Rural Physician Assistants: Clinical Roles and the Impact on Cost, Quality, and Access

Transcription

1 Rural Physician Assistants: Clinical Roles and the Impact on Cost, Quality, and Access Christine M. Everett, PhD, MPH, PA-C Assistant Professor Physician Assistant Program Dept. of Community and Family Medicine

2 Objectives What we know (and don t know) about Rural PA Roles Impact of Rural PA Roles Cost Quality Access

3 Rural PA Roles-How do we define them?

4 Defining Rural PA Roles Practice Specialty/Type Most common rural practices are primary care 1,2 Supervision/Physician Involvement Tasks Performed Patient Characteristics Substitution New Conceptualization

5 Defining Roles- Practice Setting-Hospitals 53% of rural hospitals utilize PAs 3 Rural hospital outpatient departments rely heavily on PAs and NPs 4

6 Defining Roles- Primary Care Community Health Centers & Rural Health Clinics 5,6 34% of rural primary care PAs report working in Rural Health Clinics 7

7 Defining Roles- Supervision/Physician Involvement Hours per week in same building with supervising physician 1 Rural : 24.6 Urban: states without mile limits of on-site requirements (December 2013)

8 Defining Roles- Tasks Performed Full range of tasks performed 8 PAs similar to physicians, except 6 : Well-child visits After-hours call coverage Hospital, ED, nursing home coverage Deliveries

9 Roles- Patient Characteristics Rural PAs see similar % Medicare, but greater % Medicaid patients than physicians 7 Age, gender, race/ethnicity of CHC patients seen by PA similar to those seen by physicians 5

10 Defining Roles- Substitution Substitute (Usual Provider) vs. Complement/Supplement Rural PAs report acting as principle provider for higher % of patients than urban PAs (72% vs. 54%) 2 Older adult patients with PA as usual provider more likely to live in rural areas 9 % of visits with usual provider higher for rural PAs 5

11 Patients Differ by Level of Substitution Factors predicting utilization of physician assistant (PA) and advance practice nurses (APN) in different roles (N = 6894) MD PCP + PA/Nurse visit PA or Nurse PCP RRR p-value CI RRR p-value CI Age, years 65 or older Ref ref (1.11,1.8) 2.3 <0.01 (1.56,3.31) (1,1.79) 2.4 <0.01 (1.56,3.66) <= <0.01 (1.59,3.92) Sex Male ref ref Female (1.07,1.51) (1.09,1.75) Educational attainment High school graduate ref ref Less than high school diploma Some college College degree Some postgraduate 1.5 <0.01 (1.16,2.04) County designation Large metropolitan ref ref Small metropolitan (1.02,1.99) Non-metropolitan (1,1.56) 1.7 <0.01 (1.24,2.2) Go to doctor as soon as feel bad Strongly agree ref ref Somewhat agree Somewhat disagree 0.7 <0.01 (0.53,0.88) Strongly disagree Do anything to avoid doctor visit Strongly agree ref ref Somewhat agree Somewhat disagree Strongly disagree 1.6 <0.01 (1.19,2.04) Put off needed medical care (1.05,1.59) (1.08,1.9) See same provider at usual place 0.3 <0.01 (0.19,0.34) Perceived health Excellent ref ref Very Good Good 1.8 <0.01 (1.36,2.36) (0.47,0.97) Fair/Poor 2.5 <0.01 (1.83,3.35)

12 Roles- New Conceptualization How work is divided between clinicians on a team (physician-pa dyad) 10,11,12 Level of Involvement Patients Served Tasks Performed Dependencies between team members Interdependence Autonomy

13 Impact of Rural PAs

14 Cost: Cost of Episodes of Care 13

15 Cost: Economic Benefit of PAs to Family Practice Compensation to production ratio of PA in Family Practice:

16 Cost: Economic Benefit of Rural Primary Care PA to Clinic, Hospital, Community 15 Scenario Collaborative: 40% Patient Volume (clinic + hospital) Collaborative: 50% Patient Volume (clinic + hospital) Collaborative: 75% Patient Volume (clinic + hospital) Independent: 75% Patient Volume (clinic only) Clinic/Hospital Employment Labor Income Clinic/Hospital + Community Employment Community + Labor Income 7.6 $469, $575, $553, $679, $764, $940, $253, $280,476

17 Access and Quality: Hospitalizations for Ambulatory Care-Sensitive Conditions 16 Rural counties have significantly higher rates of ACSH for pediatric and adult populations (not geriatric) Total primary care clinician supply reduces ACSH, but supply of non-physicians (PA/NP) does not

18 Access and Quality: Differences in Reported Access but not Self-Rated Health 9 Compared to those with physicians: Lower perceived access Increased chiropractor visits Decreased complete health exams Decreased mammograms Similar self-rated health Similar difficulties/delays in care

19 Access and Quality: Access to Primary Care, Satisfaction, Utilization Vary by PA/APN Role Variable Healthcare Utilization Physician PCP +PA or Nurse VisitPA or Nurse PCP RRR or RRR or p value CI p value OR OR Number of Visits at Usual Place of Care b <0.01 (0.52,0.83) (0.69,1.27) (1,1.63) 2.4 <0.01 (1.77,3.37) (0.86,1.58) 3.0 <0.01 (2.04,4.53) Emergency Department Visits c (0.78,1.36) (0.67,1.29) <0.01 (1.26,2.47) (0.66,1.87) Hospitalizations c (0.88,1.63) (0.38,1.13) Unmet Need Did not get needed medical care in past 12 months (0.89,1.98) (0.79,2.03) Patient Satisfaction Satisfaction with healthcare a Somewhat satisfied (0.99,1.53) (0.73,1.32) Neither satisfied or dissatisfied (0.88,3.25) (0.82,3.82) Somewhat dissatisfied (0.95,2.96) (0.57,1.66) Very dissatisfied (1.03,3) (0.98,3.04) Reference category is MD only; Baseline category for comparison is: a very satisfied; b 2-4 visits; c zero Bold type indicates significance at p<.05. Controlled to: age, sex, race/ethnicity, education, county designation, income, health insurance, going to doctor as soon as feel bad, do anything to avoid doctor visits, perceived health, utilization (except when dependent variable), usually see same provider, and put off care in past 12 months (and unmet need for satisfaction and utilization) CI

20 Summary PA roles can be defined in a variety of ways Usual provider is a more common role for rural PAs New way to conceptualize roles incorporate multiple factors Primary care PAs have beneficial economic impact on rural areas Limited evidence suggests primary care PAs improve access, but impact on quality is varied

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