Care of Needy Falling to Nonphysicians

Study finds increase in rural areas of California, Washington

(HealthDay is the new name for HealthScoutNews.)

TUESDAY, July 29, 2003 (HealthDayNews) -- Physician assistants have assumed the lion's share of caring for needy people in California and Washington state. They are followed by family physicians, nurses and nurse midwives.

That's the conclusion of a new study in the July/August issue of the Annals of Family Medicine, which is largely devoted to looking at ways to eliminate health-care inequalities. Erasing these inequalities is a main goal of the U.S. Department of Health and Human Services' Healthy People 2010 initiative.

Clearly, physician assistants, nurses and family physicians are part of the solution for health-care disparities. All have a tradition of serving the needy, and federal and state funds have historically been funneled into training for these professions.

"The physician assistant profession 35 years ago was created to address issues of geographical inaccessibility to care. The notion was to take individuals who had some medical training but not as much as a physician and try to extend care to people who otherwise would not have access," explains Stephen Crane, executive vice president and chief executive officer of the American Academy of Physician Assistants. "Historically, PA's have served in rural, underserved areas, so to find that this is still the case is not surprising. It's very gratifying. It's part of the original concept, and it's something that has carried over 35 years of the profession."

The problem is that many training programs are slated for cuts, says study author Dr. Kevin Grumbach, a professor and chairman of family and community medicine at the University of California San Francisco and director of UCSF's Center for California Health Workforce Studies.

"The primary-care practitioners most likely to serve in underserved areas are those whose training depends on state and federal funding," Grumbach explains. "The programs seem to be delivering the goods. It seems to be a huge problem to turn around and say, 'We're not going to support this.'"

Grumbach and his colleagues examined how primary-care professionals were geographically distributed, compared with the population as a whole.

Using data collected in 1998 by the American Medical Association and the states of California and Washington, they discovered that, in California, 22 percent of physician assistants were located in rural areas along with 16 percent of certified nurse-midwives, 15 percent of nurse practitioners and 13 percent of family physicians. Family physicians in California were twice as likely as other primary-care doctors to practice in rural areas. Thirteen percent of the state's population lived in rural districts.

Needy urban regions in California had 28 percent of urban physician assistants, 33 percent of urban nurse midwives and 21 percent of urban family physicians, compared with only 15 percent to 17 percent of urban physicians in other primary-care disciplines working in so-called "shortage areas."

Meanwhile, in Washington state, 28 percent of physician assistants were located in rural areas, where 24 percent of the population resided. Almost 20 percent of nurse practitioners and 24 percent of family physicians practiced in rural areas.

Washington state's needy urban areas had 27 percent of urban physician assistants, 26 percent or urban nurse practitioners and 32.5 percent of urban family physicians.

Overall, a higher proportion of nonphysician primary-care practitioners (such as midwives and physician assistants) than physicians practiced in underserved areas and cared for minority patients as well as patients who had Medicaid or were uninsured.

"Certainly there's a difference between the different disciplines and from a public policy perspective, if your goal is to meet these underserved needs, what types of training programs should you prioritize as being the most likely pipeline for supplying needy communities," Grumbach says. "Our data would say it's the ones that federal and state funds have traditionally supported."

Which is not to say that rural and needy urban areas have adequate supplies of health-care professionals. "There are still thousands of communities in the U.S. that qualify as shortage areas, so we still have a long ways to go," Grumbach says. "There's a lot of unmet need."

More information

For more on health disparities, visit the American Medical Association. For more on physician assistants, visit the American Academy of Physician Assistants.

SOURCES: Kevin Grumbach, M.D., professor and chairman, family and community medicine, and director, Center for California Health Workforce Studies, University of California, San Francisco; Stephen Crane, Ph.D., executive vice president and chief executive officer, American Academy of Physician Assistants, Alexandria, Va.; July/August 2003 Annals of Family Medicine
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