Utah’s Physician Assistant Workforce:
                2003

      Utah Medical Education Council

               State of ...
Utah’s Physician Assistant Workforce:
                2003

      Utah Medical Education Council

               State of ...
Acknowledgements
This study of Utah’s physician assistant workforce is a result of the efforts and contributions of
severa...
Table of Contents

1. Acronym & Abbreviation Reference Guide………………………………………….…1


2. List of Charts & Tables……………………………………...
Acronym and Abbreviation Reference Guide:


AAPA: American Academy of Physician Assistants
APAP: Association of Physician ...
List of Charts and Tables

Figure 1. Projected PA Demand (Pg. 6)

Figure 2. Gender Distribution of Utah and U.S. PAs in 20...
Executive Summary:
The Physician Assistant (PA) workforce in Utah is experiencing remarkable growth, with a 9% net
annual ...
Methodology:                                                   additional PAs per year during that period
        This stu...
older residents in the state are key                           number of medical students who enter
components in projecti...
of existing PA programs or opening new                       has a significant impact on coverage cost is
programs as a vi...
that scenario does play out, it is likely that                                         increased specialization are key
ph...
PAs, Utah continues to experience a male                                             time in order to raise families14. Th...
continues to be over represented in the PA                  licensed PAs nationwide, but only 75.1%19
workforce.          ...
Figure 4                                                                                    toward a younger workforce is ...
to the overwhelming percentage of PAs in                 provide a partial explanation as to why there
family practice. Si...
by the number of hours worked. Of those                                    in Utah (11-20 hours per week) who also
who rep...
the statewide workforce had a rural                      populations slightly over 20,000; all could
background with rural...
definition of rural being a town/city with a
population less than 50,000 persons.                      Specialty:
        ...
rates33 in the nation and has a large                                 reported practicing at three or more
dependant popul...
review during the first six months of a
working relationship, and 25% chart review                            When examini...
months to just a day or two, if the patients                              Figure 10
are willing to be seen by the mid-leve...
least 25 inpatients per week. This figure is              hospital setting (had privileges)42. By 2002,
not particularly s...
It is doubtful that this mandate                         speaking patients, up from only 50% in
caught hospital administra...
environment. It also indicates there is                     Spanish speaking students,
    not an over-supply of PAs in th...
53 hours respectively. However, mean                       Time Equivalents (FTE), with one FTE
patient care hours for bot...
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
Utah's Physician Assistant Workforce: 2003
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Utah's Physician Assistant Workforce: 2003

  1. 1. Utah’s Physician Assistant Workforce: 2003 Utah Medical Education Council State of Utah Prepared by: Boyd Chappell Research Consultant March 2005
  2. 2. Utah’s Physician Assistant Workforce: 2003 Utah Medical Education Council State of Utah Prepared by: Boyd Chappell UMEC Research Consultant March 2005
  3. 3. Acknowledgements This study of Utah’s physician assistant workforce is a result of the efforts and contributions of several individuals and organizations. Utah’s Physician Assistant Workforce: 2003 is based on a survey of all licensed physician assistants in the state of Utah as of December, 2002 that was conducted by the Utah Medical Education Council, with additional support provided by the Division of Occupational and Professional Licensing, the Utah Academy of Physician Assistants, the Bureau of Primary Care and Rural Health Systems, and the Utah Area Health Education Centers. Utah’s Physician Assistant Workforce: 2003 was prepared by: Gar Elison, Executive Director, Utah Medical Education Council Boyd Chappell, Research Analyst, Utah Medical Education Council Jennifer Ha, Research Analyst, Utah Medical Education Council Tim Salazar, Research Intern, Utah Medical Education Council Mike Bronson, Research Intern, Utah Medical Education Council* Clint Elison, Research Intern, Utah Medical Education Council* *former UMEC staff The members of the Utah Medical Education Council and Physician Assistant Workforce Committee must also be recognized for their invaluable contributions. Special thanks to Bob Bunnell, PA-C, Executive Director, Utah Academy of Physician Assistants, and Don Pederson, PA-C, Director, Utah Physician Assistant Program, for their insight and advice. A complete list of all members of both the council and the subcommittee who were involved appears in Appendix C. The data collected through the physician assistant survey can be made available for additional research or analysis of the physician assistant workforce or other relevant healthcare issues. For additional information please contact: Utah Medical Education Council 230 S. 500 E. Ste. 550 SLC, UT 84102-2062 Phone: (801) 526-4550 Fax: (801) 526-4551 Website: http://www.utahmec.org This report may be reproduced and distributed without permission. Suggested citation when referencing this report; “Utah’s Physician Assistant Workforce: 2003” Utah Medical Education Council (2005).
  4. 4. Table of Contents 1. Acronym & Abbreviation Reference Guide………………………………………….…1 2. List of Charts & Tables……………………………………………………………….…2 3. Executive Summary……………………………………………………………………..3 4. Section I – Demand for PA Services in Utah…………………………………………...4 5. Section II – Workforce Demographics……………………………………………....….8 6. Section III – Practice Characteristics……………………………………………..……14 7. Section IV – Productivity………………………………………………………..….…20 8. Section V – The Rural Workforce………………………………………………...…...22 9. Section VI – Factors Affecting Decision to Practice in Utah…………………..……...24 10. Section VII – Training Capacity………………………………………………..……...26 11. Section VIII Summary…………...……………………………………………..……...28 12. Works Consulted………………………………………………………………….…....30 13. Appendix A – Data Elements from Survey Instrument………………………………A-1 14. Appendix B – Utah Primary Care HPSAs……………………………………………B-1 15. Appendix C – Physician Assistant Workforce Committee Members………………...C-1 16. Appendix D – 2002 PA Survey Instrument…………………………………………...D-1
  5. 5. Acronym and Abbreviation Reference Guide: AAPA: American Academy of Physician Assistants APAP: Association of Physician Assistant Programs APRN: Advanced Practice Registered Nurse Clinician: Physician, Advanced Practice Registered Nurse, or Physician Assistant CMS: Center for Medicare and Medicaid Services COGME: Council on Graduate Medical Education D.O.: Doctor of Osteopathy DOPL: Division of Occupational and Professional Licensing (Utah) FTE: Full Time Equivalent GOPB: Governor’s Office of Planning and Budget (Utah) IHC: Intermountain Healthcare HPSA: Health Professional Shortage Area JAMA: Journal of American Medical Association M.D.: Medical Doctor MUA/MUP: Medically Underserved Area / Population OB/GYN: Obstetrics/Gynecology PA: Physician Assistant PA-C: Physician Assistant-Certified UAPA: Utah Academy of Physician Assistants UMEC: Utah Medical Education Council UPAP: Utah Physician Assistant Program- located in the College of Medicine at the University of Utah WWAMI: Washington Wyoming Alaska Montana Idaho Center for Health Workforce Studies- University of Washington College of Medicine Page 1 of 31
  6. 6. List of Charts and Tables Figure 1. Projected PA Demand (Pg. 6) Figure 2. Gender Distribution of Utah and U.S. PAs in 2002 (Pg. 7) Figure 3. Utah Physician Assistant Ethnicity (Pg. 8) Figure 4. Age of PA Workforce in 1998 & 2002 (Pg. 9) Figure 5. Specialty Rank by Mean Income (Pg. 10) Figure 6. Mean Gross Annual Income by Total Hours Worked per Week in Utah (Pg. 11) Figure 7. Comparison of Utah and U.S. Primary Care PAs (Pg. 13) Figure 8. Utah & U.S. Primary Care Physician/Population Ratios (Pg. 14) Figure 9. Distribution of Utah PAs by Length of Wait in Days (Pg. 15) Figure 10. Work Settings for Utah & U.S. PAs (Pg. 17) Figure 11. Utah PAs with Hospital Privileges (Pg. 17) Figure 12. Mean Productivity Measures (per week) (Pg. 20) Figure 13. Gender and Ethnicity Distribution of Rural & Statewide PA Workforce (Pg. 21) Figure 14. Age Distribution of Rural & Statewide PA Workforce (Pg. 21) Figure 15. Comparison of Rural & Urban Primary Care PAs (Pg. 22) Page 2 of 31
