Transforming Health Care Through Evidence and Collaboration
Transforming Health Care Through Evidence and Collaboration

Meeting the Demand for Primary Care: Nurse Practitioners Answer the Call

John Iglehart, Founding Editor, Health Affairs

Rapidly expanding insurance coverage and a growing and aging population are increasing the demand for health care services and the personnel who provide them. Despite a robust increase in the supply of physicians following unprecedented increases in medical school capacity in recent years, the Association of American Medical Colleges (AAMC) still projects a shortage of 130,000 physicians by 2025, split almost equally between primary and specialty care.1 At the same time, delivery and payment system reforms may already be changing the mix of personnel needed to respond to the rising demand for health care services. In this essay I consider the potential role that nurse practitioners (NPs) can play in supplementing physician supply, describing trends in the profession and developments related to state laws regulating their scopes of practice (SOP).

Nurse Practitioners "On the March"

Nurse practitioners are one of several types of personnel considered to be advanced practice registered nurses (APRNs); nurse anesthetists, nurse midwives, and clinical nurse specialists are also APRNs. The vast majority of current NPs hold a master’s degree (86 percent) or a doctorate (5 percent) in nursing. As of 2012, there were an estimated 154,000 licensed NPs in the U.S., 127,000 of whom were providing patient care. Slightly under half of those worked in primary care.2 Over the past decade, the annual number of NP graduates more than doubled to reach 14,400 graduates in 2012, and continued growth is expected. One study projects a near doubling of the total NP workforce by 20253 while another predicts the number of NPs providing primary care will increase by 30 percent by 2020.4

The shorter and less costly training pipeline for NPs relative to physicians, combined with evidence that NPs provide high quality care and achieve high patient satisfaction,5,6,7 argue in favor of the profession’s ability to quickly and effectively meet growing demand for health care services. Numerous provisions of the Affordable Care Act – including grants for nurse-managed clinics, significant financial support for NP training, and emphasis on team-based models of care – clearly envision NPs as an integral part of the future health care workforce. Recent evidence points to consumer acceptance of NPs,8 and the profession has strong backing from influential consumer advocates, including the AARP and the Robert Wood Johnson Foundation. Major corporations are also relying on NPs to staff their expanding networks of retail health clinics.

Despite this momentum, however, the efforts of NPs have been stymied in some states by laws preventing them from providing all services they are trained to provide and by requirements for physician oversight. Reflecting long-simmering disputes over “turf” and citing concerns about patient safety and quality of care due to the shorter training period, the American Medical Association (AMA), the American Academy of Family Physicians and their allies oppose SOP expansions and advocate that NPs should provide primary care within the construct of a patient-centered, physician-led team.

The Move to Expand Scopes of Practice

SOP battles are playing out across the country. The National Conference of State Legislatures reports that 100 bills related to NP scope of practice were introduced in 22 states between 2011 and mid-2013, with about one-quarter enacted. The combatants spend enormous sums of energy, money and time arguing their cases before state legislatures at a time when, ironically, collaborative care is seen as the goal at the practice level.

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