Investing in Primary Care: The Nurse Practitioner Will See You Now

Abstract

Nurse practitioners (NPs) are now the fastest growing health profession in the United States and comprise 47% of all US primary care clinicians. Decades of research confirms the safety, quality, and effectiveness of care provided by NPs, including care for complex patients, and their acceptance and approval by patients. Yet challenges remain in recruiting and retaining NPs in primary care. In addition to barriers reported by primary care clinicians in most settings, NPs in particular face (1) variation in state practice regulations and institutional policies; (2) inadequate reimbursement rates from Medicare and many private insurers; and (3) a lack of federal financing for training, support, and mentoring. Cultural norms about roles, responsibilities, and authority in health care may exacerbate these challenges. This report offers opportunities to support the continued advancement of preparation and growth for NPs to meet the population’s primary care needs. State policymakers should partner with advanced practice nurses, physicians, and others to bridge these divides and fully realize the potential of NPs to provide high-quality and effective team-based care.

Executive Summary

Nurse practitioners (NPs) have been an essential component of the US primary care workforce since the late 1960s.¹ The most recent data show that NPs comprise 47% of all US primary care clinicians and, together with physician assistants/associates (PAs) and certified nurse midwives (CNMs), comprise 52% of primary care clinicians working in community health centers.^2,3 Decades of research confirms the safety, quality, and effectiveness of care provided by NPs, including care for complex patients, and patients’ acceptance and approval of them.^4–6

At the same time, the United States is facing a worsening shortage of primary care clinicians. This shortage has many inputs: an aging physician workforce, inadequate financial support for primary care, and more physicians, NPs, and PAs choosing specialty practice areas.^7,8 It is imperative that the US invest in strategies to prepare, attract, and retain the best, brightest, most committed primary care clinician workforce; support them with satisfying and highly effective practice settings; and make those settings models of innovation, collaboration, and teamwork that enhance patient outcomes and provider satisfaction.

More than 60 years since the NP role was created, challenges and variations in reimbursement and practice authority persist. Medicare still sets NP reimbursement at 85% of the physician fee schedule (other than for institutional billers such as community health centers), a practice adopted by many insurers/payers, even when the service, complexity, and time is identical to care provided by a physician. Consequently, provider practices may opt to bill NP services “incident to” a physician in the practice, generally resulting in higher payment to the practice. While this approach may be financially advantageous, it works against transparency, accountability, and data integrity. Another challenge is state-level variation in scope of practice and practice authority for NPs. There is a trend toward full practice authority, with 28 states and Washington, DC, allowing full NP practice, but there are still 12 states with “reduced” authority (requiring supervision for at least one domain of practice) and 11 states with restricted practice^.9 The Department of Veterans Affairs (VA) sought and achieved full practice authority nationally for all VA NPs in 2016.¹⁰

Notably, community health centers and the VA, along with some private and public health systems, have been leaders in the development of formal postgraduate training programs in primary care, akin to what graduate medical education (GME) funding has supported for new physicians since 1965. New NPs have access to 12- to 24-month accredited postgraduate residency or fellowship training programs in primary care that provide a depth and intensity of clinical experience and the confidence that comes with it,^11,12 but federal dollars to support such training are limited and may be eliminated under the Trump administration’s budgets.

At the same time, virtually all primary care practices, and certainly those caring for underserved populations, face enormous pressures to provide optimum primary care that addresses the full range of health care challenges and social needs. This is occurring in a still predominantly fee-for-service environment, with the unrelenting pressures of time, documentation, care coordination and management, and patient volume. These stressors are faced by all primary care providers, not just NPs, and call for increased practice-level support in the form of team-based care that includes behavioral health support, use of emerging technology to decrease clinician documentation burden, and fair compensation for all team members.

The persistent belief by some that physicians must be in charge of primary care teams may exacerbate these challenges for NPs, even though many NPs practice independently, often in NP-owned practices, and in some of the most underserved areas of the country. Team-based care, with leadership based on clinician expertise, experience, and ability — regardless of discipline — offers perhaps the best solution to enhance productive collaboration and support staff expertise and development.

People with a usual source of care are healthier, use fewer expensive services, and report fewer disparities than those without. Ensuring that everyone has access to a usual source of care requires the recognition that primary care is most effectively delivered in a team- based model.* In this report, we seek to synthesize evidence to address three foundational questions: (1) What is the current and future role of NPs in delivering high-quality primary care, and how is this influenced by policies governing who can treat patients and under what circumstances? (2) What reimbursement and data collection issues must be resolved to realize this role? and (3) How can additional investments in postgraduate training for NPs committed to primary care benefit patients and support new clinicians? As we answer these questions, we highlight regulatory, payment, policy and training barriers and opportunities to create a future where the answer is “Yes, your primary care provider can see you now.”

_{*While this report focuses on advanced primary care clinicians, we acknowledge that all members of effective teams — including behavioral health providers, registered nurses, clinical pharmacists, and medical assistants — warrant training attention.}

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