Filling the Health Care Gap for Older Adults: An Opportunity for Physician Assistants

Eugene A. Stead Jr, MD—considered the father of the PA profession—led the way for the PA profession to become a viable contributor to care for persons of all ages. Stead recognized the skillset of military medics who had returned home from the Vietnam War with many medical skills but no comparable occupation in which to work after the completion of their military service. Four former Navy corpsman matriculated at the Duke University PA Program in 1965. Since then, the number of PAs has grown to approximately 140,000 certified PAs³ and 260 PA education programs.⁴ International opportunities for PAs are also increasing.⁵

PAs now practice in all 50 states, the District of Columbia, and Guam and are credentialed in the Air Force, Navy, Army, Public Health Service, and the Department of Veteran Affairs. To gain certification, PAs are required to graduate from an institution that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and to successfully complete the Physician Assistant National Certification Examination.⁶ To maintain certification, PAs complete 100 hours of continuing medical education (CME) every 2 years and take the Physician Assistant National Recertifying Examination every 10 years. PAs have prescriptive privilege in all 50 states and the District of Columbia and are authorized in 50 states and the District of Columbia to prescribe controlled medications.⁷

The American Academy of Physician Assistants (AAPA) defines the physician-PA relationship as one that allows PAs to practice with defined levels of autonomy and “exercise independent medical decision making within their scope of practice.”⁸ Licensing of PAs occurs at the state level. The scope of practice of PAs is defined by state law and by the experience and expertise of each PA as delegated by their supervising physician. A desirable characteristic of the PA profession is that of flexibility and the ability to adapt to the needs of a given medical practice.

PA duties typically include the following: eliciting a medical history; performing a physical examination; selecting and interpreting appropriate diagnostic tests; and synthesizing pertinent data to guide patient-care decisions. These decisions may result in therapeutic interventions that are initiated prior to physician review of the specific intervention.

A major consideration for physicians working with PAs relates to their potential malpractice liability. Compared with physicians practicing in similar roles, liability as measured by medical insurance premiums and malpractice cases is relatively low for PAs. In 1998, a 15-year retrospective review of data from the National Practitioner Data Bank, which records all medical malpractice cases and legal actions involving health care professionals in the United States, showed that the rate of settled litigation for PAs was less than that of physicians in comparable roles.⁹ A more recent review, published in 2017, indicates similar positive data regarding PAs involved in medical malpractice cases.¹⁰ The authors found that during the 2005 through 2014 study period, 11.2 to 19.0 malpractice payment reports were made per 1000 physicians, and 1.4 to 2.4 malpractice payment reports were made per 1000 PAs. Physician median payments ranged from 1.3 to 2.3 times higher than PA median payments.¹⁰

The AAPA provides the following description of PAs: “PAs are medical providers who diagnose illness, develop and manage treatment plans, prescribe medication, and often serve as a patient’s principal healthcare professional. With thousands of hours of medical education, PAs are versatile and collaborative. PAs practice in every state and in every medical setting and specialty, improving healthcare access and quality.”¹¹ The ability of PAs to work across this wide variety of roles is due to their formal medical model–based educational training that focuses on foundational, generalist medical knowledge. The formal PA educational period is on average 27 months in duration and includes both didactic and clinical instruction and experiences. Basic science, clinical science, and procedural skills are part of the curriculum in PA programs. Behavioral science, health policy, and professional practice standards are also included in PA educational requirements.¹² The PA profession’s terminal degree will be a master’s degree by 2020, with 95.5% of programs offering master’s degrees now.¹³ Currently, more than 9700 students graduate annually from PA programs.¹⁴ According to the Bureau of Labor Statistics, the number of PA jobs is projected to continue to increase by 31%, equating to an increase of 37,000 jobs by 2028.^14,15

PA programs are accredited by the ARC-PA, and accreditation is awarded based on meeting published standards that require students to receive clinical experiences in the care of older adults. Although the terms geriatrics and long-term care are not found in the ARC-PA standards, the care of those in the geriatric phase of life are definitely included in the principles to be taught during formal PA education (Table 1).¹²

Upon PA school completion, graduates work in all medical specialties. The breadth and depth of PA educational curriculum lends itself to the ability of its graduates to enter any medical specialty and contribute positively to patient care. Geriatrics and LTC are no different. The most recent available data from the Physician Assistant Education Association indicate that 23 PA educational programs have a required geriatrics rotation (out of 223 programs who responded to this question).¹⁶ Increasing geriatrics content in the PA educational curriculum would further enhance a PA’s caring for persons in the later decades of life. At our institution, an intentional effort is made to include geriatrics-specific topics throughout the didactic curriculum. Additionally, a 4-week geriatrics clerkship is a required rotation for our PA students. Although a mandatory geriatrics rotation is not required to meet ARC-PA standards, PA programs should consider program-required or elective geriatrics clerkship rotation opportunities.

