Tr e n d s
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 assis-tants (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 predomi-nantly 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 com-bined number of graduates totaled 11,585 in 2001. 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.
T
h e p r o v i s i o n o fhealth care services in the United States has undergone many changes since the mid-1970s. One of these changes is that nonphysician clini-cians are now performing many services that were traditionally the sole domain of physi-cians. Two such groups involved in providing primary care are physician assistants (PAs) and nurse practitioners (NPs). PAs are li-censed health professionals, certified by a na-tional examination process, who practice medicine with physician supervision. NPs are registered nurses who are certified or state-recognized by a national certifying body or state board of nursing. In most states NPs and PAs perform comprehensive history and physical examinations, make differential di-agnoses, and prescribe in the management of acute and chronic illnesses. Although both work in collaboration with physicians or ininterdisciplinary 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 physi-cians 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 pri-mary care) to populations that otherwise would be managed by a physician or would not receive services.1
RodHookerisanassociateprofessorandchiefoftheDivisionofHealthServicesResearch,UniversityofTexas SouthwesternMedicalCenter,inDallas.LindaBerlinisdirectorofresearchanddataservicesattheAmerican AssociationofCollegesofNursinginWashington,D.C.
This paper summarizes trends in the sup-ply and education of PAs and NPs. New infor-mation suggests that the characteristics of their education and practice capabilities may have important implications for physician workforce planning.2The 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 Physi-cian 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, pri-marily 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 esti-mated 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 great-est need of health care. For example, 23 per-cent work in rural areas, compared with only 13 percent of physicians. Some may be the sole medical clinicians in their locale for the major-ity 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).
n Education. All PAs and NPs are
gradu-ates of formal education programs that meet standards of accreditation. Graduates of these programs must pass a certification examina-tion, administered by a national or state orga-nization, in their respective disciplines. PAs
take the Physician Assistant National Certifi-cation 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 spe-cialty area is required by some certifying bod-ies and will be required by all by 2007. In most states NPs who pass a national certifying ex-amination from one of these four bodies are then granted state authority to practice. How-ever, in some states NPs may receive state “cer-tification,” “authorization,” “licensure,” or “recognition” to practice in lieu of or in addi-tion to naaddi-tional certificaaddi-tion.
As of 2001 there were 132 and 337 institu-tions with PA and NP education programs, re-spectively. 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 col-leges, hospitals, and the military. Approxi-mately 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 cur-ricula. Two of the programs are surgically ori-ented, and one is focused on pediatrics. NPed-ucation emphasizes health assessment, diagnosis, and treatment as an extension of nursing practice. NPstudents major in special-ized clinical tracks (such as pediatrics, geriat-rics, or women’s health) throughout the educa-tion process.
The backgrounds of NPs and PAs differ. All NPs are registered nurses (RNs); only 30 per-cent of PAs have a nursing background. Other PA backgrounds are military corpsmen/med-ics and allied health professionals (such as re-spiratory technicians, physical therapists, and
emergency medical technicians). All PA pro-gram 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).
n Race/ethnicity. The race and ethnicity
of PA and NP students for the most part reflect EXHIBIT 1
Selected Characteristics Of Physician Assistants (PAs) And Nurse Practitioners (NPs), 2001
PAa NP
Total graduates (2000)
Estimated number employed with title of PA or NP 52,71645,100 102,829
b
58,512b
Sex Male Female Mean age (years)
46.2% 53.8 41.5 4.1%c 95.9c 46.3c
Education (highest degree attained) Associate Baccalaureate Master’s Doctoral Other/not reported 10.0% 62.0 25.0 3.0 3.0%c 8.8c 72.4c 2.2c 13.6c
Practice site (primary employment setting) Metropolitan (urban and inner city) Suburban Rural Other 41.4% 34.1 22.7 1.8 40.7%c 36.8c 22.5c 0.0
Years of practice (mean) 9.5 9.0c
Primary specialty Family practice/family
General internal medicine (adult) Emergency/acute care Pediatrics 34.5% 8.5 10.1 2.6 36.0%c 17.8c 1.5c 13.7c General surgery
Internal medicine subspecialty Pediatric subspecialty Surgical subspecialty 2.5 8.6 1.4 18.4 –d –d –d –d Women’s health
Industrial medicine/occupational health Psychiatry/mental health Geriatrics Other 2.5 3.6 1.2 0.8 7.4 12.2c –d 3.1c 5.9c 9.8c
Average work week Full timee
Part timef 87.6%11.7 58.3%
c
32.2c
Mean salary
Statutory or regulatory prescribing authority $67,74347 states and DC $64,593
g
the active workforce for each discipline. Around one-fourth of PA students and 15 per-cent 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 ac-tive recruitment of certain ethnic minorities.
