Focusing Efforts on Rural Health through a Workforce Approach

The 2012 USPHS Scientific and Training Symposium, University of Maryland, College Park, Maryland, June 19-21 2012

Focusing Efforts on Rural Health through a Workforce Approach

Raymond FangJoshua Umar, Ann Davis, Michael Powe

American Academy of Physician Assistants

https://www.aamc.org/


Presentation Outline Determinants of Americans’ poor health

Physician shortage, high costs, and mal-distribution

Workforce approach as a solution to increase health care accessibility and affordability


Challenges Facing American’s Health


Disparities:in life expectancy between the US and mainstream high-income nations

(Data source: OECD Health Data 2009)

https://www.aamc.org/


Disparities: in life expectancy between rich and poor Americans

(Source: Gopal K. Singh and Mohammad Siahpush (2006), Widening socioeconomic inequalities in US life expectancy, 1980–2000, International Journal of Epidemiology 35(4) PP. 969-979)


(US CDC Quick Stats: Life Expectancy at Birth, by Race and Sex --- United States, 2000--2009* Weekly May 13, 2011 / 60(18);588)

Disparities: in life expectancy between ethnical groups in the US


(Data Source: The data was taken from the American Human Development Project's second national report, Measure of America 2010-2011)

Disparities: in life expectancy across geographic areas in the US

Hawaii

Californ

ia

Connecticu

t

North Dak

ota

Colorado

South

Dakota

Vermont

Iowa

Wash

ington

Rhode Islan

d

Nebraska

Illinois

Virginia

Montan

aAlas

ka

New Mexic

o

Mary

land

Indiana

Nevada

Miss

ouri

Georgia

Tennesse

e

Arkansas

Oklahoma

Alabam

a

Miss

issippi

70

72

74

76

78

80

82

6.7 Years


(Source: Cosby , AG et al (2008) Preliminary Evidence for an Emerging Nonmetropolitan Mortality Penalty in the United States, American Journal of Public Health 98(8) PP. 1470-1472)

Disparities: in mortality rates between urban and rural Americans


Determinants of Health

Health Outcomes

Genetic/Demographic Determinants

Social Determinants Socio-Demographic

Interaction

Disease

Physical/Built Environment

Social Exclusion

Behavioural Determinants

Death

Healthcare Determinants


Challenges Facing Healthcare Providers


OECD (2006) Purchasing power parities (PPPs) are the rates of currency conversion that eliminate the differences in price levels between countries.Healthcare expenditure as % of GDP

Challenges: The American Healthcare System and Physicians are Expensive


(Data source: AAMC Physician Workforce Report 2010)

Including Shortage of 46,000 Primary Care Physicians

More shortages in rural and underserved urban areas

Challenges: Physician Shortages

(Data source: American Academy of Physician Assistants 2009 census, American College of NP 2010 Report, 2011 State Physician Workforce Data Release, American Association of Medical Colleges, Center for Workforce Studies, March 2011 https://www.aamc.org/download/181238/data/state_databook_update.pdf, the American Human Development Project of the Social Science Research Council )

States are ranked from left (lowest clinician density) to right (highest)

Nevada

Oklahoma

Utah

Mississ

ippi

Indiana

Illinois

Arizona

New Mexic

o

North Caro

lina

Ohio

Nebraska

South Caro

lina

Wyoming

Minnesota

Washingto

n

North Dako

ta

Montana

Oregon

Virginia

Delaware

Hawaii

Marylan

dMain

e

New Hampshire

Connecticut

0

5

10

15

20

25

Pove

rty

Rate

Challenges: Workforce Mal-distribution

13

https://www.aamc.org/download/181238/data/state_databook_update.pdf


Study Focus:Exploring the potential roles of physician assistants (PAs) in addressing public health and health equity through strengthening primary care services to rural Americans


Why is Primary Care Important?


Why Is Rural Health Important?■ Rural residents are poorer: Poverty rate is consistently higher in

rural areas than in urban areas. In 2010, poverty rates were16.5% and 14.9% in rural and urban areas, respectively.

■ Rural residents are sicker: Rural adults are more likely to report having diabetes; Rural residents are more likely to be obese; Rural women are less likely to receive preventive screening tests. Suicide rate is higher in rural men and alcohol abuse is higher in rural youth.

