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Sharp Increases In The Clinician Pipeline: Opportunity And Danger

June 9th, 2014

The number of health care practitioners educated in the United States has grown dramatically over the past decade. This post presents data on four key health care clinicians: nurse practitioners (NPs), pharmacists, physician assistants (PAs), and registered nurses (RNs). In some cases, the pipeline for these clinicians has more than doubled in recent years. Even if there is no further growth in the educational pipeline today, the increases in educational capacity, if continued, will lead to an increase in the available supply each year for the next 30 to 35 years.

If these practitioners are fully integrated into the delivery system and allowed to practice consistent with their education and training, this growth can help assure access to cost effective care across the nation. On the other hand, because of the 30 to 35 year tail in the growth of practitioners, there is a danger that this rapid growth could also lead to significant surpluses, which would have many negative consequences.

The Recent Growth

The figures below use slightly different metrics to measure growth in the pipeline, but the patterns are consistent across professions: steady, strong growth.

NPs: Figure 1 presents the number of new NP graduates as reported by the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF). Not all new NPs will go on to practice as an NP, as some may have been working as a registered nurse (RN) during their education and some of these NPs may continue in an RN position. Others may go into administrative positions. Nevertheless, the graduation figures reflect the significant growth in the pipeline from 6,611 in 2003 to 16,031 in 2013, an increase of 142 percent over the decade.

Figure 1


PAs: Figure 2 presents the number of PAs passing the examination required for certification by the National Commission on Certification of Physician Assistants (NCCPA). In as much as almost all PAs that want to practice must first be certified by the NCCPA, their data on the number of newly certified PAs is a very good measure of the pipeline. The number of newly certified PAs went from 4,337 in 2003 to 6,607 in 2013, an increase of 52 percent. The annual number of new PAs will certainly continue to grow, as the number of PA programs increased from 154 in 2010 (likely to have produced the 2013 graduates) to 187 in early 2014. Another 65 applications for new programs are currently under review.

Figure 2


Pharmacists: According to the American Association of Colleges of Pharmacy (AACP), the number of pharmacy graduates was 7,488 in 2003. By 2013, it was estimated that the number of pharmacy graduates grew to 13,355, representing an increase 78 percent from 2003-2013. The AACP projects the number of annual graduates will grow to 14,930 by 2015.

Figure 3


Registered Nurses: To become licensed as a registered nurse, all applicants are required to take and pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). According to the National Council of State Boards of Nursing (NCSBN), which administers the examination, 76,688 U.S. nurse graduates took the NCLEX-RN for the first time in 2003. This number grew to 155,018 in 2013, an increase of 102 percent.

Figure 4


The Long Tail of Pipeline Increases

While increases in enrollment are usually in response to current or anticipated near term needs, as noted above, the impact can be a steady growth of the profession for the next 30 to 35 years. Consider a hypothetical occupation with 330,000 practitioners each working 33 years on average (say from age 25 to 58) in a steady state with 10,000 retirees and 10,000 new entrants each year. If you double production to 20,000 because of a short term need, you have to be aware that for each of the next 33 years, 10,000 will be retiring but 20,000 will be entering. Thus, an increase in educational production in 2014, if sustained, will lead to an increasing supply through 2047!

The Very Good News

These increases have the potential to help the nation meet its health care needs over the next few years. We need to ensure these practitioners are allowed to practice consistent with their education and skills and remove unnecessary or inappropriate barriers to their effective use. We also need to make sure they are effectively integrated into the delivery system and can work as full members of the care team.

There is no doubt that these practitioners will be available to help meet the needs of a growing and elderly U.S. population. Based on this data on the pipeline, the number of new NPs, PAs and pharmacists in 2013 was in the range of 36,000 and growing. This compares to an estimated 30,500 new physicians entering the pipeline in 2014.

The Danger

The danger is that these growth rates could lead to large surpluses. In the early 1980s and 1990s, the nursing job market became saturated and new RNs had a very difficult time finding jobs; as a result, applicants and enrollment plummeted significantly over a 5 to 7 year period. Some programs ended up closing. This in turn contributed to new rounds of shortages. This cycle of over- and under-production is very costly to individuals and institutions.

Some of this fluctuation reflects the open market, where all producers respond to the same signals of either a shortage (add educational capacity); or a surplus (reduce capacity). More frequent and timely assessments of gaps and projections might moderate the upward and downward swings, but it can be difficult to change the prevailing thinking of either a surplus or a shortage. Many people had a hard time understanding how health planners were worried about a physician shortage (1950 to 1980), then a physician surplus (1980 to 2000) and then again a shortage (2000 – today). In fact, the health workforce planning community was mocked at times for the apparent reversal in direction. However, the change in direction does not necessarily mean that the forecasters got it wrong: in some cases, the educational community not only responded, but over-responded.

