Nurse Practitioners and Physician Assistants: Supply, Distribution, and Scope of Practice Considerations A resource provided by Merritt Hawkins, the nation’s leading physician search and consulting firm and a company of AMN Healthcare (NYSE: AHS), the largest healthcare workforce solutions company in the United States. www.merritthawkins.com 800-876-0500 © 2015 Merritt Hawkins 5001 Statesman Drive Irving, Texas 75063 NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS: SUPPLY, DISTRIBUTION, AND SCOPE OF PRACTICE CONSIDERATIONS A resource provided by Merritt Hawkins, the nation’s leading physician search and consulting firm and a company of AMN Healthcare Introduction Many (though not all) healthcare policy analysts agree that the United States is in the midst of a widespread and growing physician shortage. The dearth of doctors has placed a growing premium on advanced practitioners, including nurse practitioners (NPs) and physician assistants (PAs) who can perform many of the duties performed by physicians. NPs and PAs also fit the concept of team-based care, in which a variety of clinicians work in a coordinated manner, performing tasks appropriate to their training on behalf of patients. Estimates suggest that primary care physicians taking sole responsibility for the care of their patients would need to spend 18 hours per day to provide a full range of diagnostic and preventive services, supporting the implementation of the team-based model of care (Transforming Primary Care: From Past Practice To the Practice of the Future.” Health Affairs). Additional factors driving the use of NPs and PAs include: o The focus on primary care. The Association of American Medical Colleges (AAMC) projects a deficit of 91,000 physicians by 2025, including a deficit of 31,000 primary care physicians. Advanced practitioners are being used to make-up this deficit, particularly NPs, 87% of whom are in primary care. o Scope of practice. State legislation has created an increasingly favorable environment for PAs and NPs to practice. Over 97% of NPs can prescribe medications while 20 states and the District of Columbia allow NPs to practice completely independently. PAs are also benefitting from a changing landscape, including reduced physician oversight and greater prescriptive authority. o Cost. With median salaries of both PAs and NPs ranging at around $100,000, advanced practitioners are a relatively cost effective source for clinical care. NPs and PAs by the Numbers Below are some key highlights of the PA and NP marketplace: Physician Assistants There are over 104,000 PAs in the United States: o About one-third work in primary care, about two-thirds work in specialties o PAs can prescribe in all 50 states o The number of PAs has increased 100% over the past decade o PAs earn a median salary of $90,000, with annual compensation totaling $100,000 o 67% of PAs are women, 33% of PAs are men o 19% of PAs are younger than 30, 56.8% are 30 to 49 years old, and 24.3% are 50 or older Source: American Academy of Physician Assistants (AAPA) Nurse Practitioners There are over 190,000 NPs practicing in the United States: o An estimated 15,000 NPs complete their training each year o 97.2% of NPs prescribe medications, averaging 19 prescriptions per day o NPs hold prescriptive privileges in all 50 states and Washington, D.C., and can prescribe controlled substances in 49 states o 87.2% are focused on primary care o Mean base salary for NPs is $91,310, and average full-time NP income is $98,760 o 70% of NPs see 3 or more patients per hour o 96% of NPs are