Advanced Practitioners Key to Expanding Primary Care

The nation's growing need for primary care providers is well documented. The numbers are staggering, and they are ratcheting up.

A study published in the November/December 2012 issue of the Annals of Family Medicine, projects that by 2025, the United States will need an additional 52,000 primary care physicians.

This figure surpasses research published by the American Association of Medical Colleges, which predicted a 46,000 primary care physician shortage by 2025. And it trumps the research published in 2008 in Health Affairs, which determined that the country would be short 44,000 primary care physicians by 2025.

Massachusetts provides a current case study of the issues around insurance expansion and primary care utilization and access. Even with the second highest state ratio of primary care physicians to population, primary care wait times increased in 2006 after the state passed its health insurance mandate.

"Reports that there were increased wait times were particularly with populations where more people were on public insurance, and particularly in places where there was a shortage of physicians, especially in rural and lower income areas," says Winston Liaw, MD, MPH, an  assistant professor at the Fairfax Family Medicine Residence Program at Virginia Commonwealth University.

"If there was a place where this would work well, where you would have a good chance of accessing a doctor, it would be in Massachusetts compared to other states. They also have a very robust network of community health centers."

A much-debated solution of to the lack of primary care physicians is advanced practitioners. "We obviously think they are a very important part of the primary care workforce and that would be a very helpful to look at how many additional advanced practitioners we would need to fill the primary care shortage," says Liaw.

According to the American Academy of Physician Assistants 2010 census, the population of PAs is twice its size from three years ago, at 83,466, with 31% specializing in primary care. The population of APRNs in 2010 practicing was 125,000, with at least 66 percent practicing in primary care, according to the American Academy of Nurse Practitioners.

These two specialties are also growing at a faster rate than primary care physicians. The number of PAs and APRNs per primary care physician doubled between 1995 and 2009, according to a 2010 report published by the Robert Wood Johnson Foundation.

"If you were to ask what is the physician assistant suited for most immediately upon graduation, the answer is primary care," says James D. Cannon, DHA, MBA, PA-C, Director-at-Large at the National Commission on Certification of Physician Assistants.

"Because all of our clinical rotations are primary care and our exam is primary care. So we are the most autonomous upon graduation in primary care. It's the specialties where we require an added level of being precepted and proctored."

"It's really a seller's market for physician assistants right now," says Dr. Brad Smith, Medical Director at Knox Community Hospital Urgent Care Center, who used to work in a family medicine practice and is hiring PAs at his urgent care center.

He sees the growth of the urgent care business as a reaction to the primary care shortage and access issues. He sees urgent care as a helpful transition for primary care, because at his center they actively try to coordinate with their patients' primary care physician to follow up on patients and collaborate around the patient's care.

But even at the urgent care center, to help cover patient volumes they staff advanced practitioners to fill the gaps between their full time physicians' shifts. They are open to hiring recent graduates and PAs with many different backgrounds of experience.

"There's a shortage of PAs out there, and they are hard to find. So sometimes you have to deal with the hand you're given, and we're very open to and excited to train a new physician assistant, because they are likely to stick around if you establish that foundation for them."

Smith says any of the physician assistants he's worked with would stack up easily with their knowledge when compared with a physician. "A middle-tier trained physician who has trained for ten years would probably have the equivalent knowledge base of a top-tier trained physician who has recently graduated," says Smith. "I think you could apply that to comparing physician assistants and physicians as well."