There are times the nation should claim success. For example, the nation’s educational programs responded very effectively to the nursing shortage: they more than doubled production in 10 years! They should be commended. But after many years of public concerns of a shortage, it may be difficult to change our thinking until new nurses can’t find jobs.

Perhaps if Congress would fund the National Health Care Workforce Commission authorized by the Affordable Care Act, we would have a national body to advise when it is time to moderate our growth or shrinkage. This wouldn’t be a panacea, but it could certainly help.

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8 Responses to “Sharp Increases In The Clinician Pipeline: Opportunity And Danger”

  1. Karen Lyon, PhD, APRN Says:

    H. Goblin admits that his information on physicians “fixing NP’s mistakes on a daily basis” is purely anecdotal. The truth is that we have reams of evidence-based data that support the excellent patient care outcomes of APRNs. I will be happy to provide those references to anyone who is interested. It is also not true that APRNs have only 1/10 to 1/4 the education of MDs. After our 4 year baccalaureate education, 2 years of which are clinically-based, we do 3-5 years of Master’s level education (docs do 4 years of medical school). So, at the end of medical school and APRN graduate school, MDs and APRNs have had essentially the same years of schooling. It is true at this point that physicians go on to specialize. The question becomes, do we really all have to get this expensive, highly specialized medical education to provide the primary care that our population needs to help them manage wellness promotion, preventive care and chronic disease management? Many clear thinking professionals in medicine, nursing, economics, epidemiology, and other disciplines don’t necessarily think so.

  2. Peter McMenamin Says:

    Current and Coming Stresses on the Clinician Pipeline for Registered Nurses
    Peter McMenamin, Ph.D.
    Senior Policy Fellow-ANA Health Economist
    American Nurses Association
    June 18, 2014

