The Executive Suite: Physician assistants improve healthcare in rural areas

I have been concerned with the maldistribution of rural health provider assets for decades. The situation is dire. The sad reality is that the number of physicians practicing in rural and medically underserved areas has been declining for decades. The reasons for this are complex. Practice in these areas is challenging from financial and quality of life perspectives. Many clinicians I know choose to work in metropolitan areas to find a “better life,” more opportunities, and more professional support.

The PAs I know who practice in rural and medically underserved areas tell me how much they love their work and their patients. They also express concerns about the isolation and the fatigue that comes with being the only provider in a small community with little professional support. It takes a special kind of clinician to work in this environment.

In a recent policy brief, the National Rural Health Association (NRHA) recognized the substantial resource that PAs represent in solving the crisis of rural healthcare and outlined steps to better utilize PAs to do so.

Approximately 15 percent of PAs practicing in 2017 (17,280 out of 115,200 total) practiced in rural or frontier counties, as opposed to 11 percent of practicing physicians. The NRHA also found that at least in Iowa, Texas, California, and Washington state, PAs practiced in rural areas in higher percentages than other providers.

PAs are uniquely qualified to fill an expanded healthcare role in rural and medically underserved areas due to their broad generalist education and a 50-year track record demonstrating competence and skill. One issue that stands in the way of PAs practicing at the top of their experience and training is overly restrictive state laws and regulations governing PA practice. The NRHA recommends, in addition to changing state laws, that scope of practice for PAs be determined at the practice level by the teams they work with.

The NRHA policy brief supports the tenets found in the American Academy of PAs’ Optimal Team Practice (OTP) policy, which are:

Emphasize PAs’ commitment to team practice;

Authorize PAs to practice without an agreement with a specific physician—enabling practice-level decisions about collaboration;

Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and

Authorize PAs to be paid directly by all public and private insurers.

The simple fact of the matter is that physicians who work in rural areas need PAs to practice to the full extent of their training and experience. It is a quality of life issue, and PAs have shown over their long history to be competent, safe, and efficient providers in rural and all other areas of medicine and surgery. PAs have also shown since the inception of the PA profession to be part of solution and not part of the problem when it comes to healthcare delivery.

I have lived in a lot of rural areas in my life, and I have practiced in medically underserved areas. Some of the reasons that physicians and PAs choose rural practice are obvious—the outdoors, clean air, simple living, low crime, low traffic, and other characteristics of rural areas appeal to folks looking for a better, simpler life. The reasons that some folks choose not to live in more isolated areas are a lack of professional support, a lack of resources, fewer opportunities for relationships, and fewer cultural amenities, among other barriers.

I have thought a lot about this problem from a policy standpoint. If we want clinicians to consider rural practice, we have to reduce some of the barriers and incentivize people to work there. It would also be helpful to remove some of rules and regulations that get in the way of team practice of medicine and the practice of medicine in general.I’ve already mentioned OTP, which would help PAs in rural practice, but things like easier implementation of telemedicine would make rural practice much more appealing by increasing providers access to specialty care in remote areas. Tax credits and loan forgiveness for physicians and PAs who commit to rural practice are other possible incentives.

This is a massive problem that will only get worse as the rural population ages and the ratio of rural patients to physicians and PAs gets more upside down. Reversing this trend will require a comprehensive policy solution that includes PAs front and center in ensuring that rural Americans have access to quality, affordable healthcare.