  7. 7. Executive Summary: The Physician Assistant (PA) workforce in Utah is experiencing remarkable growth, with a 9% net annual rate of growth since 1998. There were 84 additional PAs providing patient care in Utah in the four year period of 1998-2002, an average of 21 per year. The Utah Medical Education Council (UMEC) believes that demand for PAs will be high over the next 10-15 years, with several factors fueling this growth. The distribution of PAs in the state closely follows population patterns. The vast majority, 74%, of the PAs in the state practice in the four urban Wasatch front counties, Davis, Salt Lake, Utah and Weber. These counties are home to 77% of the state’s population. Based on population distribution, there does not appear to be a mal-distribution of the state’s PA workforce. The number of PAs practicing has increased in nearly every county in Utah since 1998. The counties that have seen the largest increase in PA workforce are Davis, Salt Lake, Utah, and Weber counties. The PA workforce also experienced significant growth in Cache, Tooele, and Washington counties as well. In 2002, PAs provided approximately 8% of the primary care provided in the state despite only constituting 6% of the primary care workforce. The contribution of PAs helps assure that Utah’s physician workforce is adequate in these specialties. Just over one-half (53%) of the state’s PAs practice in one of the four primary care specialties, Family Practice, Internal Medicine, OB/GYN, and Pediatrics. Nationally the percentage of primary care PAs is 60%. As expected, the percentage of Utah PAs in subspecialty practices increased from 44% in 1998 to 47% in 2002. The ratio of PAs in subspecialty care should continue to increase over the next five to ten years. Since 1998, certain specialties have experienced significant growth. The primary care specialties added several new practicing PAs. Family Practice added 34, Internal Medicine 18, and Pediatrics 7. The exception to the growth of the primary care specialties was OB/GYN which actually saw 4 fewer practicing PAs since 1998. Orthopedics, Cardiology, and Hematology/Oncology experienced the most growth of the subspecialties. Among these specialties there was a net increase of 11, 9, and 8, additional PAs practicing, respectively. Several other subspecialties experienced a net increase in the number of PAs as well. Since 1998, there have been an increasing number of PAs providing patient care in the state, with no Utah background, who received their training elsewhere. During this same time period, there have also been an increasing number of PAs with Utah backgrounds returning to practice in the state after graduating from out of state programs. These trends, coupled with expected demand, have led the UMEC to conclude that expansion of the PA program at the University of Utah to at least 50 graduates per year should be a priority. Page 3 of 31
  8. 8. Methodology: additional PAs per year during that period This study of Utah’s Physician that provided patient care. This constitutes a Assistant (PA) workforce is based on a 9.3% annual increase in the number of survey that was mailed to every PA with an practicing PAs in Utah over a four year active Utah license as of December 2002. period. This growth has occurred primarily Three separate mailings were conducted in the four urban Wasatch front counties from December, 2002, through March, consisting of Davis, Salt Lake, Utah and 2003, and achieved a 75% response rate. Weber, the greater metro area including The responses were weighted using a factor Summit, Tooele, and Wasatch counties, as of .25 to account for the non-respondents to well as Cache and Washington counties, the survey. It should be noted that responses which were recently given a metro area to individual questions varied only slightly designation by the Census Bureau. from the overall response rate. Weighting Approximately 90% of the PAs licensed in factors for individual questions were not the state since 1998 have located in these used to account for non-responses. areas. Generally, the number of non-respondents to individual questions was included in the While the number of PAs practicing tables included in the appendices. Utah 2002 in rural Utah has increased from 612 in 1998 data presented in this report have all been to 68 in 2002, the percentage of the overall weighted using the .25 weighting factor. workforce in rural practice has decreased from 26%3 in 1998 to 21% in 2002. The Data from the 1998 report, which is decline in the percentage of PAs working in referenced in this study, were also weighted rural Utah is due to the remarkable level of using a factor based on the response rate to growth the PA workforce has experienced in the corresponding survey. Data from the the urban and metro areas. American Academy of Physician Assistants (AAPA) are quoted directly from their The rate of growth Utah has national census of PAs. Weighting factors experienced since 1998 is consistent with were not used in the AAPA Census. national trends. The AAPA reports that from 1994 to 2003 the gross number of PAs in the Section I U.S. doubled4. This equates to a 10% annual increase, with the vast majority, over 79%, Demand for PA Services in Utah actually providing services as a PA5. Recent Trends: In 1998 there were 283 licensed PAs Projected Demand for PAs: in Utah. Of those 283 licensed, 240 actually Overall population growth in Utah provided healthcare services in the state1. In and increased utilization of healthcare 2002 the number of total PAs licensed in services due to increases in the number of Utah climbed to 377, with 324, or 86% of those licensed, providing patient care in the state. On average, the state added 21 2 ibid 3 ibid 1 4 Utah Medical Education Council (2000): Utah’s AAPA (2004) Trends in the PA Profession: 1991- Clinical Healthcare Workforce – Achieving Balance 2003 5 Through 2020. ibid Page 4 of 31
  9. 9. older residents in the state are key number of medical students who enter components in projecting demand. The primary care residencies, particularly family Governor’s Office of Planning and Budget practice programs. If the demand for (GOPB) projects Utah’s overall population primary care physicians cannot be met with to increase from 2,233,169 in 2000 to medical students, the market will likely turn 3,371,071 by 20206. The number of Utah to physician extenders, specifically PAs to residents over the age of 65 is also projected help fill the void. This factor will become to increase proportionate to the overall increasingly prominent after 2010 as increase in population7. These residents tend shortages of primary care providers and to utilize healthcare services at a much physicians in general become more acute. greater rate than do younger segments of the population. These two factors, population The PA profession is a dependent growth and increased utilization due to a profession. By design, the “PA cart” is tied corresponding increase in the number of to the “physician horse”. Factors that impact older residents will combine to be the physician supply and demand in the U.S. primary force behind increasing levels of and in Utah, will in turn affect the PA demand for PAs between now and 2020. environment. To date three studies including one prepared by the Center for Health The rate of growth experienced by Workforce Studies at the University of the PA workforce from 1998 through 2002 Albany for the Council on Graduate Medical exceeded the level of growth the Utah Education (COGME), and another authored Medical Education Council (UMEC) by Richard Cooper M.D. of the Medical projected for the same period of time in the College of Wisconsin, project a shortage 1998 report. There seems to be a number of that could approach 200,000 (20% of the causes that are spurring this growth. One of expected needed workforce) physicians by them appears to be increased utilization of the year 20208. mid-level providers i.e. PAs and Advanced