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Physician substitution is undergoing evolution and change

Physician substitution is undergoing evolution and change COMMENTARY Physician substitution is undergoing evolution and change Roderick S. Hooker, PhD, MBA, PA hysician substitution refers to a construct observed She and her team captured the daily activity of both clini- for more than 2 centuries and described in various cians in terms of clinical output, productivity, daily activ- Pways. To the medical historian, the Russian feldsher, ity seeing and not seeing patients, diagnoses, procedures, which emerged in the 1800s, remains one example of a referrals, hallway consults, charting, and in essence, all physician substitute. The offi cier de santé is a 19th-century workday activity in patient care. They found the substitu- example of a physician assistant/associate (PA) prototype tion ratio was 84% but increased to 90% in team or that improved medical services throughout rural France. partnership relationships. The salary difference in 1976 To the economist, physician substitution is the use of was 45% of a physician. less formally educated labor (such as a PA or NP) for a The observation of physician substitution has been a procedure or activity usually reserved for a higher-paid topic of growing interest since Record’s seminal cost- physician. The supply of labor and the means to produce effectiveness study of PAs. More recently, Morgan and a fi nancial result are the goals that most industries strive colleagues showed that PAs and NPs have taken on more for, and clinical medicine is an industry no different. signifi cant roles in managing complex patients with chronic In this issue of JAAPA, White and colleagues have pro- diseases in one of the most productive and effective systems duced a sharpened observation of US medical care delivery of US medicine—the Veterans Health Administration. In undergoing clinician transformation and growing physician the VA system, patient outcomes in adult medical care by substitution (“Primary care workforce paradox: A physi- PAs and NPs are identical to those of physicians, the cian shortage and a PA and NP surplus,” Ryan White, MS, resources used for care are identical, and the labor cost is MPH, PA-C; David Keahey, PA-C, MSPH; Morgan Luck, half that of a physician in the same setting. White and MS, PA-C; Richard W. Dehn, MPA, PA-C, DFAAPA). Their colleagues add another essential piece to the physician analysis reports an important trend in staffi ng community substitution picture by noting the growing presence of PAs health centers (CHCs). Using a unique nationalized data- and NPs across a broad band of primary care settings. The base of federal CHCs (2016-2019), the study shows that image of primary care shortages may have shrunk just a a growing supply of PAs and NPs are staffi ng primary care bit more. JAAPA centers. Their clinician-to-patient ratios rival that of fam- ily physicians as nearly equivalent (99% for PAs, 89% for REFERENCES NPs). The more important observation is that the data 1. Ramer SC. The Russian feldsher: a PA prototype in transition. JAAPA. 2018;31(11):1-6. capture is indifferent to the type of clinician. PAs and NPs 2. Perdicoyianni-Paleologou H. The offi cier de santé in 19th-cen- are the providers of care at an increasing rate, and their tury France: a PA prototype. JAAPA. 2017;30(9):1-3. productivity is not being discounted by any organization 3. Association of American Medical Colleges. The complexities except the American Association of Medical Colleges of physician supply and demand: projections from 2018-2033. (AAMC). At present, the AAMC forecasting model of www.aamc.org/system/fi les/2020-06/stratcomm-aamc-physician- workforce-projections-june-2020.pdf. Accessed August 18, 2021. looming medical supply and demand sets aside the high 4. Morgan P. Predicted shortages of physicians might even replacement role occurring with PAs and NPs and instead disappear if we fully account for PAs and NPs. JAAPA. offers that future physician shortages are growing. 2019;32(10):51-53. Physician substitution research has been an activity since 5. US Department of Health, Education, and Welfare; Public Health 1974, when Jane Cassels Record observed the clinical Service; Health Resources Administration; Bureau of Health Manpower. Cost effectiveness of physician’s assistants. Final activity and the replacement cost of physicians with PAs. report. HMEIA Contract No. 1-MGB-44173(P). July 1975. 6. Record JC, McCally M, Schweitzer SO, et al. New health profes- sions after a decade and a half: delegation, productivity and costs Roderick S. Hooker is a health policy analyst. The author has in primary care. J Health Polit Policy Law. 1980;5(3):470-497. disclosed no potential confl icts of interest, fi nancial or otherwise. 7. Morgan PA, Smith VA, Berkowitz TS, et al. Impact of physi- cians, nurse practitioners, and physician assistants on utiliza- DOI:10.1097/01.JAA.0000791504.22100.29 tion and costs for complex patients. Health Aff (Millwood). Copyright © 2021 American Academy of PAs 2019;38(6):1028-1036. JAAPA Journal of the American Academy of PAs www.JAAPA.com 11 Copyright © 2021 American Academy of Physician Assistants http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American Academy of Physician Assistants Wolters Kluwer Health