n NP education. There are three
path-ways for NPeducation: master’s-level pro-grams, post-master’s programs (for persons al-ready 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 rep-resented 38.3 percent of enrollees, indicating more part-time than full-time students, which has been the pattern for many years. The
pri-mary care tracks (family, adult, pediatrics, ge-riatrics, and women’s health) predominated, accounting for 79 percent of graduates. Spe-cialty 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 clini-cal nurse specialist (CNS) education.5
Since 1994, response rates for the annual survey of NPprograms ranged from 82.4 per-cent to 93.2 perper-cent. Enrollment increased steadily from 13,757 students in 1994 to 22,347 in 1997. After the 1997 peak, enrollment de-clined each year, from 22,307 in 1998 to 19,041 in 2001. 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 un-til the 2002 cohort graduates, which can be ap-proximately 2.5 years from matriculation for EXHIBIT 1
Selected Characteristics Of Physician Assistants (PAs) And Nurse Practitioners (NPs), 2001 (cont.)
PAa NP
Average number of outpatient visits per week Family practice
General internal medicine/adult Pediatrics Women’s health 105 90 134 71 75c 56c 65c 67c
SOURCES: See below.
aK. Marvelle, 2001 AAPA Physician Assistant Census Report (Alexandria, Va.: American Academy of Physician Assistants,
2001).
bE. 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).
cA. Running et al., “A Survey of Nurse Practitioners across the United States,” Nurse Practitioner (June 2000): 15–16,
110–116.
dNot available.
eFor PAs, 32 hours or more; for NPs, 35 hours or more. fFor PAs, fewer than 32 hours; for NPs, fewer than 35 hours.
gNurse Practitioner Support Services, NP Central Gateway, NP Salary Summary, www. nurse/net/cgibin/start.cgi/salary/index.
html (12 March 2002).
full-time students and twice that for part-time students. The five-year decline was not con-fined 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 attrib-utable 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 work-force, the increasing demand for health care, and the declining interest in nursing as a ca-reer.7The pipeline of future NPs is dependent
primarily on graduates from baccalaureate nursing programs. From 1996 to 2000 enroll-ment in entry-level baccalaureate programs declined steadily, with an average loss of 3,010 students and 1,216 graduates per year. Al-though enrollment from 2000 to 2001 in-creased by 3.7 percent, graduations will con-tinue to decline each year until the 2001 enrollees graduate.8
n PA education. A report titled Physician
AssistantEducationintheUnitedStates has been
is-sued each year since 1984.9This report comes
from the APAP, which collects and dissemi-EXHIBIT 2
Physician Assistant (PA) And Nurse Practitioner (NP) Educational Programs, 2001
PAa NP
Number of institutions
Number of separate clinical track programs Graduations (8/2000–7/2001) Enrollment (fall 2001) 132 132 4,287 10,100 337b 1,488b 7,298b 19,041b Full-time enrollees
Mean number of graduates per institution Range of number of graduates per institution Master’s-level graduations 100% 38 10–206 48% 40%b 24.3c 0–203c 88%b Ethnicity Black/African American Latino/Hispanic/Mexican American Asian, Native Hawaiian, Pacific Islander Native American/Alaskan Native Unknown or other White/non-Hispanic Total 7.0% 6.4 10.3 0.1 3.3 72.9 100.0 6.4% 3.6 4.4 0.6 3.1 81.9 100.0b
Percent of clinical track programs in primary care Length of program (months)
Mean Range 99% 25.5 12–39 79%d 21.5d 12–43d
Type of sponsoring institution University College Other 67% 32 1 84%c 12c 4c
SOURCES: See below.
aA. Simon, M.S. Link, and A.S. Miko, Eighteenth Annual Report on Physician Assistant Education in the United States, 2001–
2002 (Alexandria, Va.: Association of Physician Assistant Programs, 2002).
bL.E. Berlin, J. Stennett, and G.D. Bednash, Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing:
2001–2002 (Washington: American Association of Colleges of Nursing, 2002).
cAmerican Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties, unpublished data,
2001.
dL.E. Berlin et al., Master’s Level Nurse Practitioner Educational Programs: Findings from the 2000–2001 Collaborative
Curriculum Survey (Washington: American Association of Colleges of Nursing and the National Organization of Nurse
nates information about its members’ PA edu-cational activities. In the fall of 2001, 126 PA programs that were accredited at the time were surveyed. Of these, 117 (93 percent) re-sponded. 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. Ap-proximately half of the students held a mas-ter’s degree upon graduation. Employment studies suggest that the vast majority are em-ployed within three months of graduating from a PA program.10Approximately two new
programs will reach accreditation in 2002, a deceleration from an average of nine per year during 1994–2000. An average program reaches maximal output by its fourth graduat-ing class.
