The Role of Nurse Practitioners in Health Care Reform

The Affordable Care Act created new health care delivery and payment models that emphasize teamwork, care coordination, value, and prevention: models in which nurses can contribute a great deal of knowledge and skill. Indeed, the nursing profession is making a wide-reaching impact by providing quality, patient-centered, accessible, and affordable care.

– Institute of Medicine ¹

An estimated 27 million Americans have gained health insurance coverage during the past five years thanks to the Affordable Care Act (ACA).² But that, coupled with an aging population and an expansion of preventive care benefits, is putting significant strain on the country’s primary care provider workforce.

Experts agree that the current primary care provider workforce is unable to meet these growing needs. One study estimates that there will be an increase of 15 million to 25 million primary care visits by 2019 by those newly insured under the ACA, requiring between 4,000 and 7,000 additional physicians.³ By 2020, the Health Resources and Services Administration predicts the country will have a shortage of 20,400 primary care physicians.⁴

This is why a growing number of health policy experts are calling upon federal and state governments to substantially expand the role of advanced practice nurses in the primary care setting.^5,6

Advanced practice nurses have completed graduate-level education and have the clinical knowledge and skills to provide direct patient care. They include nurse practitioners (NPs), certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. NP graduation rates continue to rise, with 14,400 primary care NPs graduating in 2014, a nearly 6 percent increase over the previous year.⁷ By 2025, the number of practicing NPs is expected to double from today’s 205,000.^8,9,10 About half of these NPs currently practice in a primary care setting.¹¹

Numerous studies attest to the quality of care nurses provide, finding that NPs prescribe medications and follow clinical care guidelines as well as physicians and are well-suited for providing preventive education and chronic illness care.^12, 13, 6 In 2010, 52 percent of NPs were working as primary care providers, and they are key components of patient-centered care in rural communities. Continuing to deliver high-quality health care means continuing to include NPs as an integral part of the primary care provider workforce.^12, 13, 6

The ACA anticipated the coming provider shortage and included several components designed to strengthen the non-physician primary care workforce, including:¹⁴

Even as schools of nursing graduate record numbers of primary care advanced practice nurses and the need for their services on the front lines of primary care becomes more urgent, significant barriers prevent them from practicing to their full potential.

The greatest barrier is the plethora of scope-of-practice regulations from state licensing boards, Medicaid agencies, and individual hospitals. A 2010 Institute of Medicine report concluded that such regulations have failed to keep pace with the evolution of advanced practice nursing over the past 40 years.¹⁶

A 2012 study from the National Governors Association found significant differences in NP scope of practice requirements among states. Twenty-one states and the District of Columbia¹⁷ grant NPs authority to practice completely independently of physician oversight to the fullest extent of their training, including prescribing medications. Another eight states allow them to practice independently, but not to prescribe medications independently. Some states require additional training before NPs can prescribe independently. Colorado, for example, requires 3,600 hours of provisional prescribing.⁶

Although the ACA defines a primary care provider (PCP) as “a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services,” the law gives the ultimate authority for determining who is a PCP to state licensing and regulatory authorities. “This failure of the ACA to recognize NPs as potential PCPs may lead to decreased opportunities for efficient use of the NP workforce in primary care models,” concluded the authors of an analysis on the impact of federal policies on access to primary care and nurse practitioners.¹⁸

Indeed, if NPs were able to practice to the limits of their training, they could deliver up to 60 percent of office-based primary care.¹⁹

Another barrier to the full use of NPs is reimbursement, with significant limitations on directly reimbursing for NP-provided care. Even in states that mandate direct reimbursement for NP services provided in Medicaid programs, the total reimbursement is often less than that provided for a physician’s services. In addition, the movement to Medicaid-managed care programs is another barrier given that just 33 states and the District of Columbia allow NPs to function as primary care providers. That may change going forward, however, as value-based reimbursement replaces the current fee-for-service system and as team-based care becomes the norm.⁶

The United States is in the midst of a significant shortage⁴ in the provision of primary care, jeopardizing millions of Americans’ access to the most basic health care.²² Greater use of Nurse Practitioners could allay a significant portion of this shortage. While funding for grants and demonstration projects provided in the ACA makes a start toward greater use of NPs, risks to funding and disparate scope of practice regulations throughout the country provide significant barriers to their use.

