NPs vs PAs: What's the Difference?

Carolyn Buppert, MSN, JD,

Disclosures

August 28, 2019

Physicians looking to hire a nurse practitioner (NP) or physician assistant (PA) may wonder which role would be better suited to their medical practice. How do these two healthcare providers differ?

It's a good question. NPs and PAs (collectively known as advanced practice clinicians) might very well be competing for the same jobs. The growth of the NP and PA workforce is outpacing that of primary care physicians, and both professions can now be found in a broad range of healthcare settings, often working side by side.

How NPs and PAs Are Alike

As healthcare providers, NPs and PAs are more alike than different. Both are educated to take medical histories, perform physical examinations, diagnose medical problems, order therapy, counsel patients, and prescribe medications. With a few exceptions, both must be board certified by a national certification agency and licensed in the state where they are practicing.

Online, you can find scope-of-practice statements for PA and NP professional roles.

Research shows that the quality of care provided by NPs and PAs is similar to that provided by physicians but with lower overall costs.

Most third-party payers will reimburse for NP or PA services. The rates of reimbursement are similar but may be less than physician fee-for-service rates. Payers' rules for PAs are similar to NP billing.

Based on the most recently available data, salaries of full-time NPs and PAs are comparable. 2017 surveys found that the mean annual salary of PAs was $110,567 and NPs earned an average of $112,000. Compensation varied geographically as well as by work setting and specialty. The highest earnings of both were reported by emergency medicine PAs and acute care hospital–based NPs. Note that these salaries may not include bonuses.

For both groups, the frequency of malpractice lawsuits is low, and lower than that for physicians. The cost of malpractice coverage for an NP or PA who is employed by a physician practice is likely to be wrapped into the practice's corporate insurance policy. When an NP or PA purchases malpractice insurance as an individual, the premium is between $1600 and $2500 for an NP and between $2000 and $6000 for a PA.

Practice settings. Both NPs and PAs work in primary care as well as in dozens of specialties, in both ambulatory and inpatient settings. The most recent practice trend suggests that despite being prepared as generalists, PAs are increasingly transitioning into specialty practice. About 28% of certified PAs practice in family medicine or internal medicine, and the rest are distributed among many medical and surgical specialties. Although NPs are showing a similar trend toward specialization, the largest proportion (73%) of NPs practice in primary care. Both NPs and PAs are increasingly being used in critical care settings and as hospitalists. Primary care NPs and PAs can own their own practices, but hospital clinical and admitting privileges are not typically extended to NPs and PAs.

How NPs and PAs Are Different

The differences between NPs and PAs lie predominantly in the focus of their education and in state law mandating physician involvement in practice.

Education. Master's degree programs for PAs cover evaluation and management of patients of all ages and in all settings. PA programs prepare students as generalists, with curricula following the disease-oriented medical school model, without focusing on a particular age group or level of care. Most PAs have completed rotations in surgery as part of their master's program. Of note, the generalist training of PAs allows them to switch specialties without additional formal schooling.

In contrast, NP students select a patient population on which to focus their education and certification. For example, the focus could be an age group (pediatric or adult) plus a level of care (primary care or acute care). Family NP programs cover primary care for all ages. NPs educated in adult primary care limit their practice to adults, and pediatric NPs limit their practice to children. Specialized NP programs prepare clinicians to provide certain types of medical services: women's health, mental health, oncology, emergency, or palliative care. While some NPs work as surgical first assistants, it is not typical for NP master's programs to include surgical training.

Nearly all NPs (99%) have graduate degrees, and 77% of PAs hold master's or doctoral degrees. Many NPs earn the clinically oriented doctorate, the doctor of nursing practice (DNP). Although fewer in number, programs are also available for PAs to earn doctoral degrees in medical or health science. At this time, doctoral degrees are not required for entry-level practice for either profession.

Postgraduate clinical education is another way that NPs and PAs can expand their skills or specialize. Accredited residency (sometimes called "fellowship") programs for NPs and PAs are increasingly available. These 1- to 2-year programs, offered by colleges, universities, and healthcare organizations, are rapidly increasing in number. Residency programs in such areas as surgery or emergency medicine allow PAs to specialize earlier in their careers than might be possible otherwise. Residencies and fellowships are typically offered to both new graduate NPs and certified, working NPs who wish to transition to another specialty.