Exhibit 4 depicts the growth of PA school enrollment and graduation between 1994 and 2001; it shows an average increase of 496
stu-dents (total enrollment) per year. There was a substantial increase between 2000 and 2001— 1,968 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 per-cent increase since 1996. The ratio is changing: more PA and fewer NP graduates. If the medi-cal 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 be-fore. 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 edu-cation pipeline for physicians remains the same, a physician shortage will accumulate, re-sulting in a severe shortage by 2020. This EXHIBIT 3
Enrollments In And Graduations From Nurse Practitioner (NP) Programs, 1994–2001
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; 1998–2001 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. 25 20 15 10 5 0 Thousands 1994 1995 1996 1997 1998 1999 2000 2001 Enrollments Graduations
model accounted for the supply of PAs and NPs and projected that the nonphysician clini-cian 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 ser-vices delivery. NPs are the largest group of nonphysician primary care providers and pro-duce services in health promotion and disease prevention at much higher rates than is true for physicians or PAs.13A declining number of
NPs could mean that certain populations may not receive these services.
As is true for physicians, the major force af-fecting 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 physi-cian demand continues to correlate with eco-nomic growth, demand for PAs and NP is likely to continue as well.
T
h e g r o w i n g p r e s e n c e of PAs and NPs in American society is due to a number of factors—primarily to de-mand for their services. The education pro-cess has accommodated this demand with asupply of providers who continue to find em-ployment. 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 sug-gests 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 im-portant implications for physician workforce projections.
Theconclusions,interpretations,andopinions expresseddonotnecessarilyreflecttheviews ofthe AmericanAssociationofCollegesofNursing.
EXHIBIT 4
Enrollments In And Graduations From Physician Assistant (PA) Programs, 1994–2001
SOURCE: A. Simon, M.S. Link, and A.S. Miko, Eighteenth Annual Report on Physician Assistant Education in the United States,
2001–2002 (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, 1995–1999,” Health Affairs (July/Aug 2001): 231–238. NOTES: Number of programs is as follows: 1994, 60; 1995, 63; 1996, 86; 1997, 106; 1998, 110; 1999, 120; 2000, 126; and 2001, 132. 10 8 6 4 2 0 Thousands 1994 1995 1996 1997 1998 1999 2000 2001 Enrollments Graduations
NOTES
1. R.S. Hooker and L.F. McCaig, “Use of Physician Assistants and Nurse Practitioners in Primary Care, 1995–1999,” Health Affairs (July/Aug 2001): 231–238; and L.F. McCaig et al., “Physician Assis-tants and Nurse Practitioners in Hospital Outpa-tient Departments, 1993–1994,” Public Health
Re-ports (January 1998): 75–82.
2. R.A. Cooper et al., “Economic and Demographic Trends Signal an Impending Physician Shortage,”
Health Affairs (Jan/Feb 2002): 140–154.
3. E. Spratley et al., The Registered Nurse Population,
Findingsfrom the National Sample Survey of Registered Nurses, March 2000 (Washington: Health
Re-sources 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, 110–116.
4. Marvelle, 2001 AAPA Physician Assistant Census
Re-port; Running et al., “A Survey of Nurse
Practitio-ners”; and American Medical Association, “Phy-sician Trends,” in Phy“Phy-sician Characteristics and
Dis-tribution in the U.S.: 2002–2003 Edition, ed. T. Pasko
and B. Seidman (Chicago: AMA, 2002), 320–344. 5. L.E. Berlin, J. Stennett, and G.D. Bednash,
Enroll-ment and Graduationsin Baccalaureate and Graduate Programsin Nursing: 2001–2002 (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, 2001.
7. P.I. Buerhaus, D.O. Staiger, and D.I. Auerbach, “Implications of an Aging Registered Nurse Workforce,” Journal of the American Medical
Associa-tion (14 June 2000): 2948–2954.
8. 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, 2001–2002
(Alexan-dria, Va.: Association of Physician Assistant Pro-grams, 2002).
10. Marvelle, 2001 AAPA Physician Assistant Census
Re-port; and Running et al., “A Survey of Nurse
Prac-titioners.”
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
Ameri-can Medical Association 272, no. 3 (1994): 222–230.
12. Cooper et al., “Economic and Demographic Trends.”
13. Hooker and McCaig, “Use of Physician Assis-tants and Nurse Practitioners”; and N.B. Moody, P.L. Smith, and L.L. Glenn, “Client Characteris-tics and Practice Patterns of Nurse Practitioners and Physicians,” Nurse Practitioner (March 1999): 94–96, 99–100, 102–103.
