Understanding the Geographic Distribution of PAs in the US

Despite the steadily growing number of physician associate (PA) certifications across the country, where these healthcare providers eventually land after graduation varies — dramatically. Research on the distribution of PAs across the country demonstrates that PAs may not always gravitate where you think they would. So where are PAs practicing, and what factors drive them to those areas?

“There are many different factors that impact the density of healthcare providers — population size, state practice laws, quality of life, and recruitment efforts, just to name a few,” said Chantell Taylor, chief of Public Affairs & Advocacy at the American Academy of Physician Associates (AAPA). Taylor told Medscape Medical News that numerous studies have looked at where PAs decide to practice, findings clearly show “there isn’t a significant association between the number of providers and the population of the state.” Factors like compensation, autonomy, burnout levels, employer type and relationship, and home state, among others also play a role.

Wide, Open Spaces

Despite its immense size, Alaska has a population of just over 733,000 — making it one of the least populated states in the country. Yet, it boasts a ratio of over 93 PAs per 100,000 residents, the highest in the country. Teresa Lowe, PA-C, based in Anchorage, said this doesn’t surprise her. The vastness of the 49th state, as well as the socioeconomic status of the average resident, means that healthcare access can be hard to come by.

“I grew up in Mountain Village, which is 90 miles northwest of Bethel, which is 400 miles northwest of Anchorage,” she said. “Coming from a place like that, you understand that if someone has a significant healthcare issue, you often have to travel by air, at significant expense, to the nearest hospital or clinic.”

When these smaller communities have PAs in residence, however, patients can more easily access regular care. Lowe added that one of the biggest “assets” of practicing in the state is the collaborative relationships — and mutual respect — between different types of healthcare providers.

“It doesn’t matter if you are trained as a nurse practitioner, a doctor, a PA, or other trained healthcare provider,” she said. “There are such limited resources that we work together to help patients. We share as much of our knowledge as we can so we can support our patients to the best of our ability.”

Pushing PA Growth in Underserved Areas

In contrast, the state of Mississippi, which has a population of 3 million, has the fewest PAs per 100,000 people: Only slightly over 14. Mary King, MPH, PA-C, CAQ-Psych, a founding facility member at the University of Southern Mississippi’s PA program, Hattiesburg, Mississippi, said the state is also significantly under-resourced from a healthcare standpoint. Yet, the lack of PA roles, she argued, is the result of Mississippi being the last state in the nation to legalize PA practice.

“We’ve been behind everyone else, and our state also has the least amount of PA programs. That’s made for a slow growth process,” she said. “And because [other healthcare practitioners] in the state may not be as familiar with us in academic training institutions and residency programs, they don’t necessarily know how to best incorporate a PA into their practice.”

Beyond educating healthcare organizations about the value of PAs, however, Taylor said PAs also tend to gravitate toward areas with modernized healthcare practice regulations.

“In one study, we found that regulations changing the supervisory definition of the PAs relationship with physicians, granting full prescriptive authority and removing physician on-site/proximity/in-person meeting requirements, predicted an increase in PAs per 1000 residents between 2015 and 2019,” she said. “This speaks to the need to modernize PA practice laws to ensure that providers are able to serve patients in the areas where the need is greatest.”

Other Factors Influencing Location Selection

Each year, the National Commission on Certification of Physician Assistants (NCCPA) conducts surveys to understand the demographic characteristics of both new and experienced PAs. Andrzej Kozikowski, PhD, senior director of Research at the organization, said pay is a leading factor where PAs decide to practice.

“It’s not hard to imagine that a PA looking at different states will look at income,” he said. “And if you see that one state will offer you $20,000 more per year to work there, of course, the PA will pick that state.”

Then there’s the matter of loan repayment. Alicia Quella, PhD, PA-C, said that the majority of PAs graduate with a significant amount of educational debt. However, different programs offer scholarships or loan repayment opportunities if a PA is willing to work in a medically underserved area or healthcare professional shortage area.

“Those kinds of programs will tie new PAs to a rural area or urban area of need,” she said. It could help to explain why states like Montana (83 PAs/100,000), New Hampshire (79 PAs/100,000), and South Dakota (78 PAs/100,000) have relatively high PA-to-resident ratios.

Yet, the NCCPA’s annual survey querying newly certified PAs demonstrates that money isn’t everything. Colette Jeffery, MA, an NCCPA research analyst, said that nearly every year they’ve conducted the study, PAs report that home is where the heart is.

“For all the years we’ve been doing this survey, the number one thing we see is PAs saying that they are going back to where they grew up,” she said. “Number two, they say they found a job in the area where their PA program was located.”

Certainly, that plays a large role in why Lowe still practices in Alaska. Her grandmother was a midwife, and her mother was a health aide and a PA herself. Lowe said practicing healthcare is “kind of in our blood.” Alaska is home, she said, and she appreciates working in a place where she can continually expand her knowledge and skill set.

“This is a place where you can see firsthand the effect of the care you are giving. It’s very rewarding.”

Kayt Sukel is a healthcare and science writer based outside Houston.