Practice Registered Nurses (APRNs) in Such a shortage could prove specialist practice. Prior to 1998 only 43% catastrophic and place intense pressure on of the PA workforce practiced in the states such as Utah that rely on recruiting the subspecialties. Of those licensed in the state majority of their physician workforce from since 1998, exactly 50% were in the national pool. If a nationwide physician subspecialty care. The UMEC believes that shortage of the magnitude projected by the the use of mid-level practitioners in studies cited does in fact develop, the specialty care practices will continue to be a demand for PAs both in Utah and across the major factor driving demand for these nation will likely increase drastically. practitioners’ services in Utah between now and 2012. The option of increasing PA training will likely be seen as an attractive Another factor which will likely add alternative for states facing staggering to future demand for mid-level practitioners, physician shortages for a number of reasons. PAs in particular, is the rapidly declining States facing the prospect of expanding or opening new medical schools to meet 6 physician need must consider the expansion Governor’s Office of Planning and Budget: Population by Sex and Five Year Age Group: 1980 - 8 2030 Cooper et all: Weighing the Evidence for 7 ibid Expanding Physician Supply. Page 5 of 31
  10. 10. of existing PA programs or opening new has a significant impact on coverage cost is programs as a viable alternative. Not only geography. Utah PAs pay almost twice does it cost significantly less to train a PA ($2,160) as much through UMIA for non- than a physician or even APRN, the training Emergency Medicine or Urgent Care pipeline for PAs is also significantly shorter. specialties as do PAs in Arizona ($1,443), The timeline for physician training is California ($825-1,100), and Colorado anywhere from six to nine years depending ($1,000) on specialty, this compared to two years for PAs. Though most PAs are insured through a rider on their supervising Because of the nature of their physician’s policy, this isn’t the only option training, PAs will be in an excellent position available to PAs. There are carriers through to extend the available supply of physicians which PAs can obtain insurance on their across specialties and a variety of settings, own, for instance the AAPA has a product whether as house staff at hospitals / surgical that PAs can purchase. Again, the cost will centers, or in private physician practices. vary, depending on the factors listed above, and it behooves the practitioner to look for By design, PAs provide a cost the best price available. effective tool for providers, both physicians and institutions to extend healthcare While liability insurance costs will services. As the healthcare industry in the factor into the breakeven or profitability United States continues to search for and point for practices that choose to employ implement cost controlling measures and PAs, the UMEC believes that the effect on practices, PAs will continue to see demand future demand for PAs will be minimal. Not for their services increase. only will the added productivity and revenue generating potential PAs provide outweigh Two potential factors could arise that the cost of rising liability coverage, the would have a dampening effect on future expected shortage of physicians will exert demand for PAs. The first is the increasing pressure on the market, increasing demand cost of liability insurance for all clinicians for PAs. including PAs. The AAPA reported from its 2004 survey of PAs that 97.5% of PAs The other factor that could nationwide have their professional liability potentially have a negative impact on the insurance provided by their employers9. The demand for PAs would be third party payers UMEC did not gather data on this topic. implementing policies that reimburse PAs at However, anecdotal reports indicate that a lower rate than their supervising physician. Utah is not significantly different from the This issue has risen in the past in isolated rest of the nation in this regard. The actual incidents around the country. In nearly every rate appears to vary based on the scope and case PAs have been able to successfully specialty of the practice, amount of coverage resolve these issues. obtained, work location (Emergency Room coverage is significantly more expensive This issue would likely only have an $5,800 as compared to $2,100), and other impact on the demand for PAs if these factors, including which carrier the incidents become more widespread, and the practitioner chooses. Another factor which PA community is not able to successfully negotiate with these third party payers. If 9 AAPA 2004 Physician Assistant Census (2004) Page 6 of 31
  11. 11. that scenario does play out, it is likely that increased specialization are key physicians would have lower incentive to components in projecting future employ PAs. demand for PAs in the state. • By 2010 Utah will need 346 new The development of evidence based PAs to account for population medicine and practice guidelines for the growth, accommodate the aging delivery of medicine is also likely to provide population and replace PAs additional opportunities for PAs. Evidence leaving the state workforce. By based medicine will enhance the delivery of 2020, that number increases to medicine by healthcare teams by providing 988 (see figure 1). an additional tool for physician extenders • If current trends in the physician such as PAs to be successful. workforce aren’t reversed, demand for PAs in the primary UMEC staff has developed a model care specialties will rise by 2015. for projecting healthcare workforce needs in • Projected universal shortages of the state through 2020. This model takes physicians around the country into account expected population growth expected to develop by 2020 will and increased utilization of healthcare increase demand for PAs in Utah services due to the aging of the population. and around the country. The model also accounts for the need to • The increased productivity and replace existing practitioners at historic revenue generating potential PAs retirement / attrition rates. Given all these offer to practices will exceed any factors and assuming growth rates mitigating effect rising experienced during the past ten years malpractice liability insurance continue into the future, the state will see a might have. significant shift in the makeup of the • The issue of third party payers clinician workforce. It is conceivable that lowering reimbursement rates for PAs will make up a more significant portion PAs will also not likely have a of the clinician workforce by the year 2020, significant mitigating effect on with the number of PAs providing patient PA demand, so long as it does care even surpassing the number of APRNs not become widespread. providing patient care in the state. Figure 1 Section II Projected PA Demand Workforce Demographics EXPANSION due EXPECTED Gender: TOTAL PA to POPULATION PA TOTAL PAs According to the 2002 AAPA PA Year Population WORKFORCE GROWTH ATTRTION REQUIRED 2002 2,321,707 294 0 0 0 Census Report10, 58% of the nation’s PAs 2005 2,464,633 368 74 37 111 are women. That constitutes a 5% increase 2010 2,787,670 566 198 148 346 nationwide since 1998 when AAPA reported 2015 3,126,736 871 305 261 566 2020 3,371,071 1,340 469 469 938 52.8% of US PAs were women11. While women constitute a majority of the nation’s Conclusions: 10 • Population growth, increased American Academy of PAs (Oct.2002): 2002 AAPA PA Census Report utilization of healthcare services 11 American Academy of PAs (1998): 1998 AAPA by an aging population and PA Census Report Page 7 of 31
