The provision of health care services

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1 Health Tracking Trends Trends In The Supply Of Physician Assistants And Nurse Practitioners In The United States If numbers of NPs continue to fall, some underserved populations might not receive even the levels of primary care they do now. by Roderick S. Hooker and Linda E. Berlin ABSTRACT: In 2001 an estimated 103,612 nurse practitioners (NPs) and physician assistants (PAs) were in clinical employment in the United States. The roles of PAs and NPs in providing comparable physician services are similar; they differ in that NPs are predominantly in primary care, while PAs are divided between primary and specialty care. PA and NP education processes also differ in the student pool and trends in the output. The combined number of graduates totaled 11,585 in However, the annual number of NP graduates is declining, while the number of PA graduates is increasing. These observations have implications for the future in the types of patients they see and the degree of health care services they provide. The provision of health care services in the United States has undergone many changes since the mid-1970s. One of these changes is that nonphysician clinicians are now performing many services that were traditionally the sole domain of physicians. Two such groups involved in providing primary care are physician assistants (PAs) and nurse practitioners (NPs). PAs are licensed health professionals, certified by a national examination process, who practice medicine with physician supervision. NPs are registered nurses who are certified or staterecognized by a national certifying body or state board of nursing. In most states NPs and PAs perform comprehensive history and physical examinations, make differential diagnoses, and prescribe in the management of acute and chronic illnesses. Although both work in collaboration with physicians or in interdisciplinary teams, NPs may also work autonomously in many states. PAs and NPs were introduced in the mid- 1960s. Both roles were initiated in response to the uneven geographic distribution of physicians and primary care services, particularly in rural and inner-city areas. The acceptance and success of these roles set the stage for federal legislation regarding the funding of PA and NP education, such as Title VII and Title VIII of the Public Health Service Act. In the mid- 1990s a perceived shortage of primary care physicians prompted renewed interest in these professionals, and subsequent growth in the number of PAs and NPs has improved access to care for some patients. This suggests that NPs and PAs are providing services (especially primary care) to populations that otherwise would be managed by a physician or would not receive services. 1 Rod Hooker is an associate professor and chief of the Division of Health Services Research, University of Texas Southwestern Medical Center, in Dallas. Linda Berlin is director of research and data services at the American Association of Colleges of Nursing in Washington, D.C. 174 September/October Project HOPE The People-to-People Health Foundation, Inc.

2 Trends This paper summarizes trends in the supply and education of PAs and NPs. New information suggests that the characteristics of their education and practice capabilities may have important implications for physician workforce planning. 2 The data for this paper were obtained from the American Association of Colleges of Nursing (AACN), the National Organization of Nurse Practitioner Faculties (NONPF), the American Academy of Physician Assistants (AAPA), and the Association of Physician Assistant Programs (APAP). Demographics And Employment Characteristics In March 2000 there were an estimated 102,829 nurses with formal NPeducation, primarily at the master s degree level. Of these, 58,512 were employed with the title of NP. By 2001 approximately 52,716 PAs had graduated from an accredited program. Of these, an estimated 45,120 (86 percent) were employed as PAs. The average age of a PA was 41.5 years, and of an NP, 46.3 years. Both PAs and NPs had been in practice a mean of nine years. 