Physician Assistant vs. Nurse Practitioner

One of my favorite things about medicine is that it is always fluid and ever changing.

Guidelines, pharmaceuticals, and scientific studies are constantly in motion; each new piece of information allows us to take better care of our patients.

Like medicine, the professions within healthcare are also changing. The job demand for physician assistants and nurse practitioners are both expected to grow upwards of 30 to 35% within the next 10 years (Bureau of Labor Statistics, 2018), which is surprising for professions that did not exist 100 years ago.

So, how does one decide which path is best? Aren’t the terms interchangeable? Not exactly.

Today, we’ll look at the roles of PAs and NPs and cover two important topics within each profession: physician assistant vs. nurse practitioner salary and physician assistant vs. nurse practitioner scope of practice.

 

My Path to Becoming a Physician Assistant

I have been fortunate enough in my career prior to becoming a physician assistant as well as in my current role as a family practice and urgent care PA, to interact with a multitude of professions on a daily basis, including both PAs as well as our nurse practitioners.

Prior to applying to PA school, I did not really think much about salary or scope of practice, but in my professional career I have realized how important both are.

Before we delve a little bit deeper into both of these important topics, I’d like to add a disclaimer: Salary and scope of practice are both important pieces of the decision to pursue a career path, but they are among two of the many, many things that go into this decision.

If you’ve spent time with me during a mock interview for our pre-pa platform, you will know that I believe salary is an important piece, but should never be the primary reason to pursue a career.

After graduating from the grueling experience that is PA school, students go out to look for jobs in their respective fields. Upon my graduation, I felt a bit overwhelmed by contracts, job offers, and salary in particular.

A quote from one of my favorite authors Atul Gawande sums up my thoughts: “...I was stumped. How much do surgeons usually make, I asked” (Gawande, 113). In relation to the expanse of my education, clinical experience, and role, I also had little idea what a reasonable salary should be.

Our first goal today will be to cover some of the data related to PA and NP salary to help students identify some basics, compare the professions, and become more aware of the financial aspect of the professions.

 

Average Physician Assistant Salary

Our profession has the blessing of the AAPA (American Academy of Physician Assistants) which publishes a once per year annual salary report. According to the 2018 report, the median pay for PAs in the United States is $105,000.

Base salary is defined as an annual fixed income, with the median hourly rate for PAs at $60.00 on the nose. According to the AAPA’s calculations, this was a 2.6% growth from the previous year. The highest 10th percentile for PAs earned greater than $150,000 per year. According to the Bureau of Labor Statistics, the median salary for PAs in 2018 was $108,610.

Of course, it is important to note that there are numerous variables playing a role in a particular salary, the most influential being geographic. The AAPAs report found that the highest median pay was in California and Alaska, at $125,000 and $130,000 respectively. We must also consider cost of living in these regions as well. Lower paying states were coupled with lower cost of living lifestyles.

The mean salary does not take into account other aspects of compensation, including PTO, holidays, health insurance, but is strictly the raw salary annually. The comprehensive study of 9,140 PAs by the AAPA found that up to 48% of PAs received some type of bonus, with ½ of those PAs reporting a greater than $6000 bonus. Reasoning for bonuses cited by PAs included major career milestones, productivity bonuses, etc.

The structure of pay in general also varied throughout the study, with some PAs being compensated directly as a strict salary, others working hourly, while still others were compensated entirely based on their productivity.

 

The Average Nurse Practitioner Salary

In comparison to the nurse practitioner profession, this reader found very similar data across multiple organizations. According to the Bureau of Labor Statistics, the mean annual salary for nurse practitioners in 2018 was $113,930 (Bureau of Labor Statistics). The mean hourly pay was $55. It is important to note that this does not take into account other benefits, bonuses, or other compensation.

In concordance with what we see in the physician assistant profession, there is great variability among compensation and cost of living based on geographic area. NPs in California typically make much more than those in Florida (median pay of $126,770 versus $99,930, but cost of living must also be taken into account. Geographic trends showed west coast states such as CA as well as the New England states with the highest overall pay.

 

Increasing Demand for Both Professions

The role for rapid expansion in both careers is notable throughout the general media as well as throughout our profession. The nurse practitioner profession is expected to grow by 31% within the next 10 years, while the physician assistant profession is expected to grow by 37%, both labeled as “much faster than average”. (Bureau of Labor Statistics, 2019).

As a result of the increased demand for both PAs and NPs, the writer sees two potential outcomes. In accordance with the increased demand, many new PA and NP programs have begun, with some institutions even beginning to offer online programs to churn out graduates faster. Although the need for PAs and NPs being high is good for both professions, caution must be exercised by programs to assure that graduates know their worth and are able to negotiate for higher salaries.

