Born out of a demand for better patient access to preventive medical services, physician assistants have been around since the mid 1960’s and have been assimilated as a valuable asset to direct pay practices, and even to safety care as a whole.
While a significant number of primary care physicians join the industry each year, it is simply not enough to cover an aging American population, developments in primary care, as well as the never-ending demands of insurance companies.
This is where physician assistants come in.
When it comes to direct primary care and physician assistants, the latter are equipped to manage and assist in patient-facing preventive care operations, managing chronic conditions, as well as pre- and post-surgery care.
Having PAs in direct primary care set-ups also gives practices the capability to spend more time with patients, take on and keep in touch with more patients, sometimes even at lower costs.
Let us take a deep dive on the role of physician assistants in direct primary care (DPC).
This article discusses what their skills and qualifications are, which medical settings they can participate in, and the regulations and policies to work around when integrating PAs into DPC practices.
Physician assistants are health care professionals who are licensed to practice medicine under physician supervision.
The PA scope of practice in direct primary care includes conducting physical exams, diagnosing and treating illnesses, ordering and interpreting tests, counseling on preventive healthcare, assisting in surgery, and writing prescriptions.
PAs are also licensed to practice medicine in the form of education, research, and administrative services.
As per the AMA Journal of Ethics, physician assistants are often used to a greater degree in smaller facilities like private practices in non-urban or suburban areas.
PAs also tend to deliver a higher percentage of care to lower income patients, Medicaid patients, uninsured patients, younger patients - in a nutshell, populations which may otherwise be medically underserved.
Physician assistants in direct primary care are an important addition to day-to-day clinic operations given that both entities work towards the same goal: making primary care seamless and more accessible to a variety of patients.
Given that PAs in direct primary care work closely with physicians, PA training and education in direct primary care requires graduate-level, medical-standard programs, which are designed to complement physician training.
Contrary to popular belief, physician assistants are not meant to replace a DPC physician, instead they complement and support each other.
There are currently 164 accredited PA programs in the U.S.
The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which is the accrediting agency responsible for upholding PA educational standards in the States, evaluates programs to ensure strict medical compliance is met.
PA training and education in direct primary care resembles a condensed iteration of medical school, making physician assistants in direct primary care jacks of all trades.
Their required pre-clinical curriculums involve anatomy, physiology, pathophysiology, pharmacology and pharmacotherapeutics, and genetic and molecular mechanisms of health and disease - all of which take about 26.5 months to complete.
PAs make an important ally in direct primary care, considering their clinical education has prepared them for a variety of medical settings, including outpatient and inpatient scenarios, and even emergency and long-term care.
Physician assistants are present in a variety of medical specializations, including family medicine, general internal medicine, geriatrics, pediatrics, emergency medicine, general surgical care (including operative experiences), prenatal care, and women’s health.
Given that higher ratios of primary care visits vs. specialty visits result in more effective safety care delivery, better health outcomes, and lower medical costs, having PAs in direct primary care can be a gamechanger.
This is why it comes as no surprise that, according to studies, there is a stronger relationship between concierge medicine and PAs, as well as other medical settings where a great deal of primary care is delivered.
Primary care visits account for more than half of the 1 billion doctors appointments in the United States per year.
The Medical Group Management Association’s (MGMA) 2009 Physician Compensation and Production Survey show that, in family practice, PAs handle 42% of ambulatory cases, while 58% is taken care of by primary care physicians.
That’s about a 50/50 proportion of work spread out between primary care physicians and physician assistants.
Collaborative practice models with PAs show clinical work being equally distributed among healthcare professionals within the practice.
A study conducted by AMA Journal of Ethics indicates that PAs oversee more preventive care visits rather than chronic care appointments or pre- and post-surgical care.
Apart from assisting physicians in medical settings, PAs in direct primary care are also great allies in the non-clinical aspect of DPC.
PAs can help doctors with business operations-related tasks, like administrative work, human resource matters, and even sourcing vendors that could boost and optimize the DPC practice, like pharmaceutical vendors or appointment booking platforms.
It is important to note that most DPC practices are start-ups and/or small businesses, and so having a PA to rely on can be a big bonus for most direct pay physicians.
While some DPC and concierge medicine practices are run by physicians only, more and more practices are implementing collaborative practice models with PAs.
These practices have developed clinical approaches of employing staff with different levels of medical skill, including mid-level practitioners such as physician assistants.
In other medical settings such as rural or low-income communities, physician assistants are the patients’ first contact providers of primary care. In fact, some states allow physician assistants to work independently without needing physician supervision.
For physician assistants in the U.S., location is a major consideration because some states offer comprehensive practice regulations and more autonomy than others.
According to the American Academy of PAs (AAPA), there are three medical practice categories defined to determine a physician assistant’s scope of work.
Optimal - This is where PAs maintain a collaborative approach to patient care, working closely with other members of the healthcare team to ensure that patients receive comprehensive and high-quality care.
PAs consult with, refer to, or collaborate with other healthcare professionals as needed. They take into account the patient's specific condition, their own competencies, and the prevailing standard of care.
Additionally, healthcare teams and employers may develop guidelines that outline the parameters for collaboration, consultation, and referral, which may exceed the requirements outlined in state laws and regulations.
These laws often perpetuate outdated practice models that rely on limited delegated authority and restrictive supervision requirements, hindering the ability of PAs to provide high-quality, patient-centered care.
