Nurse practitioners, physician assistants playing larger roles in health care — why some doctors are pushing back
Nurse practitioner Payal Patel treats patient Ni-Ima Lattimer at Harmony Healthcare in Hempstead on Jan. 22. Lattimer followed Patel when she changed practices. Credit: Howard Schnapp
When nurse practitioner Payal Patel changed medical practices, patient Ni-Ima Lattimer went with her. The Hempstead woman said she’s more comfortable with her and other nurses than with physicians.
“She treats me like a person-patient, not just another case or number,” said Lattimer, 39, who has lupus.
Patel is one of more than 41,000 nurse practitioners in New York, one of the fastest-growing professions in health care.
Many patients who in the past may have visited doctors for routine health care needs now instead often see nurse practitioners or physician assistants, who also increasingly play key roles in hospitals. The expansion in nurse practitioners and physician assistants comes amid a continued shortfall of primary care physicians.
“If there's a shortage of primary care providers, there's a shortage of people's access,” said Patricia Bruckenthal, dean of the Stony Brook University School of Nursing. “This provides an opportunity for people to increase their access to care, to get the much-needed services they need.”
The burgeoning role of nurse practitioners and physician assistants is occurring as the overall demand for health care is increasing, because of an aging population with a greater need for medical care, and because the Affordable Care Act extended health insurance to more people, said Renee McLeod-Sordjan, dean of the Hofstra Northwell School of Nursing and Physician Assistant Studies.
Some studies show nurse practitioners and physician assistants provide comparable care to doctors in certain settings. But groups representing physicians say they need doctors' oversight, especially in more complex cases, and they oppose efforts to increase their autonomy.
“The physician should be the leader of the team,” said Dr. Paul Pipia, president of the Medical Society of the State of New York and deputy medical director of Nassau University Medical Center in East Meadow.
Nurse practitioner and physician assistant organizations say the supervision is unnecessary.
“We’re asking to do what we’re trained for,” Ed Mathes, president of the New York State Society of Physician Assistants, said of proposed state legislation to reduce oversight.
The number of nurse practitioners in New York has more than quadrupled between 2000 and Jan. 1, from 8,948 to 41,160, according to the state Education Department, which licenses the profession. The growth in physician assistants from 2000 to Jan. 1 was at a similar rate: from 5,347 to 22,725, state data shows.
In contrast, the number of licensed physicians increased at a much slower rate: from 72,004 in 2000 to 111,167 on Jan. 1, a 54% increase.
The nurse practitioner and physician assistant professions were created in the mid-1960s to increase access to care. Nurse practitioners, often called NPs, and physician assistants, or PAs, can prescribe medicine, make medical diagnoses and perform other duties that doctors carry out, but that registered nurses and most other medical professionals cannot.
In about half the states, nurse practitioners must work under the oversight of a physician. New York in 2022 eliminated that requirement for nurse practitioners with more than 3,600 hours of experience. Bills in the state Legislature would allow experienced physician assistants to also operate without the supervision of doctors, a move that groups representing physicians oppose.
Patel said that at federally funded Harmony Healthcare in Hempstead, where she works, there is no rule for which patients see a physician and which see a nurse practitioner.
She said her approach goes beyond the medical reason for which her patients visit her.
“We are taught in NP school more holistic care,” Patel said before walking into an exam room at Harmony to examine Lattimer.
Lattimer, the patient with lupus, regularly sees specialist doctors outside Harmony.
“My experience with doctors is like they just come in, they look over your chart, they say, ‘Everything's good. Is everything OK?’ And then boom, they’re out the door,” she said.
Nurse practitioners like Patel, she said, ask more questions and are more affable, which leads her to open up more about her health issues.
“Nurses are more personal,” she said. “They’re there for your needs.”
Shakena Smith, 40, of Wyandanch, is a patient of Harmony physician assistant Shira Portnoy. Smith said she realizes that Portnoy is not a medical doctor, but she calls her “Doctor Shira” and doesn’t see much difference in the care she receives from her and from Harmony physicians.