3 Federal and state initiatives have resulted in the dispersal of PAs and NPs in areas of greatest need of health care. For example, 23 percent work in rural areas, compared with only 13 percent of physicians. Some may be the sole medical clinicians in their locale for the majority of the week. 4 Approximately 50 percent of PAs and 85 percent of NPs practice in primary care, which includes general internal medicine, family medicine, general pediatrics, geriatrics, and women s health (obstetrics and gynecology). The remainder are in the non primary care disciplines of surgery (general, cardiovascular, orthopedics, emergency medicine, and others) and medicine (occupational medicine, neonatalogy, oncology, psychiatry, acute care, and so on) (Exhibit 1). Education. All PAs and NPs are graduates of formal education programs that meet standards of accreditation. Graduates of these programs must pass a certification examination, administered by a national or state organization, in their respective disciplines. PAs take the Physician Assistant National Certification Examination (PANCE). NP graduates are eligible to sit for national certification by one of four certifying bodies, which generally represent different practice areas: American Academy of Nurse Practitioners (AANP), American Nurses Credentialing Center (ANCC), the National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N), and the National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Nursing Specialties (NCC). Master s-level preparation in the nursing specialty area is required by some certifying bodies and will be required by all by In most states NPs who pass a national certifying examination from one of these four bodies are then granted state authority to practice. However, in some states NPs may receive state certification, authorization, licensure, or recognition to practice in lieu of or in addition to national certification. As of 2001 there were 132 and 337 institutions with PA and NP education programs, respectively. Most NPprograms (97 percent) are in universities and colleges with schools of nursing. The PA programs are spread over a wider range of institutions, from universities and colleges (90 percent) to community colleges, hospitals, and the military. Approximately half are on medical school campuses; the rest are associated with schools of allied health (Exhibit 2). All PA programs teach a core curriculum that emphasizes primary care modeled after allopathic and osteopathic curricula. Two of the programs are surgically oriented, and one is focused on pediatrics. NPeducation emphasizes health assessment, diagnosis, and treatment as an extension of nursing practice. NPstudents major in specialized clinical tracks (such as pediatrics, geriatrics, or women s health) throughout the education process. The backgrounds of NPs and PAs differ. All NPs are registered nurses (RNs); only 30 percent of PAs have a nursing background. Other PA backgrounds are military corpsmen/medics and allied health professionals (such as respiratory technicians, physical therapists, and HEALTH AFFAIRS ~ Volume 21, Number 5 175

3 Health Tracking EXHIBIT 1 Selected Characteristics Of Physician Assistants (PAs) And Nurse Practitioners (NPs), 2001 Total graduates (2000) Estimated number employed with title of PA or NP Sex Male Female Mean age (years) Education (highest degree attained) Associate Baccalaureate Master s Doctoral Other/not reported Practice site (primary employment setting) Metropolitan (urban and inner city) Suburban Rural Other PA a 52,716 45, % % % NP 102,829 b 58,512 b 4.1% c 95.9 c 46.3 c 3.0% c 8.8 c 72.4 c 2.2 c 13.6 c 40.7% c 36.8 c 22.5 c 0.0 Years of practice (mean) c Primary specialty Family practice/family General internal medicine (adult) Emergency/acute care Pediatrics General surgery Internal medicine subspecialty Pediatric subspecialty Surgical subspecialty Women s health Industrial medicine/occupational health Psychiatry/mental health Geriatrics Other 34.5% % c 17.8 c 1.5 c 13.7 c 12.2 c 3.1 c 5.9 c 9.8 c Average work week Full time e 87.6% Part time f % c 32.2 c Mean salary Statutory or regulatory prescribing authority $67, states and DC $64,593 g 50 states and DC h emergency medical technicians). All PA program students enroll full time. The education process ranges from fifteen to thirty-six months (mean, twenty-six months), and the average class consists of forty students. NP students enroll full time or part time. Program length ranges from twelve to forty-three months, with an average of sixty-nine students per school. The majority (88 percent) of NPs graduate with a master s degree; 48 percent of PAs graduate with a master s degree (Exhibit 2). Race/ethnicity. The race and ethnicity of PA and NP students for the most part reflect 176 September/October 2002