Both types of practitioners bring previous healthcare experience to their roles, but the type of experience differs. Many PAs have worked in such healthcare roles as emergency medical technician, paramedic, military medic, medical assistant, nurse, or respiratory therapist. NPs, on the other hand, typically practice as nurses before beginning study as NPs.

Certification and licensure. The regulating body for PAs and NPs differs. With few exceptions, NPs are licensed and regulated by state nursing boards, whereas PAs are licensed and regulated by state medical boards.

Before licensure, both groups must pass exams to be certified for practice. All PA students must pass the same national PA certification exam, after which they use the credential PA-C. Continuing education is required to maintain PA certification, and the certification exam must be taken every 10 years. PAs may also earn a Certificate of Added Qualifications (CAQ), a specialty credential that recognizes experience, continuing education, skills, and knowledge in cardiovascular and thoracic surgery, emergency medicine, hospital medicine, nephrology, orthopedic surgery, pediatrics, or psychiatry. In addition to passing a specialty exam, PAs must provide a physician attestation of their skills in the specialty area.

NPs are considered by most states to be advanced practice registered nurses (APRNs), along with nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. A national APRN certification exam, geared toward population focus, is required by all but three states (California, Kansas, and New York). APRN certification exams are administered by several different national certification organizations, with some overlap. A certified NP uses the credential "BC" (board certified). Certification is maintained with work experience and continuing education, and must be renewed every 3-7 years.

Mandate for physician involvement. Currently, all states require PAs to have a documented collaborative or supervisory relationship with a physician. Typically, a PA delegation agreement (also called a practice agreement), in which one or more physicians delegate the authority to perform medical acts to a PA, must be filed with a state agency. In addition, a few states require a physician cosignature on a small fraction of PA chart entries and orders. The American Academy of Physician Assistants is actively seeking to remove these administrative restrictions and promote a more collegial team approach to PA practice. Although states require physician supervision of PA practice, they don't require the physician to be physically present in the same building.

In 28 states, an NP must have a written collaborative practice agreement with a physician. Currently, 22 states and the District of Columbia permit full practice for NPs by law, with no requirement for a collaborative relationship with a physician. Sixteen states allow what is called "reduced practice," (requiring a collaborative agreement with another provider, usually a physician); and in another 12 states, NPs have "restricted practice" (requiring career-long supervision or delegation by another provider). This map shows NP scope of practice in each state and US territory.

Decision Time

Here are some self-assessment questions for physicians and other employers who are thinking about hiring a PA or NP.

  1. What are my state's requirements for physician collaboration with a PA? With an NP?

  2. Do I need a clinician who can practice with all age groups? If so, hire a family NP or a PA.

  3. What is the level of care required for my patients? If primary care, hire an adult-gerontologic, pediatric, or family NP, or a PA. If practicing psychiatry, hire a mental health NP or a PA who has specialized in mental health. If the practice is gynecology, hire a women's healthcare NP or PA who has specialized. If the practice is hospitalist, hire an NP certified in acute care or a PA.

  4. Do I need a provider to assist at surgery? If so, hire a PA, or an NP who also is certified as an acute care NP, and/or as a surgical first assistant.

  5. Do I want to work closely with the individual? Or do I want someone who is experienced enough to function on their own, without a lot of consultation? Hire an experienced clinician if you want the individual to see patients without you present at the office.

  6. What is the cost to include a PA or NP in my malpractice coverage? Obtain this information from your professional liability insurance provider.

  7. What can I offer in the way of salary, productivity incentives, bonuses, benefits, continuing education time and expenses, and mentoring and training?

  8. Do I need someone to cover after-hours call? Visit patients at multiple sites? Have hospital clinical and admission privileges? Market my practice within the community? All of these needs should be discussed in the interview.

During the job interview, here are some questions to ask a prospective employee:

  1. What was the curriculum in your master's program?

  2. What is your area of certification?

  3. What post-master's courses or residencies have you completed?

  4. What supervised on-the-job training have you completed? Do you have documentation of your on-the-job training? What procedures are you experienced with and competent to provide?

  5. What are your special interests in health/medicine?

  6. What special qualities can you bring to my practice?

  7. Have you met any state requirements for independent prescribing?

Individual NPs and PAs vary significantly in their healthcare experience, individual training, and personal preferences. In general, a good employer-employee match will depend more on the individuals than on the category of healthcare provider.

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