female o The average age for NPs is 48 years old Source: American Academy of Nurse Practitioners (AANP) As advanced practitioners, both PAs and NPs provide a specialized skill set, with different levels of training, scope of practice, and expectations as to how they fit into staff-models. Following is an examination of these considerations, including supply of PAs and NPs by state, scope of practice by state for each practitioner, and how these considerations fit into the team-based model of care. Training and Utilization NPs and PAs bring a unique skillset to the team-based model of care, each defined by the training that they receive and the way in which they are utilized PA Training and Practice Areas A Physician Assistant is a health care professional who is licensed to practice medicine under physician supervision. The PA’s role is to conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on prevention, assist in surgery and write prescriptions. A candidate is eligible for a PA training program after receiving a Bachelor’s degree with appropriate prerequisite coursework in behavioral and basic sciences, along with “hands-on” healthcare experience prior to matriculation and appropriate GRE/MCAT scores. Candidates accepted into PA training programs then complete a 26 month degree program as accredited through the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) to obtain a Master’s degree in either Physician Assistant Studies (MPAS), Health Science (MHS) or Medical Science (MMS), along with completing more than 2,000 hours of clinical rotations during education. Following this, graduates are eligible to complete the PANCE (Physician Assistant National Certifying Exam) administered by NCCPA (National Commission on Certification of Physician Assistants) to be certified as a PA. PAs then must obtain state licensure to practice. In order to maintain national certification, PAs must complete 100 hours of continuing medical education every 2 years and pass a recertification exam every 10 years. According to the AAPA Annual Survey Report for 2013, the majority of PAs that practice clinically choose to do so in various specialty areas. The numbers below show PAs by specialty area and practice type: Specialty Area General Surgery & Surgical Subspecialties 26.0% Family Medicine 23.2% General Internal Medicine & IM Subspecialties 14.8% Emergency Medicine 10.6% General Pediatrics & Pediatric Subspecialties 3.4% OB/Gyn 2.0% Occupational Medicine 1.5% Other 18.4% Source: 2013 AAPA Annual Survey Report Practice Type Single Specialty Physician Group Practice 18.7% Inpatient Unit of Hospital (not ICU/CCU) 10.6% Solo Physician Practice Office 10.4% Hospital Emergency Room 9.5% Multi-Specialty Physician Group Practice 9.2% Outpatient Unit of a Hospital 7.3% Hospital Operating Room 6.0% Other 28.3% Source: 2013 AAPA Annual Survey Report NP Training and Practice Areas A Nurse Practitioner is an Advanced Practice Registered Nurse (APRN) who has completed graduate- level education (either a Master of Nursing or a Doctor of Nursing Practice degree). An NP treats physical and mental conditions through physical exams, comprehensive evaluation of medical history, and ordering and interpreting diagnostic tests. Nurse Practitioner training involves completion of the education and clinical experience necessary to be a registered nurse (RN). This is followed by graduate-level NP program (either a Master’s or Doctorate), and national board certification in their area of specialty. If a Registered Nurse is trained at the associate (two-year) degree