This post was contributed by Debra Gordon, MS.

^{1. The Institute of Medicine [report]. “Assessing progress on the Institute of Medicine report ‘The future of nursing,’ Washington, D.C.: 2015. Available at: https://www.ncbi.nlm.nih.gov/books/NBK350166/}

^{2. Health and Human Services [press release]. “10 million people expected to have Marketplace coverage at end of 2016.” October 15, 2015. Available at: http://www.hhs.gov/about/news/2015/10/15/10-million-people-expected-have-marketplace-coverage-end-2016.html.}

^{3. Hofer AN, Abraham JM, Moscovice I. “Expansion of coverage under the Patient Protection and –Affordable Care Act and primary care utilization.” The Milbank Quarterly. 2011; 89(1): 69–89.}

^{4. Health Resources and Services Administration. “Projecting the supply and demand for primary care practitioners through 2020.” 2013. Available at: http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/.}

^{5. Green LV, Savin S, Lu Y. “Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication.” Health Affairs (Millwood). 2013;32(1):11–9.}

^{6. National Governors Association. “The role of nurse practitioners in meeting increasing demand for primary care.” 2012.}

^{7. Fang D, Li Y, Arietti R, Trautman DE. “2014–2015 enrollment and graduations in baccalaureate and graduate programs in nursing. American association of colleges of nursing.” Available at: http://c.ymcdn.com/sites/nonpf.site-ym.com/resource/resmgr/Files/NPTables2014-15.pdf}

^{8. American Association of Nurse Practitioners [fact sheet]. Available at: https://www.aanp.org/all-about-nps/np-fact-sheet}

^{9. Auerbach D. “Will the NP workforce grow in the future? New forecasts and implications for healthcare.” Medical Care. 2012;50(7): 606–610.}

^{10. American Association of Colleges of Nursing. “National profile: U.S. nursing education.” 2014. Available at: http://www.aacn.nche.edu/government-affairs/Capacity-Barriers-FS.pdf.}

^{11. Iglehart JK. “Expanding the role of advanced nurse practitioners-risks and rewards.” New England Journal of Medicine. 2012; 368(20): 1935–1941}

^{12. Newhouse P, et al. “Policy implications for optimizing advanced practice registered nurse use nationally.” Policy, Politics & Nursing Practice. 2012:13(2):81–9.}

^{13. Stanik-Hutt J, Newhouse RP, White KM, et al. “The quality and effectiveness of care provided by nurse practitioners.” The Journal for Nurse Practitioners. 2013;9:492–500.}

^{14. The Affordable Care Act. Last update: 2010. Available at: http://www.healthcare.gov/law/timeline/index.html.}

^{15. Quinn WV, Reinhard S, Thornhill L, Reinecke P. “Improving access to high-quality care: Medicare’s program for graduate nurse education.” Insight on the Issues. AARP Public Policy Institute. June 2015.}

^{16. The Institute of Medicine. “The future of nursing: Leading change, advancing health.” Washington, D.C.: 2010. Available at: https://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx}

^{17. American Association of Nurse Practitioners [interactive map]. Available at: https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment}

^{18. Brooks Carthon JM, Barnes H, Sarik DA. “Federal polices influence access to primary care and nurse practitioner workforce.” The Journal for Nurse Practitioners. 2015;11(5):526–530.}

^{19. Cooper RA. “New directions for nurse practitioners and physician assistants in the era of physician shortages.” Academic Medicine. 2007;82(9):827–8.}