IMPROVING PRIMARY CARE AND SAVING HEALTHCARE DOLLARS WITH PHYSICIAN EXTENDERS / PHYSICIAN ASSISTANTS (2022)

As Canada and the world emerge from two years of restricted health care access due to Covid and its resultant changes in the numbers of available physicians and senior health care workers, the notion of utilizing Physician Assistants/Physician Extenders makes more sense than ever. Physician assistants are educated under the same medical model used to train doctors but through a two-year graduate program. They can conduct patient interviews, provide physical examinations, perform diagnostic and therapeutic interventions, prescribe most medicines, order and read tests, and make referrals under the guidance of a physician.

The Canadian Association of Physician Assistants says a recent survey of its 800 members indicated 15 per cent want to work in BC[1]. It estimates that’s enough physician assistants to supply about 90,000 people with a primary care provider.

However, the provincial government says despite the strains on the system, adding the new position isn’t part of its plans.[2] Why not in BC? There is clear evidence that availability of primary care has significant implications for British Columbia’s economy both in terms of overall population health and the impact of employee productivity and absences on business. Though our government has made expanding availability of primary care a key priority, British Columbia suffers from a lack of primary care. In other jurisdictions, the shortage of primary care has been addressed successfully with the introduction of physician extenders, also called physician assistants. The terms are interchangeable. The British Columbia government should embrace the physician extender model so that our economy may reap the benefits of primary care and create new efficiencies in our healthcare system, truly providing universal, accessible health care for all.

Background

Macro level research indicates that health (measured in terms of life expectancy) is positively correlated with economic growth (measured in terms of GDP growth rate)[3]. Statistics show that two key drivers of employee absences:[4] either due to illness or to caregiving for family members[5] are health related.

The costs of illness-related impacts on business are immense, as demonstrated by statistics over the past fifteen years, even pre-pandemic:

• Conference Board of Canada: private sector organizations estimate direct cost of employee absences is 2.3% of gross annual payroll[6]
• Statistics Canada: in 2021, total work time missed due to illness or disability mushroomed to levels unseen previously due to the pandemic waves.

Against this backdrop, it is crucial to recognize the role of primary care in improving health outcomes and reducing the impact of employee illness on business.

• It has long been accepted and confirmed that availability of primary care is strongly linked to better health outcomes.[7] [8] In addition, a larger supply of primary care physicians is associated with lower costs of health services[9] [10] [11], and higher quality[12]. A healthier population means fewer employees who must miss work because they are sick or must provide care to a sick family member or friend.
• When employee illness occurs, primary care is in most cases dramatically more efficient than the alternative, a visit to the emergency room. Whereas physician office visits can be booked in advance to minimize work interruption, the emergency room waiting times in British Columbia are now routinely measured in terms of hours.

It is common knowledge that primary care is in short supply in British Columbia.[13] “The stats show that about 750,000 British Columbians do not have a family physician,” said Dr. Toye Oyelese, a West Kelowna family doctor and the current president of BC Family Docs. “We feel that it’s probably a little higher than that given the attrition that we’ve seen lately, and the numbers could be as high as 900,000.” The implications of BC’s primary care shortage for business are not hard to grasp. Less primary care means lower productivity.[14]

BC Budget 2019 was a disappointment with respect to healthcare investments. Health care spending for 2019 tops $21 billion. The Finance Minister said the previous government’s policies “didn’t work” but offered no specifics on the new government’s “team approach.” There was no mention of Physician Extenders. There is currently a call for a new Health Care Plan, whether as a time-limited task force, or one headed by health and finance ministries. The College of Physicians and Surgeons, patient groups and ministries must all get involved.

Can this problem be solved? One important step would be through the recognition of the Physician Extender/Physician Assistant in the Medical Services Plan Billing Scheme

A physician extender is a trained assistant who can perform several tasks that a family doctor normally performs. Physician extenders are able to relieve doctors of many less complicated cases, which frees physicians to handle more patients in general. Crucially, the medical-legal responsibility for the physician extender rests with a supervising physician, which ensures that physician extenders are delegated functions that are within their scope of practice. Accordingly, under the physician extender model, a physician retains primary responsibility for patient care, which distinguishes the use of physician extenders from other non-physician affiliated primary care models (e.g., independent nurse practitioners).

