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As primary care physician population declines, ranks of nurse practitioners fill the gaps

The increases come at a time when physician shortages, especially in primary care, loom large.

Beth Jones Sanborn, Managing Editor

While the ranks of primary care physicians continue on the decline, the number of nurse practitioners are on the rise in both rural and nonrural settings making for more diverse practice care teams, according to a new study by Health Affairs.

Approximately 234,000 NPs are licensed in the U.S and can deliver most of the services a physician can. Research has shown the care they deliver is safe and "high quality," Health Affairs said. The increases come at a time when physician shortages, especially in primary care, loom large.

The study looked at SK&A provider files from 2008-2016 to see the extent to which NPs were working in primary care physician practices during that time period in both rural and nonrural settings. Researchers look at NP and physician trends separately. SK&A is a commercial data set comprised of "practice-level characteristics" of office-based practices nationwide. Counts and proportions of NPs, physicians and physician assistants in primary care as well as the percentage and number of primary care practices employing NPs.

In rural practices, the number of NPs is growing. Their count rose from 17.6 percent of providers in rural areas to 25.2 percent from 2008 to 2016, a notable increase of 43.2 percent. Physicians, on the other hand, saw a decrease of 12.8 percent, though they still were the largest category of providers in rural areas. Physicians assistants' numbers remained largely consistent, with only a 1.4 percent increase.

An upward trend was also seen in later years nonrural settings, from 15.9 percent in 2008 to 23 percent in 2016, an increase of 44.7 percent. Meanwhile, the fraction of physicians in nonrural areas dropped 11.8 percent, from 75.2 percent to 66.3 percent. The share of physician assistants saw only a slight increase from roughly 9 percent to 10.8 percent, the study showed.

In addition to overall count, the percentage of rural practices that staffed at least one NP went up. During the study period, NP presence increased in rural practices from 31.4 percent to 43.4 percent, and in nonrural practices it rose from 18.3 percent to 26.5 percent but the trends were statistically different. The average number of NPs in rural practices went from 1.34 to 1.64 and in nonrural practices up from 1.47 to 1.67. 

Interestingly, the scope of practice allowed in the state seemed to influence the growth of NP presence. Rural practices in states with full scopes of practice had the highest proportion of practices with NPs, rising from 35 to 45.5 percent. In rural practices in states with a reduced scope, the growth was greater, from 30.7 percent to 46 percent, and in states with restricted scopes of practice the increase was from 29.9 percent to 42.3 percent. So results showed greater growth where NPs are actually allowed to do less.

"Slower growth in states with full scopes of practice could reflect the existence of more employment opportunities for NPs, such as in independent or nurse-managed practices," the study said.

Nevertheless, it is clear that nurse practitioners are a growing segment of the primary care workforce both in rural and nonrural primary care settings, and it couldn't come at a better time as shortages ramp up.

"Adding NPs is a useful way for practices to align themselves with contemporary efforts to improve access and performance. Our findings imply that primary care practices are embracing a more diverse provider configuration, which may strengthen healthcare delivery overall," Health Affairs said.

Health Affairs had previously highlighted a trend in the healthcare workforce toward specialists, only fueling the shortage in primary care physicians. In analyzing data from the Bureau of Labor Statistics' Occupational Employment Statistics files between 2005 and 2015 on ambulatory healthcare services, hospitals, and nursing and residential care facilities, the authors saw an overall net increase of 2.6 million jobs over this period, 6 percent of them being physicians. However while primary care jobs rose by roughly 8 percent, specialist jobs increased six times faster. Also, the overall share of the physician workforce constituted by primary care had fallen from 44 to 37 percent.

This caused concerns for healthcare spending, which has also notoriously been on the rise. 

The trend of more specialists working in health systems that charge facility fees on top of already expensive prices for care, and the notoriously large salaries specialists make will also likely drive spending upward, Health Affairs said.

Telehealth could be a potentially helpful tool in dealing with deepening physician shortages, especially in more remote rural areas, especially for those managing chronic illness and the aging baby boomer population. Being able to access a physician more readily through a teleconference means patients are more able to follow up on issues or questions and can check in with physicians more easily, without needing transportation. It also means physicians can do more, having the ability to have short teleconferences with patients and popping right back into a practice environment for face-to-face meetings.

Twitter: @BethJSanborn
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