    It is encouraging to think that the supply of clinicians has been elastic and increased numbers of clinicians are coming into practice when the demand for care is expected to increase. Ed Salsberg’s piece, however, did not include many of the parts about the care and feeding of the pipeline—the maintenance of the infrastructure that has often been neglected. Variations in throughput also have taken their toll. Recently, the general economy and soon, Baby Boomer-related demography have and will create their own havoc with respect to registered nurses.
    Demand for RNs will continue to increase. Every year from 2011 onward through the end of the century two to three million people will age-in to Medicare. Those new beneficiaries will be eligible for “welcome to Medicare” visits and “annual wellness visits,” both of which can be provided by Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs). RNs working in physician offices and clinics will also participate in providing those services. As the aged population continues to grow its distribution will also become more vertical each year yielding a greater number of beneficiaries in their last year of life. Dying is expensive, and end of life care most often involves more extensive use of nurses and other assistive personnel. The expansion of insurance coverage through Medicaid and the Exchanges will also increase demand, particularly for the primary care services often deferred by individuals and families previously without insurance coverage. The Affordable Care Act (ACA) also eliminated patient cost-sharing for preventive services, further increasing expected demand for RNs and advanced practice registered nurses (APRNs) who provide screening services, immunizations, and other preventive care.
    While we anticipate continuing increases in demand, another wrinkle in the Baby Boom generation story will soon lead to losses from RN supply. The major source of funding for nurse education has been Title VIII of the Public Health Service Act, introduced in 1964 as the Nurse Training Act. The Comprehensive Health Manpower Training Act of 1971 caused a spike in Title VIII spending in the early 1970s, spurring a subsequent spike in new RNs entering the profession from roughly 1978 to 1987. Just about at the same time, the number of then nontraditional occupations accessible to educated women was increasing, drawing large numbers of women away from applying to nursing schools in the late 1970s. Those who had already headed down that path were unlikely to have changed course, but the changes in the pipeline would not become evident for another 5 to 7 years.
    The result was a super-cohort of RNs who entered the profession from 1978 to 1987 in their first jobs after becoming a registered nurse. On each side of that decade there were substantially fewer young nurses in the profession. However, this pig in the python is now nearing the tail. New Bureau of Labor Statistics (BLS) occupational projections of jobs for 2012-2022 indicate that 555,100 RNs and APRNs will retire or otherwise leave the labor force. At the same time, increased demand for RNs and APRNs will generate new jobs needing an additional 574,400 nurses. In effect, along the way to 2022 the nation will need an additional 1.13 million RNs. Replacing retiring RNs may be a major and ongoing fact of life for hospitals and other health industry employers through 2030.
    The recent great recession may have delayed or masked the initiation of the wave of retirements. Mature nurses faced the prospects of loss of value of 401K and other retirement accounts, possible spouse loss of employment, and general economic uncertainty beginning in 2008. Many returned to full time work and/or deferred planned retirements. This resulted in additional frictional unemployment for new grad RNs, particularly in 2009/2010. As the economy recovers, the retirement wave may be steeper because of these recession effects.
    Another wrinkle in the Boomer story threatens to reduce the abilities of nursing colleges to augment the supply. The nursing faculty is also aging. BLS projects that replacing retiring nurse faculty and recruiting new ones by 2022 will require 50.4% more instructors than are currently employed.
    In that regard, there is another challenge. Current compensation levels for nursing instructors on average are not appreciably different than those of the average hospital staff nurse. Both current trends and the recommendations of the IOM Future of Nursing Report will require instructors with additional years of preparation such as APRNs or DNPs. The average annual compensation levels for NPs, certified nurse-midwives (CNMs), and CNSs are higher than the staff nurse salary levels by $25,000 or more. Whether nursing colleges will meet the challenge of funding additionally skilled faculty is an open question.
    There are also occasional exogenous effects on the production of new RNs. Recently the National Council of State Boards of Nursing (NCSBN) raised the bar on the National Council Licensure Examination (NCLEX), the test for licensing of nurses in the United States. After graduation from a school of nursing, one needs to pass the NCLEX-RN exam to receive his or her nursing license as a Registered Nurse. In 2013 the passing score on the exam was raised by approximately five percent. As Ed Salsberg demonstrated, the number of U.S. students who were first time test takers has increased consistently from 2001 to 2013. However, in 2013 the number of U.S. NCLEX test passers (including those retaking the exam) dropped by more than 4000 compared to 2012. This was the first drop in new RNs in more than a decade. If the 2012 passing rates had been observed in 2013 there would have been 14,206 more nursing grads qualified for their RN license.
    As previously noted the major source of funding for nurse education is Title VIII. Maintaining Title VIII funding to shepherd aspiring nurse candidates through nursing programs and into practice is another vulnerable part of the infrastructure. Following the Comprehensive Health Manpower Training Act annual funding increased by more than $90 million but in the 1980s funding dropped to pre-1971 levels continuing at those levels till the turn of the 21st Century. There were nominal increases in the Title VIII budget, but real funding continued to erode. Since 2001 there have been two substantial infusions of funds but each was followed by declines in inflation adjusted terms. In fact, on an inflation adjusted basis, the 2010 peak was about 75% less than the level of the 1973 peak funding. Other things being equal, if Title VIII funding is not made inflation proof, filling the gaps associated with the retirement tsunami may not be guaranteed.
    Producing 1.13 million additional new RNs is not an impossible goal. Title VIII could be enhanced and made inflation-proof. The Nursing Colleges could step up and increase faculty salaries to be competitive with earnings available to APRNs. And hospitals could engage in hiring new grad RNs to start growing their own experienced staff members, unlike the current pattern of flat hospital employment levels. However, even if the nation produces sufficient new RNs for the one million plus positions to be filled, what we won’t soon or easily remedy is the enormous loss of human capital. 555,100 nurses each with 30 to 40 or more years of experience cannot be fully replaced by an equivalent number of registered nurses whose nursing education is just now beginning.

  3. Charles Beauchamp MD, PhD Says:

    There is a clear failure to produce enough primary care general internists to take care of complex, multiproblem patients. Likewise there is a very clear failure to relieve general internists who are in primary care practices of the burden of computerized documentation including especially the complexity of “necessity coding” and “prior authorization” that is increasingly prevalent EVEN FOR GENERIC DRUGS that cost less than 10 dollars. For every general internist in practice or going into practice there should be two clinical medical assistants who can offload the data entry burdens that are bogging down physicians who are most needed to take care of our sickest outpatients SO the general internist can spend more face to face time and physical examination time with the patient. The VA recruits physicians saying they will see 1 to 2 patients an hour. No wonder the VA waiting list is so long! We need trained CMA’s who can act as scribes, “set-up artists”, pertinent review of systems takers and after-visit summary processors. We are not getting these things with the current dumming down profile of training primary care “providers” without having highly skille internists PLUS geriatricians to adequately take care of an increasing complex patient population.

