As the older population in the US continues to grow, simultaneously increasing the need for healthcare services and providers, patients these days might be more likely to see a physician assistant (PA) or a nurse practitioner (NP), as opposed to an physician (MD); but what’s the difference?
Let’s start out with some key facts: how does an NP’s and PA’s education, licensing, annual salary, and typical duties differ from an MD? An NP, PA and MD will all typically start with a bachelor’s degree. An NP will also have a master’s in nursing degree and possibly a Doctor of Nursing Practice degree. PAs receive degrees from accredited PA programs. MDs complete medical school, then a residency program. NPs, PAs, and MDs are all licensed by boards in each state, with certain specialties requiring specific certifications.
A government report published in 2013 projected an increase in the primary care MD workforce (from 205,000 in 2010 to 220,800 in 2020). However, even with the increase, there is a projected shortage of 20,400 physicians by 2020. The report also projected a 30% increase in the primary care NP workforce (from 55,400 in 2010 to 72,100 in 2020). An additional projected increase for primary care PAs, from 27,700 in 2010 to 43,900 in 2020, could potentially counteract the pending physician shortage.
Mean annual salaries in 2017, according to the Bureau of Labor Statistics, were $107,480 for NPs, $104,760 for PAs, and $208,560 for MDs, respectively. Responsibilities of NPs, PAs, and MDs vary from state to state based on specialty; however, general roles for all three may consist of diagnosing and managing patient’s treatment, prescribing medications, ordering diagnostic tests and providing patient education.
Moving on to a tougher question, is there a difference in the quality or type of care provided by these three types of practitioners? A recent study in Medical Care examined 2012 and 2013 Medicare claims over a 12-month period to compare the quality of care across primary care NPs, primary care MDs, and both clinicians combined.
Medicare beneficiaries seen by NPs had:
- fewer inappropriate emergency room visits
- fewer hospital readmissions
- fewer low-value imaging (MRIs) for low back pain
- fewer hospitalizations related to preventable conditions
Medicare beneficiaries seen by primary care MDs were:
- more likely to receive cancer screenings
- more likely to receive chronic disease management services.
Beneficiaries seen by both primary care NPs and MDs primarily scored in the middle, with the exception of higher cancer screening rates than those patients only seen by only an NP but not as high as those patients only seen by an MD.
The authors acknowledge that their study results may be influenced by factors that were unable to be assessed, such as differences in practice styles and philosophies of care, differences in patient characteristics, and patient preferences for provider type. NP beneficiaries were more likely to be younger, residing in rural areas, qualifying for both Medicare and Medicaid, and becoming eligible for Medicare due to disability as opposed to age. MD beneficiaries had the highest severity of illness, with NP beneficiaries having the lowest severity. All these factors could be potential contributors to their findings.
A 2013 systematic review published in The Journal for Nurse Practitioners evaluated the impact of NPs and MDs on care quality, safety, and effectiveness. The authors found patient satisfaction in primary, inpatient, outpatient, and surgical settings was similar across NPs and MDs. Further, physical function, mortality, and health status outcomes in home, ambulatory, and inpatient settings were similar for both NPs and MDs. The effectiveness of blood pressure and blood glucose control in primary ambulatory settings were also similar; however, care under an NP was associated with improved lipid control.
Another Medical Care article from 2017 looked at quality of care and practice patterns between primary care NPs, PAs, and MDs in community health centers. The authors evaluated data on 1,139 providers collected between 2006 and 2010 from the National Ambulatory Medical Care Survey. Nine patient-level outcomes were evaluated, including smoking cessation, depression treatment, statin treatment for hyperlipidemia, physical examination, total number of health education/counseling services, imaging services, total number of medications, return visit at a specified time, and MD referral. The authors found no statistically significant differences for 7 of the 9 outcomes when care provided by an NP or PA was compared to an MD. Patients that saw NPs were more likely to receive smoking cessation counseling than those who saw MDs. Patients who saw PAs or NPs received more health education/counseling services than patients who saw MDs. The authors concluded that care across NP, PA, and MD are comparable in community health centers.
Additional research and future studies are needed to continue evaluating this topic and exploring the impact on patient outcomes. An article published in Health Affairs surveyed 5,533 individuals through the Association of American Medical Colleges Consumer Survey. About half of participants indicated a preference for an MD as their primary care provider. However, when presented with a scenario that would allow them to see an NP or PA sooner than an MD, almost 60% expressed preference for the NP or PA. The authors suggest that this indicates that US consumers are becoming more open to seeing various types of providers — an important point to consider as the need for physicians outpaces the supply and the NP and PA workforce continues to grow.
Alexa Ortiz
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