Can Nurse Practitioners Fill the Void in Primary Care?

Washington, Pennsylvania, is much like other small rural towns in the United States. Founded in 1768, it sits on just 3.3 square miles of land in greater Appalachia. Its population has dwindled since the 1960s, and like the town itself, most of its residents are financially strapped. Worst yet, nearly everyone in Washington is underserved when it comes to health care. If they require serious attention from a physician or specialist, many find themselves speeding up the freeway on the 30-mile sojourn northward to Pittsburgh.

Joyce Knestrick, PhD, APRN, CFNP, wasn’t proud of that aspect of her community. For years, she watched anxiously as her neighbors struggled and failed to find appropriate care. There was a palpable tension building inside Knestrick that soon drove her to go back to school to pursue a Master of Science in Nursing. During her studies, she met a nurse practitioner (NP) and saw firsthand that the profession offered an opportunity to address the tribulations of the careworn community where she grew up.

“I was impressed with the work [the NP] was able to do and her compassion for patients,” Knestrick, told MD Magazine. Reflecting on her decision to become an NP herself, she added, “It was a great choice because I get to care for patients in the community and bring the nursing aspects of holistic, patient-centered care. At the same time, becoming an NP has afforded me the opportunity to be a force for change in the healthcare system, which needs more avenues for access to the high-quality care NPs bring to patients.”

Now, 25 years later, Knestrick teaches at Georgetown University and is the sitting president of the American Association of Nurse Practitioners (AANP). Titles aside, Knestrick hasn’t forgotten her roots. She still practices as a family NP in Wheeling, West Virginia, another small town with an underserved and low-income patient community. “Because of how nursing programs are set up and based on our original nursing model, we’re community focused,” Knestrick said. “I think a lot of NPs go back to school to be an NP because they know the problems in their community and they want to advance that community.”

Scope of Practice

The data backs up Knestrick’s claims. Most NPs—roughly 87%, according to AANP statistics—end up working in primary care, compared to only 14.5% of physicians. Additionally, most serve in rural areas where the lack of family practices and primary care physicians (PCPs) usually hits hardest. While health systems, practitioners, and patients all stand to benefit from their hard work, the degree to which NPs should be permitted to tackle patient issues is an open question.The American Association of Medical Colleges estimates that by 2030, the United States will be lacking nearly 105,000 physicians, with roughly 41% of the shortcoming falling in primary care. Meanwhile, the number of graduating NPs entering the workforce each year continues to grow. In 2007, there were an estimated 120,000 practicing NPs in the US. In just 10 years, that number has nearly doubled to 234,000.

“In most countries in the world, 70% of the doctors are primary care and 30% are specialists, in our country it's the reverse—70% specialists, 30% primary care,” said Simon Murray, MD, a clinical assistant professor of medicine at Rutgers Medical School. “I don't think the government gets it. They pay a lot of lip service to primary care and try to improve things, but they don't, nothing has changed. In fact, the work we have to do has even increased.”

Primary care physicians can see 5 patients per hour, which is, according to David B. Troxel, MD, the medical director of The Doctor’s Company, a “huge number.” With no indication that this increase in work will slow, NPs—who typically see 3-4 patients per hour—have a unique opportunity to help address the shrinking primary care provider problem. Just like medical scribes are easing the electronic health record burden on physicians, NPs can do the same for patient care, he said.

“[NPs] are really offering a service that accomplishes the same thing. They can allow the physician that they work with to see more patients and to focus on those that either have complex medical problems or diagnostic problems,” Troxel said.

But the biggest hurdle standing in the way of effective primary care is the “scope of practice” problem. Currently, NPs have full practice ability, which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications and controlled substances—under the exclusive licensure authority of their respective state’s board of nursing, in 22 states and the District of Columbia. In 16 states, NP practice is reduced, meaning NPs are subject to career-long regulated collaborative agreement with another health provider in order to provide patient care. In the remaining 12 it is restricted, resulting in required career-long supervision, delegation, or team-management by another health provider.

