With the full implementation of the Patient Protection and Affordable Care Act (ACA), there have been major concerns about the looming primary care provider shortage. The National Center for Health Workforce Analysis predicts shortages as high as 20,400 physicians by 2020, and increases in medical school graduates entering primary care residencies have been anemic.
Physician shortages can be addressed by the rapid growth of nurse practitioners (NPs), trained in primary care, along with the redesign of primary care to include teams that can be led by both physicians and NPs. But our nation’s primary care needs can only be met if states allow NPs to practice to the fullest extent of their training without unnecessary requirements for physician supervision.
2014 National Resident Matching Program Data
A year ago, we presented the primary care resident match data along with the nurse practitioner (NP) primary care graduation rates. The data were quite striking then and are again this year. The March 2014 National Resident Matching Program data show that there were merely 19 more U.S. graduate matches to primary care specialties than in 2013. A total of 1,919 U.S. graduates matched to the five primary care specialties (Family medicine specialties, Internal medicine Preventive, Internal medicine Primary, Internal medicine Pediatrics, and Pediatrics Primary) in 2013, and in 2014 there were 1,938 primary care matches.
The increase of 19 is considerably down from last year (2013) when an additional 92 U.S. graduate medical students matched to primary care specialties compared to 2012 numbers. While family medicine had the largest increase this year (42 more than a year ago) for a total of 1,416 matches, internal medicine pediatrics had a loss of 28 compared to a year ago (totaling 362 this year). When considering the entire first year match numbers of US graduates for all specialties—16,390—only 12 percent were primary care matches.
Interestingly, fewer than 50 percent of the overall primary care matches for family and internal medicine were from U.S. graduates, while 70 percent of pediatric primary care matches were from U.S graduates. The total of all U.S. and international graduates included 3,772 primary care matches in 2014 compared to 3,715 in 2013, representing an overall increase of 57 more primary care physician matches in 2014. This modest increase to the primary care physician workforce offers little redress to the primary care provider shortage.
Primary Care Nurse Practitioner Graduation Rates
Nurse Practitioner graduate rates reveal a very different story from medical student match rates. In the recently released report from the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties, the 2013 primary care NP graduate rate (reported out in 2014) totaled 13,568, which is 85 percent of the 15,970 NP graduates for 2013. The number of primary care NPs (Family, Adult/Gerontology, Women’s Health, and Pediatric) graduating in 2013 is 1,804 more than in the previous year; a year ago the increase was over 2,000 compared to the 2012 data. These substantial increases have continued over the past few years and are expected to continue.
If one compares the percentage of NPs receiving primary care education (85 percent) to the 12 percent of U.S. medical student primary care matches, and if one looks at the increase of NPs (1,804) completing primary care programs versus the addition of 19 more U.S. medical school matches, one can see the compelling evidence that NPs already have a significantly growing role in U.S. primary care delivery.
NPs “match” to primary care when they enter a NP program. Not all NPs with primary care preparation end up in primary care, just as not all medical graduates matched to primary care end up in primary care. However, the numbers for NPs are so large by comparison that if just half of the NP graduates end up in primary care practice, they still address the shortage of providers in a profoundly significant way. Data also show that NP graduates since 2008 are increasingly likely to choose primary care compared to earlier graduates.
What Does the Future Hold?
We believe that primary care is the foundation of a robust health care system. It will take all providers working to the fullest extent of their educational preparation to ensure an effective health care system that meets the triple aim of improving the patient experience, improving the health of populations, and reducing the cost of care.
However, costly and unnecessary barriers to NP practice continue to exist, impeding both NPs and physicians from working to their fullest capacity. The unnecessary requirements in numerous states for physicians to sign orders for physical therapy or other referrals, supervise NPs, or sign off on numerous other documents waste precious physician time and are not feasible in the real world.
All one has to do is look at the current numbers presented here: How will 19 more primary care physicians “supervise” almost 2,000 more NPs? The literature is replete with studies about the effective quality, safety, and cost of NP care over 40 years.
The recent Federal Trade Commission report on scope of practice states:
“While state legislators and policy makers addressing health care issues are rightly concerned with patient health and safety, an important goal of competition law and policy is to foster quality competition, which also furthers health and safety objectives. Likewise, to ignore competitive concerns in health policy can impede quality competition, raise prices, or diminish access to health care—all of which carry their own health and safety risks.”
Currently 19 states and the District of Columbia allow NPs to practice fully under their own licenses without unnecessary requirements for supervision. Numerous other states have legislation pending, yet not without physician resistance. It is time to remove barriers and support a collaborative dialogue about the needed changes in the U.S. primary care health system to attract and retain sufficient numbers of all providers—providers who experience professional satisfaction while also meeting the needs of patients with quality care, improving the health of populations, and reducing costs.