“The NP can see you now”: Modernization of Primary Healthcare Services

Jennifer B. Lemoine, DNP, APRN, NNP-BC

PhD Student

College of Nursing

University of Utah

The changing nature of the U.S. healthcare system necessitates the utilization of all healthcare providers to the fullest extent of their education and training. With the ‘graying’ of America, the rising costs of healthcare insurance coverage, and the increasing complexity of the delivery of healthcare services, Americans are paying more and receiving less.  According of the Association of American Medical Colleges (AAMC), by the year 2030, the U.S. could face a primary care physician shortage of up to 49,300 providers. This number indicates both rural and urban demands, but does not include the number of providers needed in specialty care areas such as cardiology, pulmonology and orthopedics.¹

Driving forces

Population: The population of the U.S. is expected to increase in both number and age. By 2030, a population growth of 12% is projected, which means approximately 359 million people will then reside in the U.S. Additionally, those individuals aged 65 years or older are anticipated to increase by 55%. This aging population will not only drive the demand for the expansion of healthcare services provided over the next two decades, but will also contribute to the retirement of one-third of the physician workforce who will reach age 65 within the next ten years.²   As the U.S. population increases and the ratio of physicians to the population decreases, additional strains will be placed on an already burdened healthcare system.

Health Professional Shortage Areas: The term Health Professional Shortage Area (HPSA) is used to identify communities and populations experiencing a shortage of healthcare providers. Communities receive federal designation as an HPSA based on population-to-provider ratios. For example, communities with a population-to-provider ratio of 3,500 to 1 or 3,000 to 1 in high-need areas, meet the qualifications of a federally designated HPSA. As of June, 2018, there are 7,253 Primary Care HPSA designated communities across the U.S., providing healthcare services to approximately 85,576,737 residents. Of these communities, 4,292 are classified as rural areas. It is projected that an additional 14,963 primary care providers will be needed to remove the HPSA designation from these communities.³

Number of HPSAs by state as of 2018 (1)

Achieving population health goals: The achievement of select population health goals such as decreasing obesity rates and smoking cessation can result in improved patient outcomes which may contribute to longevity, thus increasing the demand for primary healthcare services by 2030.⁴

Utilization patterns: Increased access to healthcare services, particularly primary care services, is a national goal. The removal of barriers to and utilization patterns of these services for underserved populations will ultimately increase the demand for primary care providers.⁴

Physician workforce patterns: In addition to the 2030 physician-retirement projections, there is a movement toward physicians balancing life-work demands. This change in workforce patterns is contributing to a decrease in the number of physicians who work full-time (FTEs). This factor reduces physician availability and access to services. Should this trend continue, by 2030 the supply of physicians will decrease by 32,500 FTEs, further exacerbating access to care issues.⁴

Modernization of Primary Care Services: Paradigm Shift

Nurse Practitioners: The American Association of Nurse Practitioners defines a nurse practitioner (NP) as an advanced practice registered nurse (APRN) who has completed an accredited graduate-level education program, holds unencumbered RN and APRN licenses, and has passed a national certification exam. Graduate-level education programs provide NPs with the knowledge, skill set, and clinical expertise to care for diverse populations.

NPs are NOT trained to practice medicine ‘under’ a physician or with physician supervision, but are trained to work autonomously and in collaboration with other healthcare professionals.⁵

Also, unlike their physician colleagues, NPs are NOT educated using the medical model of care, but are educated and trained using a patient-centered holistic approach, placing these providers in the prime position to positively impact health outcomes through health promotion and disease prevention strategies, as well as health education and counseling activities.⁵

Care provided by NPs: NPs provide high-quality, effective care, while decreasing the cost of health care services.  Patients who chose NPs as their primary care providers have fewer emergency department visits, shorter hospital stays, and again, a reduction in medical costs. In the U.S., approximately one billion patient visits are made to NPs each year AND extremely high levels of patient satisfaction have been reported.⁵

NP statistical trends: There are 248,000 NPs (image 2) in the U.S. Of this number, approximately 61% are trained as primary care providers and an overwhelming number of these NPs practice in rural and underserved communities. Additionally, NPs are the backbone in providing primary care services to the Medicaid population. Over the past few years, physicians have seen a reduction in the reimbursement amounts paid for Medicaid patients. This reduction has resulted in approximately one-third of U.S. physicians refusing to ‘take’ new patients who are insured by Medicaid, opting to accept those with private insurance or insured by Medicare instead.⁵  

Buzz Jeansonne ARPN, FNP-BC, Cottonport LA(3)

According to Herndon M. “Buzz” Jeansonne, Family Nurse Practitioner, owner of Louisiana Health Care Practitioners, LLC, which encompasses five primary care clinics, employs ten NPs and provides care to families residing in rural areas of Louisiana, “The clinics are located so we can serve the most people because most patients don’t want to travel out of town to been seen because they don’t have transportation or money for gas. Still, some travel 10 to 12 miles to get to one of our clinics, but the majority of our patients walk to their appointments.”

