Increasing numbers of nurse practitioners (NPs) and physician assistants (PAs) are working outside of primary care in subspecialty fields, raising serious questions as to whether NPs and PAs are a solution to the nation's growing shortage of primary care physicians. That's according to a study conducted by researchers at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
The study, published as a one-page policy brief in American Family Physician, points out that although NPs and PAs often are suggested as a solution to a looming shortage of primary care physicians, a growing number of them are choosing to work outside of primary care. Thus, the nation still needs to find innovative solutions to increase patient access to primary care.
The study itself is based on the National Provider Identifier file, which lists NP and PA clinic locations, as well as physicians working in the same locations. It was assumed that NPs and PAs in independent practice and those co-located with primary care physicians provided primary care.
- A growing number of nurse practitioners (NPs) and physician assistants (PAs) now work outside of primary care, according to a study conducted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
- The study raises questions about whether NPs and PAs are a solution to the growing shortage of primary care physicians.
- Based on the findings, the study says policymakers should not abandon solutions designed to increase the number of primary care physicians, along with NPs and PAs.
Based on this information, the Graham Center found that fewer than half of PAs and slightly more than half of NPs practiced in primary care in 2010. This trend toward choosing to subspecialize also is occurring among physicians.
"Relying on NPs and PAs to solve the problem of a growing shortage of primary care physicians may not be an option, and policymakers should not abandon policy solutions designed to increase the number of primary care physicians, NPs and PAs," said the study.
In a Graham Center press release(www.graham-center.org), Andrew Bazemore, M.D., M.P.H., director of the Graham Center, said, "The future of primary care will depend on teams of providers from various disciplines and educational policies that foster those teams. Given what we know of primary care's impact on costs, patient health and population health, we risk falling well short of our nation's health care workforce goals if efforts to increase the production of physicians, nurse practitioners and physician assistants aren't paired with efforts to further encourage trainees in each discipline toward careers in primary care."
The Graham Center research seems to contradict a report from the American Association of Colleges of Nursing (view press release; report available for purchase only(www.aacn.nche.edu)) suggesting that more than 80 percent of NP graduates entered primary care. That percentage, which was referenced in a July 2013 New England Journal of Medicine perspective piece(www.nejm.org), "captured primary care degrees at graduation, not actual practice in a primary care setting," a key difference from the Graham Center research, according to Bazemore.
"Many nurse practitioners who graduate with family, adult or pediatric degrees go on to work in subspecialty offices," said Bazemore. "This is similar to the pattern of physicians entering residency in internal medicine or pediatrics at the end of medical school who go onto further training and practice in subspecialties."
According to the Graham Center study, "Some factors that influence physicians to choose subspecialty careers may have similar effects for NPs and PAs, including student debt and income gap disparities.
"Although NPs and PAs may also benefit from factors that increase the likelihood of choosing primary care careers, such as training experiences in rural and underserved communities, debt reduction and selection of students intent on care for underserved populations, further studies are needed to know for sure."
To better understand these trends, the Physician Assistant Education Association (PAEA) recently provided a grant to the Graham Center to perform a similar study examining the effect of student debt and other factors on career choices among PAs.
The average total student debt for PAs was approximately $100,000 in 2008, according to the PAEA. Moreover, a four-year nursing degree can range from $25,000 for instate and/or a public school to $100,000 for nonresident and/or a private school. An online NP program costs an average of $35,000, according to the press release.
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