“I don’t really look at their letters, their abbreviations,” she said. “Their patient care is wonderful.”
Rebecca Charles, director of operations for Harmony Health, said nurse practitioners and physician assistants allow Harmony to better serve its patients, many of whom are uninsured or underinsured.
“We have a high volume of patients,” she said. “NPs and PAs give us an opportunity to get more of our patients seen, and to avoid long wait time for appointments.”
Nurse practitioners and physician assistants also can save health systems money, said Dr. Cameron Gettel, an assistant professor of emergency medicine at the Yale School of Medicine who studies health outcomes.
Nurse practitioners and physician assistants typically have lower salaries than physicians, and that may be an incentive for hospitals to rely more on them and less on doctors, he said.
Yet the gap in salaries is narrowing, with some experienced NPs earning more than less-experienced pediatricians, primary care physicians and others, so cost savings are less of a factor than in the past, said Eileen Sullivan-Marx, a professor and former dean of the NYU Rory Meyers College of Nursing in Manhattan.
The average salary for a nurse practitioner on Long Island in 2023 was $188,152, just below that of a family medicine physician, at $199,647, according to the state Department of Labor. Physician assistants averaged $153,263. The gap is larger when NPs and PAs are compared with specialist physicians, some of whom on average earn double what a family medicine doctor does, according to national surveys.
Sullivan-Marx said a bigger reason for the increased demand for nurse practitioners and physician assistants is that health systems today take more of a “team approach” to cases, especially more complex ones, and rely more on technology.
“A singular role of a physician doing it all just isn't how health care can be delivered these days, given all the health care technology,” she said.
There’s also more of a focus on emotional support of patients, which nurse practitioners often coordinate, she said.
Nurse practitioners in New York must choose a specialty, such as family health, pediatrics or psychiatry, while physician assistants are trained as medical generalists, said Donna Ferrara, who chairs the physician assistant program at Stony Brook.
Another difference is that physician assistants are educated more similarly to how a doctor is, to focus on the body’s respiratory, digestive and other systems, and symptoms common to those systems, said Ellen Kurtzman, a professor of health administration at Rutgers University in New Jersey. Nurse practitioners are educated more intensely on prevention and health promotion, in addition to receiving clinical training, she said.
Since 2022, nurse practitioners in New York with more than 3,600 hours of experience no longer need physician oversight — although, McLeod-Sordjan said, there are still barriers, such as a rule from Medicare and some insurance companies that won’t allow reimbursement when a nurse practitioner makes an initial diagnosis.
In addition, another Medicare rule reimburses nurse practitioners and physician assistants at 85% of the amount that a doctor receives if they bill the government independently, but 100% if they use the physician's billing number and the doctor is on-site during the patient visit. The cost to the patient is the same, Bruckenthal said.
Physician assistants have unsuccessfully lobbied to eliminate the requirement of doctor supervision.
Gov. Kathy Hochul’s fiscal year 2025 budget proposes that physician assistants not require supervision after 8,000 hours of experience, with certain additional requirements outside primary care.
A bill supported by the physician assistant society would put the floor of experience at 3,600 hours — although Mathes said the organization is willing to compromise.
He said the oversight reduces patient access, because state law limits the number of physician assistants a doctor can supervise, which can cause staffing problems.
Physician assistants now are at the mercy of doctors, he said. Mathes recalled how, years ago in Rochester, a new supervising physician barred him from doing lung biopsies, even though he had performed about 2,000 by that time.
“This one physician said, ‘Yeah, that’s not a procedure a PA should be doing,’ ” he said.
The Medical Society of the State of New York and American Medical Association, which represent doctors, have lobbied against greater autonomy for physician assistants and nurse practitioners.
Pipia said a physician has far more training and education: Four years of medical school and at least three years of a medical residency, compared with a master’s degree for nurse practitioners and physician assistants, which is typically obtained in two to three years.
“I don’t think they have the requisite knowledge by training to work independently,” he said.
Some studies have shown no difference in the care provided by nurse practitioners and physician assistants versus physicians — although experts say doctors are better at handling more complex cases.
