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Revisiting Primary Care Workforce Data: A Future Without Barriers For Nurse Practitioners And Physicians

July 28th, 2014

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.

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11 Responses to “Revisiting Primary Care Workforce Data: A Future Without Barriers For Nurse Practitioners And Physicians”

  1. Susan Weeks FNP Says:

    Seriously? Volunteer hours? Pleeez! Nurses have years of bedside training, decision-making abilities, and experience working in teams. PA’s usually are not required to be nurses and often very young and inexperienced; often right out of a bachelors program- not necessarily nursing. When you figure in the many long hours in the ER, OR, or med-surg unit managing & troubleshooting patient problems often without the pleasure of a physician, nurse practitioners have plenty of clinical hours! Yes, we are not perfect and as everyone-even physicians- we need adjustment time and a few months on the job. As for the physicians – we are not professing to compete or be medical doctors. We know you have more in-depth training and respect that! We are midlevel providers- gatekeepers, if you will. We know our limitations and yes – we refer to specialists – probably no more than anyone else. We have to work as a team! Enough of this sniveling. you know we are capable of providing good care and there is a shortage because physicians want to make more money. We are not in it for that. We are nurses- we love people and caring for them. We are now advanced practitioners who can do even more. You should be helping us and not hindering progress. Times are changing and you all need to be part of that change

  2. Carol Says:

    One additional number that needs to be factored in when calculating the total number of hours of education, training and practice that Advanced Practice Nurses (APNs) complete prior to their graduation from an accredited program (that physicians and PAs lack) are the thousands of hours spent at the bedside of critically ill patients, home care patients, clinical based patients and the like as Registered Nurses. To date, dozens of rigorous research studies have taken place that reflect very positively on quality and safety of care as well patient acceptance and satisfaction with the care they receive from APNs.
    In this era of the Affordable Care Act with the ever increasing numbers of patients in need of primary care services, shouldn’t there be a common goal (and comradery) among all health care professionals that place the best interests of the patient at the center of the model that depicts quality and affordable health care? Allowing APNs to function at “the full extent of their education and training” is a very good and important thing. Increasing the number of qualified primary care providers in the workforce is long overdue. The old ways of providing health care are obviously not working. APNs are a viable and important part of today’s solution to the health care crisis that currently exists. All one has to do is to look at the health care dollar spent on health care for each US citizen and compare those statistics to other countries to see that there is much work to be done before the world’s greatest nation can provide the world’s greatest preventive, primary and tertiary care to ALL of its citizens.

  3. Roy Stoller Says:

    The truth is MD/DO and NP/ARNP are not equal. The justification for equality of responsibility based on patients’ perception is unscientific. Liking a person better is nice, but does not equal training to work autonomously. The politics is to create a cheaper system with watered down care.

    The fact ARPN’s can change their specialization status with a six month course, when a physician has to retake a residency for three years does not make sense. The physician starts off with more advanced training.
    Six months and nursing degree does not make a specialist.

    It has become a slippery slope. It started with we need health care workers like ARPN who would be supervised delivering primary care in underserved areas. Now we have ARPN in large cities claiming they are board certified in Dermatology.

  4. Andrew Tompkins Says:

    I think most of us can agree that a robust primary care component is the foundation for good and efficient healthcare. While you cite the obvious problem in physician shortages, I believe your suggestion to reduce NP barriers to address this problem is short-sighted. While very specific studies have been done that show NP vs MD workup of back pain, etc. are equivalent, no one has done a broad utilization study to my knowledge. This has far-reaching effects such as the number of referrals and healthcare dollars spent. Speaking from personal experience, I find the NP training to be lacking. I have trained many of them in my years as a specialist. Recently, I had 2 (in separate programs) less than a year away from graduation, already having done multiple primary care rotations, and they didn’t know what the pneumatic bulb was on an otoscope. As this is the gold standard in diagnosis of one of the most common pediatric complaints you would think that was important to know. The rushed processing of NPs into the community and push to give them more power is very short sighted. I do not believe the studies that say NPs and MDs are equivalent. Until a prospective study is done that looks at utilization of healthcare and long term morbidity/mortality rates in chronic conditions consider me a non-believer. I can, however, cite a Mayo Clinic study that came out in the last year or two that, when blinded to the referring provider, found that NPs ordered more “inappropriate” consults with less understanding about the underlying disease process. To ignore these findings is simply wreckless.

  5. Patricia Kelly, PA-C, Ed.D Says:

    Many good points concerning utilizing NPs (and PAs) to expand access are listed here, as well as some concerns. The clinical hands-on training slots necessary to provide an adequate grounding in primary care practice are few and far between in our current system. NP students compete with PA students and MD/DO students for these slots.

    Currently, NP students require under 800 direct patient care clinical training hours apiece; PA students must have between 1400-2000 including mandatory experiences in many specialty areas, and MD/DO students accumulate almost 4000 during their third and fourth medical student years. NP students, including those who are direct entry from BSN programs, are mandated to have at least 600 additional training hours as nurses, but as many of half of these may be replaced by simulation. Many NPs, of course, have more. PA students have generally between 50-2000 hours in another health field as employees or volunteers, MDs frequently have none.

    These training and prior experience hours, while essential, are not easy for our health care system to provide. Therefore, the quality and direct hands-on experience for some students of all disciplines have been degraded. NP education, unlike PA and MD/DO is frequently distance based and conducted on a part-time basis, making evaluation of the quality of clinical training even more difficult.

