Are Nurse Practioners Practioners Too?

In Butte County, Idaho, there is one full-time doctor serving the county’s 2,501 residents. While the Lost Rivers Hospital makes ends meet with innovative care delivery, this reality begs the question: are we delivering sufficient primary care to those in need? According to the National Center for Health Workforce Analysis (NCHWA), the country will have a deficit of 23,000 primary care physicians (PCP) by 2025 due to aging and population growth, a deficit which will disproportionately hurt those who already have limited access to coverage. PCPs are the first physicians to see patients on a regular basis, teach patients about healthy living practices, and diagnose any serious medical issues. Even though the shortage of PCPs is dire, there seems to be little effort to address this problem. According to the NCHWA, demand for PCPs will increase by 17 percent in 2025 while supply will only grow 11 percent.

To address this shortage, hospitals and healthcare networks have looked to deal with the problem in a different way: by integrating care with other mid-level providers and shifting primary care away from PCPs. One position whose role is being expanded in healthcare is that of the nurse practitioner. Nurse practitioners (NP) play a role similar to physicians: promoting good health practices, treating illness, and providing patient education. Currently, 21 states and the District of Columbia allow NPs full practice rights without physician supervision. The Veteran’s Administration has moved its hospital network in this direction as well to address its own shortages. While the PCP population dwindles, NP supply is projected to increase by 93 percent by 2025 greatly outpacing projected demand (NCHWA, 2013).

While NPs clearly have the potential to address the deficit in primary care with their substantial addition to the workforce, there are still areas of concern. Notably, PCPs receive approximately 21,000 hours of training while NPs receive 5,000 hours. NP training is also not standardized and regulated in the same way medical education is. There is concern from physicians and the American Medical Association (AMA) that quality of care would decrease with more referrals and unnecessary billing. Regardless, the topic is still widely debated and it is unclear whether there is a significant difference in care between the two.  While quality of care remains under discussion, one thing is clear. NPs are cheaper. They are billed a maximum of 85% of a physician’s cost for a service on Medicare and there are similar deductions with other insurers.

For states knee-deep in a healthcare shortage crisis and facing increasing costs and hordes of angry voters, giving more power to NPs seems like an easy solution to a complicated problem. Lower costs, increased access to care, what more could a desperate state legislature ask for? Unfortunately, it’s not so simple. The majority of healthcare shortage occurs in rural areas, an area where family practice by physicians provides the majority of care. Furthermore, the lack of agreement over the autonomy of NPs at the federal level keeps them dependent on physician supervision in their practice. This means that the limited supply of PCPs will still restrict the ability of NPs to extend their care to the areas of America with the lowest health coverage.

When people are guided to attend intensive outpatient program for addiction near NYC to get rid off drug addiction.There raises a new problem. But this is a problem which has its solution . To simultaneously address shortages in healthcare and concerns with NPs, we can standardize scope of care at the federal level. There are many areas where NPs can provide care beyond the scope of PCPs. A study in Health Affairs has shown essentially equal performance in a system where a PCP manages a group of NPs and other advanced practice nurses and in a physician-only practice for managing diabetic patients (2013). Another study demonstrated that allowing NPs to independently operate in rural, underserved areas would provide access to primary care where PCPs don’t practice (Health Affairs, 2013). Recently, the federal government made headway in involving NPs in substance abuse management by allowing them to prescribe buprenorphine, an opiate addiction treatment, to address the burgeoning opiate addiction crisis (American Society of Addiction Medicine, 2016). Clearly, there are many ways NPs can extend quality care.

Instead of requiring states to decide whether to grant NPs independent practice rights based on immediate demand, the federal government should proactively increase the scope of care of NPs in areas such as chronic illness management, rural health care, and addiction treatment where primary care is in urgent need. On Capitol Hill, however, there is fierce opposition from the AMA against expansion of scope of practice of NPs because of the fear that NPs will cut into the care already provided by PCPs. While this fear is not unfounded, it is undeniable that there is room to expand for both groups. The healthcare system established doesn’t have to pit different health care providers against each other; it can work together to provide better care for Americans with the right mindset. For Butte County, the struggle to serve the farthest reaches of the American population is a daily battle; the least we can do is give them the tools to succeed.

Ishaan Shah ‘20 studies in the College of Arts & Sciences. He can be reached at ishaanshah@wustl.edu.