A 2017 study found no statistically significant difference in care in community health centers. The exception was that physician assistants — and especially nurse practitioners — were more likely to provide health education and counseling than physicians, said Kurtzman, a co-author of the study.
Other studies have reached similar findings for physician offices and hospital-based clinics, she said.
But a large 2022 study of Veterans Affairs emergency department patients that has not undergone peer review found that patients had worse outcomes — such as more “preventable” hospitalizations — with nurse practitioners compared with doctors.
Gettel, the Yale professor, said “the data is a little mixed” on outcomes in emergency departments, with some studies showing no differences. One reason for the conflicting results is the difficulty in making direct comparisons between the types of patients treated, he said.
Gettel said that in more severe emergency cases, physicians are preferable because of their higher level of training.
Kurtzman said if she went to an emergency room with a sore throat, foot pain or urinary tract infection, she'd “have no problem going to a nurse practitioner.” If she was having chest pain, however, “I would hope that the person seeing me was a physician.”
Portnoy, the Harmony physician assistant, said she usually doesn’t need to consult with a doctor but sometimes calls her supervising physician for more complex cases.
“Sometimes they’re complicated patients, and there are things I’ve never seen before, things I’m not sure of, and I always have that backup,” she said.
When nurse practitioner Payal Patel changed medical practices, patient Ni-Ima Lattimer went with her. The Hempstead woman said she’s more comfortable with her and other nurses than with physicians.
“She treats me like a person-patient, not just another case or number,” said Lattimer, 39, who has lupus.
Patel is one of more than 41,000 nurse practitioners in New York, one of the fastest-growing professions in health care.
Many patients who in the past may have visited doctors for routine health care needs now instead often see nurse practitioners or physician assistants, who also increasingly play key roles in hospitals. The expansion in nurse practitioners and physician assistants comes amid a continued shortfall of primary care physicians.
WHAT TO KNOW
The number of nurse practitioners and physician assistants has quadrupled in New York since 2000, as outpatient practices and hospitals increasingly rely on them for patient care.
Nurse practitioners and physician assistants can perform many of the same duties as doctors, such as prescribing medicine and making medical diagnoses.
The state projects that the number of nurse practitioners and physician assistants will continue to grow more rapidly than the number of physicians. Experts say they increase access to health care as medical needs expand amid an aging population.
“If there's a shortage of primary care providers, there's a shortage of people's access,” said Patricia Bruckenthal, dean of the Stony Brook University School of Nursing. “This provides an opportunity for people to increase their access to care, to get the much-needed services they need.”
The burgeoning role of nurse practitioners and physician assistants is occurring as the overall demand for health care is increasing, because of an aging population with a greater need for medical care, and because the Affordable Care Act extended health insurance to more people, said Renee McLeod-Sordjan, dean of the Hofstra Northwell School of Nursing and Physician Assistant Studies.
The growth of nurse practitioners and physician assistants comes as the demand for health care is rising, said Renee McLeod-Sordjan, dean of the Hofstra Northwell School of Nursing and Physician Assistant Studies. Credit: Newsday/J. Conrad Williams Jr.
Some studies show nurse practitioners and physician assistants provide comparable care to doctors in certain settings. But groups representing physicians say they need doctors' oversight, especially in more complex cases, and they oppose efforts to increase their autonomy.
“The physician should be the leader of the team,” said Dr. Paul Pipia, president of the Medical Society of the State of New York and deputy medical director of Nassau University Medical Center in East Meadow.
Nurse practitioner and physician assistant organizations say the supervision is unnecessary.
“We’re asking to do what we’re trained for,” Ed Mathes, president of the New York State Society of Physician Assistants, said of proposed state legislation to reduce oversight.
The number of nurse practitioners in New York has more than quadrupled between 2000 and Jan. 1, from 8,948 to 41,160, according to the state Education Department, which licenses the profession. The growth in physician assistants from 2000 to Jan. 1 was at a similar rate: from 5,347 to 22,725, state data shows.
