After more than a decade of practicing as a physician assistant, I have seen firsthand how APPs are expected to deliver care that matches our physician colleagues in quality, safety, documentation, and patient outcomes. And we do. Study after study shows that APPs, particularly those with 10 or more years of experience, achieve equivalent results in clinical care, patient satisfaction, and chronic disease management. In many primary care settings, we serve as independent clinicians, taking full panels, managing high patient volumes, and often filling gaps where physicians are in short supply.
Yet despite all this, we are systematically reimbursed at only 85% of what a physician would be paid for the exact same CPT-coded visit. Most APPs earn a fraction of a physician’s salary, even when working side by side and doing the same clinical work. That discrepancy has become one of the most unaddressed injustices in our health care system. And it is not just about pay, it is about the culture that justifies it.
The Cultural Undervaluing of APPs
This is not just a reimbursement issue; it is a reflection of how APPs are still viewed in many leadership structures. We are often “included” in name but excluded in decision-making. We are expected to meet the same metrics as physicians but are rarely given the same voice — or compensation. When new governance structures form, APPs are listed as afterthoughts or token participants, rather than as key clinical leaders whose perspectives shape patient care delivery.
This cultural mindset that APPs are inherently “less than” is outmoded. It persists despite overwhelming data demonstrating that experienced APPs can and do operate at a high level of autonomy and clinical competence. Culture shapes policy, and as long as APPs are viewed through a legacy lens, we will continue to see reimbursement and leadership inequities codified into compensation models and organizational charts.
The Experience Factor Is Ignored
Imagine an NP or PA with 15 years of full-time primary care experience managing 20-plus patients a day, fielding after-hours messages, supervising support staff, mentoring students, and consistently hitting productivity benchmarks. Now imagine a newly graduated internal medicine physician, with fewer years in practice, receiving double or triple the compensation for delivering similar or even lesser output.
The issue is not degree-based; it is value-based. In any other industry, outcomes and experience drive compensation. Health care should be no different. Research has shown that NPs and PAs deliver equivalent or superior outcomes to physicians in primary care — particularly in chronic disease management, preventive care, and patient satisfaction scores. Among seasoned APPs managing complex patients at high volumes, contribution to system performance is often indistinguishable from that of physician counterparts.
We say we care about access, retention, burnout, and quality. Yet the message we send to experienced APPs is: you’ll always be paid less, no matter how good you are.
We’re not arguing for identical pay across all roles — we’re advocating for targeted compensation structures that reflect the outcomes and experience delivered in practice.
Reimbursement Models Are Stuck in the Past
CMS’s longstanding 85% reimbursement cap for APPs, while intended for supervised billing, is now functionally outdated. Many APPs bill under their own NPI and practice independently in accordance with state laws and system policies. Still, the reimbursement cap persists and commercial insurers tend to follow suit. This perpetuates a structural inequity that disincentivizes retention, demoralizes clinicians, and contradicts the value-based care principles we claim to champion.
From the Insurer’s Perspective: A False Economy
Payers may argue the 85% model saves costs — but only on the surface. In reality, undervaluing seasoned APPs creates long-term expense and risk.
APPs are critical to maintaining access, especially in rural or high-need areas. When experienced clinicians leave due to compensation ceilings, the system suffers: patients wait longer, physician colleagues burn out faster, and costly locum or traveler coverage often becomes necessary. Recruiting and onboarding a new clinician, regardless of credentials, comes at a steep cost.
The more strategic approach? Retain experienced APPs who deliver proven outcomes. Insurers and health systems alike should be incentivizing that stability, not undermining it.
Addressing the Training and Complexity Argument
Critics may point out the difference in education and training between physicians and APPs and they are not wrong. Physicians undergo longer and more intense training and are indispensable in high-acuity, tertiary, and specialty care. But that is not what this piece is about. This is about primary care, rural health, chronic care, and outpatient access — settings where APPs routinely practice independently, meet the same quality metrics, and shoulder equal patient volumes.