  12. 12. PAs, Utah continues to experience a male time in order to raise families14. This trend dominated PA workforce. In 1998 a little seems to hold true for the PA workforce as a less than 64% (63.7) of Utah’s PAs were full 33% of female PAs regularly work male12. According to the 2002 survey, just fewer than 30 hours per week. This over 63% (63.2) were male. compares to only 19% of their male counterparts who work fewer than 30 hours Figure 2 per week. Conversely, nearly 32% of male PAs regularly work 41 or more hours/week while only 25% of their female counterparts Gender Distribution of Utah and US PAs in 2002 worked over 41 hours per week. 70.0% 63.2% The trend of women clinicians working 58.0% fewer hours does not seem to adversely 60.0% affect the ability of the PA workforce to 50.0% 42.0% meet the demands placed on them at this 40.0% 36.5% time. However, should the percentage of Utah PA s US PA s female PAs increase as expected, and the 30.0% trend of female clinicians working fewer 20.0% hours continue, additional PAs would be 10.0% needed to provide the same amount of service that the current workforce is now 0.0% Mal e Fe m al e able to provide. Ethnicity: Utah’s female PA population While the minority population in continues to make up only a fraction of the Utah continues to grow at an accelerating total workforce, and, unlike its national pace, minorities are still underrepresented in counterpart, continues to experience only Utah’s clinician workforce, including PAs. minimal growth. However, as is the case In 2002 nearly 15% of the state’s population around the country, the number of women was of ethnic descent15, while ethnic enrolling in the PA program housed in the minorities constituted only 7% of the PA school of medicine at the University of workforce. In 1998, 95% of the PAs who Utah (UPAP) is increasing13. If the responded to the UMEC survey indicated percentage of female students continues to ‘White/Caucasian’ as their ethnicity. In 2002 increase as expected, Utah should begin to that percentage had dipped to 93%. In 2000 experience more significant growth in the the Census Bureau reported that 85.3% of number of females entering the state’s PA Utah’s population was white (of Non workforce in the years to come. Hispanic Descent)16. As is the case in most healthcare professions, the White population Traditionally, female clinicians (physician, APRN or PA) in Utah have 14 tended to work fewer hours than their male Utah Medical Education Council (2000) 15 Population Division US Census Bureau (2003): counterparts, often choosing to work part Table ST-EST 2002 ASRD-05-49 State Characteristic Estimates 12 16 Utah Medical Education Council (2000) US Census Bureau, 2000 Census of Population, 13 American Academy of PAs (April 2002): Report of Public Law 94-171 Redistricting Data File Updated the Census Survey of New PA Students 1995-2001 every 10 Years http://factfinder.census.gov Page 8 of 31
  13. 13. continues to be over represented in the PA licensed PAs nationwide, but only 75.1%19 workforce. of the total population. The two largest minority groups, African Americans and Though minorities continue to be Hispanics, constituted 24.8%20 of the total under represented, it should be noted that population nationwide, yet only 6.4%21 of from 1998 to 2002 the state added six the nation’s PAs were from these two ethnic additional Latino PAs to its clinician groups. workforce. This more than doubles the number of Latinos in the PA workforce Figure 3 providing patient care in the state since Utah Physician Assistant Ethnicity 1998. In spite of the additional PAs who % of 2002 % of 1990 % of 2000 Change in have entered the workforce, Latinos at Workforce Population Population Population present only constitute 3% of the state’s PA African American 0.4% 0.6% 0.8% 0.2% Asian 0.4% 1.8% 1.7% -0.1% workforce. While the increase in the number Asian Indian* 0.4% NA NA NA of Latino PAs is important, it is only a first Latino 3.2% 4.7% 9.0% 4.3% step, because at 9% of the population, Native American / Alaskan 0.4% 1.3% 1.3% 0.0% Latinos now represent Utah’s largest and Pacific Islander / fastest growing minority group17. Pacific Native Hawaiian**1.1% NA 0.7% NA Islander/Native Hawaiian was the only other White/Caucasian 92.9% 89.4% 89.2% -0.2% ethnic group that experienced growth within * Not tracked by Census Bureau ** Combined with Asian in 1990 Census Data Utah’s PA workforce. Three new PAs of Pacific Islander/ Native Hawaiian descent began practicing in Utah during the period Age: 1998 through 2002. The number of PAs Examination of data collected by from the other ethnic groups remained static. UMEC in both 1998 and 2002 indicates that the vast majority of Utah PAs enter practice The disparity between the ethnic between 30 and 34 (there are five times as population and PA workforce is taken many between the ages of 30 and 34 as there seriously by UPAP. UPAP actively recruits are under the age of 30). This is not students of diverse backgrounds and particularly surprising considering that ethnicities. The issue appears to lie in UPAP, the source of 60% of the state’s PAs, retaining these students in the state’s is a graduate level program. In addition, the workforce upon graduation. The UMEC program requires students to have prior believes that the state will be able to develop clinical experience as well. These stringent a more ethnically diverse PA workforce only requirements are part of a national trend in when more ethnic students from UPAP are which more and more PA programs are successfully recruited into the state’s becoming graduate level programs and workforce. requiring students to have prior clinical experience. The trend toward graduate level Utah is not unique in the trend of training for PAs will undoubtedly affect the under representation among minority groups age of PAs entering the states workforce. in the PA profession. In 2002, ‘White/Caucasians’ constituted 89.4%18 of 19 Population Division US Census Bureau (2003) 17 20 Population Division US Census Bureau (2003) ibid 18 21 American Academy of PAs (Oct.2002) American Academy of PAs (Oct.2002) Page 9 of 31
  14. 14. Figure 4 toward a younger workforce is positive, making it less likely that large concentrations of PAs will be retiring over Age of PA Workforce in 1998 & 2002 the next 15 to 20 years. Wide fluctuations in age are usually not ideal, as expanding 80 professions such as the PA profession, do 70 69 best over the long run with consistent rates 69 59 of growth. 60 55 54 50 50 Income: 48 The UMEC was interested in 43 40 33 learning about income levels among Utah 33 PAs, as wage level is one indicator of either 30 24 a saturated market, or just the opposite, a 20 18 workforce shortage. The 2002 survey asked 10 9 PAs to estimate average gross annual 10 income based on ranges of $10,000. In order 0 1 1 to convert responses from a range to an 21-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ actual figure, each response was randomly 2002 1998 assigned a specific figure within the corresponding range of response. The mean According to the 1998 survey, two income levels reported in this section thirds (67.2%) of Utah’s PAs were between represent approximations based on these the ages of 40 and 5422. Responses to the randomly generated figures. 2002 survey indicate that the percentage of PAs in this age group has fallen to 47.5%. The mean income earned by Utah Meanwhile, between 1998 and 2002, the PAs ($73,000) was slightly higher than the percentage of PAs under the age of 40 rose national average ($72,000)24. It appears from 24.4% in 199823 to 36.4% in 2002. through analysis conducted by the UMEC This is a significant increase in the that gender, age, county of practice (rural or percentage of younger PAs providing patient urban), and hours worked all have a care in Utah. Statistical data also indicates statistically significant impact on PA income that Utah’s PA workforce was younger in in the state. Neither of the following 2002 as compared to 1998. In 1998, the potential factors, specialty (primary care vs. mean age for PAs in the state was 43.9. In subspecialty care), or ethnicity affected 2002, the mean age was down slightly to income at a statistically significant level, 43.5. though there was significant variation in income levels between specialties. While Utah’s PA workforce was slightly younger in 2002 than in 1998, the Again, using randomly generated mean age of the nation’s PAs was income figures in order to calculate mean essentially unchanged, rising from 41.1 in income figures, specialties in which at least 1998 to 41.3 in 2002. The trend in Utah three PAs are practicing, were compared to the mean income for family practice PAs. The family practice mean was selected due 22 Utah Medical Education Council (2000) 23 24 ibid American Academy of PAs (Oct.2002) Page 10 of 31
