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Commentaries on health services research

Coplan, Bettie MPAS, PA-C; Dehn, Richard W. MPA, PA-C, DFAAPA; Hooker, Roderick S. PhD, PA

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Journal of the American Academy of Physician Assistants: January 2018 - Volume 31 - Issue 1 - p 53-54
doi: 10.1097/01.JAA.0000527702.08322.c3
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Examining the gap: Compensation disparities between male and female PAs


Pay differences between men and women have been problematic for decades. The authors examined the compensation gap in the PA profession. Data from 2014 were collected by the American Academy of PAs (AAPA) in 2015. Practice variables, including experience, specialty, and hours worked, were examined for disparity in total compensation. Without controlling for practice variables, a total compensation disparity of $16,052 existed between men and women in the PA profession. Even after PA practice variables were controlled for, the compensation disparity of $9,695 remained (95% confidence interval, $8,438-$10,952). A 17-year trend indicates the disparity between men and women has not lessened. Even when compensation-relevant factors such as experience, hours worked, specialty, postgraduate training, region, and being on-call are controlled for, the pay difference between men and women remains substantial. Remedies include raising awareness of compensation differences, teaching effective negotiation skills, assisting employers as they develop equitable compensation plans, having less reliance on past salary in position negotiation, and professional associations advocating for policies that support equal wages and opportunities, regardless of personal characteristics.1

Commentary by Bettie Coplan: When it comes to pay in the PA profession, men still dominate. In this study, researchers took a fresh look at the pay gap between female and male PAs. The good news for most PAs (the 67.7% who are women): it could be worse.2 Study authors note that across all professions, compensation for women is 77% of compensation for men; in the 17-year time frame for this study, female PAs made 86.8% of what male PAs made. The bad news: the absolute pay disparity between women and men has not improved over time. Compared with male colleagues, female physicians fare no better or worse.3

Proposed solutions include teaching women to more effectively negotiate. For this strategy to be successful, women must first expect more. Morgan and colleagues revealed that, even as PA students, women anticipate making less.4 When it comes to patient care, however, research published in 2016 showed that Medicare patients of female physicians had better outcomes than those of male physicians. Although female and male PA patient outcomes have not been compared, these results suggest that women perform as well (or better) than men at the examination table. When will women be able to say the same about female skills at the PA negotiating table?


    Quantifying benefit of PAs and NPs on surgical services


    With the introduction of resident duty hour restrictions and the resulting in-house trainee shortages, the authors examined the use of PAs and NPs on surgical/trauma services and their effect on patient outcomes and resident workload through a systematic review of the literature. The review included studies that examined the use of PAs and NPs on adult surgical and trauma services that reported the following outcomes: complications, length of stay, readmission rates, patient satisfaction and perceived quality of care, resident workload, resident work hours, resident sleep hours, resident satisfaction, resident perceived quality of care, other healthcare worker satisfaction and perceived quality of care, and economic effect assessments. Excluded studies were those assessing nonsurgical/trauma services and pediatrics and review articles. Twenty-nine articles met the criteria. With the addition of PAs and NPs, patient length of stay decreased, and morbidity and mortality were unchanged. In addition, resident workload decreased, resident sleep time increased, and operating time improved. Patient and healthcare worker satisfaction rates were high. Several studies reported cost savings after the addition of PAs and NPs. The addition of PAs and NPs to surgical/trauma services appears to be a safe, cost-effective method to manage some of the challenges arising because of resident duty hour restrictions. More high-quality research is needed to confirm these findings and to further assess the economic effect of adding PAs and NPs to the surgical team.1

    Commentary by Richard W. Dehn: This paper is of interest to healthcare workforce researchers and policy experts for two reasons—first, because literature is lacking describing plastic surgery and PAs, and second, that it uses a pre-post study design that was common in early years of the PA profession but has not been used recently.2 Although the pre-post results show, as with most specialties and settings, that the addition of PAs increases the efficiencies and productivity of physicians in plastic surgery, the most interesting finding of this study is that it again demonstrates the economic value of provider teams using PAs. Studies demonstrating provider economic value will likely help guide future healthcare team structures. Illustrating this trend toward factoring economic value into policy, the Centers for Medicare and Medicaid Services is proposing bundling not just event but episode of disease management, which would enhance the role of PAs based almost entirely on their advantageous labor cost.


      Are PAs and NPs cost effective in primary care?


      Are PA and NPs more likely to order ancillary services or order more costly services among alternatives than primary care physicians (PCPs)? The authors compared prescription medication and diagnostic service orders associated with PA and NP versus PCP visits for management of neck or back pain or acute respiratory infection. This was a retrospective observational study of visits from 2006 to 2008 in the adult primary care practice of Kaiser Permanente in Georgia. Data were obtained from electronic health records. On propensity score-matched neck or back pain visits (N = 6,724), PAs and NPs were less likely than PCPs to order a CT or MRI (2.1% versus 3.3%) or opioid analgesic (26.9% versus 28.5%) and more likely to order a nonopioid analgesic (13.5% versus 8.5%) or muscle relaxant (45.8% versus 42.5%). On propensity score-matched acute respiratory infection visits (N = 24,190), PAs and NPs were more likely than PCPs to order any antibiotic (73.7% versus 65.8%) but less likely to order a radiograph (6.3% versus 8.6%), broad-spectrum antibiotic (41.5% versus 42.5%), or rapid strep test (6.3% versus 9.7%).1

      Commentary by Roderick S. Hooker: This is the second of two papers examining primary care in an HMO where the authors have documented that medical care is cost-beneficial when PAs and NPs are part of the team.2 When PAs and NPs are removed from members of the primary care team then costs increase for the same episode due to more resource-intensive care and higher labor cost. Why do PAs on teams (in this HMO and elsewhere) use fewer medical resources per visit?3 One theory is that PAs and NPs may be delegated less-severe cases. A second theory is familiarity with conditions—after a period of experience, pattern recognition becomes finely tuned; PAs and NPs are better able to distinguish which cases will benefit most or least from laboratory studies or radiographs. The third is that perhaps an improved outcome occurs in patient care when a PA or NP is part of the team. Instead of negating their labor cost benefit by using more resources for an episode of care, they use less than physicians. Time-motion studies and variable-controlled investigations are needed.


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