This chapter summarizes the original practice environment index developed by Sekscenski et al, the 2000 update of this index and the new professional practice index developed in this study for Physician Assistants for the fifty States plus the District of Columbia.  It includes the following subsections:

• Introduction
• The Original Practice Environment Index for PAs
• The New Professional Practice Index for PAs
• Discussion

Detailed criteria and scoring sheets for the three professional practice indices for PAs for the 50 States and the District of Columbia can be found in Appendices C and D.

From the beginning, PAs have provided primary care services to patients in a wide range of settings including physician offices, hospitals, health clinics, correctional facilities, emergency centers, outpatient clinics, and a variety of military settings. PAs are recognized as providers of quality health services who are closely tied to physicians in medical practice. PAs work under varying degrees of supervision ranging from direct or personal supervision to indirect or remote supervision depending on the State in which practice occurs, on the setting in which care is offered and on the particular services which are being provided.  

In 2000 there were about 40,000 PAs in active practice^[32] working in both primary and specialty care. PAs are increasingly finding work in specialty practices including emergency medicine, allergy, orthopedics, cardiology, and neurosurgery.  In recent years, the supply of PAs has expanded considerably with a variety of opportunities emerging for the profession. The practice environments of PAs vary significantly across States.

The original PA practice environment index developed by Sekscenski et al for 1992 was based on three broad criteria and point allocations reflecting the then present practice environment for the profession. The specific criteria and point allocations used in creating the index were Legal Status (Maximum Score  = 20);  Reimbursement (Maximum Score = 40); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for the original index for PAs in 2000 are presented in Table C-2 in Appendix C.

The original practice environment index scores for PAs for the 50 States resulting from the criteria in Appendix C are summarized in Table 5-1. The scores show a definite trend toward greater professional practice opportunities across the fifty States and the District of Columbia between 1992 and 2000. The increases in the index scores indicate greater professionalization, socialization, and standardization of professional practice for PAs over the last decade.

To better reflect the subtle differences that often exist in professional practice across the 50 States, a new index was developed as part of this study that incorporates more criteria and more variability in the scores assigned. The new professional practice index more accurately reflects the practice environments of PAs across the U.S. Most States scored lower on the new index than on the original index for 2000, which reflects the greater ability of the new index to distinguish subtle differences in professional practice that the original index.

The broad scoring criteria for the new PA Professional Practice Index are the same as for the original index, but the point allocations are different. The new PA index incorporates more detailed criteria than those used in the original index to more accurately reflect the practice environments of PAs across the U.S. The three criteria are: Legal Status (Maximum Score  = 35);  Reimbursement (Maximum Score = 25); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for each of the criteria in the new index for PAs for each of the 50 States are presented in Appendix D.

The resulting professional practice index scores for PAs are presented for the 50 States in Table 5-1. A qualitative overlay has been applied to the new index scores to identify States that provide Excellent, Favorable, Acceptable, Limiting, and Restrictive practice environments for PAs. These are not hard-and-fast terms or categories, and they are provided only to help readers to characterize the practice environments in the different States. The ratings do generally conform to characterizations of the practice environments in States by knowledgeable PAs.

The scores on the original PA practice environment index reveal a trend toward greater professional practice options for PAs across the fifty States and the District of Columbia between 1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, and standardization of the PA profession over the last decade. Additional analyses of the index scores are described and summarized in Chapter 7.

As is true with many such indices, the true differences that underlie small differences in the scores are generally very small. Thus, States that are close on any of the indices are not significantly different in their professional practice. The authors have applied a qualitative overlay to the new index scores to identify States they believe provide Excellent, Favorable, Acceptable, Limiting, and Restrictive environments for PAs. These are not hard-and-fast terms or categories, and they are provided only to help readers to characterize the practice environments in the different States in a more qualitative way. The terms do generally conform to characterizations of the practice environments in States by knowledgeable PAs.

Comparisons of individual PA professional practice scores on a State-by-State basis should be made with caution. The scores reflect general, not particular, conditions in the State regulatory environments. Comparing one State with another on the original index may not fully indicate the similarities or differences in actual practice patterns. The index is a good indicator of the trend toward broader practice environments, but it does not effectively capture the detailed variations in State requirements.