The United States pioneered the use of physician extenders in the 1960s. Their use of physician extenders has led to dramatic improvements in efficiency and PAs are widely accepted part of the primary care system in the United States.[15] The PEs and PAs profession is regulated in Manitoba, Alberta, Ontario and New Brunswick, according to the Canadian Association of Physician Assistants. Nova Scotia is near the end of a three-year physician assistant pilot project to address wait times. The military has also used physician assistants for over a century, though the term was only adopted in 1984.

In Canada, physician assistants were first introduced into the Canadian Forces to address a shortage of military physicians and remain an integral part of the armed forces healthcare system. Today, more than 800 physician assistants are working in clinics, communities and hospitals in Canada, qualified to do physical examinations, take medical histories, order tests, prescribe certain medications, and assist surgeons before, during and after surgeries.[16] Their taxpayer-funded salaries range from about $75,000 to $150,000, comparable to what nurse practitioners earn.[17] BC could expand its care profile, make clinics more profitable, and reduce the associated HR issues detailed earlier in this paper by adopted PAs immediately into the health care system. Issues around financial cost of expanding physical space in clinics can be dealt with through the range of financial models suggested by the Conference Board of Canada.[18] [19] Clinics in Peachland, Kelowna and Cranbrook all are experiencing first-hand not only physician shortages, but inabilities of physicians to expand their clinics for the potential inclusion of PAs without financial assistance.

The experience in other provinces demonstrates that physician assistants can improve health efficiencies in the Canadian health care setting.[20] [21] As the use of physician assistants expands, formalized post-secondary education programs for physician assistants have been established at the Universities of Toronto, McMaster University and the University of Manitoba.

The success and promise of physician extenders have not gone unnoticed by business. A report from the Conference Board of Canada[22] found that physician extenders are able to substitute for more than 29 per cent of a physician’s time, and that adding them to orthopaedic and emergency room care generates savings when they substitute for specialists’ time. The report also concluded that integrating more physician extenders into health care teams “can help alleviate the increase in demand, decrease wait times, and alleviate workforce shortages.”

THE CHAMBER RECOMMENDS

That the Provincial Government:

1. Integrate the role of “physician assistants/physician extenders” as an additional solution to the primary care shortage in British Columbia
2. Recognize PEs/PAs in the Medical Services Plan Billing Scheme
3. Provide British Columbia’s family physicians with the ability and incentives to financially integrate physician extenders into their practices
4. Support necessary training and regulation of PAs/PEs to ensure that British Columbians receive the best quality, most cost-efficient care.
5. Call a time-limited task force with representatives from doctors, health and finance ministries, oversight bodies and patient groups to address the systemic issues leading to lack of primary care for British Columbians.

[1] Canadian Press, February 20, 2022. https://www.winnipegfreepress.com/arts-and-life/life/health/physician-assistants-could-fill-part-of-bcs-need-for-more-doctors-advocates-576229122.html

[2] “Health Minister Adrian Dix said Sunday that introducing physician assistants would require developing new programs to train them. Instead, he said the government's focus is on doubling the number of nurse practitioners, who work in teams with doctors, dieticians and other care providers. ‘We don't exclude the idea of including physician assistants in that but our priority has been to increase the number of nurse practitioners,’ he said.” Physician assistants could fill part of B.C.'s need for more doctors: advocates, Brieanna Charlebois, The Canadian Press https://vancouverisland.ctvnews.ca/physician-assistants-could-fill-part-of-b-c-s-need-for-more-doctors-advocates-1.5789059

[3] D. E. Bloom, D. Canning, and J. Sevilla, “The Effect of Health on Economic Growth: A Production Function Approach,” World Development 32, no. 1 (2004): 1-13

[4] Employee absences cost the British Columbia economy more than a billion of dollars annually. Stewart, Nicole, “Missing in Action: Absenteeism Trends in Canadian Organizations,” The Conference Board of Canada, September 2013 http://www.conferenceboard.ca/e-library/abstract.aspx?did=5780

[5] Dabboussy, Maria and Sharanjit Uppal, “Work absences in 2011,” Statistics Canada, April 20, 2012 http://www.statcan.gc.ca/pub/75-001-x/2012002/article/11650-eng.pdf.

