Physician assistants, nurse practitioners fill gap on primary care

(Idaho Statesman) The statistics sound abysmal. Idaho is at the bottom of national rankings for doctors per capita. Almost the whole state has a primary-care doctor shortage. And after many of Idaho’s doctors retire in the next several years, it’ll be even worse.

Most health care leaders agree that Idaho is struggling with a paucity of doctors who can cure most of what ails you. They are bracing for 2014, when tens of thousands more Idahoans are projected to start seeking primary care.

But the situation is not quite so bad when nurse practitioners and physician assistants are considered. Idaho might rank dead last in the U.S. for primary-care doctors per person, but it is tied for 14th for physician assistants and 45th for nurse practitioners, according to the Kaiser Family Foundation’s latest data.

The people responsible for much of Idaho’s primary health care are assembling teams that include NPs and PAs to help ease the crisis.

“I don’t think we have our primary care needs met” in Idaho, but “I definitely think they’re filling an important role as part of the health care team,” said Patrice Burgess, a family doctor for Saint Alphonsus Health System.

Burgess’ clinic on Overland Road in Boise is one of the pilot sites for a model of patient care that stresses the team approach. Her office has four doctors each working with teams of four or five people, including a physician assistant, nurses and other non-physician employees. Each team sees about 20 patients a day.

The demand for PAs and NPs has risen, and so has enrollment at Idaho State University for both professions.

The ISU physician-assistant program started in 1995 with 20 students on the main campus in Pocatello. It has grown to 60 students with a satellite campus in Boise. The program received 500 applications last year.


The school’s distance-learning program for family nurse-practitioners started a few years before the PA program with 10 students, and it has quadrupled since then, said Cathy Arvidson, the program’s coordinator and associate professor.

Noting that the Idaho Department of Labor expects the number of PA jobs in Idaho to grow more than 40 percent between 2008 and 2018, ISU recently announced it will launch a PA program at the College of Idaho.

Of the more than 500 graduates from the program, most have found jobs in Idaho, thanks to demand in rural areas or community clinics that don’t attract as many doctors, said Paula Phelps, program director and PA. The same is true of nurse practitioners fresh from the ISU program. Some graduates have moved to hamlets in northern Idaho to do primary care for those communities.

There are continuing efforts by the program that help pay for medical students from Idaho, Wyoming, Alaska and Montana to attend medical school at the University of Washington, and by the Family Medicine Residency of Idaho, to bring more beginning doctors to the state, especially to small, remote towns. But the primary-care shortage in rural Idaho persists.


There’s no primary-care doctor shortage in Ada County — though there is in Canyon County — so PAs and NPs aren’t finding many jobs in Boise and its suburbs.

But in some Idaho clinics, like the ones operated by the nonprofit Terry Reilly, physician assistants and nurse practitioners outnumber physicians.

“They’re critical,” said Bethany Gadzinski, Terry Reilly’s homeless services and medical operations program manager. Through PAs and NPs, the Terry Reilly clinics have been able to meet primary-care needs for rural communities like Homedale, Melba and Marsing, Gadzinski said. It still can take a while for a patient to get a primary-care appointment in the Boise metro area, though, she said.

“We see a lot of satisfaction among our (PAs and NPs), because they are getting to practice at a higher scope” than in non-shortage areas, said Katrina Hoff, workforce development director for the Idaho Primary Care Association.

Physician assistants and primary-care doctors of all stripes made up equal shares of full-time staffs in Idaho’s community health centers last year, and they each handled about one-fourth of all the visits to those clinics, according to federal data. Nurse practitioners made up about 2.3 percent of full-time staff and took 10.8 percent of the visits.


Physician assistants and nurse practitioners also make up a large number of the providers at Primary Health Medical Group, a business with 12 offices in the Treasure Valley. An urgent-care patient there is at least as likely to find a family nurse practitioner or a PA as a doctor.

Nurse practitioners can prescribe drugs and see patients without a doctor’s supervision, though they collaborate with doctors. Physician assistants can work independently but must be supervised by a licensed physician.

In Idaho, doctors can supervise up to three physician assistants at the same time, or up to six with a waiver from the state Board of Medicine. Caps on the number of PAs a doctor may supervise at one time can limit opportunities for PAs.

“There’s a push nationally to get all licensed providers to work to the full ability of their training, and one of the obstacles is the number of PAs that can be under a physician,” Phelps said.

Advocates see loosening of the caps as one possible way to give patients more access, she said.


“Through our combination clinic model, Primary Health continues to see growth and success,” said David Peterman, a pediatrician who heads the company. “We have expanded hours of operation at many of our clinics and recently opened a new location to serve the Downtown [Boise] community.”

Nurse practitioners and PAs also are part of the model that St. Luke’s Health System is moving toward.

St. Luke’s had 136 PAs and NPs on staff as of August. In some of its clinics, such as those in eastern Oregon, those providers equal the number of doctors on staff. Saint Alphonsus employs 84 NPs and PAs.

“Most of our shortage we’re seeing really in the rural areas,” said St. Luke’s spokesman Ken Dey. “We’ve had a bit of a surge in family medicine physicians that has offset some of the demands.”

The system added 30 nurse practitioners and physician assistants in the 2012 fiscal year and has budgeted to add 43 more in fiscal 2013.

“They are definitely helping,” Dey said.

In Canyon County, West Valley Medical Group has 10 primary-care doctors who work in concert with seven nurse practitioners and physician assistants.

The group added three doctors and two NPs/PAs in the past year, according to Wendy McClain, spokeswoman for West Valley Medical Center in Caldwell. The center found the community needed 34 more primary-care providers in 2011, and it expects those needs and its own primary-care staff to grow in the next few years.