When we, the healthcare community, talk about the lack of access to care in rural America, the focus is very often on physicians. Solutions tend to center around how to effectively recruit more physicians to practice in rural communities. That’s understandable, given that a study in The New England Journal of Medicine predicts the number of practicing rural physicians to fall by about a quarter by 2030.
However, to truly solve the rural access crisis, we need to consider every possible solution. While the number of rural physicians is important, equally important is the number of rural advanced practice providers such as physician assistants (PAs).
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There are more than 131,000 PAs in the U.S., and the Bureau of Labor Statistics expects the profession to grow 31% between 2018 and 2028. Already, around 1 in 6 PAs, about 16%, practice in non-metro or completely rural areas, according to the American Academy of PAs’ 2019 Salary Report.
(American Academy of PAs)
The healthcare situation in our country’s rural communities is, as we all know, dire. According to the National Rural Health Association (NRHA), patients in rural areas tend to be poorer, older, more likely to be uninsured and have more frequent occurrences of diabetes and coronary heart disease. It is up to us to explore every possible solution to this problem, because these patients need us.
How do PAs contribute to rural healthcare?
In a recent policy brief (PDF) co-authored by NRHA members, the organization cites PAs as an important part of expanding rural access—a profession that “will be indispensable providers in rural areas.”
“In rural practices, PAs are likely to take a call; provide home, nursing home, and hospital visits; provide direct emergency and urgent care services; perform office procedures; and provide after-hours telephone and internet/email consults,” the authors wrote.
While there are still some state laws that make it more difficult for PAs to practice at the top of their education and experience in rural areas, even with these barriers in place, it’s clear that the profession is already a critical asset in rural communities.
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As high-quality providers with thousands of hours of medical training, PAs diagnose illness, develop and manage treatment plans, prescribe medications and often serve as a patient’s principal healthcare provider. Adding more PAs to rural practices will undoubtedly help more patients access high-quality care more quickly—and that is our primary goal.
What can we do to bring more PAs to rural areas?
While a significant number of PAs already work in non-urban and rural areas, there are certainly ways to increase that number. To start, removing administrative barriers to PA practice will allow more PAs to more easily shift into rural practice settings, should they choose.
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Provisions in state laws, such as PA-physician ratio restrictions and physician proximity requirements, for example, impose unnecessary barriers to PA practice. As the NRHA notes, a PA may be the only provider in some rural communities—and unnecessary restrictions “increase costs, burden physicians and PAs, making recruiting physicians more difficult, and reduce patient access to care.” Thankfully, states and the federal government are starting to recognize that these restrictions don’t help rural patients, and we have seen tremendous momentum over the last several years to eliminate barriers to PA-provided care.
For example, North Dakota, where about 40% of the population (PDF) lives in rural areas, was the first state to remove a significant administrative burden for nearly all PAs—the requirement to have an agreement with a specific physician in order to practice. Additionally, the final 2020 Physician Fee Schedule Rule, issued by the Centers for Medicare & Medicaid Services, changes Medicare’s supervision requirements for PAs by largely deferring to state law on how PAs practice with physicians and other members of the healthcare team. This will ensure Medicare policy will stay aligned with changes in state laws. By clearing the way for as many PAs as possible to practice at the top of their education and experience in rural settings, we will see more PAs choosing to work in underserved, rural areas.
Additionally, to encourage more PAs to make this choice, we need to focus efforts on recruiting PAs as much as physicians. While our goal is not to replace physicians, it’s clear that rural areas need more than just one type of provider to meet the current need.
PAs are eligible for the National Health Service Corps Scholarship Program, funded through the Health Resources and Services Administration. But there are more ways to reach PAs. Everything we are doing to recruit and retain physicians in rural areas—such as incentives from employers, support programs, outreach to students and tax credits—should be expanded and applied to PAs.
PAs are ready to meet rural communities’ needs
It’s in the PA’s DNA to be collaborative and patient-focused. Thanks to PAs’ generalist medical education, we are a critical component of the rural access toolkit. Not only can we lower costs, improve access and provide high-quality care—we can also help relieve overworked physicians in rural areas.
When it comes to the rural access crisis, it’s a team effort. Every provider should have a hand in this solution, and PAs are ready to answer the call.
David E. Mittman, PA, DFAAPA, is the president and chairman of the board of the American Academy of PAs.