Why Nurse Practitioners Are No Longer Primary Care Solutions

Robert C. Bowman, M.D.    rcbowman@atsu.edu

Nurse practitioners have contributed to primary care. Nurse practitioners will still contribute to primary care. There is nothing wrong with nurse practitioner primary care quality. But nurse practitioner graduates no longer are solutions for primary care shortages.

To solve massive primary care deficits, a health workforce source must remain in primary care, remain active, deliver 35 years of a health career, and deliver top volume.

 

Solutions for primary care require the following

·         Must remain in primary care at 80% or greater levels – Only one-third of nurse practitioners remain in primary care and the level continues to fall with each class year and each year after graduation. Nursing is 80% hospital, 10% public health, 10% ambulatory and the hospital focus dominates, which is why 6% of NP and increasing is in cardiology and why NP percentages are double the physician percentages in four main IM subspecialty areas and in other specialties such as psychiatry.  –

·         Must have a maximal number of years in a career such as the 35 years from age 30 to age 65 – Nurses complete nursing school at age 31 and nurse practitioner training follows 8 years of nursing experience. The 27 years of a nurse practitioner career represents a loss of 23% of a workforce contribution before starting a primary care career. Extensions of training for graduate degrees, specialty training, and an additional 2 years for nurse doctor training will make primary care contributions worse in more than just the years lost.

·         Must have 80% of graduates active – Nurses, nurse practitioners, and nurse midwives are about  55 – 65% active (your state may have higher due to inmigration for employment with higher percentages active, but nationwide the level is lower). Again with only about 60% active this is a substantial proportion of workforce lost. This is also why the nation will be 1 million short of basic nurses in 2020, the result of insufficient support of nursing, losses of nursing faculty to become nurse practitioners, and students that select nursing school that have 60% activity levels.

·         Must deliver 80% or more of the volume of the most productive primary care forms, family physicians – Nurse practitioners deliver only 50 – 60% of the volume of a family physician. This could be higher, but again nurses are trained to be one on one detailed care givers in hospital settings. The requirements for health access recovery over the next 30 years demand more volume, activity, years, and primary care retention. Nursing leadership clings to the high quality-low volume-high satisfaction approach for nurse practitioners.

·         Must remain in the broad generalist family practice role that multiplies rural, underserved, and all needed health access contributions – Nurse practitioners are leaving the family practice broad generalist role during training, at graduation, and each year after graduation. About 40 – 45% train as family nurse practitioners, but only 20 – 25% of nurse practitioners remain in this broad generalist family practice role.

Family physicians are permanent primary care sources that remain in primary care at 90 – 95% levels, remain 35 or more years in a career, remain active at 85% levels, and deliver the top volume of primary care of any source. This results in fewer family physicians to deliver the same primary care workforce compared to flexible primary care sources (IM, NP, PA) that can and do leave primary care during training, in fellowships, at graduation, and each year after graduation.  Departures have been rapid in the past ten years.

The primary care retention woes of physician and non-physician flexible primary care forms are about health policy that determines market forces. These market forces shape movements of the flexible forms to hospital and specialty care. For example the 1998 PA graduates began at over 54% in primary care but are now down to 33%. New 2008 graduates began in primary care at 28% and declines will continue at the same 1 – 2 percentage points found each annual survey for the past decade. The intermittent nurse practitioner surveys confirm the same declines. Nurse practitioner and physician assistant declines for the past 25 years have averaged 2 – 3 percentage points fewer in primary care with each passing year.

 Health policy shapes movements of nurse practitioners and physician assistants to hospital careers, specialty careers, and practice locations in higher income and more urban areas. Training shapes nurse practitioners to hospital careers where 80% of nurses are found. Training locations are also in most urban areas with concentrations of physicians, health resources, and health professionals. These are all factors to concentrate nurse practitioners in medical centers just as physicians and physician assistants are concentrated in these locations.

Standard Primary Care Year Graphic

Rural Standard Primary Care Year Graphic

Basic Health Access Concepts Site, Tables

 

Nurse Practitioner Calculations from Bowman article on the Standard Primary Care Year in Rural and Remote Health

Goolsby, AANP - Nurse practitioner with 22,000 FTE from 39,000 returned surveys in 2004 (not counting missing, probably fewer of the 30% that stayed in hospitals after NP training - overestimate)   see AANP research site if it puts this study back online 

What Are the Primary Care Calculations?

56% baseline or 22000/39000 surveyed by Goolsby and AANP in the 2004 annual survey (note no correction for missing graduates likely to be inactive or in hospital careers not using the NP degree)

15% deduction for women’s health (11%) and geriatrics (4%)

41% for 2004 but 5 years later with declines of 1 – 2 percentage points each year as in the past decade

8% deduction for 2004 to 2009 (with more to come with each passing year after graduation

33% estimate but less than 30% for an entire career for the next 27 years is more likely for NP   37% if you like geriatrics covered, but again facilities vs office based a problem

 

What is the Maximal NP Primary Care Contribution?

Each form of primary care is limited by the characteristics of selection and training

Nurses now graduate at age 31 from nursing school

Nurse practitioners started with 10 years of RN but this is down to 8 years

NP training is 15 – 24 months and getting longer

Nurse doctor training is 2 years – losses from primary care include administrative losses to teach, losses to specialization, and losses directly due to training time – sorry, no primary care benefit from nurse doctors – the nurse practitioner vehicle for primary care is family nurse practitioners that remain in the broad generalist family practice mode, but they are leaving the family practice mode.

Maximum NP Primary Care = 27 years times 60% active times 60% of the volume times 90% primary care retention (if forced to remain)

About 9 Standard Primary Care Years if NPs remained 90% in primary care

Multiplied by 33% in primary care (or higher for those that are inclusive) for  3 – 4 SPC years

Nurse practitioners are not good primary care solutions; however, their lower volume and other areas indicate hospital and specialty advantages, especially in their cost of support, salaries, benefits.

Likely State to State Variations

Hopefully no one is bold enough to claim over 60% in primary care and even this results in a 5.4 SPC year contribution for nurse practitioners or about one-fifth of a family doc

And in the locations with top concentrations of physicians where NPs are found in cardiology, other internal medicine subspecialties and other situations not primary care, the level is 20 – 25% for about 2 - 2.5 SPC years per graduate

These are still much smaller primary care contributions for a lifetime compared to family physicians

The Higher Activity Argument

There really is no higher activity argument as nursing forms are less active – characteristic of nursing

There are states such as Arizona where nurses are imported and do have 80% of nurses active

But these are imported nursing personnel, not native to the state, and moving to a state for employment is common – a bias in activity compared to national data

Constant 60% levels of nursing activity are found in cross sections such as Vermont AHEC studies, with 50% active for nurse midwives

Future production of workforce must consider native state workforce, not importation which is a state policy design issue

Arizona is not a primary care friendly state and NPs who want to be more active can do much better in hospital and specialty careers

Why NP Makes More Sense for Hospital and Specialty Contributions

NP is much lower cost than physician specialists at $300,000 to $600,000 for salary, benefit, and special costs

And NPs deliver decent volume of specialty patients compared to lower volume specialty physicians (women’s health, geriatrics, ER, cardiology)

NP buys and builds market share for specialists and systems as NP specialists in the current policy design, just as in a decade ago when the managed care design used NP as primary care (complete policy reversal and complete change in use of IM, NP, and PA)

Even if an NP begins in primary care, the market forces shaped by policy result in conversion to hospital and specialty care

But the cost savings should be shared with the nation and with patients rather than accumulated by health systems and physician specialists.

 

To Sum Up

Nurse practitioners begin at about age 38 and have 27 years of a career on average with wide age of entry variations and wide ranges of reasons for NP careers that also involve specialty and hospital career preferences

Nurse practitioners give up 27 years as an RN or about 27 X 0.6 active for 16.2 FTE of nursing

They give the nation 3 – 4 Standard Primary Care years worth of primary care in a 27 year career

But there are many difficulties for NP studies that tend to involve the active graduates that are illustrative of the points that nurse practitioners want to make as compared to national contributions relevant to health workforce decisions made by a nation.

Studies fail to consider NPs inactive or significant portions likely to be in hospital careers (which would reduce primary care retention percentages)

Studies have not counted the 15% in administrative careers (4 times other primary care sources) or increases with expansions of training (graduate degree, longer training, nurse doctor training)

Studies have not considered the older age primary care losses likely regarding activity, volume, administrative careers

Nurse practitioner training may cost less but the primary care contribution is low and getting lower with each passing year

A good estimate is that a family practice residency graduate will provide the same primary care contribution of 7 – 10 nurse practitioners

Then there is the consideration of who is served – greatest need areas

Rural – only the NPs that stay in the broad generalist family practice role contribute and NPs are leaving this FP role

Underserved – only the NPs that stay in the FP mode contribute at higher levels in underserved populations

Only FP forms of DO, MD, NP, and PA have 50 – 60% found serving the pop left behind - 65% of the population with only 20 - 30% of physicians (and non-physicians) – leave this FP mode and you leave needed access

Elderly - 2004 Medical Expenditure Panel Study – even with geriatric and adult and Family NPs, equal to family physicians in numbers, FP multiple times more likely to serve the elderly (Ferrer) with 63% seeing a family physician and this was a time period with higher % NP in primary care and in the family practice mode – also this analysis overcounts the NP data because the basic nursing encounters were included in NP services.

From Ferrer – National Surveys - Fraction of US Population That Visited Specific Clinician Types 2004 – Senior Ambulatory using MEPS data 

http://www.annfammed.org/cgi/content/abstract/5/6/492

Family Physicians Compared to Nurse Practitioners with similar numbers in primary care (and twice as many total NP graduates – Ferrer Study in Annals of FM

Family Physicians were 3 times as likely to be seen by age 65 or older for ambulatory care compared to nurse practitioners

Family Physicians were 4 times as likely to be seen by adults for ambulatory care

Family Physicians were 3 times as likely to be seen for women’s health ambulatory care

FM is the top contributor in all of the above

FM second only to PD in pediatric care

Nationwide Studies of CHC Personnel Nationwide Rosenblatt and Hart in JAMA

http://jama.ama-assn.org/cgi/content/abstract/295/9/1042

Family med physicians at 3100 compared to NP at 2100

FM almost the same as RN at 3400

FM the most numerous and the most recruited compared to nurse practitioners even with similar total national graduates

The CHC choices represent a natural experiment in preference for care of the underserved

There were plenty of all types of primary care

Once again, the NP graduates were more numerous with 160,000 compared to FM at 90,000

This natural experiment demonstrated that family physicians were more likely to select CHCs and CHCs were more likely to select family physicians and are still desperate for enough basic nurses and family physicians.

 

Also NP has limitations in high poverty states and in border US counties   http://bhpr.hrsa.gov/healthworkforce/border/default.htm

Nurse practitioner and physician assistant graduates are no more likely to deliver primary care compared to the average medical school graduate at about 3 to 4 SPC years per graduate. Physicians and non-physicians are all leaving primary care at similar rates. Those remaining in primary care in schools, programs, types of graduates, are those remaining in the family practice mode.

Facts Important in Basic Health Access

www.basichealthaccess.org

www.physicianworkforcestudies.org

www.ruralmedicaleducation.org