Full Practice Authority

Collaborative practice agreement: In order to practice, many states require NPs to have a collaborative practice agreement (CPA) with a physician or a group of physicians, which outlines practice parameters. Full practice authority (FPA) refers to the utilization of nurse practitioners to the highest level of their education and training, without the requirement of a CPA.

                

Collaborative practice agreements DO NOT:

• Require the collaborating physician to be present while the NP is providing care;
• Stipulate the number of patient charts to be reviewed by the collaborating physician (in some cases, no charts are reviewed);
• Require the collaborating physician to be located with “X” number of miles of the NP’s practice;
• Require the collaborating physician to visit the facility at any time;
• Require the NP and the collaborating physician to communicate;
• Provide malpractice insurance for the NP (NPs must provide and pay for their own malpractice insurance); and
• Regulate the NP’s scope of practice (scope of NP practice is regulated by individual State Boards of Nursing).

Collaborative practice agreements DO:

• Require the collaborating physician’s signature;
• Allow for the CPA to be revoked at any time;
• Allow for the collaborating physician to charge the NP for his/her signature (there is no cap on the amount of funds that can be requested); and
• Require the NP to seek a new collaborating physician in the event of the physician’s retirement, loss of license, death, or choice to end the collaboration, with or without cause (upon termination of the CPA, the NP CANNOT practice until a new CPA has been signed and approved by the appropriate State Board of Nursing).

 “Providers at each of our clinics see up to 50-60 patients each day. Should we lose our collaborating physician, by law, we would not be able to see patients. This means approximately 8,000 – 9,000 residents would immediately lose the only access they have to a primary care provider.” Buzz Jeansonne, Family Nurse Practitioner, owner of Louisiana Health Care Practitioners, LLC

2018 Nurse Practitioner State Practice Environment: As of 2018, 23 states and the District of Columbia have FPA for NPs (image 4).

Conflict, Controversy & Tension

The dominant paradigm: The dominant paradigm continues to be ‘physician led medicine.” Therefore, it is not surprising to find that the majority of primary care physicians are opposed to FPA. Over the past decade, powerful professional medical organizations including the American Medical Association and the American Academy of Family Physicians have successfully blocked legislative efforts in many states in which NPs sought FPA. 

Turf wars: Battles between primary care physicians and NPs in the political arena have resulted in “turf wars.” For example, in 2016 during the Louisiana State Senate Health and Welfare committee hearing of SB 187, a bill relative to full practice authority, during his testimony one physician likened the primary care provider shortage to this scenario “if you don’t have enough airplane pilots, now we’re going to let the stewardess fly the plane…” This analogy was not well received and further disrupted the discourse between opposing parties.

Potential Impact of Paradigm Change

Health outcomes: At the center of the debate is the patient. Removal of barriers to access to care, such as the CPA , have the potential to positively affect diverse patient populations. States with restrictive NP practice have poorer health outcomes than states with FPA.⁶

NPs provide….“Not Just Healthcare, Exceptional Care!”

Louisiana Association of Nurse Practitioners

References

[1] Association of American Medical Colleges. (2018). New research shows increasing physician shortages in both primary and specialty care. Retrieved from https://news.aamc.org/press-releases/article/workforce_report_shortage_04112018/

[2] Kirsch, D. G., & Petelle, K. (2017). Addressing the physician shortage: The peril of ignoring demography. Journal of the American Medical Association, 317(19), 1947-1948.

[3] Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services. (2018). Third quarter of fiscal year 2018 designated HPSA quarterly summary. Retrieved from https://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Qtr_Smry_HTML&rc:Toolbar=false

[4} HIS Markit Ltd. (2018). The complexities of physician supply and demand: Projections from 2016 to 2030. Retrieved from https://aamc-black.global.ssl.fastly.net/production/media/filer_public/85/d7/85d7b689-f417-4ef0-97fb-ecc129836829/aamc_2018_workforce_projections_update_april_11_2018.pdf

[5] American Association of Nurse Practitioners. (nd.). What’s an NP? Retrieved from https://www.aanp.org/all-about-nps/what-is-an-np

[6] Sonenberg, A., & Knepper, J.J. (2017). Considering disparities: How do nurse practitioner regulatory policies, access to care, and health outcomes vary across four states? Nursing Outlook, 65(2), 143-153.

Images: according to appearance in the post

[1] Kaiser Family Foundation. (2017) Primary care health professional shortage areas (HPSAs). Retrieved from https://www.kff.org/other/state-indicator/primary-care-health-professional-shortage-areas-hpsas/?activeTab=map&currentTimeframe=0&selectedDistributions=total-primary-care-hpsa-designations&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

[2] American Association of Nurse Practitioners. (2018a) Nurse practitioners. Retrieved from https://www.aanp.org/images/about-nps/npgraphic.pdf

[3] Future of Nursing: Campaign for Action in Louisiana. (2013). Rural health care. Retrieved from

https://www.louisianafutureofnursing.org/single-post/2013/11/08/Rural-health-care

[4] American Association of Nurse Practitioners. (2018b). State practice environment. Retrieved from https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment