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

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]