level, he or she must complete a Bachelor of Science (BSN) degree before they can become an NP. Some NPs are be able to work independently of physicians, while others sign a collaborative agreement with a supervising physician to practice. Scope of practice regulations, including clinical autonomy, prescribing level, responsibilities and medical treatments and other considerations afforded to an NP vary based on state regulations. According to the AANP, the majority of NPs practice in Primary Care (87.2%). The table below shows NPs by practice area and average age: Practice Area Percent of NPs Average Age Acute Care 6.3% 46 Adult* 18.9% 50 Family* 48.9% 49 Gerontological* 3.0% 53 Neonatal 2.1% 49 Oncology 1.0% 48 Pediatric* 8.3% 49 Psych/Mental Health 3.2% 54 Women's Health* 8.1% 53 *Denotes Primary Care focus Source: AANP Below is a breakdown of NPs by practice setting: Practice Setting Ambulatory setting 56.7% Private physician office/practice 31.6% Hospital setting 31.6% Hospital inpatient unit 13.4% Hospital outpatient clinic 10.8% Long-Term and Elder Care 4.7% Public or Community Health 2.1% Other Settings 5.0% Source: National Sample Survey of Nurse Practitioners, Health Resources Services Administration (HRSA) Physician supply per state also is a function of how many medical residents trained in a given state the state is able to retain. California is the most successful state in retaining its medical residents, while New Hampshire is the least successful. PA Supply and Distribution There are currently 104,337 PAs actively practicing throughout the country. A distribution by state can be seen below, with the top 5 most populous states of New York, California, Texas, Pennsylvania and Florida comprising 38.9% of the PA population. These 5 states compose 37.1% of the U.S. population, although a clear discrepancy is seen between the percentage of PAs versus the percentage of U.S. population in California (9.4% compared to 12.2%) and Texas (6.6% compared to 8.5%). Number of PAs Percentage of PAs Percentage of U.S. Population New York 10,866 10.4% 6.2% California 9,836 9.4% 12.2% Texas 6,898 6.6% 8.5% Pennsylvania 6,678 6.4% 4.0% Florida 6,332 6.1% 6.2% North Carolina 4,969 4.8% 3.1% Michigan 4,089 3.9% 3.1% Georgia 3,305 3.2% 3.2% Ohio 2,934 2.8% 3.6% Maryland 2,784 2.7% 1.9% Illinois 2,709 2.6% 4.0% Colorado 2,591 2.5% 1.7% Virginia 2,560 2.5% 2.6% Washington 2,534 2.4% 2.2% Massachusetts 2,428 2.3% 2.1% New Jersey 2,292 2.2% 2.8% Arizona 2,241 2.1% 2.1% Wisconsin 2,034 1.9% 1.8% Minnesota 1,811 1.7% 1.7% Connecticut 1,774 1.7% 1.1% Tennessee 1,561 1.5% 2.1% Oklahoma 1,360 1.3% 1.2% South Carolina 1,277 1.2% 1.5% Oregon 1,237 1.2% 1.2% Kentucky 1,212 1.2% 1.4% Kansas 1,072 1.0% 0.9% Indiana 1,055 1.0% 2.1% Iowa 1,026 1.0% 1.0% Nebraska 980 0.9% 0.6% Utah 969 0.9% 0.9% West Virginia 948 0.9% 0.6% Missouri 917 0.9% 1.9% Louisiana 862 0.8% 1.5% Maine 763 0.7% 0.4% Idaho 753 0.7% 0.5% New Mexico 732 0.7% 0.7% Alabama 718 0.7% 1.5% Nevada 670 0.6% 0.9% New Hampshire 629 0.6% 0.4% South Dakota 515 0.5% 0.3% Montana 511 0.5% 0.3% Alaska 465 0.4% 0.2% North Dakota 346 0.3% 0.2% Vermont 304 0.3% 0.2% Rhode Island 303 0.3% 0.3% Arkansas 291 0.3% 0.9% Delaware 290 0.3% 0.3% Wyoming 235 0.2% 0.2% Washington, D.C. 233 0.2% 0.2% Hawaii 225 0.2% 0.4% Mississippi 164 0.2% 0.9% Puerto Rico 12 0.0% 1.1% Total 104,337 Source: American Medical Association Master File/MMS/U.S. Census Bureau This distribution can also be quantified on a per capita level. Nationally, there are 33 PAs per 100,000 population, with ratios varying widely by state (see below): State PAs per 100,000 Alaska 63 South Dakota 60 Maine 57 New York 55 Pennsylvania 52 Nebraska 52 West Virginia 51 North Carolina 50 Montana 50 Connecticut 49 Vermont 49 Colorado 48 New Hampshire 47 North Dakota 47 Maryland 47 Idaho 46 Michigan 41 Wyoming 40 Kansas 37 Massachusetts 36 Washington 36 Washington, D.C. 35 Wisconsin 35 New Mexico 35 Oklahoma 35 Arizona 33 Minnesota 33 Iowa 33 Utah 33 Georgia 33 United States 33 Florida 32 Oregon 31 Delaware 31 Virginia 31 Rhode Island 29 Kentucky 27 South Carolina 26 New Jersey 26 Texas 26 California 25 Ohio 25 Tennessee 24 Nevada 24 Illinois 21 Louisiana 19 Indiana 16 Hawaii 16 Missouri 15 Alabama 15 Arkansas 10 Mississippi 5 Puerto Rico 0 Source: American Medical Association Master File/MMS As these numbers indicate, the top 5 most populous states for PAs on a per capita basis are Alaska, South Dakota, Maine, New York and Pennsylvania. While some large states have a correspondingly large number of PAs, the ratio of PAs per population in these states is low. For example, Texas (26 PAs per 100,000 pop.), California (25 PAs per 100,000 pop.) and Florida (32 PAs per 100,000 pop.) fall below the national average of 33 PAs per 100,000 pop. NP Supply and Distribution There are currently 190,802 NPs in active patient care in the United States. The top 5 most populous states of California, Florida, New York, Texas and Pennsylvania include 33.9% of the NP workforce and 37.1% of the general population. Number of NPs Percentage of NPs Percentage of U.S. Population California 17,167 9.0% 12.2% Florida 15,338 8.0% 6.2% New York 13,666 7.2% 6.2% Texas 11,074 5.8% 8.5% Pennsylvania 7,460 3.9% 4.0% Massachusetts 7,221 3.8% 2.1% Illinois 7,141 3.7% 4.0% Tennessee 6,709 3.5% 2.1% Ohio 6,636 3.5% 3.6% New Jersey 5,650 3.0% 2.8% Georgia 5,644 3.0% 3.2% North Carolina 5,365 2.8% 3.1% Virginia 5,027 2.6% 2.6% Michigan 4,678 2.5% 3.1% Arizona 4,204 2.2% 2.1% Maryland 4,028 2.1% 1.9% Missouri 3,865 2.0% 1.9% Washington 3,819 2.0% 2.2% Indiana 3,609 1.9% 2.1% Kentucky 3,601 1.9% 1.4% Connecticut 3,546 1.9% 1.1% Colorado 3,455 1.8% 1.7% Minnesota 3,212 1.7% 1.7% Wisconsin 3,106 1.6% 1.8% Alabama 2,790 1.5% 1.5% South Carolina 2,564 1.3% 1.5% Oregon 2,538 1.3% 1.2% Louisiana 2,508 1.3% 1.5% Mississippi 2,447 1.3% 0.9% Kansas 2,246 1.2% 0.9% Iowa 1,921 1.0% 1.0% Arkansas 1,668 0.9% 0.9% Utah 1,514 0.8% 0.9% Oklahoma 1,429 0.7% 1.2% New Mexico 1,351 0.7% 0.7% New Hampshire 1,273 0.7% 0.4% Maine 1,226 0.6% 0.4% West Virginia 1,209 0.6% 0.6% Nebraska 1,193 0.6% 0.6% Nevada 959 0.5% 0.9% Delaware 895 0.5% 0.3% Idaho 851 0.4% 0.5% Rhode Island 840 0.4% 0.3% Alaska 632 0.3% 0.2% Montana 627 0.3% 0.3% North Dakota 595 0.3% 0.2% Vermont 527 0.3% 0.2% South Dakota 521 0.3% 0.3% Washington, D.C. 479 0.3% 0.2% Hawaii 412 0.2% 0.4% Wyoming 311 0.2% 0.2% Puerto Rico 23 0.0% 1.1% Total 190,802 Source: American Medical Association Master File/MMS/U.S. Census Bureau As with PAs, per capita distribution of NPs varies widely by state. State NPs per 100,000 Massachusetts 107 Tennessee 102 Connecticut 99 New Hampshire 96 Delaware 96 Maine 92 Alaska 86 Vermont 84 Mississippi 82 Kentucky 82 North Dakota 80 Rhode Island 80 Kansas 77 Florida 77 Washington, D.C. 73 New York 69 Maryland 67 West Virginia 65 New Mexico 65 Colorado 65 Oregon 64 Missouri 64 Nebraska 63 New Jersey 63 Arizona 62 Iowa 62 Montana 61 South Dakota 61 Virginia 60 United States 60 Minnesota 59 Pennsylvania 58 Alabama 58 Ohio 57 Arkansas 56 Georgia 56 Illinois 55 Indiana 55 Washington 54 North Carolina 54 Wisconsin 54 Louisiana 54 Wyoming 53 South Carolina 53