Although some states are making small, incremental steps toward expanding the NP scope of practice, Knestrick said that “in many states there are barriers put up against NPs attaining full practice authority.” Even so, NPs hold prescriptive privileges in all 50 states and Washington, DC. In fact, 95.8% of NPs prescribe medications, with those in full-time practice averaging 23 prescriptions per day. Despite being trusted to write scripts, in many of those states they are unable to practice without supervision. “I just think there are a lot of outdated laws, at the state and the federal level, that impact the care NPs can provide,” Knestrick said. “Some of these laws were written so long ago that [NPs] didn’t even exist yet. We need to allow NPs to practice to the full extent of their practice ability and training. I think that nurses can make a huge difference in the health care system, particularly in primary care, and allowing us to do what we are licensed to do will make a big impact.”

In a recent study conducted by researchers from The Doctor’s Company, data from more than 1000 claims over 6 years was used to assess the differences in care provided by PCPs and NPs. The data revealed that 48% of claims against NPs were diagnosis-related compared to 41% for PCPs. Likewise, 24% of claims were medication-related for NPs, compared to 19% for PCPs. NPs were shown to be the recipients of very few claims, and even as physician claims numbers decrease, they still lead NPs in the total, Troxel said. In most instances, the claims were traced back to system factors in the office setting. The main reason for most of them? Failure to adhere to nurse practitioner scope of practice.

“The concern is that each state has its own regulations defining ‘scope of practice’ for NPs,” Troxel, the co-author of the study, said. “But what we did see, repeatedly, were examples of cases in which, if there were written protocols, they weren’t being followed correctly; or there weren’t written records that they could discover showing adequate physician supervision; some of the claims against NPs alleged failure in consulting with the physician they were working with or referring the patient either to the physician they were working with directly or a specialist.”

Troxel told MD Magazine that while the data showed a number of NPs were practicing beyond that scope, the issue is most likely an administrative one. “I just don’t know the extent to which physicians check with their state’s regulations on NPs defining their scope of practice. Maybe they all do, but I have my doubts,” he said. From what Troxel sees, it seems that resolving the scope of practice issue could be as simple as “[sitting] down when they’re first hired and [agreeing] on the level of supervision that’ll be exercised, agree on those diagnoses that should always go to the physician,” he said.

Pushback from Organized Medicine

It comes down to basic accountability, Knestrick said. If NPs aren’t able to practice to the fullest extent of their training, they cannot bill under their own names. Extending that scope will hold NPs accountable for their care and could improve the care they provide. “We can’t accurately see what everyone’s doing when they’re not billing under their own name,” she said. “It makes it hard to get clear data. [Allowing it] will improve our data about the high-quality care that we give out.”Quality is certainly a concern. Murray told MD Magazine that as the pool of internal medicine candidates decreases and would-be primary care practitioners siphon into specialties, the integrity of family practice and primary care could decline. “That void is going to be filled by nurse practitioners and by PAs [physician assistants],” he said. “Frankly, I don't think PAs have the ability to practice primary care medicine like a doctor can. I'm sorry to say it. They can do a lot of things, but they just can't. They don't have the training or the background to do it. But that's how [the medical community] intends to fill it.”

“There is no question that PAs are positioned to practice in primary care and offer a solution to provider shortages," L. Gail Curtis, PA-C, MPAS, DFAAPA, president and chair of AAPA’s Board of Directors, told MD Magazine in a statement. "PAs have been practicing medicine for more than 50 years, and a wealth of research exists that points to the high-quality care that PAs provide. Trained in the medical model, often alongside our physician colleagues, PAs expand access to care and frequently serve as a patient’s principal healthcare provider.”

While PAs certainly have the ability to help fill the gaps in primary care, some, like Murray, would argue not without physician guidance. Likewise, that argument is made against NPs as well. Notably, both PAs and NPs have the ability to exercise autonomy in practice and initiative in clinical decision-making—in 22 states, NPs can practice completely without a physician.

But that isn’t always the case. Knestrick said that physicians put up the limitations on their practice—not the everyday physicians they work with, who she says are “generally supportive of the role”—it’s mostly organized medicine, and the traditional principles held by leading medical organizations, that puts the push out against NP licensure. The physicians who have worked with and were treated by NPs, though, seem to agree with Knestrick.

“The NPs I have met as a patient, I have been very impressed with. They were very professional, and I thought they handled themselves very well and did everything just as well as a physician would,” Troxel said. “And they were practicing in health systems where protocols are required by the [Joint Commission on Accreditation of Hospitals] during inspection and whatnot, so I’m sure they did have written protocols. I think the problems have to be more in the doctor’s office—and it’s not a big problem. We had a relatively small number of claims over a 6-year period [in our study], so it’s not as if NPs are getting sued left and right, because they’re not.”

AANP data support Troxel’s assertion. Only 1.9% of NPs have been named the primary defendant in malpractice cases. Knestrick said that patients are trusting of NPs, and more likely to come back to an NP for their primary care because of that. “My patients know I’m an NP, and they want me to provide their care. Even though there are no physicians in the practice, they continue to come back to receive care,” she said.

The pushback for expanding the NP role in primary care is strange, considering its roots and the trends in medicine. Knestrick noted that as medicine moves toward more rounded and complete care models—such as the rise of individualized care—the training NPs undergo makes them a good fit for the path medicine as a whole is moving toward.

“Our model is based off of a nursing holistic care model, and even though physicians talk about treating the whole patient, we really see them continue to specialize,” Knestrick said. “I have a great respect for physicians in primary care, but it’s definitely an area where NPs are educated, trained, and capable, and I think the evidence shows that we do a good job in filling those gaps.”

While some are fearful that the NP role is growing too rapidly, Knestrick insisted that the growth is a symptom of a challenged healthcare system, and an opportunity to overcome some of those challenges. Their area of expertise, she argues, is in primary care, where they have the greatest chance to make an impact on the patients who are most in need of care. “The role itself hasn’t changed. Really, it’s just that more states have removed outdated licensure barriers and more NPs are billing under their own numbers and so forth, which gives us more data [on NP practices], whereas before, we were pretty much hidden providers,” she said.

Ultimately, Knestrick believes that allowing for NPs to provide patient care is good for the patient. There is a need for health care professionals to work together, and as medicine becomes more connected and the patient population grows and ages, that need will only increase. Allowing NPs to enter primary care fills an ever-growing void and helps health systems, their workforces, and their patients, she said.

“Whether the NP is working within a practice or in their own, it enables the patient to have a choice—they’re able to pick the provider they want, and that provider can bill under their own number and be accountable for their own work,” Knestrick said. “NPs like to make sure the patient is the center of care. We know it should be whatever it takes to give the best care to the patients.”

Note: A previous version of this story included a paragraph that has since been altered for better clarity, including a statement from the president of the AAPA.

REFERENCES:

1. NP fact sheet. AANP website. aanp.org/all-about-nps/np-fact-sheet. Updated January 22, 2018. Accessed April 16, 2018.

2. State Practice Environment. AANP website. aanp.org/legislation-regulation/state-legislation/state-practice-environment. Updated December 2017. Accessed April 16, 2018.

3. Nurse practitioner closed claims study: top risks in the changing delivery of primary care. The Doctor’s Company website. thedoctors.com/articles/nurse-practitioner-closed-claims-study-top-risks-in-the-changing-delivery-of-primary-care. Published March 18, 2018. Accessed March 20, 2018.

4. Keyes L. Nurse practitioner vs. physician assistant: which career is right for you? MastersinNursing.com. mastersinnursing.com/guide/nurse-practitioner-vs-physician-assistant-which-career-is-right-for-you. Published 2014. Accessed April 17, 2018.

5. Scope of practice. American Nurses Association website. nursingworld.org/practice-policy/scope-of-practice. Accessed April 17, 2018.