A Solution for America's Primary Care Shortage
The federal government estimates that roughly 84 million Americans presently lack adequate access to primary care, and prospects for shrinking this number are not good. The problem has been years in the making. For decades the graduate medical education system in the United States has not produced enough primary care physicians, and many doctors are due to retire over the next 10 years, just as more baby boomers become eligible for Medicare. Policies associated with the Affordable Care Act intensify the problem by increasing access to health insurance without substantially addressing the factors leading to the persistent scarcity of doctors providing primary health care. By 2030, the shortage of primary care physicians is expected to grow to 49,300. Particularly hard-hit by this crisis will be people living in rural areas, who are generally older, poorer, sicker, and less well-insured than their urban counterparts.
Despite the problems, primary care is still a crucial component of American healthcare. Primary care clinicians treat a variety of health conditions, from asthma to thyroid dysfunction and nearly every ailment in between, including basic maternal and child health-care services. Ample evidence suggests that primary care lowers healthcare costs, decreases ER visits and hospitalizations, and decreases premature deaths.
While the current number of physicians is not adequate to meet America’s need for primary care (and the future looks even bleaker), there is a way to expand the capacity of the nation’s primary care workforce by using nurse practitioners (NPs). These registered nurses have advanced clinical knowledge and training, and are able to help patients in major primary care specialties: family health, adult and geriatric care, pediatrics, and women’s health. Graduate level courses and clinical practice equip NPs with specialized knowledge and clinical competency to practice in primary care settings where they assess patients, order and interpret diagnostic tests, and initiate and manage treatment plans. In other words, they can do most of what primary-care physicians do. There is increasing support from researchers, analysts, federal agencies and health policymakers, for the idea of using NPs to fill the void left by the lack of primary-care physicians. This would also improve the uneven geographic distribution of primary care.
Recent projections of future physicians and NPs show that the NP workforce will increase rapidly through 2030 — much faster than the physician workforce. NPs are projected to nearly double in size from 157,000 in 2016 to just under 400,000 in 2030 (a 6.8 percent annual growth rate) whereas the total number of physicians is expected to increase from just over 920,000 to 1,076,000, growing at only 1.1 percent annually over the same period.
These projections mean little without assurance that NPs could provide comparable levels of care. In fact, countless studies have produced evidence confirming that the quality of care provided by NPs is as good and, in some cases, even better than that provided by primary-care physicians. Recent studies that my research team has conducted using national samples of Medicare beneficiaries (now gathered in a new paper) confirm the comparable quality of care provided by NPs.
Critically, the findings demonstrate that NPs provide care at a cost which is up to 30 percent lower than what physicians receive for treating the same types of patients. Moreover, results show that NPs are significantly more likely than physicians to practice in rural areas and provide care to vulnerable Medicare beneficiaries: women, non-whites, American Indians, people who qualified for Medicare as a result of a disability, and beneficiaries dually eligible for Medicare and Medicaid.
If the benefits of using NPs are so clear, what’s stopping them from providing primary care now? The answer is state regulations — currently in effect in one form or another in 28 states — which restrict NPs’ scope of practice. Some physicians and professional medical associations have justified their support for such regulations on the grounds that they are necessary to protect the public from low-quality providers.
Studies show no evidence to support this belief. What studies do show is that Medicare beneficiaries living in states that impose restrictions on treatment by NPs have significantly less access to primary care than those in states with no constraints.
These facts lead to three recommendations to overcome the growing challenges in delivering primary care to Americans. First, entities such as hospital boards and credentialing bodies should allow NPs to practice to the fullest extent of their training and licensure. Second, physicians should understand that NPs provide quality health care to those in need. They should be encouraged to work with NPs in a complementary and not antagonistic way. This would ensure the delivery of primary care for the people and communities who need it. Finally, state legislators and public policymakers should lift the restrictions which limit the NPs’ scope of practice. The healthcare of millions of Americans will increasingly depend on this in the coming years.
Peter Buerhaus is a health care economist and professor of nursing at Montana State University.