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Research by Marty Stempniak

The country is bracing for a sizable physician shortage. The Association of American Medical Colleges estimates that already there's a shortfall of about 25,000 primary care physicians, and that will grow to 45,000 by 2020.

Even though the AAMC reported a 3.1 percent uptick in medical school applications in 2012, it will be years before those students enter the workforce as full-fledged doctors. Medical school and residency programs simply can't churn out graduates fast enough to relieve the shortage.

Some experts advocate for the increased use of physician assistants and nurse practitioners to help relieve the primary care shortage. These clinicians can perform some of the same duties as physicians, provide support to PCPs and help to coordinate care. "Everybody in policy has drunk the Kool-Aid of 'primary care is good,' and if you're a health system, investing in better primary care could very well save you money in the long run," says David Auerbach, a health economist with the RAND Corp.

NPs and PAs are critical to coordinated, team-based care models such as patient-centered medical homes and accountable care organizations, Auerbach notes. One study by RAND found that medical homes use 20 percent more NPs per doctor, and 10 percent more PAs than traditional models.

The supply of both professionals is expected to grow. There were about 155,000 practicing NPs in the country in 2010; that will balloon by 57 percent to 244,000 in 2025, RAND estimates. The PA supply will grow by about 73 percent during the same period, from 74,000 to 128,000, according to the American Academy of Physician Assistants.

Some groups, such as the American Academy of Family Physicians, have expressed skepticism about overusing NPs, particularly to replace the primary care physician. Advocates, on the other hand, point to studies showing that using NPs or PAs as part of the care team can yield equal or better care. "Medicine is a team sport, and it's something that PAs are really well-suited for and understand very well," says Tricia Marriott, a 26-year physician assistant who works in the advocacy department of the AAPA. "Patients need more access and PAs provide more access, in a variety of different settings."

Different states have different rules and regulations governing what NPs and PAs can and can't do. Advocates say it's important to allow these nurses to practice to their full abilities and not have them performing administrative duties or working as scribes. "We want to have privileges that reflect our skills of practice," says Mary Jo Goolsby, an NP and vice president of research, education and professional practice for the American Association of Nurse Practitioners. "Part of respect is not bringing us in to do something that really does not take a nurse practitioner to handle."

It's also important for hospitals to partner with academic institutions to create a steady stream of professionals and provide clinical sites for NPs to train and work, says Pam Thompson, CEO of the American Organization of Nurse Executives. NPs can be an ideal fit for rural or low-income areas where it can be harder to recruit physicians, she adds.

This gatefold explores the role of nurse practitioners and physician assistants, salary figures for the two positions, and recommended strategies to attract and retain such employees.


The gap between physician shortage vs. demand grows ...

There's a growing shortage of physicians that's only expected to get worse after full implementation of the Affordable Care Act. The Association of American Medical Colleges anticipates that the shortage in all specialties will grow from 7,400 in 2008 to 130,600 by 2025 (65,800 in primary care alone).

... but patient-centered medical homes are filling that gap.

The RAND Corp., a nonprofit focused on research and analysis, predicts that if patient-centered medical homes increase the number of patients they serve using NPs and PAs, it will help to relieve the physician shortage.


Questions worth asking when deciding to hire an NP/PA vs. MD/DO

Here are some questions and words of advice when thinking about hiring a nurse practitioner or physician assistant, as suggested by the American College of Physicians:

Before starting the search:

Do I want to hire a nurse practitioner or a physician assistant?

• Which are in greater supply?
• What duties do I need them to perform?
• What are the restrictions in my state?

Narrowing the list:

Are they qualified?

• Educate yourself about the certifications and regulations.
• Explore the state's guidelines.
• What is the person's experience level?

The Interview:

What about the interview?

• Who will I include in the hiring process?
• How will the PA or NP mesh with my staff?

After the hire — private and public hires:

How will I be reimbursed for the NP or PA duties?

• Medicare defers to state law in defining scope of practice, but doctors can bill one of two ways:

1: Under the PA's or NP's own name and National Provider Identification number
(reimbursed at 85 percent of the fee schedule)

2: By "incident to" services under the supervising physician's name and NPI
(reimbursed at 100 percent, though Medicare applies restrictive physician supervision
and treatment requirements)

• Private payers often take one of two approaches:

1: Enrolling the clinicians and having the practice bill under their own NPI and the group tax ID

2: Not enrolling them and having practices bill for services under the supervising
physician's name and NPI

Source: American College of Physicians, 2010


NP, PA salaries skyrocket over the past decade

Salaries for both nurse practitioners and physician assistants have shot up over the past decade or so. For NPs, the average full-time salary has increased by 43.4 percent since 2001, up to $90,583, according to the ADVANCE for NPs and PAs 2011 national salary survey of nurse practitioners. Meanwhile, the average PA salary has ballooned by 33.5 percent over the same period, up to $94,870, according to American Academy of Physician Assistants census reports.


A closer look at nurse practitioners and physician assistants

Nurse Practitioners

Definition: "Nurse practitioners are registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute health care services to individuals of all ages," according to the American Association of Nurse Practitioners. "NPs complete graduate-level education preparation that leads to a master's degree. NPs take health histories and provide complete physical examinations; diagnose and treat many common acute and chronic problems; interpret laboratory results and X-rays; prescribe and manage medications and other therapies; provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed. NPs are authorized to practice across the nation and have prescriptive privileges, of varying degrees, in 49 states."

Typical workplace setting in 2012:

Private physician - 29.0%
Hospital outpatient clinic - 23.6
Hospital inpatient - 9.8
Rural health clinic - 6.7
Emergency department/urgent care - 6.3
Private NP practice - 6.0
Retail-based clinic - 3.5
Long-term care facility - 3.5

Average salary by specialty in 2011:

Emergency department - $103,722
Neonatal unit - 99,810
Retail clinic - 96,800
Hospital - 96,124
Gerontology - 94,485
House calls - 93,785
Mental health - 92,396
Surgery - 91,023
Oncology clinic - 90,862
Cardiology clinic - 90,370
HIV clinic - 89,506
Family practice - 89,317
Diabetes/endocrinology - 88,397
Aesthetics/skin care - 88,106
Internal medicine - 87,950
Academia - 87,643
Corrections - 85,521
Women's health - 82,183
Pediatrics - 82,101
College health (12 months) - 80,521
Elementary or secondary school - 69,945
College health (9 months) - 60,684

Sources: American Association of Nurse Practitioners, American Academy of Physician Assistants, ADVANCE for Nurse Practitioners, 2012


Physician Assistants

Definition: "A physician assistant is a medical professional who works as part of a team with a doctor," according to the American Academy of Physician Assistants. "A PA is a graduate of an accredited PA educational program who is nationally certified and state-licensed to practice medicine with the supervision of a physician. PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling, and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice and prescribe medications."

Typical workplace setting in 2011:

Primary care - 30%
Other - 22%
Surgical subspecialties - 21%
Emergency medicine - 11%
Internal medicine subspecialties - 11%
General surgery - 3%
Pediatric subspecialties - 2%

Salary by specialty in 2011:

Mental health - $112,445
Surgery - $104,703
Emergency department - $101,688
Diabetes/endocrinology practice - $100,000
Cardiology practice - $98,209
Academia - $96,200

Sources: American Association of Nurse Practitioners, American Academy of Physician Assistants, ADVANCE for Nurse Practitioners, 2012


How We Did It

This gatefold was produced by researching published studies and articles and conducting interviews with hospital and industry executives.

Research: Marty Stempniak, mstempniak@healthforum.com

Design: Chuck Lazar, clazar@healthforum.com