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Can nurse practitioners solve the country’s primary care shortage?

Can nurse practitioners solve the country’s primary care shortage?

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[Photo by John Moore/Getty Images]

Joyce Knestrick, the president of the American Association of Nurse Practitioners, grew up in a housing project in Appalachia.

After receiving a nursing degree, a master’s degree, and a doctorate, she chose to work at a community clinic in Wheeling, West Virginia, a city about 25 miles from where she attended school as a child. There, patients work long hours in service industry jobs, struggle with smoking and diabetes, and often miss appointments because they lack transportation.    

“I’ve always practiced in rural and underserved areas,” Knestrick said. “That’s my way of giving back to society for what it’s given me.”

Her story isn’t unusual for nurse practitioners (NPs). Since training programs often educate nurses in their own communities, they tend to stay in those areas. That could explain why rural primary care physician practices are increasingly relying on NPs, according to a recent study in Health Affairs. Interestingly, though, researchers also found that the presence of NPs is expanding in nonrural areas, too — underscoring their important role in addressing the country’s growing shortage of primary care doctors.

The study’s findings support other research that has found significant national growth in NPs. Last year, nearly 28,000 people graduated from nurse practitioner programs, more than three times the number who graduated a decade before, according to Edward Salsberg, director of health workforce studies at the Health Workforce Institute at George Washington University.

“The rapid growth of NPs could help mitigate the worries about shortages,” Salsberg said. “There’s real hope that help is on the way.”

The nurse practitioner will see you now

While there’s been speculation that NPs are playing a key role in tackling the primary care gap, it was interesting to see the numbers confirm that, said Hilary Barnes, an assistant professor at the University of Delaware School of Nursing and the lead author of the Health Affairs study.

Researchers looked at the proportion of NPs, physicians and physician assistants in both rural and nonrural primary care practices from 2008 to 2016. By the end of that period, NPs made up more than 25 percent of providers in rural practices, up from 17.6 percent in 2008.  In nonrural practices, the percentages grew from nearly 16 percent to 23 percent during that same timeframe. Meanwhile, physician percentages decreased in both rural and urban settings. The proportion of physician assistants stayed relatively constant.

Barnes attributes these workforce changes in part to the growing national physician shortage, which is only expected to worsen as a wave of baby boomer doctors retire. As the numbers of NPs soar nationwide, attitudes toward them are also shifting. More and more patients are open to seeing NPs for their primary care needs, Barnes said.

Nurse practitioners don’t go it alone

While this rapid growth is improving access in underserved urban and rural areas alike, Salsberg cautioned against considering NPs a substitute for physicians. Instead, he says the providers are increasingly working together in a team-based approach to care.

For example, some patients’ concerns — such as a difficult diagnosis — might require a physician, while routine health needs may be more easily served by a nurse practitioner or physician assistant.  Personally, Salsberg says he’s confident that a NP would refer him to a physician if his care needs were beyond their expertise.

“I bristle when people suggest it’s either-or,” he said. “In more and more of the practices I visit, the physicians are working with NPs and PAs.”

He pointed to research from UCSF’s Thomas Bodenheimer who has argued that primary care capacity can be greatly increased by allowing other providers — such as registered nurses and pharmacists — to address care needs traditionally handled by a doctor. 

What does your state allow?

Figuring out just how much autonomy a NP should have, though, isn’t without controversy.  While some states allow a NP to practice more independently, other states may require NPs to discuss a patient’s care with a physician, have a physician sign their charts, or limit their ability to prescribe drugs.  

Groups such as the American Medical Association have opposed expanding the authority of non-physicians in ways that would “threaten the health and safety of patients,” saying that wellbeing could be harmed “by practitioners who lack the education, training or experience to perform procedures…”  But a June report from the Brookings Institution found that the more limiting laws “restrict competition, generate administr­ative burdens, and contribute to increased health care costs, all while having no discernable health benefits.”

