Joanne M. Pohl PhD, ANP-BC, FAAN, FAANP Professor Emerita,

The University of Michigan School of Nursing

Compare NP workforce data with PA and Physician data

Discuss regulatory scope of practice issues Discuss reimbursement issues

Improving Access and Overall Health System Performance

Macrosystems • Policies, regulations,

organizations and environmental forces that support or provide barriers to microsystems – Federal/State regulations – Reimbursement policies – Educational

standards/policies – Accreditation – National boards

Microsystems • People, processes and

practices that interact directly with patients or support patient care at the local level

• Primary care practices • ED • ICU

*Federation of State Medical Boards Data 2012 **Kaiser Foundation: http://kff.org/other/state-indicator/total-nurse-practitioners/ ***AAPAs Vital Statistics 2012 National Commission on Certification of Physician Assistants

AHRQ (2012) . Primary care workforce facts and stats #1, 2. http://www.ahrq.gov/research/pcworkforce.htm

Total (2013 data) Percent primary care

(AHRQ (2012). Primary care workforce facts and stats #2.)

http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html

# Practicing primary care

Physicians (878,194) Federation of State Medical Boards Data

33% 208,807 (2010) 289,804 (2013)

NPs 106,073 180,233 Kaiser Foundation: http://kff.org/other/state-indicator/total-nurse-practitioners/

52% - 66% (AHRQ-AANP)

55,625 (2010) 93,721-108,000 (2013)

PAs 86,500 AAPAs Vital Statistics 2012 National Commission on Certification of Physician Assistants

43.4% 30,402 (2010) 37,541 (2013)

Total 1,144,927 294,834 (2010) 421,070 + (2013)

http://kff.org/other/state-indicator/total-nurse-practitioners/http://kff.org/other/state-indicator/total-nurse-practitioners/http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://kff.org/other/state-indicator/total-nurse-practitioners/http://kff.org/other/state-indicator/total-nurse-practitioners/

Geo-graphy

NP PA Family physicians

Gen Internal Med

General Peds

US Population

Urban 72.2% 75.1% 77.5% 89.8% 91.2% 80%

Large Rural

11.0% 11.7% 11.1% 6.7% 6.2% 10%

Small Rural

7.7% 6.9% 7.2% 2.4% 1.8% 5%

Remote Rural/ Frontier

9.1% 6.3% 4.2% 1.1% 0.8% 5%

http://www.ahrq.gov/research/pcwork3.htmhttp://www.ahrq.gov/research/pcwork3.htm

Only 92 additional U.S. graduates matched to primary care specialties compared to 2012 ◦ Family Medicine match by U.S. medical students: 1,374

(an increase of 39 from 2012) ◦ General Internal Medicine Primary Care matches by U.S.

medical students: 200 (an increase of 14 from 2012). ◦ Primary Care Pediatrics match by U.S. medical students :

30 (an increase of 3 from 2012) ◦ Internal Medicine Pediatrics match by U.S. medical

students: 312 (an increase of 36 from 2012)

Total of 1,916 U.S. medical school graduates matched to primary care residency programs

Including international graduates, 3,715 primary care matches

http://www.nrmp.org/data/resultsanddata2013.pdfhttp://www.nrmp.org/data/resultsanddata2013.pdf

●14,401 graduates from all NP programs in 2012 ●11,936 (82%) prepared in primary

care roles an increase of about 2,000 from

2011 graduates ◦ Enrollment rates continue to

grow ◦ Currently a total of about

180,000 NPs nationally

American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF)(2013). Enrollment & Graduation Annual survey.

Specific Primary Care NP Rates • Family NP: 8,107 • Adult NP: 1,867 • Peds NP: 888 • Gero NP: 81 • Adult/GNP: 398 • Women’s Health: 423

NPs choose and practice in primary care to a larger degree (by %) than either physicians, or PAs U.S. Primary Care Physician numbers are basically stagnant based on 2013 Match data while Primary Care Physicians continue to choose specialty practices over primary care for very complex reasons PAs tend to follow physician practice decisions; although numbers are increasing, fewer PAs are practicing in primary care. ›Need for more accurate workforce data

22 states and DC allow independent practice with some prescriptive limits National State Boards of Nursing https://www.ncsbn.org/2567.htm

•17 states and DC allow NPs to practice fully under their own license (full plenary authority) including prescriptive authority •12 states considered restricted

AANPhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf

•Five states have legislation in process (California, Massachusetts, Michigan, New Jersey, Pennsylvania)

•Substantial evidence to support NPs practicing to their full extent of educational preparation (Macy Foundation Report, IOM reports, National Governors Association Report, )

https://www.ncsbn.org/2567.htmhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttps://www.ncsbn.org/2567.htmhttps://www.ncsbn.org/2567.htm

