There’s a dire shortage of primary care physicians in the US, and it’s only going to get worse.
As life expectancy increases, and baby boomers live longer, demand on the already-overburdened healthcare system will likely skyrocket.
A 2013 study from the Health Resources and Services Administration found that, by 2020, there will be a shortage of 20,400 primary care physicians nationwide. For seniors and people in rural communities, access to adequate care will become even more difficult and time-consuming than it already is.
But there may be a solution, according to some healthcare experts: Nurse practitioners.
Nurse practitioners (NPs) are registered nurses (RNs) who go through an additional two- to three-year master’s program specifically focused on their chosen area of practice.
Out of approximately 205,000 NPs around the country, 86.5% are trained in primary care, according to the American Association of Nurse Practitioners — more than enough to make up for the lack of physicians.
“It’s really about the effective utilization of existing healthcare practitioners,” Alex Krouse, a healthcare lawyer based in Indiana who works across the US on these issues, told Business Insider. “It’s one of those things where the amount of residency spots is a function of federal and state tax dollars — and there’s just not enough money to train and provide more residency spots at the level that’s actually needed.”
For the last 50 years, Krouse said, doctors and the medical industry in general have been aware of the looming shortage. It’s only in the last 20 years that nurses have started getting the kind of advanced training that could help them solve the primary care shortage, he said.
Nurses are traditionally viewed as ancillary to doctors; they take your blood pressure while the doctor diagnoses you and prescribes the medication. Nurses, however, comprise the largest sector of the US healthcare workforce. Plus, they’re less expensive — and take less time to train — than physicians, Matthew Yglesias reported for the Slate blog Moneybox.
An evolving career path
In the last 10 years, NP education has evolved to bring it more in line with the requirements for physicians. While NPs can practice with only a master’s degree, many NPs now opt to complete doctorates in nursing — DNPs.
Unlike physicians, which must go to medical school and complete four years of general medical education before specializing in their residencies, NPs study their chosen field intensively for three to four years in order to complete their degree. NPs who want to study primary care will focus solely on primary care during graduate school.
And although doctors attend more school overall, NPs are able to provide similar quality of care thanks to their specialised education, said Krouse.
But Krouse cautions that assessing quality of care isn’t so simple. “It’s a weird concept. We’re looking 50 years down the road, and asking, did this one visit with this one physician matter? It’s a tough thing to quantify.”
Still, while the quality of care that’s being given may be difficult to measure, the plan of care — the care the patients actually receive — isn’t.
“Lots of studies ask the question: If we give them the same patient, and if we give them the same control, what type of plan of care do they develop?” says Krouse, “Often, they’re developing the same plans of care.”
A 2000 study published in the Journal of the American Medical Association backs up this claim, finding no difference between patient outcomes whether they visited NPs or regular physicians.
But there are some legal difficulties with this solution.
In many states, NPs can’t practice to the full extent of their training. “Historically speaking, nurse practitioners are on the newer end of healthcare professionals,” Krouse said. “It’s been 50 years since the profession has developed. But we’ve seen the most advancement, in terms of education and utilization, within the last 20. The law is playing catch-up.”
In large, rural states like Montana where the primary care shortages are more acute, NPs are allowed to practice with full autonomy. They can own their own practices, prescribe medication, and care for patients fully without physician oversight.
Here’s a map from the Simmons School of Nursing and Health Sciences showing nurses’ scope of practice across the US:
Brought to you by [email protected]: Nurse Practitioner Scope of Practice Map
A solution people should be talking about
Other states have reduced practice or collaboration models, meaning NPs can run their own clinics, but only with explicit physician oversight. In these states, like Indiana, NPs can prescribe medication, but must consult with a physician regularly.
Only a handful of states are still restricted-practice, meaning physicians must employ and directly supervise NPs at all times. “You could have the same nurse practitioner with the same schooling who worked in Indiana,” Krouse said. “If that person decides to move to Florida, the law would treat them completely different.”
In order to effectively combat the primary care shortage, said Krouse, NPs must be able to practice autonomously in all 50 states. They are trained to do the job, but the law needs to let them.
“From a numbers standpoint, allowing NPs to provide primary care wouldn’t be a band-aid solution. It really can be a situation where we can continue to train more physicians, and allow NPs to function to the full extent of their training.”
“It’s a solution people should be talking about.”
Some physicians think differently, however.
According to the Washington Post, when the Institute of Medicine issued a report in 2010 recommending that Medicare reimburse nurses for some of the primary care services limited to physicians, the American Medical Association responded that, “Nurses are critical to the healthcare team, but there is no substitute for education and training.”
Dr. John Thieszen, an internist in Colorado, said that while nurses can play a role in filling in primary care gaps, the government ultimately needs to help reduce the financial burden of attending medical school, and create more residency spots. Massive debt often forces medical school students to choose lucrative specialties, like dermatology, over the more stressful primary care.
Thieszen himself is a locum tenens physician, meaning a staffing agency places him into medically underserved hospitals and clinics, often in remote areas, for temporary positions.
“Locum tenens is about improving distribution,” Thieszen. “There’s a shortage everywhere, and it’s an excellent way for doctors to provide necessary care while supplementing their income.”
Thieszen pointed to programs like the US Public Health Service, which provide medical school scholarships to young physicians who want to practice in medically underserved areas, as examples of how the government can help rectify the primary care shortage.
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