Viewpoints: Hiring and Utilizing Physician Assistants

Hiring a physician assistant (PA) can be an exciting step for an aesthetic practice. However, before taking this leap, there are many elements to consider. Beyond scope of practice and the exact role a PA would take up, physicians also need to think about salary, non-compete agreements, and the overall vision and work flow for the practice.

A recent roundtable discussion among top aesthetic physicians highlighted the different ways in which many of us hire and utilize PAs in practice. The discussion shed light on the range of ways physicians can manage a practice from both the business and medical perspectives. Ahead, we will share some of the pearls discussed.

Salary and Bonuses

One of the first points to consider when it comes to hiring a PA is the total cost to a practice. According to the Department of Labor (2014 data), the average annual salary for a PA is $97,280.1 Thus, when accounting for other expenditures, such as bonuses, malpractice insurance, and health benefits, the total cost of a PA to a practice could be as much as $125,000 per year. If the PA is hired as an independent contractor, he or she is responsible for paying malpractice and health insurance, as well as Medicare and Social Security taxes.

Based on our discussion with fellow colleagues, however, PA salaries and pay structures can vary greatly. For instance, some physicians opt to pay hourly wages plus bonus and others pay a salary (usually between $90 and $100K annually) plus bonus. An average PA works about 40 hours per week. One physician noted employing a 100 percent aesthetic PA to do injections and lasers and paying about $35 per hour plus about eight percent bonus after collections. Other scenarios include paying a PA purely on bonus, although a base salary plus bonus is arguably more common.

While basic salaries can range dramatically both in total amounts and structure, there are also several different ways to handle bonuses. For example, the formula for determining a bonus can range from individual productivity to group bonuses divided among all practice employees to encourage team building. One physician claimed that his PA collects over one million dollars and was therefore paid in the top one percent (over $400K annual). PAs receiving lower salaries tended to have more aggressive benefit packages, such as retirement, budget for CME, and health insurance. Notably, comparing salaries between employees at a practice was often forbidden and grounds for firing by some physicians. It's also worth noting on the point of discussion of salary that in some states it is illegal to forbid discussion. In fact, a new law proposed by President Obama would make this practice illegal nationwide, if passed.

Training and Scope of Practice

When it comes to scope of practice, the role of the PA can vary depending on the needs of the physician and the practice. Our roundtable discussion with colleagues distilled a wide range of potential capacities in which PAs can be employed. Some physicians prefer to use PAs in very strict capacities. For instance, some PAs are hired to do only medical dermatology, and others may only perform laser treatments but not injections. Other physicians allow PAs to perform a variety of aesthetic procedures.

Even though the PA can provide excellent care as a physician extender, nearly all of physicians in our discussion agreed that the stress of dealing with unhappy patients, complications, and ultimately malpractice rests on the shoulders of the hiring physician. This underscores the critical importance of training. There is obviously a significant gap in knowledge and training between physicians and PAs. Generally, patients are attracted to a practice because of the expertise of the physicians, not the PA. One physician in our discussion stated that he made more money when he let his PA go and subsequently discovered many medical errors and misdiagnoses of patients. Some physicians related having to manage unhappy patients treated with neurotoxins and fillers, but they still felt the PA was worth it.

About 30 to 50 percent of PAs take call, which is a huge advantage for many physicians. Among our sample, most of the physicians required their PAs to sign non-compete agreements. One physician stated that he invested a significant amount of time over the course of a year to train his PA, who then left the practice, which was a devastating loss. Moreover, some of these PAs open their own facilities to compete with the physician-owned practices form which they received training.

Although physicians can use non-compete agreements to encourage PAs to work out differences before leaving a practice, the underlying problem still persists and may grow into a more significant problem for physicians in the future.

In some states, PAs purchase their own lasers and equipment and then hire a non-core physician to be their “medical director.” In other states, a PA can own their practice outright. However, most participants in our discussion amongst physician colleagues felt that patients come to a practice based on the reputation of the physician rather than the PA. One physician even mentioned that patients are required to pay more for the physician to perform injections as opposed to the PA, to maintain perceived difference in quality and reputation.

The Right Ways Toward Growth

Though we highlight some potential negative experiences, the reality is that most physicians have respectful and trusting relationships with their PAs. Nonetheless, when hiring and incorporating a PA into practice, physicians should always define the parameters of a PA's responsibilities and address any problems at their root before they damage the practice.

Even within our small discussion group, opinions and experiences on the hiring and use of PAs varied greatly. Thus, it is essential that all physicians are engaged to these issues and mindful of our relationships with PAs. The addition of the PA to a practice can be an integral step towards practice growth that can be very rewarding.

1. www.bls.gov