  15. 15. to the overwhelming percentage of PAs in provide a partial explanation as to why there family practice. Six specialties had a mean is a difference in income levels, though it income which varied significantly from the probably doesn’t explain such a large family practice mean. Internal Medicine, disparity. Pulmonary Disease CCM, and Neurology, all had mean income levels that were Figure 5 significantly lower than Family Practice. Specialty*Rank by Mean Income Specialty Rank Three other specialties had mean Plastic Surgery 1 income levels that were significantly higher Cardio-Thoracic Surgery 2 than Family Practice. These specialties were Pediatrics 3 Pediatrics, Cardio-Thoracic Surgery, and Preventive Med / Public Health / Occ. Med 4 Plastic Surgery. However, when the mean Gastroeneterology 5 Other Surgical Sub-specialty 6 income for all primary care specialties was Dermatology 7 compared with the mean of all sub-specialty Cardiology 8 PAs, the difference in mean income levels Pediatrics Sub-specialty 9 was not statistically significant. Mean Family Practice 10 income data for individual specialties would Urology 11 be more reliable if larger populations existed Psychiatry 12 within those specialties. Internal Medicine and Pediatrics 13 Orthopedic Surgery 14 OB/GYN 15 When examining individual counties, Hematology / Oncology 16 there was a lot of variation in income levels Emergency Care 17 between counties. Not surprisingly, when Pulmonary Disease CCM 18 the mean income for all rural counties was Internal Medicine 19 compared to the mean income for the four Neurology 20 urban counties along the Wasatch front, the General Surgery 21 difference was statistically significant, with * Includes only those specialties with at least 3 the mean rural income significantly lower physician assistants reporting income. ($67,000) compared to the urban mean ($74,000). Survey data from 1998 indicated According to survey responses, female PAs that, less than 20% of Utah PAs had gross in the state earned nearly $20,000 dollars annual incomes over $80,00025. According less (gross annual income) than their male to the 2002 survey, that percentage had risen counterparts ($60,000 vs. $80,000). Further to 29%. Not only has the number of PAs in analysis showed that while the mean ages of the upper income bracket (over $80,000 per male and female PAs weren’t significantly year) risen, the number of PAs earning less different (44 and 43 respectively), the mean than $60,000 a year decreased from 39%26 number of hours worked was. The mean in 1998 to 27% in 2002. Ironically, the number of hours worked per week by male percentage of PAs who reported income PAs was 39.2, while their female under $39,000 rose from 2.1% to 6.8%. counterparts only worked a mean of 35.5 However, this is probably explained in part hours per week. The fact that female PAs tend to work significantly fewer hours per 25 Utah Medical Education Council (2000) week than their male counterparts may 26 ibid Page 11 of 31
  16. 16. by the number of hours worked. Of those in Utah (11-20 hours per week) who also who reported gross annual income under worked significant hours (over 10 hours per $39,000 in 2002, 83% reported working week) out of state was not significant. thirty hours or less at their primary practice location. Not surprisingly, in addition to hours Figure 6 worked, age appears to be yet another factor in determining PA income. Those under the age of 40 are more likely to fall into the under $60,000/year income bracket. Mean Gross Annual Income by Total Hours Worked Between the ages of 45 and 60, PAs are per Week in Utah 120000 more likely to fall into the over $80,000 97943 income bracket. This trend reverses itself 100000 83679 once PAs reach age sixty, when they are 77403 72292 80000 Income 71409 80972 again more likely to have an annual income less than $60,000. This decrease in income 60000 50750 parallels a reduction in the number of hours 40000 worked per week by those over the age of 41100 sixty. 20000 0 PA Background/Upbringing: 0-10* 11-20 21-30 31-40 41-50 51-60 61-70 71+ In order to get a better understanding Hours Worked of the background of the state’s PA workforce, questions regarding the state of high school graduation were asked on both Even though the majority of PAs are the 1998 and 2002 surveys in order to paid a salary rather than an hourly wage, the determine background. In 2002, just over relationship between hours worked and half (52%) of the overall PA workforce income is very strong for Utah PAs. For came from a Utah background, this those working 11 to 20 hours per week the compared to 53%27 in 1998. For purposes of mean income was $41,100. For those this report, a Utah background is defined as working between 21 and 30 hours the mean having graduated from a Utah high school. increased to $50,750. For those working The ratio of rural PAs with a Utah between 31 and 40 hours and 41 to 50 hours background was very similar. per week, mean income levels were not Approximately 55% of the rural PAs came significantly different, with $71,409, and from a Utah background. In 1998, 59% of $72,292 respectively. Those who put in the rural workforce had a Utah more than 51 hours per week all made background28. significantly more than those only working between 31 and 40 hours. One group, which In order to better understand the on the surface appeared to be an exception number of Utah PAs who come from a rural to this, was those working 10 hours or less background, PAs were asked about per week. Analysis showed that their mean population levels in the town/city where income was a lofty $77,403. This apparent they spent the majority of their upbringing. anomaly is explained by the fact that 18 of Responses to this question show that 22% of the 20 PAs in this category worked at least 40 hours per week outside the state of Utah. 27 ibid The number of those working reduced hours 28 ibid Page 12 of 31
  17. 17. the statewide workforce had a rural populations slightly over 20,000; all could background with rural being defined as a be considered rural. There are several Utah town/city with a population less than 50,000. communities with populations approaching This definition is used in this section solely the 10,000 level, all of which would qualify due to the design of the survey question, as rural regardless of the definition used. which asked for population ranges of the town / city of upbringing. The definition of There are several cities in the rural used by other state agencies, such as western U.S. which approach the 50,000 the Department of Health, is based on population level and could be considered population density on a county wide basis; rural based on population density of the for example, a county is designated rural if it county. Examples include: Grand Junction, has a population density between 6 and100 Colorado (41,986), Cheyenne, Wyoming persons per square mile. A frontier county is (53,011), Casper, Wyoming (49,644), Idaho one with a population density of six or fewer Falls, Idaho (50,730), Pocatello, Idaho persons per square mile. The section of this (51466), Missoula, Montana (57,053) and report that focuses on the rural workforce Santa Fe, New Mexico (62,203)29. used the definition of rural utilized by the Utah Department of Health to designate Based on the responses to the counties of primary practice as rural or question regarding population and urban. background, and the definition used by the UMEC, approximately one-third of the rural The 50,000 population level being workforce had a rural upbringing. According used in this section of the report to define to the 1998 survey, 39 of the 61, or 63% of rural is probably a realistic measure, the state’s rural PAs came from a rural especially in the western states, where larger background. It is highly unlikely that in just cities, even MSAs (metropolitan service four years, Utah’s rural PA workforce would areas) can be in counties whose population have changed so drastically that it would go density is less than 100 persons per square from two-thirds of the workforce with a mile. However, due to Utah’s unique nature rural background to just one-third. This in which 70% of the population is probably reflects changes in the design of concentrated in four urban counties that the survey. make up less than 5% of the total land area, it probably isn’t an appropriate definition for In 1998, respondents were asked to communities in this state. indicate if they came from a rural, urban, or suburban background. This is problematic in In Utah, the only cities with that a standard definition of what constitutes populations approaching 50,000 that are not rural, urban, and suburban, was not in the four urban counties are Logan, located employed, thus raising questions about the in Cache County, and St. George, located in soundness of the data. Unfortunately, the Washington County. These two areas were 2002 survey also appears to provide recently designated as MSAs by the Census problematic data, due to the fact that it asked Bureau, yet under the definition used by the for population ranges of towns/cities, not state’s health department would still qualify population on a countywide level. The as rural. Three other Utah cities have design of the question resulted in a “best fit” populations near the 20,000 level. Cedar City, Brigham City, and Tooele all have 29 US Census Bureau (2000) Page 13 of 31
