Have a shortage of doctors in your community? New research suggests physician assistants and nurses may be just as able to fill the gap.
Organizations calculating primary care shortages, including the Association of American Medical Colleges, suggest that it takes two to four physician assistants or nurses to match the productivity of one family doctor.
But a new study from the Rutgers University School of Health Professions in New Jersey reports that workforce projections for primary care underestimate the coverage that physician assistants and nurses can provide and overstate the overall shortfall in primary care.
Ryan White, the study’s lead author, reports that productivity is actually higher for allied health professionals, like physician assistants. To confirm their theory, White and his colleagues looked at the number of clinic visits at federally qualified health centers using information from the Uniform Data System.
The study was published in the October issue of the Journal of the Association of American Physician Assistants.
In it, researchers say they found the combined clinical productivity of full-time physician assistants and nurses was similar to that of all doctors.
So, the researchers say, it would be a mistake to imagine a future with significant primary care doctor shortages, while there are surpluses in physician assistants and nurses, and suggest communities will be underserved.
An inaccurate forecast of shortages in primary care could lead to misguided priorities, says White.
“If the shortage is less severe than we think it might be, our policies and programs may be better focused on the geographic distribution of providers instead of the sheer number of providers,” he says.
More accurate projections, he says, might steer funding toward incentives that encourage clinicians to work in rural areas rather than increase the workforce.
But the study looked at productivity and not quality of care or outcomes. Doctors’ groups have said that more doctors are needed to improve care, and allied health professionals, who have less training, should not be used to ease shortages.
“That’s certainly a response that we’ve heard,” says White. “We’ve also heard that the complexity of patients might be different between patients treated by physicians and those treated by physician assistants and nurses. But we don’t see that borne out in the literature. There are a number of studies that show that care provided in team-based environment is superior and outcomes are better when patients receive care from teams that include physicians, physician assistants, and nurse practitioners.”
COVID Upset Workforce Demand
The COVID-19 pandemic already upended workforce demand for doctors, physician assistants, and nurses, according to an annual review of doctor and advanced practitioner recruiting trends done by Merritt Hawkins.
This is first time in the review’s 28-year history that nurses have topped the list of the most recruited practitioners.
Although the pandemic fueled a growing demand for nurses, the demand for primary care doctors has dropped.
Still, by 2034, the shortfall of primary care doctors is expected to range from 17,800 to 48,000, according to the Association of American Medical Colleges’ 15-year outlook. That projection persists under most likely scenarios, which include “a moderate increase in the use of advanced practice nurses and physician assistants, greater use of alternate settings such as retail clinics, and changes in payment and delivery such as using accountable care organizations.”
The use of productivity numbers alone to calculate workforce projections pits professionals against each other, said Bianca Frogner, PhD, director of the Center for Health Workforce Studies at the University of Washington.
Patient visits are a valid measure of productivity, she says, but what needs to be considered is the type of patient best served by physician assistants and nurses and the type best served by primary care doctors.
Workforce projections are difficult because patient demand is even harder to predict than clinician supply, she says.
Increases in the supply of allied health providers are on track to change the current ratio of doctors to allied care from 2:1 to 1:1 by 2034, the Association of American Medical Colleges workforce update states.
And projections for the demand and supply of primary care doctors in 2030 were recently updated by the Health Resources and Services Administration.
These models are incredibly complex and sometimes imprecise, says Frogner. Policy changes should not be based on sheer numbers, and demand and supply should be continually reassessed, she says.
The pandemic presents an opportunity to re-evaluate what each type of clinician can do most effectively and what settings and locations need which kind of clinicians.
Upheaval will continue, she says, as the health care system adjusts to the needs of patients with long-haul COVID-19.
“We also need to better understand the term ‘surplus,’ ” she says. That can send the incorrect message that there are too many allied health professionals. And, “You’re scaring the future generation of people who may consider the job.”
The immediate task is to identify the areas where primary care shortages are most acute and where there are surpluses of clinicians. And there should be a way to encourage surplus physician assistants and nurses to move to areas of need, she says.
Ryan White, physician assistant, Rutgers University School of Health Professions, Piscataway, NJ.
Journal of the American Academy of Physician Assistants: “Physician substitution is undergoing evolution and change.”
Merritt-Hawkins: “2021 Review of Physician and Advanced Practitioner Recruiting Incentives.”
American Association of Medical Colleges: “Physician Supply and Demand — A 15-Year Outlook: Key Findings,” “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034.”
Bianca Frogner, PhD, director, Center for Health Workforce Studies, University of Washington, Seattle.
Health Resources and Services Administration: “Primary Care Workforce Projections.”
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