Blog Non Physician Providers Want to Be Doctors

For the past three years, we have tracked primary care workforce numbers comparing the annual primary care residency match data with the primary care nurse practitioner (NP) graduation rates. The physician numbers continue to be relatively flat while the nurse practitioner data continues to surge.

Under the Affordable Care Act (ACA), 16.4 million people are now enrolled for health care coverage. But we have yet to see the same sorts of increases in medical school graduates entering primary care. The National Center for Health Workforce Analysis (HRSA) predicts primary care shortages as high as 20,400 physicians by 2020.

However, we have seen large increases in NP graduates each year. We must, therefore, eliminate the barriers to NPs practicing to the fullest extent of their training. Only then will the nation reap the full benefit of expanded access to quality primary care services and a reduction in unnecessary costs to the health care system.

2015 National Resident Matching Program Data

Two years ago, we presented the primary care resident match data along with the nurse practitioner primary care graduation rates. The data were quite striking then, and even more so in 2014. The March 2014 National Resident Matching Program data disclosed that there were merely 19 more U.S. resident matches to primary care specialties—in Family Medicine, Internal Medicine, and Pediatrics—than in 2013. This year, there were 42 more U.S. residency primary care matches, representing only a slight "uptick."

To further break down the data from this year, there were nine more U.S. Family Medicine matches than in 2014. Internal Medicine matches had the largest increase, 41 more than in 2014. Sadly, U.S. Pediatrics Primary Care had eight fewer matches than in 2014. In total, 1,965 U.S. medical student graduates matched to primary care specialties. When considering the entire first-year match numbers of U.S. graduates for all specialties—16,932—only 11.6 percent of those were for primary care specialties, slightly down from 12 percent a year ago.

When international graduates are included, the total primary care match numbers almost double from 1,965 to 3,843, and that has changed little over the past three years. It is the international medical student graduates who rescue the U.S. primary care match numbers – that is, almost half (49 percent) of primary care matches are from international graduates.

This lackluster increase to the primary care physician workforce offers little hope of significantly remedying the potential primary care provider shortage.

Primary Care Nurse Practitioner Graduation Rates

Nurse Practitioner graduate rates continue to tell a different story than medical student match rates. According to a recently released report from the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties, the 2014 primary care NP graduate rate (reported in 2015) totaled 14,400 – over 800 more than in the previous year (13,568). These 14,400 primary care NP graduates represent 85 percent of the 16,972 total new NP graduates. The NP increases, far more than a mere "uptick," have been consistent over the past five years and are expected to continue.

If one compares the percentage of NPs receiving primary care education (85 percent) to the 11.6 percent of U.S. residency primary care matches, and the increase of NPs (832) completing primary care programs versus the addition of 42 more U.S. medical school graduate matches, the evidence is compelling that NPs already have a significantly growing role in U.S. primary care delivery. Further, if one looks at this comparison over three years as depicted in Table 1, it is evident that NPs are rapidly becoming a substantial and critical part of the primary care workforce.

NPs "match" to primary care when they enter a NP program. Not all NPs with primary care preparation end up in primary care, just as not all medical student graduates matched to primary care end up in primary care. However, if even only a half or a third of the NP graduates practice in primary care, these NPs will have a profound impact on the potential shortage of providers.

What Does The Future Hold?

We believe that primary care is the foundation of a robust health care system. It will take all providers working to the fullest extent of their educational preparation to ensure an effective health care system that meets the triple aim of improving the patient experience and the health of populations, and reducing the cost of care.

However, costly and unnecessary barriers to NP practice continue to exist, impeding both NPs and physicians from working to their fullest capacity. The unnecessary requirements in numerous states for physicians to sign orders for physical therapy or other referrals, supervise NPs, or sign off on numerous other documents are costly, waste precious physician time, and are not feasible in the real health care world.

Millions are now enrolled under the ACA, and many of those are covered through expanded Medicaid plans. NPs are more likely to care for Medicaid patients and to practice in rural areas than physicians. Regulations that support a patient's access to NPs are essential to fully meet this new demand.

Looking at this data, you might ask "How will 42 more primary care physicians 'supervise' the 832 new NPs?" The answer, in general, is that they don't have to. The literature is replete with studies about the effective quality, safety, and cost of NP care over 40 years. Data from economists Jeffrey Traczynski and Victoria Udalova report that in states with less restrictive NP regulations, emergency room visits decrease for ambulatory sensitive conditions; access increases; and health outcomes improve.

Currently 21 states and the District of Columbia allow NPs to practice fully under their own licenses without unnecessary requirements for supervision. Numerous other states have legislation pending, but with strong physician guild resistance. It is time to remove barriers and support a collaborative dialogue about the needed changes in the U.S. primary care health system. If we can embrace models to promote strong patient- and family-centered care, we can move away from restrictive regulations and a silo approach to workforce development.

We hope that in the not-so-distant future we will report on the collective increases in primary care health workforce numbers and no longer need to compare physician vs. nurse practitioner data. We can work together to attract and retain sufficient numbers of all providers – providers who experience the joy of practice and work together in teams whenever possible, while also better meeting the needs of patients with quality care, improving the health of populations, and reducing costs.