Despite a burgeoning older adult population with a number of unmet health needs, PAs have not been encouraged to focus on geriatric care. The AAPA surveys clinically practicing PAs annually. Although the data are unpublished, the AAPA national surveys of practicing PAs in 2016 and 2017 provide some insight into the PA geriatric workforce. These survey results indicate that geriatric PAs’ primary practice setting is an extended-care facility or nursing home, with the second most common practice setting being a physician office or clinic. Geriatrics PAs see 48 to 50 patients each week. PAs whose primary practice specialty is geriatrics have worked in the field for more than 14 years on average, and the majority of these PAs reported that they would choose to pursue the geriatrics specialty again if asked. Two-thirds are women, and four-fifths are under the age of 50. PAs are educated in 2.5 years at one-fourth the cost of a physician and begin delivering patient care 4 years before a physician is independently functional.

Only 7% of the students, irrespective of their phase of education, reported having an interest in geriatrics practice. This preference was based on experiences in clinical rotations or interest in and passion for the specialty. Interestingly, employment projections appear to have little influence on students’ interest in specialty practice.^17,18

A significantly small proportion (0.6%) of all clinically active PAs responding to the AAPA survey reported that they practice either in a nursing home or other LTC facility. While a small percentage of PAs identify geriatrics as their primary specialty, many PAs treat elderly patients, arbitrarily defined as those 65 years of age or older.

A distinction should be made between PAs caring for people aged 65 years and older and those PAs providing comprehensive geriatric care. A geriatric care model has a holistic perspective, focusing on function, cognition, and special needs of patients who are typically 75 years of age or older. There has been little documentation on the role that PAs have in caring specifically for this population.

Several reasons given for the lack of interest in geriatrics among health professionals include a “shortage of time in packed curricula, lack of geriatrics-trained educators, absence of financial incentive, and low student demand (resulting from limited exposure to older adults and gerontological stereotyping) as barriers to improving geriatrics training.”¹⁷

While the ARC-PA standards specify that PA education include content that covers the lifespan, including topics of care for older adults, a required geriatrics clinical rotation is not mandatory. Additionally, exposure to a LTC facility is optional. These factors are important, since some PA students will be influenced in their decision by a mentor who plants a seed of encouragement to pursue a specialty path. Other specialties often receive more attention from students during their pre-, intra-, and post-PA education period. For example, the percentage of PAs who work in surgery and the surgical subspecialties has increased over time. One reason for this increase may be the influence that PAs receive from surgical preceptors during their required surgical rotation during PA school. New PA graduates may be unaware of the opportunity to work in LTC settings.

Other researchers have also defined factors that affect PAs’ choice of specialty practice. Table 2 summarizes two insightful articles^18,19 on this topic.

PA graduates generally receive multiple job offers, with 77.4% of those accepting a clinical position being offered 2 or more job opportunities.²⁰ Similar to physicians choosing their specialty focus, numerous factors ultimately determine where PAs choose to be employed.^21,22 Unlike physicians, it is easier for PAs to move from one specialty to another throughout their career based on needs of a practice or specialty and an individual’s interest in changing specialties.

Additionally, new graduates may choose a specialty based on a higher salary due to accumulated debt from their educational training. The mean educational debt of PAs was reported as $114,706 in 2017.²⁰ Reimbursement models should support the complex nature of care that is delivered by health care providers to persons during the geriatric years of their life.

