Using More Hospitalist PAs Lowers Costs Without Hurting Quality of Care

November 2nd, 2016

ANNAPOLIS, MD – Lowering the cost of hospitalist programs by increasing the percentage of patients treated by physician assistants does not appear to affect the quality of care, according to a new study.

The article in the Journal of Clinical Outcomes Management points out that increasing numbers of medical centers employ hospital-based internal medicine specialists who coordinate the complex care of inpatients. The question is how to manage those costs.

The 18-month study, conducted at Anne Arundel Medical Center in Annapolis, compared two hospitalist groups:

• one with a high physician assistant (PA)-to-physician ratio ("expanded PA"), and
• one with a low PA-to-physician ratio ("conventional").

"We believe this is the first study of its kind of directly compare outcomes and costs between different staffing models using hospitalist PAs and hospitalist physicians,” explained senior author Henry Michtalik, MD, MPH, MHS, an assistant professor of medicine at Johns Hopkins University School of Medicine. “It shows that the expanded use of well-trained PAs within a formal PA-physician collaboration arrangement can provide similar clinical outcomes with lower costs, potentially allowing hospitalists to provide additional or different services.”

For the study, which was conducted between January 2012 and June 2013, the expanded PA group consisted of three physicians and three PAs, with PAs caring for 14 patients each day.

That system was compared to a conventional hospitalist group composed of nine physicians and two physician assistants who cared for nine patients each day. In both groups, physicians cared for about 13 patients a day.

In the expanded PA group, 35.73% of visits were conducted by a PA, compared to 5.89% in the conventional group.

The report points out that PAs were responsible for independent rounding and clinical decision-making, but physicians in both groups took primary rounding responsibility for patients with more complex cases. In addition, an in-person physician visit was mandated at least every third hospital day in both groups.

Prearranged consultations with primary care physicians determined the group to which patients were assigned.

According to the results, 14.05% of patients were readmitted within 30 days in the model with greater PA involvement vs. 13.69% in the conventional staffing model, while the mortality rate in the PA group was 1.3% compared to a 0.99% in the conventional care group. Neither is considered statistically significant.

The overall costs for the study's "standard" patient -- between 80 and 89 years old with Medicare insurance and a categorized major severity of illness, defined as the extent of physiologic decompensation or organ system loss of function -- was found to be $2,644 in the expanded PA group, with an average consultant use of 0.55 and 4.1 day length of stay, plus or minus 3.9 days, and $2,724 in the conventional group, with an average consult use of 0.56 and a median length of stay of 4.3, plus or minus 5.6 days.

"The expanded PA model could free up physicians' time to focus on more complex cases or allow hospitalists to provide additional or different services," noted Michtalik, who added that a limitation to the study is that the research focused only on a single medical center.