    Community primary care medical practices are so busy and burdened with documentation and reimbursement requirements that they frequently cannot afford to train students. Slots for students in high acuity areas such as emergency departments and obstetrics are becoming increasingly rare. Continuity slots where the trainers really get to know and mentor the students are also scant in number. Fragmented and brief clinical training experiences for MD/DO/PA/NP students are becoming the norm. Clinical training and insuring student competence is a very complicated endeavor and can’t be accomplished by short episodes where students do not have any primary or longitudinal responsibility to the preceptor or the patient.

    Practicing in a vacuum is no longer possible for anyone Training, also, must become more interprofessional, interdependent, continuity-based and competency based for all primary care providers. Extending GME and undergraduate educational support programs equivalently to these three major groups of primary care providers could accomplish that and develop a more uniform playing field, while guaranteeing that all providers are capable of practicing “at the full scope of their licensure” in an interdependent fashion to provide the safest patient care for consumers. The current disparate training environments cannot ensure either adequate numbers or the quality and depth of clinical experiences to educate enough primary care providers of any group to care skillfully for our population.

  6. Karla Morrow FNP Says:

    Re: Dave
    You are absolutely correct. In Texas legislation this year all bills passed included NPs and PAs. I was happy to see that.

  7. Debbie Says:

    Yes, anytime supply of anything exceeds demand, it places pressure on prices. The missing part of the equation is that the final demand for services is completely unknowable at this point.

    In general, economic principles suggest that provision of like services with like outcomes commands like pricing. Over the past two decades APRN’s have repeatedly demonstrated higher patient satisfaction rates than MD’s with better control of costs and in far more than the just primary care market. 19 states currently allow full, independent NP practices. In the past six months three additional states changed APRN Scope of Practice restrictions allowing less supervision and greater prescriptive authority. Nationwide advancements in the independent practice of APRN’s are being made in spite of the frequently and fraudulently reported “patient safety concerns” often touted by traditional providers of primary care who are getting squeezed from all sides as APRN’s claim a larger slice of the pie.

    NP’s need not fear a lack of future demand. Other providers need to be alerted to the fact that limited funding, the increasing number of NP providers and vastly increasing consumer demand, will continue to place pressure on pricing, changing the economics for everyone. Adjusting to a reduced level of revenue generated by a primary care practice is not as tough on an NP with, maybe, 20% of the educational debt load typically piled up while completing medical school. Hence, the explosion of DNP programs. This is not to say, that every single graduate of a DNP program (or a medical school) will necessarily be a competent practitioner. But all graduates must pass boards in order to get a license to practice and provide care.

  8. MacGyver Says:

    NPs are multiplying so rapidly that their brand is going to deteriorate. Indeed there are over 100 online-only DNP programs now in the United States. These 100% online programs place NP students in remote clinics with no quality control over their rotations. Many of these “rotations” consist of nothing more than shadowing.

    There are over 200 new DNP programs scheduled to develop or open in the next 10 years. That projects to a QUADRUPLING of the NP workforce in less than 15 years.

    NPs are quickly working themselves out of a job. When there is a glut in providers, NPs and PAs will be the odd ones out because in a crowded marketplace the MD credentials will always hold superior.

    The mass glut of NPs coming into the world in the next decade will force many NPs to abandon “advanced practice” and go back to being a regular RN. There are already many case reports of NPs who couldnt find jobs and had to go back to floor nursing.

    NPs, beware.

  9. bben Says:

    Re Lana: many physicians are in favor of this bill. You may find the following commentary interesting. It is a summary of the evidence surrounding full practice authority in Michigan. It was compiled by David Gorski, MD, PhD -Chief, Division of Breast Surgery, Associate Professor of Surgery and Oncology, Wayne State University School of Medicine; Medical Director, Alexander J. Walt Comprehensive Breast Center, Barbara Ann Karmanos Cancer Institute- a supporter of patients, outcomes, & full practice authority for APRNs:

  10. Lana Says:

    I understand and can appreciate the value NPs bring to the primary care arena. They are able to provide more interaction time with patients, help establish care across the continuum, and (with years of hands on experience) be able to make informed decisions about what lab/diagnostic tests to order and diagnose certain conditions (such pink eye, bronchitis, ear infections, etc, like my grandmother after having raised 9 children).

    While NPs play an important role they are not and will never be doctors (unless they graduate from medical school and successfully complete training). What I cannot understand is their need to be paid at the same level as primary care physicians and enjoy all the same patient care privileges when their education and training do not merit it. I understand that they are not claiming to be doctors. But, when you want the privileges and responsibilities that come with the profession you in fact are claiming to be doctors. In my medical group, I’ve had several NPs order numerous/unnecesary and costly tests to diagnose conditions a doctor fresh out of residency would have been able to diagnose without such tests (and with a more intricate understanding of the condition and treatment course and outcomes). Also, are NPs really more likely to move to the middle of Idaho or other areas to set up shop to provide care?

    Furthermore, why is physician supervision and involvement in NP care of patients unnecessary? I certainly would not want my medical care and advice coming from an individual who completed the bulk of their “medical” education online. Nurses/NPs are indubitably an asset to medical care and can certainly improve primary care outcomes when they work in collaboration with medical doctors.
    – MD/JD/MPH

  11. Dave Mittman, PA, DFAAPA Says:

    While I applaud your call to decrease barriers for the NP profession, there is another profession that could also significantly provide primary and specialty care to the citizens of America. PAs like NPs profession have close to a fifty year track record of providing high quality primary care in all fifty states and, also like NPs, have substantial barriers preventing them from providing that care.

    PAs and NPs should not omit at least the mention of each other in these discussions. Doing so keeps keep each other invisible and does a disservice to both professions. We all have too much to offer the citizens of America regarding the future of healthcare delivery.

    Dave Mittman, PA, DFAAPA
    President, PAs for Tomorrow

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