4 Trends EXHIBIT 1 Selected Characteristics Of Physician Assistants (PAs) And Nurse Practitioners (NPs), 2001 (cont.) Average number of outpatient visits per week Family practice General internal medicine/adult Pediatrics Women s health PA a NP 75 c 56 c 65 c 67 c SOURCES: See below. a K. Marvelle, 2001 AAPA Physician Assistant Census Report (Alexandria, Va.: American Academy of Physician Assistants, 2001). b E. Spratley et al., The Registered Nurse Population, Findings from the National Sample Survey of Registered Nurses, March 2000 (Washington: Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, 2001). c A. Running et al., A Survey of Nurse Practitioners across the United States, Nurse Practitioner (June 2000): 15 16, d Not available. e For PAs, 32 hours or more; for NPs, 35 hours or more. f For PAs, fewer than 32 hours; for NPs, fewer than 35 hours. g Nurse Practitioner Support Services, NP Central Gateway, NP Salary Summary, www. nurse/net/cgibin/start.cgi/salary/index. html (12 March 2002). h L. Pearson, Fourteenth Annual Legislative Update, Nurse Practitioner (January 2002): the active workforce for each discipline. Around one-fourth of PA students and 15 percent of NPstudents are nonwhite (Exhibit 2). For both groups the trend has been toward greater diversity and increasing the visibility of underrepresented minorities. These trends are consistent with policy efforts by the Health Resources and Services Administration (Title VII and VIII) to provide educational grants to institutions that can demonstrate active recruitment of certain ethnic minorities. NP education. There are three pathways for NPeducation: master s-level programs, post-master s programs (for persons already holding master s degrees in nursing), and post basic RN certificate programs, which admit nurses without master s degrees. All schools with NPprograms are surveyed annually by AACN/NONPF. In fall 2001 there were 337 institutions in the United States and its territories with NPprograms (1,488 tracks), of which 297 (88 percent) were in the AACN/ NONPF database. There were 19,041 enrollees and 7,298 graduates. Graduates represented 38.3 percent of enrollees, indicating more part-time than full-time students, which has been the pattern for many years. The primary care tracks (family, adult, pediatrics, geriatrics, and women s health) predominated, accounting for 79 percent of graduates. Specialty tracks (neonatal, occupational health, acute care, oncology, and psychiatric/mental health) accounted for 12 percent of graduates. The remaining 9 percent were persons who majored in two NPpractice areas (family and geriatric) and those seeking both NPand clinical nurse specialist (CNS) education. 5 Since 1994, response rates for the annual survey of NPprograms ranged from 82.4 percent to 93.2 percent. Enrollment increased steadily from 13,757 students in 1994 to 22,347 in After the 1997 peak, enrollment declined each year, from 22,307 in 1998 to 19,041 in Graduations increased each year from 1994 to 1998, going from 2,537 to 8,199; then declined steadily to 7,298 in 2001 (Exhibit 3). Five-year trend data in the same 243 schools reporting to AACN/NONPF between 1997 and 2001 showed an average decrease of 682 NPstudents and 92 graduates per year. Even if enrollment increased dramatically in 2002, graduations will continue to decline until the 2002 cohort graduates, which can be approximately 2.5 years from matriculation for HEALTH AFFAIRS ~ Volume 21, Number 5 177

5 Health Tracking EXHIBIT 2 Physician Assistant (PA) And Nurse Practitioner (NP) Educational Programs, 2001 Number of institutions Number of separate clinical track programs Graduations (8/2000 7/2001) Enrollment (fall 2001) Full-time enrollees Mean number of graduates per institution Range of number of graduates per institution Master s-level graduations Ethnicity Black/African American Latino/Hispanic/Mexican American Asian, Native Hawaiian, Pacific Islander Native American/Alaskan Native Unknown or other White/non-Hispanic Total Percent of clinical track programs in primary care Length of program (months) Mean Range Type of sponsoring institution University College Other PA a ,287 10, % % 7.0% % % 32 1 NP 337 b 1,488 b 7,298 b 19,041 b 40% b 24.3 c c 88% b 6.4% b 79% d 21.5 d d 84% c 12 c 4 c SOURCES: See below. a A. Simon, M.S. Link, and A.S. Miko, Eighteenth Annual Report on Physician Assistant Education in the United States, (Alexandria, Va.: Association of Physician Assistant Programs, 2002). b L.E. Berlin, J. Stennett, and G.D. Bednash, Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing: (Washington: American Association of Colleges of Nursing, 2002). c American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties, unpublished data, d L.E. Berlin et al., Master s Level Nurse Practitioner Educational Programs: Findings from the Collaborative Curriculum Survey (Washington: American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties, 2002). full-time students and twice that for part-time students. The five-year decline was not confined to just NPs but was true for all master s degree level enrollees/graduates, which showed an average decrease of 480 students and 155 graduates per year. 6 The declining trend in NPsupply is attributable to a host of factors related to the overall general U.S. nursing shortage. This is expected to persist, given the aging of the nursing workforce, the increasing demand for health care, and the declining interest in nursing as a career. 