Since the early 1980s, researchers have recognized the potential value of PAs and NPs working in geriatrics,^23-25 particularly in the face of persistent geriatrics workforce shortages.^26,27 In 2014, PAs and NPs together accounted for more than 23% of visits for Medicare patients, up from 11.9% in 2008.²⁸ During that time, PA Medicare visits increased from 4.9% to 9.0%.²⁸ PAs can positively affect the geriatrics workforce and provide quality care to geriatric patients.^29,30 Specifically, one case series²⁹ showed this improvement in quality of care—the addition of a PA to the care team, which increased the number of health care provider nursing home visits by 62%, decreased hospital admission rates while reducing the number of hospital admission days per 1000 patient-years. The PA visited the nursing home 3 to 4 days each week to address residents’ acute medical needs. Routine visits were alternated between the PA and the physician. Positive reimbursement outcomes were also noted.²⁹ Residents of nursing homes and other LTC settings, sites, and facilities can be benefitted by PAs and NPs with reduced hospitalizations³¹ and reduced avoidable hospitalizations,³² thus reducing health care costs. Strategies should be developed to remove barriers to increase the number of PAs working in PA-LTC. The following approaches, regardless of a PAs current educational or career phase, should be considered.

An issue that pertains to health professional educational programs is the availability of sufficient numbers of clinical training sites. LTC facilities such as nursing homes and assisted-living facilities may be an ideal untapped resource to provide PA students with an opportunity to be exposed to ill and nonacutely ill older adults. Expert clinical preceptors will be needed to facilitate these clinical experiences.

PA education has begun to develop postgraduate options that build on the foundation of the PA’s medical knowledge. The development of optional postgraduate PA residencies could deepen knowledge, skills, and attitudes in geriatrics and PA-LTC. Currently, there are two geriatrics-focused postgraduate PA education programs.^35,36

Similar to medical students, a consensus of PA student geriatrics competencies³⁷ could be developed, although there is likely to be a fair amount of overlap between the two documents. Postgraduate PA educational programs, like physician residencies or fellowships, could further provide the opportunity to develop skilled and expert geriatrics PAs who practice in PA-LTC, using these developed competencies as a curricular template.³⁸ PAs are well-positioned to function on interdisciplinary teams, because they are educated to provide care in a team model. The American Geriatrics Society³⁹ and the American Medical Association⁴⁰ support an interdisciplinary approach and specifically include the PA as a provider along with the MD and NP.

A review of reimbursement models may encourage health professionals to consider this clinical setting. Perry⁴¹ demonstrated that as PA practice authority has expanded over recent years, physician incomes have increased.

Regardless of the approach taken, enthusiastic mentors are needed to guide those who are new to treating older adults. The mentors can share the lifestyle benefits of working in their specialty as well as promote opportunities for career development. Whiteman and colleagues⁴² provide a case study of the benefits of utilizing students in a practice.

A greater percentage of NPs choose to work in geriatrics compared with PAs, although it is not entirely clear as to why this is the case. Of the 290,000 NPs currently licensed in the United States, 12.9% work in a clinical focus area of adult-gerontology primary care, adult-gerontology acute care, or geronotology.⁴³ The fact that NPs select a focus area during their formal educational training, including geriatrics as an option, might lend itself to a career dedicated to geriatrics.

PAs and NPs, while often performing similar clinical tasks, are different in key ways, specifically, their education backgrounds (Table 3). According to the American Academy of Nurse Practitioners, NPs “are licensed, independent practitioners who practice autonomously and in coordination with health care professionals and other individuals. They provide primary and/or specialty nursing and medical care in ambulatory, acute, and long-term care settings. NPs are registered nurses with specialized, advanced education and clinical practice competency to provide health care for diverse populations in a variety of primary care, acute, and long-term care settings.”⁴⁴ NPs are educated in the “nursing model,” an approach that includes patient-focused management and a holistic approach to care. PAs are educated in the “medical model,” described as a disease-focused approach that mirrors physician education, except that it is shorter.

In PA education, the average program length is 27 months, is full-time, and includes an average of 2250 hours of supervised clinical practice experiences.¹³ NP programs are typically 15 to 24 months. Full-time, part-time, and online NP education training options are available. One NP certifying body, the American Academy of Nurse Practitioners Certification Board, requires candidates for the adult-gerontology primary care certification to complete an accredited graduate, postgraduate, or doctoral educational program and obtain the “NP educational program’s required number of faculty supervised direct patient care clinical hours.”⁴⁵ The American Nurses Credentialing Center, another NP-certifying body, requires a certification candidate to obtain 500 faculty-supervised clinical hours in the adult-gerontology primary care NP role and population.⁴⁶

Perhaps the biggest difference between NPs and PAs is full practice authority. NP professional organizations advocate for independent practice, and NPs currently have full practice authority in 22 states and the District of Columbia.⁴⁷ PAs do not have full practice authority in any state, and there are no large-scale plans to break from physicians and practice independently.

