R e s e a rc h A r t i c l e

Utilization of Physician Assistants: Incentives and Constraints for Rural Physicians Fred R. Isberner, PhD; Leslie Lloyd, PhD; Bret Simon, MS; Joyce M. Craven, PhD Introduction: The physician assistant (PA) profession is projected to be one of the fastest growing in the nation through 2010, yet physician receptivity in terms of role, responsibilities, and competencies remains a concern of PA educators. Method: This study surveyed primarily rural Illinois physicians to identify incentives and constraints that influence their receptivity to utilization of PAs. Results: Receptive physicians reported 6 incentives related to appointments, workload, productivity, education/counseling, complex cases, and patient satisfaction. Unreceptive physicians identified 4 constraints related to perceived patient opposition, malpractice risk, overstepping authority, and continuity of care. Receptive physicians also identified perceived patient opposition as a constraint. Conclusions: PA educators need to inform PA students about incentives and constraints influencing physician and patient receptivity, especially in rural and underserved communities. (Perspective on Physician Assistant Education 2003;14(2):69-73)

Introduction The Federal Bureau of Labor Statistics predicts that the PA profession will be one of the fastest growing in the nation through 2010 and predicts that the number of PAs will increase by 53% between 2000 and 2010.1,2 Yet physician receptivity to the utilization of PAs remains a concern as questions about the role, responsibilities, and competencies of PAs continue to be raised. While some physicians utilize PAs to the full extent of Fred Isberner is a professor in the Heath Care Professions-Health Care Management Program, Southern Illinois University Carbondale, Carbondale, Illinois. Leslie Lloyd is an assistant professor in the Health Care Professions-Physician Assistant Program, Southern Illinois University Carbondale. Bret Simon is a lecturer for Southern Illinois University Carbondale. Joyce M. Craven is an assistant professor for the Health Care Professions-Health Care Management Program, Southern Illinois University Carbondale. Correspondence should be addressed to: Fred Isberner, PhD College of Applied Sciences and Arts Southern Illinois University Carbondale, Illinois 62901-6604 Voice: 618-453-7285 E-Mail: [email protected]

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their capabilities, others are reluctant to use them.3 This issue is of particular importance to PA programs that are preparing PAs to practice in rural and medically underserved areas, since it is in these areas that PAs may present the greatest potential for improving access to health care. Early PA education programs did, in fact, focus on training PAs to assist in primary care and practice in medically underserved areas. For a variety of reasons, however, those original objectives were not achieved entirely. Current PA practice statistics reveal a much different picture of employment conditions than what was originally anticipated. In fact, only about half of practicing PAs are employed in primary care (family medicine, internal medicine, pediatrics, obstetrics and gynecology).4 Similarly, only about one-fourth of PAs are employed in areas with a population of less than 50,000. PAs have surely improved access to health care in some rural and medically underserved areas, and some PA education programs do emphasize the need for rural service in their admissions and training, yet large

areas of the United States continue to be designated as medically underserved.5 If the PA profession is to provide an answer to the problem of equal access to health care, then the factors that contribute to placement and hiring decisions need to be investigated. A review of the PA literature reveals a number of potential incentives and constraints to hiring a PA. Some of the more frequently cited incentives include decreasing the physician’s workload, increasing the productivity of a physician’s practice, improving the nature and quality of patient care, decreasing patient wait time, and placing more emphasis on patient education.6-14 Also frequently mentioned were the opportunities to expand a practice’s services and improving cost effectiveness.6,8,9,11,15,16 Finally, increasing access to primary care services, especially in rural and underserved areas, has been cited as an incentive.11-13,16-18 The literature also identifies a number of potential constraints to hiring a PA. Often cited as barriers were the perceived lack of patient acceptance, concerns about PAs’ knowledge of the limits and scope of their practice, and competition

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between PAs and other health care providers.8,10,15 Financial issues also were often cited, including reimbursement for PA services and coding and billing confusion.17,19 Of note are the frequently cited concerns related to supervision and liability.7,9,15,20,21 For example, physicians reported lack of guidelines on how to supervise a PA.21 While they were concerned about legal liability for a PA, as implied in the doctrine of respondeat superior, many physicians nonetheless identified as constraints 2 factors that could actually decrease liability exposure—state laws requiring close supervision of PAs and those limiting a PA’s prescriptive privileges.22 This study surveyed family physicians from the predominantly rural, southern three-fourths of Illinois to identify current incentives and constraints to the utilization of PAs and to assess overall receptivity to hiring a PA. Findings may be useful to physicians, educators, and policy makers interested in improving PA utilization in rural and underserved areas.