7 The pipeline of future NPs is dependent primarily on graduates from baccalaureate nursing programs. From 1996 to 2000 enrollment in entry-level baccalaureate programs declined steadily, with an average loss of 3,010 students and 1,216 graduates per year. Although enrollment from 2000 to 2001 increased by 3.7 percent, graduations will continue to decline each year until the 2001 enrollees graduate. 8 PA education. A report titled Physician Assistant Education in the United States has been issued each year since This report comes from the APAP, which collects and dissemi- 178 September/October 2002

6 Trends EXHIBIT 3 Enrollments In And Graduations From Nurse Practitioner (NP) Programs, Thousands 25 Enrollments Graduations SOURCE: Authors tabulations of NP databases from the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties. NOTES: Master s and post-master s programs through 1997; includes post basic certificate programs. Programs and response rates are as follows: 1994, 252 programs, no denominator/response rate available; 1995, 255/82 percent; 1996, 274/88 percent; 1997, 295/93 percent; 1998, 324/90 percent; 1999, 333/91 percent; 2000, 336/88 percent; and 2001, 337/88 percent. nates information about its members PA educational activities. In the fall of 2001, 126 PA programs that were accredited at the time were surveyed. Of these, 117 (93 percent) responded. PA programs per state range from nineteen to one, with a mean of three, in the forty states that have a PA program. The mean program length was twenty-six months ( 13 months). All are full-time education programs, although most programs allow deceleration of course work for certain student situations. In 2001 there were 10,100 PA students. At year s end 4,261 had matriculated and passed the PANCE. All states require a passing grade on the PANCE before granting a license. Approximately half of the students held a master s degree upon graduation. Employment studies suggest that the vast majority are employed within three months of graduating from a PA program. 10 Approximately two new programs will reach accreditation in 2002, a deceleration from an average of nine per year during An average program reaches maximal output by its fourth graduating class. Exhibit 4 depicts the growth of PA school enrollment and graduation between 1994 and 2001; it shows an average increase of 496 students (total enrollment) per year. There was a substantial increase between 2000 and ,968 students. The five-year graduation rate trend reveals an average increase of 363 more than the previous year. Future NP And PA Supply Implications The combined annual number of PA and NP graduates in 2001 was 11,559 almost a 50 percent increase since The ratio is changing: more PA and fewer NP graduates. If the medical marketplace remains strong, there could be 110,000 clinically active NPs and PAs over the next few years, or one-sixth of the nation s corps of providers. This output of education programs has increased the visibility of PAs and NPs, providing health care consumers with a greater choice of providers than ever before. During the 1990s there were predictions of a physician surplus, largely based on past performance and the improved efficiency of managed care. 11 However, those predictions have not come to fruition. Instead, Richard Cooper and colleagues project that if the education pipeline for physicians remains the same, a physician shortage will accumulate, resulting in a severe shortage by This HEALTH AFFAIRS ~ Volume 21, Number 5 179

