Let physician associates work.
America needs more providers and we shouldn't tether them to physicians
Source: American Academy of Physician Associates
Much ink has been spilled on the market imbalance facing the US healthcare market. Demand is growing. The Baby Boomer generation is at or very close to retirement age. People are also living longer and this is a wonderful development— medical breakthroughs have improved longevity. Medicaid expansions have also boosted demand.
In many markets if demand is steadily increasing, supply has the flexibility to rapidly adjust. This doesn’t happen in the market for healthcare. Outdated regulatory restrictions that don’t account for improvements in education and technology restrain progress and keep Americans from accessing the care that they need.
Physician associates are highly trained medical providers with master’s degrees. You may have previously known these providers as physician assistants. Given their evolving role and regulatory changes that I will discuss shortly, a name change seems appropriate. For those that know these turf battles well, it should come as no surprise that physician professional associations have loudly objected to something as simple and innocuous as a name change.
This isn’t the first time that the market needed to be adjusted given growth in demand. Physician assistants didn’t even exist prior to 1967 and were first recognized as a provider by the American Medical Association in 1971. Demand was surging for healthcare after the introduction of Medicare and Medicaid in 1965 and it was clear that more providers were needed.
For most of the 1970s, physician associates did not have the authority to prescribe controlled substances to treat patients. This began to change in 1977 when Arizona became the first state to grant physician associates prescription privileges. Today all states provide physician associates the ability to prescribe controlled substances although the extent of these privileges varies from state to state.
The first academic journal article that I wrote on scope of practice back in 2017 estimated the effects of granting physician associates prescriptive authority on the cost of care provided to Medicaid patients. I estimated that this change reduced the cost of care received by Medicaid patients by as much as 16%. Much of this change can likely be attributed to lower Medicaid reimbursement rates for care provided by physician associates. Medicare also reimburses physician associates at 85% of the physician rate.
Ben McMichael at the University of Alabama has done some amazing work estimating additional benefits of physician associates receiving permission to work to the full extent of their training. His recently published piece in the Journal of Public Economics finds that broadening the scope of practice of physician associates reduces healthcare amenable deaths by 10 per 100,000 individuals. Another recent publication by McMichael finds little evidence that physician associates provide more specialty services after being granted broader practice authority— alleviating concern that they will work beyond their training after reform takes place.
In short, history tells us that physician associates have been capable of stepping up and doing more as the healthcare market has adapted and changed. And sound academic research has established that there are measurable cost savings and benefits to patients with no evidence of additional risks.
The figure at the top of the article shows the most up-to-date classification of states based on the practice authority of physician associates. In 2019, North Dakota became the first state in the country to provide a pathway for independent physician associate practice—paving the way for physician associates to own and operate their own healthcare facilities. Since that time five other states including Iowa, New Hampshire, Montana, Utah, and Wyoming have granted similar authority to physician associates.
Given the realities of the healthcare market, and the strong track record physician associates have shown to adapt to an ever-changing market, this seems like the next logical step. Indeed, nurse practitioners have already obtained more autonomy in the majority of states today.
We already have some great research on the impact of these more recent changes to physician associate autonomy. A recent publication by PhD student Tulasiram Nepal and Shishir Shakya finds that states that grant physician associates a pathway to independent practice attract more physician associates and are also able to better retain the professionals. In short, physician associates seem to prefer having a pathway to work more independently and states looking to recruit more professionals would be well-served to offer a pathway to independent practice.
Physician associates have adapted as the healthcare market has changed and they have helped to alleviate persistent imbalances in the market. Several states are considering further reform. Common sense reforms that create more flexibility on the supply side of the health provider market are cost friendly and can help fill in gaps in access to much-needed care.