PAs and NPs are required to take certifying examinations after completing their initial education, but maintenance of their licensure/certification varies. NPs are required to have 100 hours of continuing education and 1000 hours of clinical experience every 5 years. PAs, on the other hand, need 100 hours of CME every 2 years. NPs are not required to retake their board examinations after initial completion; however, PAs are required to recertify every 10 years.

NPs can practice independently, and PAs work with a supervisory physician. NPs, similar to PAs and physicians, must maintain their own individual National Provider Identifier (NPI) number to be credentialed and paid; if NPs cannot bill directly, the supervising physician’s NPI number is used and reimbursed at the physician fee amount.⁴⁸ For NPs with the ability to bill directly, payment levels vary per insurance. Medicare sets NP payment levels at 85% of the physician fee schedule; Medicaid varies by state, with about half of states providing pay parity with physicians and others reimbursing 75% to 95% of physician pay rates; and commercial plans pay from 70% to 100%.⁴⁹ While PA reimbursement rates are similar to those of NPs, PA reimbursement is provided directly to the PA’s employer.⁴⁹

Some have called for independent practice for NPs, PAs, and unmatched medical school graduates in primary care based on the length of their education and the fact that, in the case of NPs and PAs, some contributions to the medical literature have suggested clinical outcomes comparable with those of physicians.⁵⁰ While additional future studies will provide additional enlightenment, there is not a sufficiently organized movement toward this idea. In recent years, some PA advocates have suggested the value of a concept known as optimal team practice (OTP). OTP is defined as occurring when “PAs, physicians, and other healthcare professionals work together to provide quality care without burdensome administrative constraints.”⁵¹ The aim of OTP, which is in its early stages of implementation, is to ensure that PAs work to the highest level of their education and licensure.

PA schools should recruit and cultivate role models and content experts in geriatrics and LTC.

Additional required geriatrics curricular content and LTC clinical exposure should occur during the formal education of PAs. PA programs should consider LTC settings as clinical educational sites as experience for PA students. Postgraduate PA educational programs should also be utilized to prepare PAs for opportunities in LTC.

Policy changes must be implemented to affect reimbursement to represent the value of interprofessional teams, including PAs, when caring for geriatric patients in LTC settings.

Research must be conducted that highlights the quality of care provided by PAs in the geriatrics and LTC settings. Potential research themes might include the following: PAs’ decision to choose geriatrics and LTC as a career choice, PAs’ involvement with patients of varying acuity levels, PAs’ adaptability to various practice styles, and PAs’ interaction with physicians, to name a few.

Now is the time to magnify and advance these efforts to improve the access of quality care delivered to an aging population. 

Authors: 
Benjamin J Smith, DMSc, PA-C¹ • James C Zedaker, DMSc, PA-C² • Paul R Katz, MD³ • James F Cawley, MPH, PA-C⁴

Affiliations:
¹ Assistant Professor, Director of Didactic Education, School of Physician Assistant Practice, College of Medicine, Florida State University, Tallahassee, Florida
² Associate Dean and Founding Director, Associate Professor, School of Physician Assistant Practice, College of Medicine, Florida State University, Tallahassee, Florida
³ Professor and Chair, Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, Florida ⁴ Professor, School of Physician Assistant Practice, College of Medicine, Florida State University, Tallahassee, Florida; Visiting Professor and Scholar-in-Residence, Physician Assistant Leadership and Learning Academy, University of Maryland Baltimore, Baltimore, Maryland

Disclosures:
The authors report no relevant financial disclosures.

Acknowledgment:
The authors thank Lisa Granville, MD, and Noël Smith for assisting in the writing of this article by providing constructive feedback.

Address correspondence to:
James F. Cawley, MPH, PA-C, Professor,
School of Physician Assistant Practice,
College of Medicine, Florida State University,
1115 W Call St, Tallahassee, FL 32306-4300
(james.cawley@med.fsu.edu)