Methods Based on a review of the literature, a survey instrument was developed to assess physicians’ attitudes, experiences, and practices regarding the utilization of PAs. Specifically, questions were written to solicit information about perceived incentives and constraints influencing the use of PAs as well as how physicians may use PAs in their medical practice. Routine demographic data also were collected, including personal and practice characteristics. An expert panel of PAs reviewed the survey; it was then pilot tested with a panel of physicians. The methods and revised survey were reviewed and approved by the Southern Illinois University Carbondale Human Subjects Committee. Our focus is on increasing the number of PAs practicing in rural and underserved areas. We therefore limited our sample selection to those providers practicing in roughly the southern threefourths of Illinois. This decision did not eliminate all urban areas, as several metropolitan statistical areas were still included in the survey area, but it did

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exclude Chicago and the largely metropolitan area surrounding it. We contacted the Illinois Academy of Family Physicians (IAFP), who provided a list of current (year 2000) members. From this list, all members that listed a practice address within the target area were identified, resulting in a total of 647 physicians. In May 2000, surveys and prepaid return envelopes were sent by first-class mail to all 647 physicians. The survey was confidential—physicians did not indicate their name or practice location—but a numerical code did allow for 2 follow-up mailings. If no response was received within 4 weeks, a second survey was mailed. After another 4 weeks, a final survey was mailed to those physicians who had still not responded. Six weeks were allowed to pass after this final mailing (14 weeks after the initial mailing) before data were analyzed. Of the 647 mailed, a total of 226 completed surveys were returned, for a 35% response rate. The principal objective of this study was to identify incentives and constraints that influence physician receptivity to the utilization of PAs. However, the overall response of physicians to PA utilization was generally positive, and this created a problem. It was likely that the much larger number of favorable responses would mask any real but less frequently reported constraints. We therefore limited our data analysis to those respondents who were most and least receptive to the utilization of a PA. By limiting our analysis to those physicians with the strongest opinions—both positive and negative—we were able to identify incentives and constraints that have the greatest potential to influence PA utilization. We asked physicians to respond to the 5-point Likert-style question “Overall, what is your opinion on having a physician assistant in your practice?” Responses ranged from “not at all receptive” to “very receptive.” Responses to this question were ranked, and the top and bottom quartiles were selected for further statistical analysis. Data for this question were negatively skewed, and as more than one-quarter of the subjects

indicated “very receptive,” observations from this topmost group were randomly selected to obtain the number of subjects necessary to represent one quartile (n=56). Differences between the receptive and unreceptive groups were assessed using chi-square analyses.

Results A similar number of physicians from both groups reported working in communities of less than 10,000, between 10,000 and 50,000, or more than 50,000 (see Table 1). Physician receptivity to the utilization of a PA, therefore, was not predicted by community size. Practice setting, however, was related to receptivity. Physicians in solo practice were less receptive to PA utilization than those practicing in a group setting (HMO, managed care, hospital, rural and community health centers). Health Provider Shortage Area (HPSA) or Medically Underserved Area (MUA) designation did not predict receptivity; similar numbers from both high and low receptivity groups reported practicing in such settings. There was little difference in mean year of medical school graduation for the high and low receptivity groups (1979 and 1978); however, the range was slightly greater in the PA supportive group. When physicians were asked whether they currently employed a PA, a much higher proportion of the high receptivity group indicated they did. We also asked physicians whether they had experience with PAs “during training, previous practice, current practice, as a preceptor, or never.” As can be seen in Table 1, there was a relationship between experience and receptivity. Physicians that reported no experience with PAs were far less likely to be receptive to their use. A full third of the physicians in the low receptivity group reported that they had no experience with PAs. This means that twothirds of the unreceptive physicians did indeed have experience with a PA in some form, either currently or in the past. We did not, however, ask whether these physicians worked with PAs in a direct supervisory role or in some other

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Table 1 Demographic Characteristics of Physicians by Physican Assistant Receptivity Quartile (n=116)

Community Size Less than 10K 10–50K More than 50K Practice Setting Solo Group† HPSA/MUA designation Practice Currently Employs a PA Experience Working with a PA§ None During training Previous practice Current practice As a preceptor PA Policy Recommendations Increase autonomy Leave regulations as they are Impose further restrictions

Low Receptivity % n

High Receptivity % n

39.3 39.3 21.4

22 22 12

35.1 20 33.3 19 31.6 18

.10 .22 1.20

41.3 58.7 35.6 8.6

19 27 16 5

17.8 8 82.2 37 31.9 15 70.7 41

4.48* 1.56 .03 28.17**

34.5 24.1 19.0 25.9 8.6

20 14 11 15 5

1.7 17.2 24.1 75.9 46.6

1 10 14 44 27

17.19** .67 .36 14.25** 15.12**

5.3 45.6 49.1

3 26 28

18.5 10 79.6 43 1.9 1

3.77 4.19* 25.14**

χ2

†

Includes HMO, managed care, hospital, or community health center Check all that apply * p