[6] Stewart, Nicole, “Missing in Action: Absenteeism Trends in Canadian Organizations,” The Conference Board of Canada, September 2013, http://www.conferenceboard.ca/e-library/abstract.aspx?did=5780. https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-11-90 Statistical estimates of absenteeism attributable to seasonal and pandemic influenza from the Canadian Labour Force Survey show the effects in 2022 continue to escalate as thousands leave the workforce and the healthcare system “is on the brink of collapse”

[7] Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x.

[8] Pierard, E. (2009). The effect of physician supply on health status as measured in the NPHS. Retrieved February 25, 2012 from http://www.rdc-cdr.ca/effect-physician-supply-health-statusmeasured-nphs.

[9] Hollander, M.J., Kadlec, H., Hamdi, R. & Tessaro, A. (2009). Increasing value for money in the Canadian healthcare system: new findings on the contribution of primary care services. Healthcare Quarterly, 12(4), 32-44

[10] Mark, D.H., Gottlieb, M.S., Zellner, B.B., Chetty, V.K. & Midtling, J.E. (1996). Medicare costs in urban areas and the supply of primary care physicians. Journal of Family Practice, 43, 33-9.

[11] Baicker, K. & Chandra, A. (2004). Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs, (Suppl. web exclusive), W4-184−197).

[12] Baicker, K. & Chandra, A. (2004). Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs, (Suppl. web exclusive), W4-184−197).

[13] “Physician assistants could fill part of B.C.’s need for more doctors: advocates - Pandemic and opioid crisis have highlighted B.C.’s lack of doctors” THE CANADIAN PRESS, Feb. 20, 2022 https://www.nanaimobulletin.com/news/physician-assistants-could-fill-part-of-b-c-s-need-for-more-doctors-advocates/

[14] BC Docs Report highlights challenges aspiring B.C. family doctors face – Nov 13, 2021. https://bcfamilydocs.ca/

[15] See B. Hague, The Utilization of Physician Assistants in Canada, An Environmental Scan, Health Canada, April 2005. Available online: https://capa-acam.ca/wp-content/uploads/2012/06/2005_The-Utlization-of-PA-in-Canada-An-Environmental-Scan.pdf

[16] P. Fayerman, “Pressure on government to recognize physician assistants”, The Vancouver Sun, November 6, 2018. Available online: https://vancouversun.com/news/local-news/pressure-on-government-to-recognize-physician-assistants and, https://capa-acam.ca/about-pas/pa-fact-sheet Canadian Association of Physician Assistants February 2022

[17] Ibid.

[18] Physician Assistants Are Making Health Care Accessible: Why not in BC? October 10, 2018 A presentation to the Select Standing Committee on Finance and Government Services, BC Patrick Nelson, Executive Director, CAPA-ACAM https://capa-acam.ca/pa-news/physician-assistants-are-making-health-care-accessible-why-not-in-b-c/

[19] http://www.conferenceboard.ca/e-library/abstract.aspx?did=8107; http://www.conferenceboard.ca/e-library/abstract.aspx?did=8347; http://www.conferenceboard.ca/e-library/abstract.aspx?did=9090

[20] Decloe, McCready, Downey, Powis Improving health care efficiency through the integration of a physician assistant into an infectious diseases consulting service at a large urban community hospital. Can J Infect Dis Med Microbiol. 2015 May-Jun;26(3):130-2. http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/26236353/

[21] M. Vanstone, S. Boesveld and K. Burrows, Introducing Physician Assistants to Ontario, Health Reform Observer, vol. 2, no. 1 (2014). https://mulpress.mcmaster.ca/hro-ors/article/view/1187/1226

[22] The Conference Board of Canada, Gaining Efficiency: Increasing the Use of Physician Assistants in C