Advanced Practice Provider Influx Will Reshape Primary Care

Marcia Frellick

June 20, 2018

Two thirds of the healthcare providers joining the US workforce by 2030 will be nurse practitioners (NPs) or physician assistants (PAs), researchers project.

Physician numbers, constrained by longer training times and number of residency spots, are growing, but not nearly as fast, according to an analysis by David I. Auerbach, PhD, from the Center for Interdisciplinary Health Workforce Studies in the College of Nursing at Montana State University in Bozeman, and colleagues. Their findings were published online today in the New England Journal of Medicine.

The authors say the number of full-time equivalent physicians will grow by just more than 1% per year as retirements are offset by increased entry. At the same time, numbers of NPs are projected to grow 6.8% and PAs are expected to grow by 4.3%.

Table. Growth in Number of Full-Time Equivalents

Provider Type 2010 2016 2030 (Projected)
Physicians 862,698 920,397 1,076,360
Nurse Practitioners 91,697 157,025 396,546
Physician Assistants 88,047 102,084 183,991

In fact, a new report from Merritt Hawkins, a national healthcare recruiting firm, indicates that demand for NPs and PAs is already accelerating. The company conducted more searches for NPs and PAs last year than in any 12-month period since they started tracking them. Similarly, the average starting salary for NPs, at $129,000, is higher than they’ve seen before.

Effect Concentrated in Primary Care

The large influx will have its greatest effect in primary care, where NPs and PAs are more prevalent and where fewer physicians are choosing to practice.

"We've gotten used to thinking of these nonphysician providers as a small group existing only in certain places, but it's really a mindset shift to say, 'no, this is going to be the mainstream,' " Auerbach told Medscape Medical News.

"There are always going to be some practices that are physician-only. But those will be fewer and fewer," Auerbach said. In fact, he said he expects to see more NP-led clinics and a greater presence of NPs and PAs in multispecialty practices.

Just more than two thirds (67.3%) of practitioners added between 2016 and 2030 will be NPs or PAs, and the combined number of NPs and PAs per 100 physicians will nearly double from 28.2 in 2016 to 53.9 by 2030, according to the new projections.

Peers Within 20 Years

Ateev Mehrotra, MD, MPH, a hospitalist and an associate professor of health care policy and medicine at Harvard Medical School in Boston, Massachusetts, predicts dramatic shifts in provider roles within the next 20 years.

Because of the rise in numbers of advanced practice nurses entering the workforce with doctor of nursing practice (DNP) degrees, he says, primary care will eventually not make such a distinction between MDs and DNPs. The process of becoming peers rather than continuing a hierarchical relationship with MDs at the top will resemble the decades-long process it took for doctors of osteopathic medicine to be recognized as the same level of provider as MDs, he said.

If doctorate-level physicians and nurses become peers in primary care, then that will pose the question of why medical school training takes so many extra years, Mehrotra noted.

"I hope this will cause some reexamination of what's really necessary," for physician training, and where the value is added, he said. "I don't know what the right answer is, but it makes us ask some tough questions.

"MDs are going to feel very threatened that these other people with different training are entering and being seen as equivalent," he said. But he added "it's already happening."

Opportunity to Relieve Burnout

Leigh Simmons, MD, from the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital in Boston, told Medscape Medical News the influx of NPs and PAs brings opportunity for relief for primary care physicians, but that will take training and careful thought about what each provider can do at the top of their licenses.

Physicians feel defeated as they perform some of the same tasks as NPs and PAs, but with greater malpractice liability and sometimes on-call work, she explained. Likewise, advanced practice providers are discouraged when they perform tasks registered nurses could do.

"One real gap in physician knowledge is how NPs and PAs are trained," she said.

That gap can also contribute to burnout, as some physicians see the influx of advanced practice providers as further erosion of the physician role.

"Too often there's a thought that [they] will replace us," she said. "The cure for that is learning how they are trained and finding out what they are able to do to help you do your job even better."

Some parts of primary care can be handled equally well by physicians and NPs and PAs, as research has shown, she said.

"But not all of it," Simmons said. "What we've done a relatively poor job of is figuring out who needs to see the doctor and who is better served by seeing a nurse practitioner. We shouldn't all be doing the same work."

The effect of the shifting makeup of primary care providers will be buffered by a new generation of providers coming from medical schools and nursing schools, where working in interprofessional teams is, and will be, the norm, Simmons said.

"What we may be worrying about may simply be solved as retiring physicians are replaced with younger physicians," she said.

Training Needed for "New Reality"

"Physicians, NPs, and PAs will all need to be trained and prepared for this new reality," the authors write.

Fewer years of clinical training has been a major argument against proposals to expand the scope of NPs in states where that is being debated. Some physician groups also cite the relatively fewer years of training NPs and PAs have, in arguing against broader roles for them.

One sign of progress in training can be found in a separate article also published in this week's issue of the New England Journal of Medicine by Linda H. Aiken, PhD, RN, from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, and colleagues. Aiken and colleagues detail the success of the Centers for Medicare & Medicaid project to modernize Medicare's payment model for nurse training.

Traditionally, the Centers for Medicare & Medicaid had spent very little on training nurse practitioners, the authors write, until the Graduate Nurse Education Demonstration, a $200 million, five-site project authorized under the Affordable Care Act.

It has shown that payments to Medicare providers enabled more of them to engage in clinical training of Advanced Practice Registered Nurses.

The authors conclude the Graduate Nurse Education model "has the potential to improve access to primary care nationwide."

Disclosure forms available at NEJM.org Auerbach and coauthors report receiving grants from Johnson & Johnson and the Gordon & Betty Moore Foundation outside the submitted work. One coauthor also reports receiving personal fees and other funding from ArborMetrix, Inc. Another coauthor reports receiving grants from the American Association of Nurse Practitioners, the Robert Wood Johnson Foundation, the Initiative for Applied Regulatory Economic Analysis, and personal fees and nonfinancial support from the American Association for Physician Leadership, as well as chairing the National Health Care Workforce Commission (Commission) to advise Congress and the Administration on national health policy. Simmons and Mehrotra have disclosed no relevant financial relationships.

N Engl J Med. 2018;378:2358-2363. Published online June 20, 2018.

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