Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners

Abstract

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008-16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.

Keywords: Nurse Practitioners; Primary Care; Rural Health Care; Team-based Care; Workforce Issues.

EXHIBIT 1

Primary care provider mix in rural and nonrural settings. 2008–16 SOURCE Authors’ analysis of data for 2008–16 from SK&A and the Area Health Resources Files. NOTES Rural location was established using core-based statistical areas from the Office of Management and Budget. Based on analysis-of-variance tests, the following changes in share of providers from 2008 to 2016 were significant: Nurse practitioners (NPs) increased in both rural and nonrural areas (p < 0.001), and physicians decreased in both rural and nonrural areas (p < 0.001).The changes over time in the share of physician assistants (PAs) were nonsignficant in rural areas and small in nonrural areas (p < 0.01).

exhibit 2

Percentages of primary care practices with nurse practitioners (NPs) and average number of NPs in primary care practices in rural and nonrural areas, 2008–16 SOURCE Authors’ analysis of data for 2008–1 6 from SK&A and the Area Health Resources Files. NOTES Rural location was established using core-based statistical areas from the Office of Management and Budget. Based on analysis-of-variance tests, differences in trends over time in the percentages of rural and nonrural practices with NPs and growth over time in the average numbers of NPs in rural and nonrural practices were significant (p < 0.001).

EXHIBIT 3

Percentages of primary care practices with nurse practitioners in rural and nonrural areas, by scope of practice (SOP), 2008–16 SOURCE Authors’ analysis of data for 2008–1 6 from SK&A and the Area Health Resources Files. NOTES Thirteen states that adopted full or reduced SOP (with restricted SOP, explained in the text) during the study period were eliminated from the analyses (see the text for states). Rural location was established using core-based statistical areas from the Office of Management and Budget. differences in trends over time were significant: in rural areas, full SOP versus reduced SOP (p < 0.001); in nonrural areas, full SOP versus reduced SOP (p < 0.05).

EXHIBIT 4

Percentages of primary care practices with nurse practitioners, by state Medicaid expansion status, 2008–16 sources Authors’ analysis of data for 2008–16 from SK&A and the Area Health Resources Files; Advisory Board. Where the states stand on Medicaid expansion (note 30 in text); and the Kaiser Commission on Medicaid and the Uninsured. States getting a jump start on health reform’s Medicaid expansion (note 31 in text). NOTES Medicaid expansion status refers to whether or not a state expanded eligibility for Medicaid through the Affordable Care Act. Rural location was established using core-based statistical areas from the Office of Management and Budget. Differences in trends over time between expansion and non-expansion states were non-significant in rural areas and significant (p < 0.001) in nonrural areas.