loss of medicare GME funding by incorporating... the reimbursable revenue generated by PA's in providing inpatient clinical services, which include laboratory tests and clinical procedures." (p31)
   
   First, this indicates cost shifting, not cost savings in using PA's (reimbursement shift from GME to clinical).
   Second, the hospital now reaps the revenues rather than the clinician, so has an interest in pushing this model.
   Third, why should the use of physician extenders indirectly increase the hospital revenues at all? This contradicts statements that NPP's "perform medical diagnostic and theraputic function at lower costs than physicians." (p21) There should be a need for less clinical reimbursement, not more.
   
   
7. "After more than 20 years of an open-door policy in U.S. medical education, immigration laws pertaining to International Medical Graduates entry tightened. Many large, urban teaching hospitals depended on IMG's to meet personnel requirements in GME programs and clinical inpatient settings." (p33) Thus the increased demand for non-physician practitioners is made more acute by the policies regarding training programs which utilized foreign medical graduates in this role.
   
   
8. "It may be unrealistic to expect that physicians will by themselves reverse trends of professional specialization." (p34) Note: it was the federal government policy which created the trend towards specialization in the first place. In addition, there is an assumption that currently specialists don't provide appropriate care. The effectiveness of generalists, or specialists, requires careful evaluation- all generalists, all specialists are not equivalent, and some may be effective, and some not.
   
   
9. "Restructuring the health care system to deliver the bulk of primary care through PA's and NP's and having physicians assume increased management and consulting duties would likely be more economical." (p34) See other comments elsewhere. This has not been demonstrated.
   
   
10. There is a "general lack of accurate information on non-physician activities in the health workforce." (p35)
    
    
11. In spite of the above comments, this chapter (by a PA) recommends to "increase PA supply by expanding PA educational program output." (p36)