  18. 18. definition of rural being a town/city with a population less than 50,000 persons. Specialty: Utah PAs practice in a variety of However problematic the question specialties, including both primary care on the 2002 survey proved to be, the data specialties (Family Practice, Internal collected is still more reliable than the 1998 Medicine, Pediatrics, and OB/GYN) as well data, because the issue of self-definition was as the sub-specialties. In 2002, 53% of the eliminated. state’s PAs practiced in one of these four primary care specialties. This is lower than Conclusions: the 60% who reported practicing in primary • Utah is likely to see an increasing care nationally at the same time30. The percentage of female PAs in the next breakdown of PAs in Primary Care (2002) 10-15 years. for Utah and the US31 is as follows: • If female PA productivity patterns continue, more PAs will be needed Figure 7 to offset lower productivity of female PAs. Comparison of Utah & US Primary Care PAs • The number of ethnic minorities in Utah PAs US PAs % of % of the PA workforce is inadequate. Primary Primary Additional PAs of ethnic descent, Care Care especially Latino PAs, are needed to Specialty Workforce Count Workforce Count Family Practice 73.5% 139 70% 5400 assure Utah has a culturally 25 1419 Internal Medicine 13.5% 18.4% competent workforce. OB/GYN 2.6% 5 5.9% 451 • The relative age of the workforce is Pediatrics 10.5% 20 5.7% 438 not a significant concern when evaluating the adequacy of the The presence of the primary care current workforce, nor is it likely to PAs in the state amplifies the capacity of be significant in the near future. physicians in these specialties. Utah’s • Statewide income for PAs is physician/population ratios for Family comparable to the national mean Practice, Internal Medicine, Pediatrics, and though it varies by location, OB/GYN are all significantly lower than US specialty, gender, and the number of ratios32. The following chart shows hours worked. physician / 100,000 population ratios. • Background, where a PA is from and The ratios would appear to be even where he/she was trained, plays a more marginally adequate considering Utah very significant role in determining ranks among the highest (5th) in health where a PA will decide to practice. • Utah has an attractive work environment for PAs. The state 30 American Academy of PAs (Oct.2002) 31 should be competitive in the 32 ibid retention and recruitment of PAs in American Medical Association. 2001 Physician Characteristics and Distribution in the U.S. (2003- the future. 2004 Edition) U.S. Census Bureau. Annual Population Estimates, by State. July 1, 2001 Estimates Section III [online] Practice Characteristics http://eire.census.gov/popest/data/states/tables/ST- EST2002-01.php [retrieved 3/5/2003] Page 14 of 31
  19. 19. rates33 in the nation and has a large reported practicing at three or more dependant population in both the locations in 2002. child/adolescent and elderly cohorts. It is clear that PAs augment what would It is unclear whether the increase in otherwise be insufficient capacity in the the number of PAs practicing at one location state. reflects an actual trend within the PA workforce, or if the shift is due to changes Figure 8 within the UMEC survey which would influence the responses. According to the 2002 AAPA Census, 83.1% of PAs Utah & US Primary Care Physician/Population Ratios nationally practice for one employer36. This Utah US data may not reflect accurately the number Specialty Physicians Physicians* of practice sites these PAs are working at, as Family Practice 27.8 29.9 one employer could potentially have Internal Medicine 15.9 26.5 multiple practice locations. However, the OB/GYN 12 15 similarity in figures seems to indicate that Pediatrics 15.2 18.6 Utah is close to national norms in regards to *American Medical Association. Physician Characteristics the number of worksites. and Distribution in the U.S., 2003-2003 Edition. On-Site Supervision: The percentage of Utah PAs working As of November 15, 2001, the Utah in subspecialty care rose from 44%34 in Division of Occupational and Professional 1998 to 47% in 2002. Among those who Licensing (DOPL) has removed arbitrary obtained a Utah license during or after 1998, supervision requirements for PAs. The new the percentage in subspecialty care is 50%. requirements are more relaxed and no longer The trend toward specialization of the PA affix an arbitrary percentage of direct profession is expected to continue into the supervision and chart review by the foreseeable future and will be a key factor in supervising physician37. In spite of the fueling increasing demand for PAs. Since updated rules, just over half (51.3%) of Utah the 1998 report, Utah has an additional 28 PAs reported practicing with 91-100% on- PAs practicing one of the Internal Medicine site supervision. Three-quarters (76%) subspecialties, and 25 additional PAs reported practicing with at least 71% on-site practicing in Surgery or one of the surgical supervision. According to the survey, just subspecialties. These PAs represent 46% of over 17% of the state’s PA workforce the total increase since 1998. indicated that they practice with 50% or less direct, on-site supervision. The 50% direct Concurrent Worksites: supervision figure is significant because Since 1998, the number of PAs prior to the November 2001 rule change, working at one site increased from 53%35 to that was the arbitrary figure designated by nearly 73% (72.5%). Correspondingly, the DOPL as the minimum level of direct number practicing at two or more sites supervision, in addition to 100% chart decreased from 29 % to 23%. A total of 5% 36 American Academy of PAs (Oct.2002) 37 Utah Administrative Code (November 15, 2001) 33 United Health Foundation (2004) R156-70a-501 Working Relationship and Delegation 34 Utah Medical Education Council (2000) of Duties 35 Utah Medical Education Council (2000) PA Practice Act Rules R156-70a Page 15 of 31
  20. 20. review during the first six months of a working relationship, and 25% chart review When examining patient wait times, after the first six months38. the median wait time probably more accurately reflects what is actually taking It is the expectation of the UMEC place than does the mean wait time. A slight that increasing numbers of supervising majority, 51%, of the respondents to the physicians will take advantage of the relaxed survey indicated that new patients typically supervisory regulations, allowing more wait three days or less to see a PA. While flexibility within their working relationships 64% reported established patients usually with the PAs they supervise. The changing wait three days or less for an appointment. dynamics of the supervising physician-PA Just over 25% of respondents reported wait relationship should begin to be reflected in times longer than one week for new patients. the next UMEC survey, to be conducted in For established patients, the percent of PAs 2006. who indicated wait times longer than a week was only 13%. These relatively short As the amount of direct supervision waiting periods for patients seem to indicate decreases, it is plausible that other forms or that the demands being placed on Utah’s PA methods of supervision, especially workforce is not excessively burdensome. telecommunications, will become more prevalent. In the 2002 survey, 225 (63.6%) In addition to the patient-clinician PAs indicated that they never use relationship, specialty also appears to be a telecommunications as a method of significant factor in affecting the length of