June 29th, 2016
The Specialty Shuffle
People tell me new things about my profession all the time. Forbes magazine loves to periodically declare it the best career in the country or the world or the universe, depending on the article. I find it hard to believe the people who write about money all day had time to sample every career before they crowned a winner, but if they want to validate my life goals, I guess I’ll take it.
More recently, a well-meaning acquaintance told me that the PA profession was important because “most of you work in primary care, right?” While I felt the comment required some factual correction, I found my own response somewhat lacking. The actual percentage of PAs in primary care is somewhere between 20 and 30%, I told him. But I couldn’t answer the next question: why?
I could just point to physicians. After all, we do “pretty much” what they do, right? It makes sense that our specialty distribution should mirror theirs and the same factors pulling physicians away from family practice should affect PAs as well.
But it’s not that simple.
New research by Perri Morgan and colleagues published in the Journal of the American Academy of Physician Assistants (JAAPA) sheds light on the interplay of physician-PA specialty selection. To start, the study confirms that the proportion of PAs entering primary care is declining, from 50% in 1997 to 30% in 2013. It’s a finding that mirrors trends in other healthcare professions and by itself is not surprising.
But the authors found another correlation in their data: the positive link between PA employment and the ratio of MD-to-PA salary. If that one made you pause, it should. Of course PAs might be attracted to specialties in which we make higher salaries. But why would there be more PAs in specialties in which our physician colleagues collect bigger paychecks relative to PAs?
Perhaps the answer lies not in the supply of PAs (i.e., where we choose to practice) but in the demand for them (i.e., the number of jobs available). High-earning physicians stand to make more money when they free up time by offloading clinical tasks to PAs (like a surgeon who operates more by hiring a PA to provide post-operative care). PAs in these fields also represent a better bargain when compared to hiring another highly paid physician in the same specialty.
It might sound intuitive and straightforward, but the economics of specialty distribution are essential to understanding why a smaller proportion of PAs are entering primary care. If there really is a primary care provider shortage, one that is set to worsen in the coming decades, we should consider insights from research like the Morgan study before planning interventions.
If PA salaries rise at rates greater than those of our primary care physician colleagues, practices will reap fewer financial rewards by hiring PAs. If well-meaning incentives designed to lure PAs to underserved primary care clinics (like salary increases, bonuses, or loan repayment) drive up the average cost of a PA in primary care beyond what non-subsidized practices can afford, we may see a further decline in the overall percentage of PAs in primary care.
Of course, we have always needed a healthy supply of primary care providers and the percentage of clinicians in that field must grow as we insure more Americans and as our population ages. But the choppy seas of healthcare economics respond to legislative and financial interventions in unpredictable ways. More healthcare workforce research might help us see the waves before they come crashing down.