The number of physician assistants has grown dramatically as well as the number working in specialty care, according to an annual census report issued Sept. 8 by the American Academy of Physician Assistants. "There's a true increase in demand from all sectors of the health care community recognizing the value of the physician assistant as part of the team," said Michael Powe, AAPA's vice president of reimbursement and professional advocacy. A total of 40,469 physician assistants were practicing in 2000. The number grew to 83,466 in 2010. Other surveys also have noted that physician assistants, along with nurse practitioners and certified nurse midwives, have become common in medicine. A data brief issued Aug. 17 by the Centers for Disease Control and Prevention's National Center for Health Statistics found that 49% of physicians worked with the allied practitioners. Experts say the shift is a result of changing payment patterns. Payment of physician assistant services is more common than ever, but reimbursement rates for many physician services have not kept up with the increasing cost of maintaining a practice. PAs may be a way for a practice to meet patient demand cost-effectively and stay healthy financially. "With reimbursement as flat as is has been for primary care, there's no way that I could do this without my physician assistant," said James Cunnar, MD, a family physician in solo practice in Naperville, Ill. Medicare started paying for physician assistant services in rural areas in 1977. The policy slowly expanded and covered all settings as of 1998. Medicaid and private payers followed suit. Prescribing rights have expanded, although they vary by state. In addition, academic centers are using physician assistants and other nonphysicians to fill the gaps created by resident work-hour restrictions. The use of PAs is expected to grow even further because of an ongoing physician shortage, particularly in primary care. This is expected to become a bigger issue as the health system attempts to respond to the demands of an aging population and people who will become newly insured as reform rolls out. "There is still a massive shortage of MDs or DOs choosing primary care," Dr. Cunnar said. "This will continue to worsen. I think you're going to see more physician assistants collaborating with physicians." The U.S. Bureau of Labor Statistics projects that the number of PA jobs will increase by 39% from 74,800 in 2008 to 103,900 in 2018. The number of physician assistant jobs in doctors' offices is expected to drive much of the growth and increase 18.7% from 39,300 positions in 2008 to 58,000 in 2018. The numbers are slightly different from the AAPA totals because the BLS counts jobs. The AAPA statistics count individual physician assistants, who might hold more than one job at any given time. Most physician organizations, including the American Medical Association, support doctor-led, team-based care that may include physician assistants and other clinicians. The American Academy of Family Physicians issued a statement Feb. 22 in conjunction with AAPA calling for health policies recognizing physician assistants as primary care clinicians in multidisciplinary, doctor-directed teams. "Physicians and physician assistants are mutually committed to continuing to improve safe access to health care by providing patient-centered quality care within integrated, coordinated and physician-led teams," said AMA President Peter W. Carmel, MD. "With millions more insured Americans under the Affordable Care Act, health professionals need to continue to work together to meet the surge in demand for health care." Though many PAs are in primary care, the AAPA report documented a trend that industry watchers have been noticing for some time. A growing proportion are in specialty settings. About 51% of PAs were in the primary care setting in 2000, with the remainder in a wide array of specialties. In 2010, only 31% worked in primary care. Researchers say the actual number of physician assistants in primary care has not gone down, but the growing number in the specialty setting has changed the ratio. Experts said this trend reflects the general shift of physicians toward specialty care. Physician assistants, who do not work independently, are following. "Physician assistants can't go out and hang a shingle," said Carl Fasser, director of the physician assistant program at Baylor College of Medicine in Houston. "That trend mirrors the distribution of physicians. It also is a reflection of needs within the medical marketplace." Health care industry watchers suspect that specialists are becoming more comfortable with physician assistants and other health professionals. A study by the American Society of Clinical Oncology published Sept. 15 in the Journal of Oncology Practice found that nonphysicians could increase a practice's productivity while maintaining physician and patient satisfaction. The survey of 27 practices found that those that allowed nurse practitioners or physician assistants to work with all doctors in a practice, rather than being exclusively attached to one physician, improved productivity by 19%. Patients and doctors reported a high level of satisfaction with this collaboration. "Coordinated and integrated cancer care provided by both oncologists and nonphysician providers is a very successful model," said Dean Bajorin, MD, co-chair of ASCO's Workforce Advisory Group. About 1,011 PAs worked in oncology in 2010, according to the AAPA census, compared with only 202 in 2000. 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