■ Rural physicians are fewer and older: More physician shortage especially in primary care in rural areas. There were 55 primary care physicians per 100,000 residents in rural areas in 2005, compared with 72 in urban areas. More rural physicians are close to retirement age.

■ Health insurance is less sufficient: Rural residents are less likely to be medically insured at the same level of urban residents.


Why Physician Assistants?

Median Compensation Level in the US in 2010

Type of Practice *Physician **Physician Assistants

Primary Care*** $202,392 $85,000

Specialty Care $356,885 $93,400(Source: *MGMA Physician Compensation and Production Survey: 2011 Report based on 2010 data** American Academy of Physician Assistants PA Census: 2011 Report Based on 2010 data*** Primary care includes general internal medicine, family medicine, general pediatrics, and geriatrics)

Physician Assistants (PAs): are clinicians licensed to practice medicine as members of physician-directed teams.Currently there are about 90,000 practicing PAs in the US.


PhysiciansPAs

NPs

0%

5%

10%

Remote Rural/Frontier Small Town Large Town

PAs and NPs are More Likely to Practice in Rural America

(Percentages of rural healthcare providers by level of rurality in 2010)Pe

rcen

t (%

)

(Data source: AHRQ Primary Care Workforce Facts and Stats No.3, AHRQ Pub. No. 12-P001-4-EF, January 2012)


Distribution of PAs Practicing in Rural America in 2010

(Percentages of PAs by Level of Rurality with 95% Confidence Intervals)

(Data source: American Academy of Physician Assistants, AAPA 2010 Census; 1.2% of PAs with unknown rurality were excluded)

16.9%

9.6%

4.3%3.0%

16.3%

9.1%

4.0%2.7%

17.5%

3.3%4.6%

10.1%

0%

5%

10%

15%

20%

Rural Large Town Small Town RemoteRural/Frontier

Level of Rurality

Perc

ent o

f PAs

Level of Rurality

■U.S. population in rural areas: 20% ■Physicians in rural areas: 11%


Study Goals:

Increase accessibility to care Address physician shortage and mal-distribution Lower health care costs Implement patient-centeredness Strengthen prevention, coordination of care,

chronic disease management, consultation, and other primary care interventions

Workforce solutions to


DefinitionsPrimary Care: includes family medicine,

general internal medicine, general pediatrics and geriatrics.

Urban-Rural Areas: rural and urban designations are taken based on standard U.S. Census classification scheme. Roughly, urban populations≥500,000; large town populations =10,000-50,000; small town populations = 2,500–9,999; and remote village populations ≤2,500 people.


Data and Methods

■ Clinical Data: Clinical characteristics of PAs were examined with data from the American Academy of Physician Assistants’ (AAPA) 2010 annual census survey.

■ Demographic/Certification Data: Demographic characteristics and certification status were from data from AAPA Masterfile

■ Complex Survey Analysis: Complex survey analytic tool in SPSS was used to provide a stratified survey analysis with 95% confidence interval.

■ Sample Weights: Post-stratification weights were assigned to base survey respondents based on demographic and certification status and to module survey respondents by additional stratification variables number of years as a PA, clinical setting and specialty to ensure the data would be representative of the entire PA population.


PAs Perform Clinical Functions That Traditionally Physicians Do (Mean percentages of PAs with specific clinical functions with 95% CIs)

(Data source: American Academy of Physician Assistants, 2010 PA Census,)

In Physician Offices

In Health Centers

In Hospitals


Level of Autonomy Varies across Clinical Work Settings(Mean Percentages of Patient Visits Made to PAs without a Need for

Physician Consultation with 95% Statistical Confidence Intervals)

(Data source: American Academy of Physician Assistants, AAPA 2010 Census,)

Health Centers

Physician OfficesHospitals


Rural PAs are More Likely to Practice in Primary Care

(Percentages of PAs in Primary Care with 95% Statistical Confidence Intervals)

(Data source: American Academy of Physician Assistants, AAPA 2010 Census)

