Why Nurse Practitioners Will Not Solve the Primary Care Crisis

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9% are African American, 3.7% are Asian or Pacific Islander and 2% are Hispanic. Further, the geographic distribution of NPs and physicians assistants alike is close to that of physicians. A June 2013 assessment found that the distribution for urban, rural and isolated rural frontier primary care providers is within a few percentage points for NPs and PCPs.

Ezra Klein was not wrong in his assessment that physicians are often influenced by income. However, it seems likely that financial incentives are drivers for many professionals in the health care sector, including nurse practitioners, registered nurses and physicians assistants (PAs). Dr. Andrew Bazemore, Director of theRobert Graham Center for Policy Studies in Primary Care in Washington, DC has done significant research in this area. His perspective is that, “The suggestion that runaway health system costs could be contained simply by replacing higher salaries of physicians for lower salaried substitutes with less training misses the point – that cost containment will most likely result from optimizing primary care functions such as prevention, population management, care coordination, and avoidance of unnecessary referrals, procedures, ER use and hospitalizations of primary care providers.” Dr. Bazemore asserts that, “Achieving that level of effectiveness likely involves teams that include primary care physicians, NPs, PAs, behavioral and community health workers, and other important components, operating in a transformed practice setting.”

It is also correct that regulation on NPs is onerous and sometimes oppressive. Across the nation, regulation on NPs is exceptionally disjointed and often results in unnecessary hurdles for all involved, called scope-of-practice laws. Although impediments are common in the health care system, it is extensively difficult for NPs and similar non-physicians to break into a system that is deeply rooted in tradition.

However, by honing in on one piece of the puzzle, Mr. Klein missed the bigger picture. The principals of substitution do indicate that on the supply side, NPs stepping into roles for PCPs would better meet demand. But that is not the real world outcome. The broader landscape shows us that instead of a 1:1 substitution, nurse practitioners are compliments in the overall care system, important roles that fulfill many primary care needs.

Therefore, policy changes are still needed to improve patient health outcomes and forge a team-based relationship between care providers. Incentives to enter primary care and needed across the disciplines, as are models of team-based training that build on the strengths of each in managing whole persons and populations. Ezra Klein fails to note that most primary care shortage estimates implicitly include NPs and PAs already working in primary care while not accounting for the fact that NPs and PAs are choosing specialization over primary care for the same reasons as physicians.

Instead of an environment where NPs and PCPs are positioned to compete with one another, federal and state legislators should spend more time crafting policy that equalizes the distribution of care providers across the system. That redistribution means incentivizing, monetarily or otherwise, primary care clinicians to stay in general medicine and work in tandem with other providers. Whether it be the reformation of medical school, constructing a more honest approach to population health or restructuring pay scales and incentives, team-based medicine with improved access and outcomes should be the real discussion.

Nicole Fisher is a Senior Policy Advisor and policy expert on health economic analyses mainly focusing on Medicare, Medicaid and health reform, specifically as they impact women and children. She is also currently pursuing her PhD at the University of North Carolina in the Health Policy and Management Department. This post originally appeared in Wright on Health.

11 replies »

  1. It seems unlikely that any one change to healthcare will have significant enough effects to completely correct the many challenges we face in providing quality care for our nation. As I become more familiar with the role of nurse practitioners, I have to recognize the significance of the historical evolution of the nursing profession. Look back 10-20 years ago at what was expected of nurses and compare the RN scope of practice to today’s RNs and their role in hospitals. As needs increased, the scope of the RN evolved as well as the role of the physician and their interactions with nurses. I believe history is repeating itself. I am confident that as roles evolve, quality of care will increase and we will again witness an effective shift of responsibility. Will additional evolution in healthcare be necessary? Most definitely, I think recognition of geographic needs is a great observation, though I am not sure it is a compelling argument in the case of the evolution of nurse practitioner’s role in primary care.

  2. Alan,

    I would also like to see some of the data you are referncing. I am all for reducing costs but not by decreasing the level of health care

  3. Alan,
    I’d love to see some of the data you are referencing about the cost of test, etc… This will not be the last time I write about this or we, as a society, have this discussion.
    All resources are welcome.

  4. Alan,

    I’d love to see some of the data you are referencing about the cost of test, etc… This will not be the last time I write about this or we, as a society, have this discussion.
    All resources are welcome.

  5. EX MILITARY MEDICS A RESOURCE IGNORED In California some reports indicate we have 11,000 former medics from Asian wars who in many cases would be great physicians assistants and or nurse practioners. Some states like Texas have fast tract programs to bring these people into service to help fill the Family Practice Doctor shortage. Other rural states are doing the same thing but elevating these Physician Assistants to even high levels where they are the primary provider in rural America. Unfortunately here is California the all powerful unions deter efforts to use this resource despite Federal funding available to launch such fast tract programs as Texas.

  6. It’s refreshing to see an article as politically incorrect as this one. You are absolutely correct on many fronts. NP’s and PA’s are currently and should continue to serve as complements to physicians, not replacements.

    Having worked in the VA system, where ancillary providers are often given the same scope of practice as MD’s due to the high volume of patients and remote care facilities, it has become evident to me that not all providers are created equal. No one doubts that there is variability of quality amongst practitioners of every kind. But the more important issue is one of standardization.

    I have been truly surprised at the incredibly variable care by NP’s and their total lack of accountability. For all the quality metrics and liability issues imposed upon physicians, NP’s have none. And yet, they are given the same responsibility and a relative lack of supervision. I have seen patients with cancer or severe infection whose diagnosis and treatment were delayed by weeks to months by their NP. But what was most concerning was that the NP didn’t know what they didn’t know.

    One thing I will say for MD’s is that we learn quickly the levels of our expertise, even though there are more or less aggressive amongst us. The problem for many of these NP’s is that they haven’t had enough years of training, enough years of experience, or enough experience of witnessing of mistakes in their training process to understand that they aren’t physicians and should have a very low threshold to get someone more experienced involved.

    For all the policy debate pushing scope of practice and explaining how we really don’t need physicians, there is a real lack of accounting for their difference in ability and experience. And even NP’s who realize they are in over their heads are not always able to get help since they are expected to manage issues independently, and the only one who really suffers is the patient.

  7. Equal malpractice premiums and responsibility?
    Aprns and PAs can replace primary care physicians but the level of care will be no where near what a family physician or general internet does. Nor Pediatrics, where they can more readily replace the pediatricians as the complexity of overall care in that age population is much less. Many more normal exams, simple common sense counseling and immunizations.
    But aprons and PAs may get paid less but they will cost the system much more in referrals, tests and all too often missed and delayed diagnoses leading to even greater costs.

  8. “To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.”

    I’m not sure I totally get the Ezra Klein worship in policy circles. Who is this man? Why does everybody reference him like some sort of deity?