In the last three years alone, North Dakota, Utah, and Wyoming have eliminated legal requirements for PAs to be tied to a physician or any other healthcare provider. These three states are where PAs in direct primary care experience the most independence.
More than half of the states in the U.S. practice “moderate” or “reduced” categories of physician assistant implementation. Below is a diagram detailing which states practice what kind of PA category.
States in East, North Central and West U.S.A., such as Massachusetts, North Carolina, Rhode Island, Vermont, Michigan, Minnesota, Alaska, and Arizona, are known to be more lenient with PAs.
These states give PAs considerable autonomy and reduced restrictions unlike their neighboring states.
In Michigan, PAs are recognized as “full prescribers” because of the 2016 Healthcare Modernization Bill.
This bill grants PAs greater autonomy, even so far as recognizing physicians as “participating” rather than “supervising”. This removes the responsibility of having to supervise PAs within a medical practice.
States such as Massachusetts, North Carolina, Rhode Island, Vermont, and Minnesota are also the only five states to achieve all of the six key elements of a PA practice.
A bill enacted in 2016, called H.F. 1036, also removed administrative burdens for PAs starting their practice in Minnesota.
North Dakota, a generally rural state, offers some of the most autonomy for PAs. The state does not limit the number of PAs who can collaborate with a single physician.
The state also allows a PA’s scope of practice to be determined onsite. As per the Bureau of Labor Statistics, North Dakota is also among the top-paying states for PAs.
In contrast, states like Ohio, South Dakota, and Illinois limit the PA-to-physician ratio within their states, albeit they still allow practice autonomy and prescription authority to PAs.
As of 2023, the Bureau of Labor Statistics estimates 145,740 employed physician assistants across the United States, with 80,160 working in private physician offices and 14,060 working in outpatient care centers.
Another survey by the American Academy of Physician Assistants (AAPA) also notes that, out of the 19,830 PAs who participated in the study, “2,966 were employed in family medicine and another 1,768 in family medicine with urgent care provision.
25% of the participants were employed in solo practice physician offices and rural and community health centers.
The Bureau of Labor Statistics also reports that the mean annual wage of physician assistants in direct primary care is at $130,490. It is also interesting to note that New York and California have the highest physician assistant employment rates as of 2023.
Continuously evolving DPC models, as well as government legislation within the concierge medicine space, have the potential to increase the capacity of primary care delivery by PAs.
Bipartisan bills like H.R. 3029 (The Primary Care Enhancement Act) and H.R. 3836 (The Medicaid Primary Care Improvement Act), once fully implemented, shall give rise to notable changes within the healthcare industry.
The Medicaid Primary Care Improvement Act, or H.R. 3836, was already passed in November 2024.
This act simplifies DPC access for Medicaid patients, indicating that patients are no longer required to secure a Centers for Medicare & Medicaid Services (CMS) waiver to avail of direct primary care services.
On the other hand, H.R. 3029, or the Primary Care Enhancement Act, shall allow patients to use HSA accounts to pay for DPC fees once passed.
Both bipartisan bills will give greater primary care access to more American citizens, including lower income patients.
On that note, physician assistants in direct primary care are a vital way to manage the upcoming influx of patients in DPC and concierge medicine models.
Nonetheless, the ongoing industry debate on whether physician assistants should be allowed to work independently remains.
It appears that the industry is split between being for or against PAs having their own independent practices without the supervision of physicians.
Medical organizations like the American Medical Association (AMA) have come out with statements indicating that they do not support independent practices run by physician assistants.
Their reason is because they have not undergone the rigorous medical training that doctors have. Possible implications of this may include patient care not being as accurate or comprehensive as it should be.
In hindsight, it helps to have a diplomatic view on this ongoing debate. There are both benefits and drawbacks that come with letting PAs run their own independent practices.
The final say is left upon the organizations who make these decisions, and more importantly, the primary stakeholders of the healthcare industry: the patients who are on the receiving end of medical care.
As more and more practices realize the impact of PAs on patient satisfaction in direct primary care and concierge medicine models, PAs are slowly integrated as a patient’s first contact of care and entry into primary care practices.
Because PAs are well-versed in a wide selection of responsibilities, such as physical examinations, investigations, diagnosis and treatment as agreed with their supervising doctor, this upholds coordination of care and comprehensiveness of services.
Truly, the utilization of physician assistants in direct primary care has helped address the shortage and lapses in primary care delivery.
Because of the rigorous and physician-guided education they undergo, PAs in direct primary care are versatile, reliable allies that deliver effectiveness, patient satisfaction, safety, and outcomes of care highly similar to that of a physician.
PAs are well-positioned to help meet the growing demand for primary care services.
We can expect to see more PAs working in direct primary care settings, providing high-quality, patient-centered care to individuals and families.
As the profession continues to grow and mature, we can also expect to see more PAs taking on leadership roles in direct primary care, helping to shape the direction of the field and ensure that patients receive the best possible care.
The integration of PAs into direct primary care practices will likely become more seamless, with PAs working alongside physicians and other healthcare professionals to provide comprehensive, coordinated care.
The use of technology, such as telemedicine and electronic health records, will also continue to play a larger role in direct primary care, enabling PAs to provide more efficient and effective care to patients.
As the healthcare system continues to shift towards value-based care, PAs will be well-positioned to help drive this transformation, providing high-quality, cost-effective care that meets the needs of patients and payers alike.
Ultimately, the future of physician assistants in direct primary care is bright, and we can expect to see this profession continue to grow and thrive in the years to come.
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