In general, scope of practice — what a health care provider is allowed to do — is a ripe area for journalists to explore, Barnes said. She suggests reporters look into what the laws look like in their  state. California reporters, for example, might be surprised that the state is among the most restrictive, she said.

As for Salsberg, he recommends reporters look at the big picture when reporting on primary care. While pockets of shortage will remain — providers aren’t distributed evenly across the country — it’s important to situate those gaps within the overall context: the increase in NPs is significantly improving the country’s health care workforce shortages.

“The challenge for press is trying to understand extent of the problem,” he said. “We can always find an anecdote of some physician retiring and someone unable to find a doctor.”

[Photo by John Moore/Getty Images]


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There is no workforce cure that can result from any training source. Massive overexpansions of MD DO PA and NP annual graduates at 6 to 12 times annual population growth since the classes of 2000 have not resolved the shortages because they cannot. Primary care and general specialty workforce are both half enough for half of the population - by financial design.

You cannot double primary care, women's health, mental health, general surgery, general orthopedics, and other general specialties for half of the population without budgets that support the office, team members, clinicians, physicians, and all of the substantial costly bells and whistles added over the recent decades. The greatest increase in population growth, demand, and complexity is specific to this half of the population and there is no response specific to the basics, the generalists and general specialists, needed most who provide 90% of local services for these populations.

The workforce designers have failed utterly as the challenges of 2040 needed to be addressed before 2010 to impact a generation of workforce - and the financial design has been changed in a substantially negative direction.

The revenue design actually worsens across the span of higher to lower workforce concentration settings. This is a direct parallel of the most powerful, most organized, and most concentrated as compared to the practices and populations least organized, least powerful, and most ignored.

The insurance plans involving public and private are worst where access is most needed. The payments decrease by 15 - 25% for office services where most Americans most need care (Medicare 2011). The reductions for NP and PA services are not the only reductions reducing workforce.

Costs of delivery are a key component of the financial design. These costs are highest for lower workforce concentration practices due to lack of purchasing power and lack of economy of scale. Turnover costs are highest and frequencies of turnover are highest where workforce is most needed - essentially another 15% reduction in revenue. Regulatory and innovative changes have also subtracted additional costs of delivery equivalent to a 15% decrease in revenue or another $100,000 per primary care physician or equivalent.

Rapid change, negative budgetary changes, stagnant to declining revenue, and declining productivity worsen the situations facing those fewer who remain where needed. Studies indicate that small and medium practices cannot handle usual disruptions well (Mold Annals FM supplement), much less the chaos of the last decade. The balance is tipped far in favor of those larger where plans are better and patients inherently have better outcomes.

Primary care retention continues to decline class year to class year across all sources of workforce with the one-two punch of departures for more new specialties and the worsening financial design for basic services. This has also fueled every higher costs of health care. In fact, more subspecialists from MD DO NP and PA are essential to those largest, most organized, and receiving the most lines of revenue and the highest reimbursement in each line.

There is little indication that expansions add any to primary care delivery capacity. What changes occur are rearrangements of the deck chairs due to departures and replacements - replacements that do not stay to provide continuity or other key areas needed for primary care workforce. The nation has a primary care workforce with less and less experience each passing year with worse to come.

The fact of the matter is that the nation does not value primary care - especially primary care where most needed. It also does not value mental health or other general specialty services. Women's health is also in decline and the controversies only hide the main story of declining workforce and access.

In a time where value based aberrations make matters worse for practices facing the most challenge, there is only one route to more primary care revenue and it is the opposite of value based. In this scenario practices being paid less are taken over by larger entities - and get a 15 - 30% bump in payment for the same services. More payment without changes in outcomes is the opposite of value based. The bigger and more powerful entities do not want those smaller for a number of reasons including lesser outcomes and greater complexity because of the populations that they serve.

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Mr. Bowman, your contention as I understand it is that government gets the opposite of its stated goal (which I believe as well). Our choices are to institute changes through public health/population health, which would take a generation to “move the needle” of cost for quality outcomes. What other options do we have?


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