supervision, while only 40 (11.3%) reported time patients must wait to see a Utah PA. more than 50% supervision via For new patients of a primary care PA, the telecommunications. The number of mean wait is nine days, and for established physician/PA teams utilizing patients, three days. The median wait for telecommunications as the primary method both new and established patients of primary of supervision should grow during the care PAs is one day. The number of days a coming years, especially among those patient must wait to see a sub-specialist PA working in multiple sites and/or rural is significantly longer. For a new patient the practice sites. mean waiting period is seventeen days. For established patients, it is eleven days. The Patient Wait Time: median waiting period to see a sub-specialist The amount of time most patients PA for new patients is seven days, for must wait to see one of Utah’s PAs is established patients, four days. Again it relatively short, though it does vary based on appears that the median wait time more patient-clinician relationship. The mean wait accurately reflects the experience of the for a patient with an established relationship majority of Utah PAs. with a PA, regardless of specialty, is six days, while the median established patient Anecdotal accounts suggest that the wait is one day. For a new patient, the mean utilization of PAs or other mid-level wait is twelve days, the median, two days. providers in sub-specialty care settings can greatly reduce the amount of time patients, 38 especially new patients, must wait before Utah Academy of PAs: http://www.utahapa.org/portal/content/currentnews.js receiving specialist care, often reducing the p [accessed amount of time from a matter of weeks or 04/01/2003] Page 16 of 31
  21. 21. months to just a day or two, if the patients Figure 10 are willing to be seen by the mid-level practitioner for initial consultation. Such accounts warrant further study, and may be used to model how the use of PAs or other Work Settings for Utah & U.S. PAs mid-level providers such as APRNs can 40% increase a sub-specialty practice’s capacity 38% and efficiency. 35% Figure 9 29% 30% 28% Distribution of Utah PAs by Length of Wait in Days 25% 23% for Both New & Established Patients 2002 New New Est. Est. 20% Length of Wait Patient Patient Patient Patient 17% 17% in Days Count Percent Count Percent 15% 13% 13% 0 83 23.3% 99 28.0% 12% 1-3 100 28.1% 126 35.7% 9% 10% 4-5 19 5.3% 15 4.2% 6-7 29 8.1% 30 8.5% 5% 8-10 9 2.5% 6 1.7% 11-15 33 9.3% 16 4.5% 0% Solo Physician Group PhysicianHospitals / Community / Other 16-20 4 1.1% 6 1.7% Practice Practice Clinics Rural Health 21-25 6 1.7% 4 1.1% Clinics* 26-30 14 3.9% 3 0.8% 31-40 4 1.1% 1 0.3% Utah U.S. 41-50 5 1.4% 4 1.1% 51-60 5 1.4% 1 0.3% 81-90 3 0.8% 1 0.3% According to the 2002 AAPA 91 + 9 2.5% 3 0.8% Survey, nearly 38% of the PAs across the Not Reported 33 9.3% 38 10.8% US work in a hospital setting (9% higher Total 356 100.0% 353 100.0% than Utah), while 40% work in either a group physician practice or solo physician Work Setting: practice39. A larger percentage (13%) of Utah PAs worked in a variety of Utah PAs worked in community or rural settings in 2002. Private physician practice, clinics than their counterparts across the including both solo (23%) and group (17%) country. Only 9% of all PAs in the US offices, was the most prevalent work setting worked in either a community health clinic for Utah PAs, combining for 40% of the or some type of Federally Qualified Health workforce. Nearly a third (29%) of the Center (FQHC)40. workforce was employed in either a hospital or clinic setting. Approximately 13% of the Type of Patients Treated: PA workforce reported working at The vast majority of Utah PAs see community/rural health clinics. Other work more outpatients than inpatients. The vast settings included physician practice majority, 88%, of the respondents to the management organizations (PPMO), survey reported seeing at least 25 outpatients college/university faculty, and HMOs. Ten per week, while only 8% reported seeing at respondents to the survey indicated that they were self-employed. 39 American Academy of PAs (Oct.2002) 40 ibid Page 17 of 31
  22. 22. least 25 inpatients per week. This figure is hospital setting (had privileges)42. By 2002, not particularly surprising given the ratio of the percentage of PAs in the US with outpatient procedures to inpatient hospital privileges had increased slightly to procedures performed in the state and the 37.9%43. various settings where PAs were employed in 2002. Less than a third of the state’s PAs Figure 11 were employed in a hospital / clinic setting and only a third had hospital privileges. A Utah PAs With Hospital Privileges Hospital Privilege bias toward hiring APRNs over PAs to work Type 1998 2002 Change in hospital settings appears to exist among None 137 213 76 the state’s major healthcare providers. While there were just over 100 PAs employed in Inpatient Care of hospital / clinic settings, there were 319 Children (Non- APRNs (approximately 40% of the Newborns) 41 41 0 workforce) employed in the same settings. Labor & Delivery 5 1 (4) First Surgeon for Hospital Privileges: Other Major Med In both the 1998 and 2002 surveys, procedures 6 16 10 the UMEC asked Utah PAs to list which, if Inpatient Care of any, hospital privileges they have been Adults 68 96 28 granted at Utah hospitals. In 1998, 43% reported having privileges at Utah Care of Newborns 17 14 (3) hospitals41. The 2002 survey revealed that 1st Assistant for Major Surgeory/ 40% had hospital privileges. The following C-Sections 39 55 16 chart illustrates the number of PAs with Intensive / various privileges in both 1998 and 2002, as Coronary Care 17 31 14 well as the actual change in numbers for each type since 1998. The UMEC does not specify whether these PAs have admitting Beginning July 1 2003, the Accreditation privileges or not. Council for Graduate Medical Education (ACGME) issued a mandate to all 7,800 Unfortunately, no national data residency programs accredited by the exists which specifically delineates the council that they limit the number of number of PAs with hospital privileges. In required duty hours to a maximum of 80 per the absence of specific data, UMEC used week. Previously it wasn’t uncommon for data gathered by the AAPA in their annual residents to be on duty (patient care hours, survey of PAs regarding primary work call, and didactic training) from 80 to 120 setting. While this data fails to show the hours per week. The AAPA recognized the number with admitting privileges, it does opportunity this mandate created for the PA show the number of PAs who work in profession and aggressively sought to various hospital settings including both educate hospital administrators of the inpatient and outpatient units, thus making it benefits of utilizing PAs to fill the void in an acceptable proxy measure. According to patient care created by this mandate. the 1998 AAPA survey, 37.1% of the nation’s PAs worked in some type of 42 American Academy of PAs (1998) 41 43 Utah Medical Education Council (2000) American Academy of PAs (Oct.2002) Page 18 of 31