7 Health Tracking EXHIBIT 4 Enrollments In And Graduations From Physician Assistant (PA) Programs, Thousands 10 Enrollments Graduations SOURCE: A. Simon, M.S. Link, and A.S. Miko, Eighteenth Annual Report on Physician Assistant Education in the United States, (Alexandria, Va.: Association of Physician Assistant Programs, 2002); and R.S. Hooker and L.F. McCaig, Use of Physician Assistants and Nurse Practitioners in Primary Care, , Health Affairs (July/Aug 2001): NOTES: Number of programs is as follows: 1994, 60; 1995, 63; 1996, 86; 1997, 106; 1998, 110; 1999, 120; 2000, 126; and 2001, 132. model accounted for the supply of PAs and NPs and projected that the nonphysician clinician workforce will not be able fill the gap in physician services. 12 Regardless of how the growing supply of PAs and NPs is viewed, the change in ratios could have some consequences in health services delivery. NPs are the largest group of nonphysician primary care providers and produce services in health promotion and disease prevention at much higher rates than is true for physicians or PAs. 13 A declining number of NPs could mean that certain populations may not receive these services. As is true for physicians, the major force affecting the demand for PA and NP services is the economy. If health care becomes available or affordable for more people, opportunities for NPs and PAs are likely to increase. If physician demand continues to correlate with economic growth, demand for PAs and NP is likely to continue as well. supply of providers who continue to find employment. Demand for their services will likely continue in the near future as they fill niches where physician services are in short supply and where their economic labor makes them desirable. The education pipeline suggests that a rise of PAs and a decline of NPs may produce output parity in the near future, but the overall effect will be a net increase of providers. These observations may have important implications for physician workforce projections. The conclusions, interpretations, and opinions expressed do not necessarily reflect the views of the American Association of Colleges of Nursing. The growing presence of PAs and NPs in American society is due to a number of factors primarily to demand for their services. The education process has accommodated this demand with a 180 September/October 2002

8 Trends NOTES 1. R.S. Hooker and L.F. McCaig, Use of Physician Assistants and Nurse Practitioners in Primary Care, , Health Affairs (July/Aug 2001): ; and L.F. McCaig et al., Physician Assistants and Nurse Practitioners in Hospital Outpatient Departments, , Public Health Reports (January 1998): R.A. Cooper et al., Economic and Demographic Trends Signal an Impending Physician Shortage, Health Affairs (Jan/Feb 2002): E. Spratley et al., The Registered Nurse Population, Findingsfrom the National Sample Survey of Registered Nurses, March 2000 (Washington: Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, 2001); K. Marvelle, 2001 AAPA Physician Assistant Census Report (Alexandria, Va.: American Academy of Physician Assistants, 2001); and A. Running et al., A Survey of Nurse Practitioners across the United States, Nurse Practitioner (June 2000): 15 16, Marvelle, 2001 AAPA Physician Assistant Census Report; Running et al., A Survey of Nurse Practitioners ; and American Medical Association, Physician Trends, in Physician Characteristics and Distribution in the U.S.: Edition, ed. T. Pasko and B. Seidman (Chicago: AMA, 2002), L.E. Berlin, J. Stennett, and G.D. Bednash, Enrollment and Graduationsin Baccalaureate and Graduate Programsin Nursing: (Washington: American Association of Colleges of Nursing, 2002). 6. Ibid.; and American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties, unpublished NP data, P.I. Buerhaus, D.O. Staiger, and D.I. Auerbach, Implications of an Aging Registered Nurse Workforce, Journal of the American Medical Association (14 June 2000): Berlin et al., Enrollment and Graduations. 9. The latest report is A. Simon, M.S. Link, and A.S. Miko, Eighteenth Annual Report on Physician Assistant Education in the United States, (Alexandria, Va.: Association of Physician Assistant Programs, 2002). 10. Marvelle, 2001 AAPA Physician Assistant Census Report; and Running et al., A Survey of Nurse Practitioners. 11. Council on Graduate Medical Education, Patient Care Physician Supply and Requirements: Testing COGME Recommendations, Eighth Report (Rockville, Md.: COGME, 1996); and J.P. Weiner, Forecasting the Effects of Health Reform on U.S. Physician Workforce Requirement: Evidence from HMO Staffing Patterns, Journal of the American Medical Association 272, no. 3 (1994): Cooper et al., Economic and Demographic Trends. 13. Hooker and McCaig, Use of Physician Assistants and Nurse Practitioners ; and N.B. Moody, P.L. Smith, and L.L. Glenn, Client Characteristics and Practice Patterns of Nurse Practitioners and Physicians, Nurse Practitioner (March 1999): 94 96, , HEALTH AFFAIRS ~ Volume 21, Number 5 181