  4. Diana Hyden Says:

    I take issue with the Nursing home can have a 1:10 ratio but the patients will be seen once every 4 wks if lucky because that is reimbursement driven. There will never be greater reimbursement just more products(patients) to increase income. Therefore less time spent, less quality, for some. These new jiggles ” at the top of their license”. .you do mean under your control …right… where have they practiced in the past, at the discretion of direction; by whom. Do your numbers reflect all of our society or just our citizens. In Europe where they have such great numbered ratios, they have great lines for access. Why do they come to America for surgery if care is so affordable and accessed with ease. I do agree that the aging population will do well in the hands of APRN. They have vast experience and will be honored to be in trusted with that role.

  5. H. Goblin Says:

    The answer to physician shortage is to…increase more physicians. It is not to churn out NP’s and DNP’s who have 1/10 and 1/4 the education of physicians, respectively. Studies that demonstrate “equivalent” care are limited, biased, and do not reflect the reality of taking care of patients with multiple problems in the real world. Indeed, on an overwhelming anecdotal basis, physicians must fix NP’s mistakes on a daily basis. Hence, NP’s seldomly “practice within their scope” and are really practicing medicine–without being as legally responsible since they are not held to the same standard of care. NP mistakes increases health care utilization and costs our system even more. Moreover, there is an NP movement to get paid just the same as physicians. For those of you in charge of our health affairs, The NP Scope of Practice Scam must Stop.

  6. Robert C. Bowman Says:

    The reason for insufficient primary care is insufficient health spending for primary care. Stagnant spending plus rapidly increasing cost of delivery plus lower volume per clinician all spell declines in primary care delivery capacity. Designs for payment and for training have a 30 year track record leading to the current health access failure with innovative designs continuing this pattern.

    Generic physician, physician assistant, and nurse practitioner expansions are all great sources of non-primary care with all less than 30% active clinician primary care result for a career (and falling). The US is indeed experiencing the most rapid rise of non-primary care workforce in its history with more disciplines, more in each discipline, more in non-primary care, and more converted to non-primary care from primary care trained graduates. The physician component is led by subsubpecialty fellowships increasing at 11% a year with 4% a year for subspecialty fellowships (Jolly, Academic Medicine) NP and PA workforce has followed this pattern of more specialties added with more in each specialty leaving primary care and family practice further behind.

    Family practice positions filled by MD, DO, NP, and PA workforce are the best health access solution but the current medical education design prevents family medicine choice with FM locked at about 3000 annual graduates since 1980. The flexible designs for NP and PA fail for family practice or optimal primary care result. NP and PA are free to follow health spending patterns – patterns the opposite from health access requirements. What appears to be primary care growth from more NP and PA workforce is actually NP and PA replacing the declines from internal medicine – moving from over 100,000 to less than 40,000 by 2030. Thirty years of 1500 or less per year for primary care since 1998 will result in half the workforce as compared to 3000 per year for 1980 to 1998.

    Designs increasing payment for primary care, increasing payment for care where needed, and resulting in 90% family practice position result for a career are specific to recovery of health access. Designs specific to core specialty (general surgery, ob-gyn, ortho) result rather than ever greater specialization are also specific to the workforce needed for most Americans. The populations in need of workforce are growing faster and are growing faster in demand for primary care and core specialty services. Movements in the opposite direction represent failure by design.

  7. Diana Hyden Says:

    We don’t need another funded committee, we require less greed. The double digit response to shortage was funded by double digit enrollment funds pouring in with little or no effort to ensure educational standards. First time test takers were followed by 2 and 3 attempts while seeking education thru workshops( for a fee) to make up for education lacking (already got the money and run) “fly by night” institutions. The push for over supply would be encouraged and under gov. comm. would be prodded beyond consumption in an effort to Decrease Cost; supply and demand 101. What you will never see…decreased cost. The profits are redistributed into non-providers pockets, who in turn line the pockets of lobbyist, who in turn line the pockets of politicians, who in turn pass bills that line the pockets of CEO,s; and the beat goes on. Want to improve access and speed in health services. Pass laws that reimbursement of services goes directly_directly to provider who provides. The VA and any other institutions competes for good providers, if they choose.

  8. Earl W. Ferguson, MD, PhD Says:

    Increasing the number of midlevel providers is absolutely necessary if we are to coordinate care more efficiently and effectively and adequately provide care in Patient Centered Medical Homes or other systems. It will require that they practice at the top of their license. These requirements are necessary because we do not have an adequate number of primary care physicians to meet thse needs for high quality, high value care in our country. We have only 30 primary care physicians per 100,000 patients, compared to 80 for the UK and >150 for France and Germany. We also need many more primary care physicians if we are to meet our needs.

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