26.3%

43.8%

63.9%

78.4%

25.5%

41.2%

60.3%

74.8%

27.0%

82.1%

67.5%

46.5%

10%

30%

50%

70%

90%

Metropolitan Large Towns Small Towns RemoteRural/Frontier

Level of Rurality

Perc

ent o

f PAs

in P

rimar

y Ca

re Rural Areas: 55.1% (53.1% - 57.1%)Urban Areas


Rural PAs are More Likely to Practice in Health Centers

(Percentages of PAs Working in Health Centers with 95% Confidence Intervals)

8.6%

18.7%

29.5%

51.6%

8.1%

16.6%

25.9%

46.9%

9.2%

56.2%

33.2%

20.9%

0%

20%

40%

60%


Level of Rurality

Perc

ent o

f PAs

Wor

king

in H

ealth

Cen

ters

Rural Areas: 27.3% (25.5.% - 29.1%)Urban Areas



Rural PAs are More Likely to PerformClinical Preventive Services

(Percentages of PAs Performing Clinical Preventive Services with 95% Confidence Intervals)

59.6%

66.1%69.1%

79.5%

58.0%

61.7% 61.4%

73.2%

61.2%

85.7%

76.8%

70.5%

50%

60%

70%

80%

90%


Level of Rurality

Perc

ent o

f PAs

Per

form

ing

Clin

ical

Pre

senti

ve

Serv

ices

Rural Areas: 69.8% (66.5% - 73.0%)Urban Areas



Rural PAs are More Likely to PerformChronic Disease Management

(Percentages of PAs Performing Chronic Disease Management with 95% Confidence Intervals)

63.9% 65.2%68.1%

80.3%

62.3% 60.8%60.0%

74.2%

65.5%

86.5%

76.2%

69.8%

50%

60%

70%

80%

90%


Level of Rurality

Perc

ent o

f PAs

Per

form

ing

Chro

nic D

isea

se

Man

agem

ent




Rural PAs are More Likely to PerformCoordination of Care

(Percentages of PAs Performing Care Coordination with 95% Confidence Intervals)

45.1%48.0%

56.4%

64.6%

43.4% 43.2%

48.2%

57.3%

46.8%

71.9%

64.5%

52.7%

40%

50%

60%

70%

80%


Level of Rurality

Perc

ent o

f PAs

Per

form

ing

Care

Coo

rdin

ation




PAs Practice at Top of License in Rural Areas(Mean Percentages of Patient Visits Made to PAs without a Need for Physician

Consultation with 95% Statistical Confidence Intervals)

67.4%

78.6%73.0%

83.3%87.7%

66.3%

76.7%

70.1%

79.1%

85.0%

68.5%

90.3%87.5%

75.9%

80.5%

40%

60%

80%

100%

Urban Rural Large Rural Small Town RemoteRural/Frontier

Level of Rurality

Perc

ent o

f PAs

with

Hig

h Au

tono

my

(Data source: American Academy of Physician Assistants, AAPA 2010 Census; 1.2% of PAs with unknown rurality were excluded)

Level of Rurality


Graduates from Rural PA Programs are More Likely to Practice in Rural Areas

(Percentages of PAs practiced in rural areas with 95% Confidence Intervals)

15.9%

32.8%

15.3%

29.6%

16.5%

35.9%

10%

20%

30%

40%

Graduates from Urban PA Programs Graduates from Rural PA Programs

Level of Rurality

Perc

ent o

f PAs

Pra

ctici

ng in

Rur

al A

reas



ConclusionsPAs who practice in rural areas are more likely to practice

in primary care with high autonomy

PAs are more likely to practice in rural areas

PAs who practice in rural areas are more likely to perform services in clinical prevention, chronic disease management, and care coordination

PAs who practice in rural areas are more likely to work in health centers where most underserved patients are seen

PAs who graduated from rural PA schools are more likely to work in rural areas

Both incentives and policy interventions are needed to engage PAs in practicing in rural areas


Questions? Thank You!

Raymond FangVice President for ResearchAmerican Academy of Physician Assistants2318 Mill Road, Suite 1300Alexandria, Virginia 22314United States of AmericaEmail: [email protected]: (571) 319-4327

mailto:[email protected]

Documents

Focusing Efforts on Rural Health through a Workforce Approach