Harnessing the Capacity of Nurse Practitioners to Increase Access to Primary Care in Disadvantaged Communities

Primary care in the United States is in dire straits. Every year, it seems the national primary care scorecard is more sobering than the year before: more and more patients are going without a usual source of care, while fewer and fewer residents are choosing to practice primary care. It’s even tougher in rural and low-income communities, where easy access to primary care could bring the most benefit. Amidst the gloom and doom, there is a glimmer of hope.   

The number of nurse practitioners (NPs) — a profession first introduced in the 1960s to address a primary care shortage in the rural west — is growing rapidly. In fact, they are among the fastest growing professions (behind only renewable energy technicians). The number of NPs quadrupled from 91,000 in 2007 to 431,000 in 2024, outpacing prior projections at a growth rate (46%) that far exceeds the national average occupation growth rate (4%).  

But does this remarkable growth result in improved access to primary care where it is needed most? NPs, overall, seem to gravitate towards rural and low-income areas, but is this also true of primary care NPs?

Are Primary Care NPs Likely to Practice in Rural and Low-Income Areas?

This question is surprisingly difficult to answer because distinguishing between primary care and specialty care NPs is a challenge in commonly used big datasets, like Medicare claims.

We set out to answer this question with IQVIA OneKey, a unique national 2023 dataset of primary care practices, with and without NPs. We used Census data to examine the socioeconomic characteristics of neighborhoods (i.e., Census tracts) where the practices were located, including the Area Deprivation Index (ADI), an overall measure of socioeconomic disadvantage. We then compared the differences between communities with primary care practices that employed NPs with those that did not employ NPs.

We found that in 2023, 53.4% of all primary care practices in the U.S. employed an NP, up from 21% in 2012. We also found that primary care practices with NPs, compared to those without, were more likely to be in rural areas and communities of socioeconomic disadvantage. In fact, there was a consistent pattern: as socioeconomic disadvantage increased, primary care practices were more likely to employ NPs (Figure 1). For example, in communities with the lowest decile ADI (i.e., least disadvantage), 33.4% of practices employed NPs. In contrast, in communities with the highest ADI (i.e., most disadvantaged), 66.0% of practices employed NPs. 

Not surprisingly, communities with greater socioeconomic disadvantage had fewer primary care practices. But as the overall supply declined, primary care practices with NPs represented an increasingly larger share – particularly in the Southeast (Figure 2). These results confirm a long-standing assumption: NPs are key to improving access to primary care in the most disadvantaged communities.

Figure 1. Comparison of the Area Deprivation Index (ADI) Between Communities with Primary Care Practices with or without NPs 

Figure 2. Distribution of the Number of Primary Care Practices in Low-Income Census Tracts with or without NPs, per 100,000 People Across Census Divisions

NP Practice Barriers

Despite the importance of NPs to increasing access to primary care in disadvantaged areas, there are multiple layers of practice barriers (i.e., federal, state, organizational and payer) that restrict NP care. These barriers require physician supervision of NPs (such as periodic review of documentation and co-signature on orders and prescriptions) and often create administrative burden for both NPs and physicians. This time spent on paperwork takes time away from direct patient care, and when supervision requirements are removed, both NPs and physicians see more patients.

Required supervision of NPs does not improve quality of care or population health. NPs consistently provide high-quality, evidence-based care and organically collaborate in team-based care models with or without a mandate. In the context of a projected shortfall of up to 40,000 primary care physicians by 2036, this is wonderful news. But state policymakers can advance policies that allow NPs to most effectively meet the primary care needs of underserved communities. To that end, we recommend a multi-pronged policy approach:

• Modernize state scope of practice laws. Currently, 27 states have passed laws allowing NPs to practice to the full extent of their license and training, without required physician supervision. Outdated laws in the remaining states continue to impede access to primary care. Almost all states in the Southeast place restrictions on NP practice, even though disadvantaged communities in the Southeast are most reliant on primary care NPs and have population health outcomes that are among the worst in the country. Lifting supervision requirements will optimize the available workforce resources and expand access to much needed primary care.
• Incentivize organizations to implement modernized state scope of practice laws. Implementing new scope of practice laws inside organizations is another challenge, as employers are often slow or resistant to revising internal policies when state law changes. State policymakers can use a range of levers to encourage organizations to revise their policies and procedures to facilitate implementation and achieve improved access to care as intended.
• Ensure NP signature recognition on routine forms. As a part of routine primary care, providers regularly sign forms to authorize safe participation in sports, school, or work, the need for disabled parking placards, and to certify end-of-life orders. Currently, 16 states recognize NP signatures on all forms. In the remaining 34 states, the lack of authority to sign routine forms leads to unnecessary inefficiencies and delays for patients. Advocating for global recognition of NP signatures will minimize inefficiencies in this routine part of primary care and subsequently help expand access to care.
• Update NP reimbursement policies. There are a range of NP reimbursement policies under the purview of the states. Medicaid reimbursement rates for NPs vary by state, ranging from 75%-100% of the physician fee schedule. However, NPs increase access to care for Medicaid beneficiaries, and thus Medicaid pay parity is necessary to sustain their care of vulnerable populations and in disadvantaged communities. As states pilot innovative approaches to health care delivery and payment, it is essential to allow the full participation of primary care NPs in these new models of care. Ensuring NPs are included in network directories and allowing enrollees to choose NPs as their designated primary care providers will help achieve this goal.

As the demand for primary care rises, the presence of primary care practices with NPs in rural and low-income communities will be crucial to eliminate disparities in access to primary care. Promoting policies that optimize the primary care NP workforce will also help avoid the costly utilization of the emergency department and specialty care. Such steps would expand the capacity of the primary care system to better meet demand in communities where it is needed most.