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.
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.
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.
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.
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 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.