Physician substitution is undergoing evolution and change

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Wolters Kluwer Health
Copyright
Copyright © 2021 American Academy of Physician Assistants
ISSN
1547-1896
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0893-7400
DOI
10.1097/01.jaa.0000791504.22100.29
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Abstract

COMMENTARY Physician substitution is undergoing evolution and change Roderick S. Hooker, PhD, MBA, PA hysician substitution refers to a construct observed She and her team captured the daily activity of both clini- for more than 2 centuries and described in various cians in terms of clinical output, productivity, daily activ- Pways. To the medical historian, the Russian feldsher, ity seeing and not seeing patients, diagnoses, procedures, which emerged in the 1800s, remains one example of a referrals, hallway consults, charting, and in essence, all physician substitute. The offi cier de santé is a 19th-century workday activity in patient care. They found the substitu- example of a physician assistant/associate (PA) prototype tion ratio was 84% but increased to 90% in team or that improved medical services throughout rural France. partnership relationships. The salary difference in 1976 To the economist, physician substitution is the use of was 45% of a physician. less formally educated labor (such as a PA or NP) for a The observation of physician substitution has been a procedure or activity usually reserved for a higher-paid topic of growing interest since Record’s seminal cost- physician. The supply of labor and the means to produce effectiveness study of PAs. More recently, Morgan and a fi nancial result are the goals that most industries strive colleagues showed that PAs and NPs have taken on more for, and clinical medicine is an industry no different. signifi cant roles in managing complex patients with chronic In this issue of JAAPA, White and colleagues have pro- diseases in one of the most productive and effective systems duced a sharpened observation of US medical care delivery of US medicine—the Veterans Health Administration. In undergoing clinician transformation and growing physician the VA system, patient outcomes in adult medical care by substitution (“Primary care workforce paradox: A physi- PAs and NPs are identical to those of physicians, the cian shortage and a PA and NP surplus,” Ryan White, MS, resources used for care are identical, and the labor cost is MPH, PA-C; David Keahey, PA-C, MSPH; Morgan Luck, half that of a physician in the same setting. White and MS, PA-C; Richard W. Dehn, MPA, PA-C, DFAAPA). Their colleagues add another essential piece to the physician analysis reports an important trend in staffi ng community substitution picture by noting the growing presence of PAs health centers (CHCs). Using a unique nationalized data- and NPs across a broad band of primary care settings. The base of federal CHCs (2016-2019), the study shows that image of primary care shortages may have shrunk just a a growing supply of PAs and NPs are staffi ng primary care bit more. JAAPA centers. Their clinician-to-patient ratios rival that of fam- ily physicians as nearly equivalent (99% for PAs, 89% for REFERENCES NPs). The more important observation is that the data 1. Ramer SC. The Russian feldsher: a PA prototype in transition. JAAPA. 2018;31(11):1-6. capture is indifferent to the type of clinician. PAs and NPs 2. Perdicoyianni-Paleologou H. The offi cier de santé in 19th-cen- are the providers of care at an increasing rate, and their tury France: a PA prototype. JAAPA. 2017;30(9):1-3. productivity is not being discounted by any organization 3. Association of American Medical Colleges. The complexities except the American Association of Medical Colleges of physician supply and demand: projections from 2018-2033. (AAMC). At present, the AAMC forecasting model of www.aamc.org/system/fi les/2020-06/stratcomm-aamc-physician- workforce-projections-june-2020.pdf. Accessed August 18, 2021. looming medical supply and demand sets aside the high 4. Morgan P. Predicted shortages of physicians might even replacement role occurring with PAs and NPs and instead disappear if we fully account for PAs and NPs. JAAPA. offers that future physician shortages are growing. 2019;32(10):51-53. Physician substitution research has been an activity since 5. US Department of Health, Education, and Welfare; Public Health 1974, when Jane Cassels Record observed the clinical Service; Health Resources Administration; Bureau of Health Manpower. Cost effectiveness of physician’s assistants. Final activity and the replacement cost of physicians with PAs. report. HMEIA Contract No. 1-MGB-44173(P). July 1975. 6. Record JC, McCally M, Schweitzer SO, et al. New health profes- sions after a decade and a half: delegation, productivity and costs Roderick S. Hooker is a health policy analyst. The author has in primary care. J Health Polit Policy Law. 1980;5(3):470-497. disclosed no potential confl icts of interest, fi nancial or otherwise. 7. Morgan PA, Smith VA, Berkowitz TS, et al. Impact of physi- cians, nurse practitioners, and physician assistants on utiliza- DOI:10.1097/01.JAA.0000791504.22100.29 tion and costs for complex patients. Health Aff (Millwood). Copyright © 2021 American Academy of PAs 2019;38(6):1028-1036. JAAPA Journal of the American Academy of PAs www.JAAPA.com 11 Copyright © 2021 American Academy of Physician Assistants

Journal

Journal of the American Academy of Physician AssistantsWolters Kluwer Health

Published: Oct 1, 2021

References