Compensation and production in family medicine by practice ownership
The increasing focus on high-performance, patient-centered, team-based care calls for a strategy to evaluate cost-effective primary care. Productivity measures establish provider value and help inform decision making about resource allocation in this evolving healthcare system. In this survey of family medicine practices, PA productivity, as defined by mean annual patient encounters, exceeded that of both NPs and physicians in physician-owned practices and of NPs in practices owned by hospitals or integrated delivery systems. Total compensation for physicians is significantly more compared with both PAs and NPs, regardless of practice ownership or productivity. PAs and NPs earn equivalent compensation, regardless of practice ownership or productivity. Not only do these data support the value and role of PAs and NPs on the primary care team, they also highlight differences in patient encounters between practice settings. Research is needed to inform both organizational and policy decisions for the provision of high-quality, cost-effective, and accessible primary healthcare.1
Commentary by Noël Smith: The authors looked at compensation and productivity of PAs and NPs compared with family medicine physicians. The findings confirm that family medicine physicians have greater compensation than PAs and NPs and that family medicine physicians earn more in physician-owned practices compared with practices owned by hospitals or integrated delivery systems. Annual patient encounters were the proxy for productivity. The difficulty in measuring productivity lies in the lack of transparency in billing and disparities based on patient acuity, hours worked, and time spent on service-valued activities.2,3 Although PAs and physicians in family medicine have equal productivity overall, physician productivity is the same regardless of setting but PAs are less productive in practices owned by hospitals or integrated delivery systems and more productive in physician-owned practices. Practice ownership as a relevant variable is a new finding in the measurement of annual productivity and may be important as more and more physician-owned practices are purchased by hospitals or integrated delivery systems.4
1. Essary AC, Green EP, Gans DN. Compensation and production in family medicine in practice ownership. Health Services Res Managerial Epidemiol. 2016;3:1–5.
2. Ogunfiditimi F, Takis L, Paige VJ, et al. Assessing the productivity of advanced practice providers using a time and motion study. J Healthc Manag. 2013;58(3):173–185.
3. Pickard T. Calculating your worth: understanding productivity and value. J Adv Pract Oncol. 2014;5(2):128–133.
The Physicians Foundation. Health reform and the decline of private physician practice: a white paper examining the effects of the Patient Protection and Affordable Care Act on physician practices in the United States. http://www.physiciansfoundation.org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_Practice.pdf. Accessed July 28, 2016.
Has there been a shift in applicants to PA programs?
This study analyzed 10 years of data (2002-2011) from the Central Application Service for Physician Assistants (CASPA) and 5 years of PA matriculate data (2007-2011). The authors found a 93% increase in the number of CASPA-participating programs and a 255% increase in the number of unique applicants. Applicants per seat rose from 1.8 to 2.8. Relatively constant trends were identified in age, sex, ethnic composition, and disadvantaged status of applicants. Female matriculates ranged from 73% to 77% but other major demographic features of matriculates remained relatively constant. Trends in academic data of matriculates revealed a rising undergraduate total grade point average (GPA). The percentage of students with military experience declined. Establishing a baseline of applicant characteristics can help refine program recruitment strategies at state and national levels and help target applicants not previously included.1
Commentary by Todd J. Doran: Contemporary PA matriculates are 74% female, 4% military, progressively younger, and have significantly less healthcare experience, which is a departure from the past. Optimally, the profession should seek to develop admission policies designed to achieve a desired workforce composition, otherwise only high-GPA applicants will dominate the profession. Heavily weighting GPA in the selection process will deliver a class that is overly represented by young white women of high socioeconomic status who have little healthcare experience, as reinforced by the data presented here.2 Disturbingly, this article highlights that applicants who are disadvantaged in socioeconomic status have lower admissions success. Although most applicants apply to as many as six programs, applying to 12 programs may double the chance of acceptance. Another observation is that economically disadvantaged students are 15% to 25% less likely to matriculate when controlling for GPA above or below the median, respectively. Programs interested in widening the diversity of their cohorts should develop strategies to assist students of low socioeconomic status in the application process. Programs should consider normalizing GPA based on admission disadvantage or weighting noncognitive factors differently. To do this means adding variables such as institutional context: public/private, region, and age of program in an effort to highlight contextual differences of where disadvantaged students are likely to succeed. The profession needs to train a workforce reflective of the society it will serve to achieve desired healthcare outcomes, and the selection process starts with admissions policies. The data presented in this study are a wake-up call.3
1. McDaniel MJ, Hildebrandt CA, Russell GB. Central Application Service for Physician Assistants ten-year data report, 2002 to 2011. J Physician Assist Educ. 2016;27(1):17–23.
Bowen W, Kurzweil M, Tobin E. Race in American Higher Education in Equity and Excellence in American Higher Education. Charlottesville, VA: University of Virginia Press; 2005.
US Health Resources and Services Administration. The rationale for diversity in the health professions: a review of the evidence. http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf. Accessed July 28, 2016.
How could NPs and PAs be deployed to provide rural primary care?
New (2014) rural enrollees in the insurance plans available on federal and state exchanges generate about 1.39 million primary care visits per year. At a national level, this would require 345 full-time equivalent (FTE) physicians to provide those visits to new rural enrollees. Using data on rural insurance uptake and expected use and productivity of physicians, PAs, and NPs is an opportunity to examine how different provider mixes might meet expanding population requirements for care. The staff ratio simulations vary from 100% physician to 50% physician, 50% PA, or NP. The need for providers to meet the rising demand of new enrollees varies substantially based on geographic region; high levels of need are found in the East North Central, West North Central, and South Atlantic Census divisions.1
Commentary by Fred C. Eilrich: What is the projected increase in demand for primary care visits? Aging baby boomers, increased healthcare use, expanded insurance coverage: For all these reasons and possibly more not yet researched, the debate will continue. PAs and NPs are an important part of the current primary care delivery system. Most likely, the proportion of primary care visits provided by PAs and NPs will continue to increase, particularly in the rural areas. Along with mentioned scope of practice barriers, supply limitations from constrained medical school capacity and personal reluctance to practice in a rural area also affect current staffing scenarios. The delivery model is changing and must continue to evolve to successfully improve the quality of health in rural areas. States will soften restrictions as needed. Technology will continue to advance. Free markets do work, when allowed. Supply, demand, and unbiased consideration for beneficial change will result in the proper staffing scenarios.
Larson EH, Andrilla CHA, Coulthard C, Spetz J. How could nurse practitioners and physician assistants be deployed to provide rural primary care? Policy brief #155. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, March 2016.