In contrast, the number of licensed physicians increased at a much slower rate: from 72,004 in 2000 to 111,167 on Jan. 1, a 54% increase.
NYS bills would expand autonomy
The nurse practitioner and physician assistant professions were created in the mid-1960s to increase access to care. Nurse practitioners, often called NPs, and physician assistants, or PAs, can prescribe medicine, make medical diagnoses and perform other duties that doctors carry out, but that registered nurses and most other medical professionals cannot.
In about half the states, nurse practitioners must work under the oversight of a physician. New York in 2022 eliminated that requirement for nurse practitioners with more than 3,600 hours of experience. Bills in the state Legislature would allow experienced physician assistants to also operate without the supervision of doctors, a move that groups representing physicians oppose.
Patel said that at federally funded Harmony Healthcare in Hempstead, where she works, there is no rule for which patients see a physician and which see a nurse practitioner.
She said her approach goes beyond the medical reason for which her patients visit her.
“We are taught in NP school more holistic care,” Patel said before walking into an exam room at Harmony to examine Lattimer.
Lattimer, the patient with lupus, regularly sees specialist doctors outside Harmony.
“My experience with doctors is like they just come in, they look over your chart, they say, ‘Everything's good. Is everything OK?’ And then boom, they’re out the door,” she said.
Nurse practitioners like Patel, she said, ask more questions and are more affable, which leads her to open up more about her health issues.
“Nurses are more personal,” she said. “They’re there for your needs.”
Shakena Smith, 40, of Wyandanch, is a patient of Harmony physician assistant Shira Portnoy. Smith said she realizes that Portnoy is not a medical doctor, but she calls her “Doctor Shira” and doesn’t see much difference in the care she receives from her and from Harmony physicians.
Shira Portnoy, a physician assistant, at Harmony Healthcare in Hempstead, has one patient who calls her "Doctor Shira." Credit: Howard Schnapp
“I don’t really look at their letters, their abbreviations,” she said. “Their patient care is wonderful.”
Rebecca Charles, director of operations for Harmony Health, said nurse practitioners and physician assistants allow Harmony to better serve its patients, many of whom are uninsured or underinsured.
“We have a high volume of patients,” she said. “NPs and PAs give us an opportunity to get more of our patients seen, and to avoid long wait time for appointments.”
Cost savings for systems
Nurse practitioners and physician assistants also can save health systems money, said Dr. Cameron Gettel, an assistant professor of emergency medicine at the Yale School of Medicine who studies health outcomes.
Nurse practitioners and physician assistants typically have lower salaries than physicians, and that may be an incentive for hospitals to rely more on them and less on doctors, he said.
Yet the gap in salaries is narrowing, with some experienced NPs earning more than less-experienced pediatricians, primary care physicians and others, so cost savings are less of a factor than in the past, said Eileen Sullivan-Marx, a professor and former dean of the NYU Rory Meyers College of Nursing in Manhattan.
The average salary for a nurse practitioner on Long Island in 2023 was $188,152, just below that of a family medicine physician, at $199,647, according to the state Department of Labor. Physician assistants averaged $153,263. The gap is larger when NPs and PAs are compared with specialist physicians, some of whom on average earn double what a family medicine doctor does, according to national surveys.
Sullivan-Marx said a bigger reason for the increased demand for nurse practitioners and physician assistants is that health systems today take more of a “team approach” to cases, especially more complex ones, and rely more on technology.
“A singular role of a physician doing it all just isn't how health care can be delivered these days, given all the health care technology,” she said.
There’s also more of a focus on emotional support of patients, which nurse practitioners often coordinate, she said.
Nurse practitioners in New York must choose a specialty, such as family health, pediatrics or psychiatry, while physician assistants are trained as medical generalists, said Donna Ferrara, who chairs the physician assistant program at Stony Brook.
Another difference is that physician assistants are educated more similarly to how a doctor is, to focus on the body’s respiratory, digestive and other systems, and symptoms common to those systems, said Ellen Kurtzman, a professor of health administration at Rutgers University in New Jersey. Nurse practitioners are educated more intensely on prevention and health promotion, in addition to receiving clinical training, she said.