Health systems may be willing to increase pay due to demand for both professions, but clinicians must know their worth. An additional concern is the cost of education, the rising student debt crisis, which some people think puts great pressure on new graduates to take whatever salary they are offered.

 

Scope of Practice

Another important factor to be mentioned that can vary between physician assistants and nurse practitioners is scope of practice. Scope of practice is the care, procedures, and actions that a PA or NP is allowed to undertake in relation to their license. Both PAs and NPs have similar general explanations on both the American Academy of Physician Assistants and American Association of Nurse Practitioners webpages.

The AAPA describes a PA as someone who “can perform history and physicals, diagnose illnesses, create treatment plans, prescribe medications, and assist in surgery”.

The AANP describes scope as working “autonomously and in collaboration with health care professionals and other individuals, NPs provide full range of acute and specialty care services”. (AAPA and AANP websites)

The scope of practice for physician assistants is variable with the state one practices in. In general, the AAPA describes the four main factors which contribute to establishing a scope of practice as education and experience, state law, policy of the employer/facility, and the needs of the patient.

PAs are required to graduate from an accredited program, pass the NCCPA board exam (PANCE), and receive a medical license from the state they choose to practice.

The AAPA maintains that the vast majority of scope of practice occurs at the practice level and that scope of practice is fluid and adaptable over time.

In my experience, my practice has changed as I have progressed throughout my career, in that I have been able to master more procedures after initially performing them under the supervision of my supervising physician.

In addition to this, my number of patients per hour/day has increased, and so has the complexity of patients. Many times in the hospital setting, clinicians will request privileges through the hospital and the PA may have to perform a certain number of procedures with their SP prior to performing them independently.

According to the American Medical Association, PAs in 47 states are required to have a supervising physician, be it an MD or DO. The amount of PAs a physician is allowed to supervise varies state by state. In fact, the vast majority of states determine the overall scope of practice at the individual practice site and this may vary with location, experience, and overall comfortability between physician and PA.

The individual states in regards to scope of practice vary as well. It was very interesting in my research to see the very different legislation and rules in regards to a supervising physician co-signing a physician assistant’s charts.

Some states, such as my place of practice in Pennsylvania require initially that all notes be signed by a physician, while other states such as MA, NY, NC do not require notes be co-signed by a physician. Other states indicated that “10% per month” would be signed, while other states were less clear, indicating that “regular ongoing evaluation of a representative sample of charts” was necessary.

The term supervising also varied as well, some states indicated that the physician needed to be on site with the PA, while others indicated that the physician needed to be available for consult via some type of telecommunication. (AMA 2018)

In regards to nurse practitioner scope of practice, the researcher immediately finds that the language differs greatly in description, authority, and scope. The term “licensed independent practitioner” immediately jumps out, but when describing the assessment, treatment, management of acute and chronic illness, one is left to question how the scope between PAs and NPs differs.

The term supervising is the hallmark of the PA to physician relationship, while NPs advocate for the term collaboration, which in many cases is more accurate for both professions.

The education as discussed for PAs is similar, nurse practitioners usually have a background in nursing, with many students having a previous R.N. degree, working clinically for some time. Passing an accredited program, passing the national board exam, and obtaining a license in the state of practice are required.

Again, the language dictates collaboration and many states allow for granting of independent practitioner status. Many states require no supervising physician, but other states mandate “collaborative agreements” which are similar to the supervising physician agreements as discussed above. In many states, such as Connecticut, the first three or so years are required to be supervised by a physician, while other states leave it up to the practice site.

Regardless of role and scope of practice, PAs and NPs continue to play a pivotal role in the healthcare field in general. With the projected shortage of primary care physicians over the next few years, PAs and NPs will continue to expand their roles in health care in general, particularly in primary care.

Salaries should continue to rise accordingly with demand, but programs should be wise to teach students negotiation skills, to protect salaries. Scope of practice will continue to be discussed for both professions, but may continue to be adaptable over time.

 

References

American Academy of Physician Assistants (2018). 2018 AAPA Salary Report. Date of Access 29 May 2019.

American Academy of Physician Assistants Website (2019). Date of access 29 May 2019.

American Association of Nurse Practitioners website (2019). Date of access 29 May 2019.

American Medical Association (2018). Physician Assistant Scope of Practice. AMA Advocacy Resource Center.

American Medical Association (2018). Nurse Practitioner Scope of Practice. AMA Advocacy Resource Center.

Bureau of Labor Statistics (2019). Nurse Practitioners. Department of Labor.

Bureau of Labor Statistics (2019). Physician Assistants. Department of Labor.

Gawande, Atul (2007). Better. Picador Publishing.