Physicians looking to scale their practices cost-effectively face a tough choice when it comes to deciding who to hire. While bringing on another physician may seem logical, non-physician practitioners (NPPs)—also called mid-level practitioners—can be a superior alternative.
NPPs fall into two categories: nurse practitioners (NPs) and physician assistants (PAs). Many misconceptions exist about these two roles. The most common is that NPs and PAs are unable to practice at the same level as physicians. However, decades of studies have demonstrated that, when permitted to practice to the full extent of their training, NPs and PAs can perform a majority of the tasks that physicians do while providing the same quality of care.
In this article, we take an in-depth look at the benefits of NPs and PAs to help you determine which is the right choice to help you grow your practice.
NPs vs. PAs: A Side-by-Side Comparison
|Nurse Practitioners||Physician Assistants||Physicians|
|Degree(s) awarded||Master’s Degree or Doctor of Nursing Practice (DNP)||Physician Assistant Certified (PA-C), usually also a Master’s Degree||Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.)|
|Number practicing in U.S.||155,000||83,600||691,000|
|Percent in primary care||70-80 percent||31 percent||30 percent|
|Number of education programs in U.S.||257 DNP programs||170||141|
|Base salary (2010)||$89,845||$89,726||$173,175|
The Rapidly Growing NP and PA Workforce Can Help Fill the Looming Physician Gap
The American Association of Medical Colleges (AAMC) estimates that the U.S. will face a physician shortage of over 90,000 physicians by 2020; a figure that’s expected to reach over 130,000 by 2025. (11) This shortage is propelling NPs and PAs into an increasingly important role in primary care as more healthcare providers employ them to fill the gap. In 2012, 10 percent of all staffing requests from hospitals and clinics were for mid-level practitioners, compared to just two percent in 2010. (12)
Physician supply isn’t only failing to keep pace with the current demand—it’s losing ground. Primary care medicine residency programs declined by three percent between 1995 and 2006, while primary care training programs for nurse practitioners grew 61 percent. (13) NPs constitute the most rapidly growing area of the primary care workforce, with over 30,000 enrollees in NP programs each year. (14)
Ellen T. Kurtzman, MPH, RN, FAAN and an assistant research professor at The George Washington University School of Nursing, co-authored a 2012 Health Affairs report on the role of NPs in reinventing primary care. She believes the increase in NPs is good news for the healthcare industry.
“It’s likely to alleviate some of the unmet demand for primary care—demands which are projected to swell as the number of insured increases under the Affordable Care Act,” Kurtzman explains. “In states that have large rural, underserved and vulnerable communities, an increase in the number of nurse practitioners will expand access among the most needy.”
The PA workforce is also increasing to meet this demand. From 1991 to 2008, the number of practicing PAs more than tripled, from 20,000 to 68,000. (15) There is currently around one PA for every 10 physicians in clinical practice, and approximately one PA enters the U.S. workforce for every six physicians.
Along with higher demand, another contributing factor to the rapid increase in the number of practicing mid-level practitioners is the amount of education required to practice. NPs and PAs can enter the healthcare system after just two to three years of advanced training, compared with around eight years for physicians. (16)
NPs and PAs Offer Considerable Cost Savings in Many Areas
One of the most significant benefits of hiring an NP or PA is the sizeable financial savings they can yield. This comes from several areas:
Reduced salary expenses. The base physician salary of $173,175 (listed in the table above) is more than double that of mid-level practitioners. “If you can hire a PA, you’ll get something that is very similar for a fraction of the cost—that’s one of the biggest benefits for healthcare companies and physicians,” says Joshua Johnson, a PA for Oak Orthopedics in Bradley, IL. “You can get another person to help you practice and do almost the same things, and not have to pay what you would for a physician.”
Lower overhead costs. A study by the University of Texas Southwestern Medical Center found the overhead costs of PAs to be lower than physicians by department, patient demographics and medical care resource use. As a result, it’s estimated that a typical PA can boost the bottom line by $30,000 or more. (17)
Lower costs of care. A study in Tennessee found that costs at NP-managed practices were 23 percent below the costs of care delivered by other primary care providers. (18) This figure can translate into considerably lower costs for states. An analysis of NPs conducted by the RAND Corporation on behalf of the state of Massachusetts estimated total statewide savings of $4.2-$8.4 billion from 2010 to 2020, assuming the average cost for an NP visit to be 20 to 35 percent lower than that of a physician visit. (19)
Higher patient volumes. One study found that adding an NP to a practice could virtually double the typical patient panel and result in a yearly revenue increase of $1.65 million per 100,000 enrollees. (20)
Reduced insurance and liability costs. The liability risk cost for PAs has been found to be one-third of a physician’s liability rate, (21) and NPs have remarkably lower rates of malpractice claims and lower costs per claim. (22)
NPs and PAs Can Provide a Comparable Level of Patient Care
Despite their considerably lower salaries, NPs and PAs have a similar skill set to that of physicians. NPs can perform approximately 85 percent of the tasks that primary care physicians do, while it’s estimated that physician assistants can perform around 80 percent of tasks. (23, 24) These may include performing physical exams, writing prescriptions and ordering diagnostic tests, diagnosing and treating conditions such as diabetes or high blood pressure, and educating patients on health and lifestyle choices.
Many NPs and PAs have their own patient panels. “I do my own clinics, I see my own patients, and a couple of days a week I’m in the office by myself,” says Johnson.