Debate over autonomy
Since 2022, nurse practitioners in New York with more than 3,600 hours of experience no longer need physician oversight — although, McLeod-Sordjan said, there are still barriers, such as a rule from Medicare and some insurance companies that won’t allow reimbursement when a nurse practitioner makes an initial diagnosis.
In addition, another Medicare rule reimburses nurse practitioners and physician assistants at 85% of the amount that a doctor receives if they bill the government independently, but 100% if they use the physician's billing number and the doctor is on-site during the patient visit. The cost to the patient is the same, Bruckenthal said.
Physician assistants have unsuccessfully lobbied to eliminate the requirement of doctor supervision.
Gov. Kathy Hochul’s fiscal year 2025 budget proposes that physician assistants not require supervision after 8,000 hours of experience, with certain additional requirements outside primary care.
A bill supported by the physician assistant society would put the floor of experience at 3,600 hours — although Mathes said the organization is willing to compromise.
He said the oversight reduces patient access, because state law limits the number of physician assistants a doctor can supervise, which can cause staffing problems.
Physician assistants now are at the mercy of doctors, he said. Mathes recalled how, years ago in Rochester, a new supervising physician barred him from doing lung biopsies, even though he had performed about 2,000 by that time.
“This one physician said, ‘Yeah, that’s not a procedure a PA should be doing,’ ” he said.
The Medical Society of the State of New York and American Medical Association, which represent doctors, have lobbied against greater autonomy for physician assistants and nurse practitioners.
Pipia said a physician has far more training and education: Four years of medical school and at least three years of a medical residency, compared with a master’s degree for nurse practitioners and physician assistants, which is typically obtained in two to three years.
“I don’t think they have the requisite knowledge by training to work independently,” he said.
“I don’t think they have the requisite knowledge by training to work independently,” Dr. Paul Pipia, president of the Medical Society of the State of New York, said of nurse practitioners and physician assistants. Credit: Daniel Goodrich
Studies on health outcomes vs. doctors
Some studies have shown no difference in the care provided by nurse practitioners and physician assistants versus physicians — although experts say doctors are better at handling more complex cases.
A 2017 study found no statistically significant difference in care in community health centers. The exception was that physician assistants — and especially nurse practitioners — were more likely to provide health education and counseling than physicians, said Kurtzman, a co-author of the study.
Other studies have reached similar findings for physician offices and hospital-based clinics, she said.
But a large 2022 study of Veterans Affairs emergency department patients that has not undergone peer review found that patients had worse outcomes — such as more “preventable” hospitalizations — with nurse practitioners compared with doctors.
Gettel, the Yale professor, said “the data is a little mixed” on outcomes in emergency departments, with some studies showing no differences. One reason for the conflicting results is the difficulty in making direct comparisons between the types of patients treated, he said.
Dr. Cameron Gettel, of the Yale School of Medicine, said physicians’ higher level of training makes them preferable in an emergency. Credit: Yale School of Medicine
Gettel said that in more severe emergency cases, physicians are preferable because of their higher level of training.
Kurtzman said if she went to an emergency room with a sore throat, foot pain or urinary tract infection, she'd “have no problem going to a nurse practitioner.” If she was having chest pain, however, “I would hope that the person seeing me was a physician.”
Portnoy, the Harmony physician assistant, said she usually doesn’t need to consult with a doctor but sometimes calls her supervising physician for more complex cases.
“Sometimes they’re complicated patients, and there are things I’ve never seen before, things I’m not sure of, and I always have that backup,” she said.
David Olson covers health care. He has worked at Newsday since 2015 and previously covered immigration, multicultural issues and religion at The Press-Enterprise in Southern California.
SBU students protest ... Plea in crash that killed 4 ... Westbury streetscaping begins ... World's 'Flair'
SBU students protest ... Plea in crash that killed 4 ... Westbury streetscaping begins ... World's 'Flair'