In many of these same clinical environments, APPs also handle high complexity patients independently too. Rather than denying this, systems should track complexity-adjusted outcomes and tie compensation accordingly. Additionally, physician leadership in complex or tertiary care should be valued differently, but not at the expense of undervaluing APPs who deliver equal value in their scope.
In these contexts, the training gap has less bearing on daily performance. Experience matters. Productivity matters. Outcomes matter. If compensation structures ignore those factors, we risk hemorrhaging the very workforce that’s keeping the system functional.
This Isn’t About Attacking Physicians
Let me be clear: this is not a call to diminish or displace physicians. Physicians and APPs are essential parts of a collaborative, interdependent team. This advocacy is about making sure every team member is valued for their contribution and outcomes, not their degree alone.
Our aim should be to improve retention, recruitment, morale, and access, all of which benefit when compensation aligns more closely with performance and experience.
Common Misconceptions
“APPs don’t have the same training, so they shouldn’t expect the same pay.”
True. Our training pathways are different. But compensation in modern health care should reflect the scope of practice, clinical outcomes, and value delivered. An APP with 15 years of experience and high-quality metrics may add more value than a new graduate physician in many care environments.
“APPs are supposed to be support staff, not replacements.”
This framing is outdated. APPs are not assistants; we are licensed, board-certified, and in many states, independently practicing clinicians. We do not seek to replace. We seek to collaborate, while being compensated for the work we actually do.
“85% is still generous compared to training costs.”
Health care is not about training investment returns. It is about access, outcomes, and sustainability. Underpaying high-performing clinicians based on an education they completed 10–20 years ago is shortsighted and regressive.
Financial and Liability
Another frequent argument is that APPs should not be paid more because their malpractice liability is lower or their training cost is less. But this misses the point too. Many APPs carry their own malpractice insurance and face litigation risks, documentation burdens, and productivity expectations nearly identical to their physician peers. And while training costs differ, compensation should reflect value to the system, not past tuition bills.
Undercompensating experienced, high-performing APPs may feel financially conservative in the short term, but it’s a false economy. Turnover, lost productivity, locum coverage, and disrupted continuity of care are far more expensive. A recent Medical Group Management Association study estimates that replacing a single primary care clinician can have a direct cost between $85,000–$114,000, and this fails to take into account any indirect costs.
The Cost of Underpaying APPs
The implications are far-reaching. When seasoned APPs burn out or leave due to financial stagnation, organizations lose high-yield clinicians who require no additional training. Patients lose trusted clinicians. Physician colleagues lose essential teammates. Systems lose opportunities to enhance access and improve margins through optimized team-based care.
This is not just a matter of fairness. It is a strategic misstep.
What Needs to Change
We do not need blind pay parity. We need outcome-aligned, experience-informed compensation models. Health systems should:
1) Reassess RVU credit structures to reflect actual productivity.
2) Develop experience-based pay tiers for APPs, just as they do for physicians.
3) Incorporate APPs into compensation committees and leadership roles.
4) Advocate for CMS reform of outdated billing policies that penalize independence.
And most of all, we need to challenge the culture that keeps APPs boxed into subordinate roles. That shift starts with leadership recognizing that parity is not just about numbers, it is about respect.
A Call for Culture and Policy Reform
Health care is in a crisis of access, cost, and clinician burnout. Experienced APPs are an essential part of the solution. But as long as we continue to ask these clinicians to function at the top of their license while compensating them as second-tier clinicians, we will continue to hemorrhage talent and undermine our workforce.
This is about future-proofing the health care workforce. If we want sustainable access, reduced burnout, and high-performing care teams, we must stop treating experienced APPs as expendable labor. If the standards and outcomes are equal, especially in primary care, then the respect, compensation, and representation must begin to match.
What common misconceptions about APPs bug you the most? Share in the comments!
Michael J. Steger, MMS, PA-C is a family medicine physician assistant with over 12 years of clinical experience and a current Master of Health Care Administration (MHA) candidate. He serves on the governing board of UNC Physicians Network and contributes to multiple systemwide leadership initiatives focused on clinical governance, compensation reform, and APP optimization. Michael is passionate about advancing equity, retention, and innovation in the health care workforce.
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