While PAs cannot practice independently of physicians, there are approximately 250 practices across the U.S. that are run solely by NPs. (25) Nursing organizations seek to increase this number, and are currently pushing for legislation that will increase the number of states that permit NPs to practice independently from 16 to 30. (26)
Both NPs and PAs hold prescriptive abilities in all 50 states, (27, 28) though stipulations regarding controlled substances and the need for physician supervision vary by state. In terms of specialty, NPs tend to practice in primary care more often than PAs do, with 70 to 80 percent practicing in this area, compared with only 31 percent of PAs. Common specialty areas for PAs include emergency medicine, surgical subspecialties, pediatrics and internal medicine. (29)
NPs and PAs Have a Positive Effect on the Patient Experience
Studies have shown that NPs and PAs have an effect upon the patient experience that is comparable with, if not superior to, physicians. Consider these findings:
- According to a Berkeley HealthCare Forum report, a systematic review of 16 studies revealed that “no significant differences in patient satisfaction were found between NPs and PAs versus physicians.” (30)
- A survey released in Medscape found that only 50 percent of physician patients reported that they felt doctors “always” listened carefully, compared with more than 80 percent of NP patients. (31) Another report found that NPs “achieved consistently better results than their physician colleagues on measures of patient follow-up, consultation time, satisfaction, and the provision of screening, assessment, and counseling.” (32)
- A study in the British Medical Journal (BMJ) reported higher satisfaction rates among patients who experienced consultations with NPs than with doctors. (33)
- Studies have shown that PAs score equally with physicians in terms of patient satisfaction. (34) The Kaiser Permanente Center for Health Research found that patient satisfaction levels based upon interpersonal care, confidence in the provider and understanding of patient problems ranged between 89 and 96 percent for PAs. (35)
“When you start to build a history and rapport with a patient, they’re just as happy seeing a PA as a physician,” says Johnson. “It’s a matter of getting out that understanding of what we do to the general public.”
The effect an NP or PA has upon the patient experience can have serious implications for a practice. As the healthcare system continues to shift toward a patient-centric model of care, satisfaction ratings are becoming increasingly important. Popular consumer-facing websites like HealthGrades and Vitals let patients rate their experience, which can affect a practice’s retention rate and ability to accrue new patients.
NPs and PAs: More Than Just Health Care Providers
The biggest difference between NPs and PAs is in the role each plays beyond that of health care provider and is a direct result of the education each receives. PAs are trained according to the same model as doctors, forming an approach that focuses on the study of disease. The nursing-centric education model for NPs produces a more comprehensive approach that includes a health-promotion perspective. (36)
“NPs approach patient health care by looking at the patient as a whole, by looking at their social needs as well as their medical needs,” says Mary Bidgood-Wilson, CNM, FNP and the Executive Director of the New Hampshire Nurse Practitioner Association. “They bring a more holistic approach to treating the patient.”
This holistic philosophy of care leads NPs to approach and engage with patients differently than PAs. “Nurse practitioners also function as a combination of a patient educator and a social worker,” says Anne Norman, DNP, FNP and the Associate Vice President of Education for the American Association of Nurse Practitioners (AANP).
Kurtzman elaborates on this, saying, “Nurse practitioners are experts in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of common, and complex, acute and chronic diseases.”
By functioning as a “one-man shop,” NPs offer benefits that extend beyond those of PAs and can be a stronger fit for primary care practices. Their nursing background and education equips them with the ability to connect with and educate patients, leading them to rate highly in achieving patient compliance. (37) This results in fewer follow-up visits and lower hospitalization rates, (38) which translates to reduced healthcare costs.
As mentioned earlier, however, PAs tend to practice in specialty areas more than NPs. So while NPs may be ideal for a primary care practice, PAs may be a better choice for surgical, pediatric, or other subspecialties. As with hiring any new employee, practices must first identify their needs and conduct the appropriate research in order to determine the best course of action.
NPs, PAs and Physicians Don’t Have to Compete for Patients
To be successful, practices must enable all health care providers to function at the top of their license in order to provide patients with the best possible treatment. NPs and PAs are a valuable resource for practices looking for a cost-effective way to expand. They can perform almost all tasks as physicians and provide a comparable level of patient care.
But make no mistake—contrary to popular belief, NPs, PAs and physicians do not need to engage in a turf battle. “Perhaps one of the biggest misperceptions of all is that NPs, PAs and physicians have to compete for patients,” explains Dr. Mary Jo Goolsby, Vice President of Research, Education and Professional Practice for the AANP.
“If every nurse practitioner, physician assistant and physician were out there delivering care, there still wouldn’t be enough—there are so many more patients out there than we can handle. We all need to roll up our sleeves and do the best we can to meet their needs.”
1. American Association of Nurse Practitioners
2. Bureau of Labor Statistics
3. Bureau of Labor Statistics
4. Health Affairs
5. Agency for Healthcare Research and Quality
6. American Association of Colleges of Nursing
7. American Association of Medical Colleges
8. Staff Care
9. Health Affairs
10. American Association of Nurse Practitioners
11. National Center for Biotechnology Information
12. Utilization Solutions in Healthcare, Inc.
13. Health Affairs
14. American Association of Nurse Practitioners
15. Utilization Solutions in Healthcare, Inc.
17. LeMoyne College
18. The New York Times
19. The Washington Post
20. American Association of Nurse Practitioners
21. Berkeley Healthcare Forum
22. The Clinical Advisor
23. Health Affairs
25. Utilization Solutions in Healthcare, Inc.
26. The Permanente Journal
27. NGA Center for Best Practices
28. American Journal of Managed Care