Green: Full Authority Yellow: Limited Authority Red: Restricted practice

http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf

Education

Certification

Medicaid Reimbursement Rate*

75% 4 States 80% 3 States 83% 1 State 85% 4 States 90% 7 States 92% 1 State (for “some”

services) 95% 1 State 100% Remainder &

DC *http://kff.org/medicaid/state-

indicator/nurse-practitioner-services/#table

Medicare: NPs reimbursed directly at 85% physician rate with collaborative agreement ◦ 100% if billed “incident

to”/under physician

Medicaid: State by state policies ranging from 75%- 100% rate of physicians

Commercial insurers: vary, some using Medicare policy and others at 100%

http://kff.org/medicaid/state-indicator/nurse-practitioner-services/http://kff.org/medicaid/state-indicator/nurse-practitioner-services/http://kff.org/medicaid/state-indicator/nurse-practitioner-services/

About 12,000 NP new graduates per year prepared as primary care providers

Substantial evidence over 40 years that NPs provide quality, cost efficient care, high patient satisfaction

NPs well positioned to be part of the solution to issues of access to primary care

Auerbach, D.I. Will the NP workforce grow in the future? Hew forecasts and implications for healthcare delivery. Medical Care, 50(7), 606-610, 2012. (AHRQ. Primary care workforce facts and stats #2. and #3, 2012. ttp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html a http://www.ahrq.gov/research/pcwork3.htm American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF). Enrollment & Graduation Annual survey., 2013. AANP, 2013: http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf. Cronenwett, L.. & Dzau, V.J. Chairman’s summary of the conference. In Culliton, B., (Ed.), Who will provide primary care and how will they be trained? Durham, NC: Josiah Macy Jr. Foundation, 2010. Iglehart, J.K. Expanding the Role of Advanced Nurse Practitioners--Risks and Rewards. NEJM, 368;20, 1935-1941, 2013. IOM. The Future of Nursing: Leading Change, Advancing Health. National Academies Press, 2011. IOM. Geographic Adjustment in Medicare Payment Phase II: Implications for Access, Quality, and Efficiency. National Academies Press, 2012. National Governors Association. The role of nurse practitioners in meeting increasing demand f or primary care. 2012. http://www.nga.org/cms/home/nga-

center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.html National Residence Match Program, 2013. http://www.nrmp.org/data/resultsanddata2013.pdf. National Council of State Boards of Nursing (NCSBN), Association of Social Work Boards, Federation of State Boards of Physical Therapy, Federation of State

Medical Boards, National Association of Boards of Pharmacy, & National Board for Certification in Occupational Therapy, eds. Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations. Chicago: NCSBN. 2006.

Naylor, M.,D., & Kurtzman, E.T. The role of nurse practitioners in reinventing primary care. Health Affairs, 29 :893-899. doi: 10.1377/hlthaff.2010.0440., 2010.

Newhouse, RP, Stanik-Hutt, J, White, KM, Johantgen, M., Bass, EB., Zangaro G, et al. Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economics, 29, 1-21, 2011.

Pohl, J.M., Hanson, C., Newland, J., Cronenwett, L. Unleashing the full potential of nurse practitioners to deliver primary care and lead health care teams. Health Affairs,29, 900-905, 2010.

Pohl, J.M., Barksdale, D.J. ,Werner, K. Primary Care Nurse Practitioner and Physician Workforce: The Latest Data-Can We Afford to Waste our Workforce? Health Affairs Blog, June 18, 2013. http://healthaffairs.org/blog/author/pohlbarksdalewerner/

Safriet, B.J. Federal options for maximizing the value of advanced practice nurses in providing quality, cost-effective health care. In Institute of Medicine (Ed.), The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press., 2011.

Traczynski, J. & Udalova, V. Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes. Presented at the Fourth Annual Midwest Health Economics Conference, April 4-5, 2013, in Madison, Wisconsin.

References

http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://www.ahrq.gov/research/pcwork3.htmhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.htmlhttp://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.htmlhttp://www.nrmp.org/data/resultsanddata2013.pdfhttp://www.ncbi.nlm.nih.gov/pubmed?term=Zangaro%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22372080http://healthaffairs.org/blog/author/pohlbarksdalewerner/

Role of Nurse Practitioners in Meeting the Nation’s Primary Care Needs�National Health Policy Forum�Reconsidering Scope of Practice�November 15, 2013Presentation Focus�Improving Access and Overall Health System PerformanceIs The Number of Primary Care Providers in U.S. Over 400,000?Geographic Distribution of Health Care Professionals in Primary Care, 2010 �AHRQ (2012). Primary care workforce facts and stats #3. http://www.ahrq.gov/research/pcwork3.htm �2013 Primary Care Workforce Data�2013 Physician Match Data�http://www.nrmp.org/data/resultsanddata2013.pdf��2013 Primary Care Workforce Data�2012 NP Graduation Rates Summary of Data TrendsState Scope of Practice Regulations� https://www.ncsbn.org/2567.htm ; AANP, 2012State by State Regulation�(AANP, 2013: http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf)Scope & Regulation: Macrosystem �Four “Legs” of Regulation� Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations, 2007.Current Reimbursement PolicyNPs Are Part of the Solution to the Critical Primary Care Workforce IssuesReferences