  23. 23. It is doubtful that this mandate speaking patients, up from only 50% in caught hospital administrators by surprise as 199846. As the state’s population continues many were taking measures to be compliant to become increasingly diverse, all clinicians prior to the July 1, 2003 deadline. This may in the state, not just PAs, will need to be be a partial explanation for the rise in the aware of the increasing number of number of PAs working in hospitals individuals who could in effect be denied between 1998 and 2002 cited above. The adequate healthcare because of language UMEC believes that this change in the way barriers. hospitals meet their patient care staffing needs will positively effect the PA The UMEC encourages both policy profession; but, any increases in the number makers and leaders in government and the of PAs resulting directly from this change healthcare industry to take significant have largely occurred already. It is the measures to ensure access to adequate UMEC’s position that future growth of the healthcare for all residents in the state, PA profession in the hospital setting will be regardless of their primary language. largely due to other factors, especially in Utah, where we have a relatively small Medicare / Medicaid Patients: portion of the national pool of residents As in the 1998 survey, questions were included in the 2002 survey regarding Interpretation Services Offered: whether or not the PA accepted new Utah’s population is becoming Medicaid, Medicare, or other types of new increasingly diverse. The Latino population patients, as well as the percentage of patients has experienced remarkable growth in recent that were either Medicaid, Medicare, private years. From 1990 to 2000 the Latino insurance, self-pay, or some other billing population more than doubled, growing type. Additionally, PAs were asked from 84,59744 to 200,98545.Utah has also regarding the use of sliding fee scales, which seen an influx of Eastern European are utilized to make healthcare more immigrants in recent years as well. Many of affordable for low income patients by Utah’s immigrant populations are non- adjusting the fees billed based on the English speaking and may potentially find patient’s income. Most PAs have no control language a barrier to accessing healthcare over decisions regarding the acceptance of services. new patients, in determining the percentage of patients of the various billing types, or the Given this increasing diversification use of sliding fee scales. For this reason, the of the state’s population, cultural data gathered via these questions are not competence is becoming increasingly included in this study. important for Utah’s clinician workforces, including PAs. Over two-thirds (68%) of the Conclusions: states PAs currently offer some form of • The PA workforce will continue to language interpretation for non-English expand into the subspecialties. • Specialization will continue to be a 44 U.S. Census Bureau (1990) principle factor in workforce growth. http://eire.census.gov/popest/archives/state/rank/hisp. • The vast majority of PAs working at txt [accessed 06/07/2003] one location indicates a stable work 45 U.S. Census Bureau (2000) http://quickfacts.census.gov/qfd/states/49000.html 46 [accessed 06/07/2003 Utah Medical Education Council (2000) Page 19 of 31
  24. 24. environment. It also indicates there is Spanish speaking students, not an over-supply of PAs in the regardless of ethnicity. state. • More relaxed supervision Section IV requirements are good for the PA Productivity profession and will likely encourage additional physicians to employ PAs According to survey responses, as the PA-physician relationship is approximately 70% of Utah’s PAs work at viewed as being less burdensome. least 36 hours per week at their primary • Based on patient wait times, it work location. An examination of various appears that the current ratio of factors such as gender and specialty practitioners (physicians, PAs and practiced revealed no significant variations APRNs) to the state’s population is in hours worked per week. This examination adequate for most specialties. revealed that 73% of male PAs worked at • Most job opportunities for PAs in the least 36 hours per week as opposed to only state appear to be in private 63% of their female counterparts. Primary physician offices (both group and care PAs (72%) were slightly more likely to solo practices). Barring a significant work a minimum of 36 hours than their philosophic shift within the major specialty care counterparts (66%). Age, healthcare systems in the state, rural/urban practice and work setting were private physician practice will likely also examined. There was almost no continue to be the primary source of difference between the percentage of rural job growth for PAs. and urban PAs who worked a minimum of • The percentage of Utah PAs with 36 hours per week. Interestingly, PAs hospital privileges is in line with the between the ages of 35 and 44 were more nation as a whole. There is still room likely to work less than the 36 hour for growth in this arena. standard. For the most part, there was little • The percentage of PAs who offer correlation between work setting and hours language interpretation has improved worked. A clear majority, approximately since 1998, though there is room for 70%, of respondents in all work settings improvement. reported working at least 36 hours per week. Recommendations: A comparison of productivity data • The state should strive to for physicians statewide, PAs statewide, and maintain current rural and urban PAs revealed some practitioner/population ratios if important trends. When looking at mean not increase them in some total hours worked and mean patient care specialties. hours, both were slightly higher (43 and 42 • Supervision requirements for respectively) for the rural PA workforce, PAs should be maintained at the compared to the statewide PA workforce (42 levels currently mandated by and 41 respectively). This analysis also state statute. revealed that the rural workforce spends • The University of Utah’s PA virtually 100% of work time in patient care program should place more activities. For both urban PAs and emphasis on training PAs with physicians statewide, the mean total hours language skills, especially worked, were significantly higher at 46 and Page 20 of 31
  25. 25. 53 hours respectively. However, mean Time Equivalents (FTE), with one FTE patient care hours for both of these equaling 105 outpatients seen per week47. constituencies were similar to the rural PAs and statewide PA workforce, with urban Based on this methodology, the PAs providing 41 hours of patient care per state’s PA workforce only contributed 8% of week and Utah physicians providing 43 the total FTE available throughout the state. patient care hours. This is probably explained by the fact that PAs make up the smallest constituency of While Utah physicians work more clinicians in the state (only 354 providing hours overall and spend more hours in patient care). What was somewhat surprising patient care, Utah PAs, especially the rural was the fact that the state’s APRN(s) only PAs, see more outpatients per week. This is contributed about 10% of the total FTE probably to be expected for a number of based on this formula, despite more than reasons. PAs practice within the scope of tripling the number of PA(s). Basing practice of their supervising physician; productivity solely on outpatient data however, PAs generally perform more probably discounts APRN productivity routine procedures and treat patients with significantly, as many Utah APRNs dedicate more routine problems, while referring more a significant portion of time to RN type complicated cases to the supervising activities and/or inpatient care. Like the physician. This may allow them to see more Washington study, the significance of this patients in a shorter period of time. Also, analysis lies in the fact that combined, Utah physicians see far more inpatients per Utah’s PAs and APRN(s) provide nearly week than do the state’s PAs. one-fifth of the state’s clinician FTE, a significant portion of the care provided in Figure 12 the state. Mean Productivity Measures (per week) Using the same methodology used to Rural Urban MDs / PAs PAs PAs DOs measure productivity of the overall clinician workforces, UMEC analyzed the Total Hours Worked 42 43 46 53 contribution of PAs practicing in rural Utah Patient Care Hours 41 42 41 43 as well as those working in primary care. Outpatients 79.1 81.3 77.9 70.54 Rural and primary care PAs provided Inpatients 5.4 3.6 6.4 9.4 roughly the same proportion of FTE as the Total Patients 84.5 84.9 83.9 79.94 overall workforce. The 68 rural PAs in the state provided 9% of the clinician FTE in Utilizing a method of analysis based rural Utah. Primary care PAs contributed on one used by the Washington, Wyoming, 9% of the primary care FTE contributed by Alaska, Montana, and Idaho (WWAMI) PAs and physicians. Center for Health Workforce Studies and the WWAMI Rural Research Center in the Data collected in the survey study “The Contribution of Nurse regarding non-patient care activities reveals Practitioners and PAs to Generalist Care in that PAs spend a larger percentage of work underserved areas of Washington State”, the number of outpatient visits per week as 47 reported by the state’s clinicians in the Larson, Palazzo, Berkowitz, Pirani, Hart (2001): The Contribution of Nurse Practitioners and PAs UMEC surveys were converted into Full to Generalist Care in Underserved Areas of Washington State Page 21 of 31

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