Pennsylvania Families Increasingly Depend on Nurse Practitioners for Primary Care
A report by the Pennsylvania Coalition of Nurse Practitioners August 2020
Primary Care in Pennsylvania
Robust access to primary care is the foundation of successful health care. For families, it improves health outcomes and quality of life. For policymakers, it increases efficiency and lowers overall costs.
Primary care providers are paramount in an emergency like the COVID-19 pandemic. They serve at the front line, helping patients individually, and helping broader public health efforts to track and stop the spread. Every individual provider has an impact, especially in underserved and rural communities.
Pennsylvania’s primary care workforce is undergoing a major transition. Patients increasingly receive their primary care services from nurse practitioners (NPs) and less so from physicians.
As lawmakers consider legislation to modernize Pennsylvania’s rules for NPs, the Pennsylvania Coalition of Nurse Practitioners (PCNP) reviewed recent data to map the course of this change.
Primary Care Physicians Decrease
In 2015, the Joint State Government Commission issued a serious warning. It called for an additional 1,039 primary care physicians (PCPs) by 2030 – an 11% increase – just to maintain the status quo in primary health care access. Unfortunately despite the warning, the downward trend continued in subsequent years.
PCNP analyzed data from the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services.[i] We looked at county-level data for primary care providers in 2015, 2016 and 2017, the three most recent years that data are available since the JSGC report.
Overall Pennsylvania lost 112 of its primary care physicians (defined as MDs and DOs who practice in family medicine, general practice, internal medicine, or pediatrics). HRSA data show a total of 12,829 physicians in 2017, down 1 percent from the 2015 total.
Thirty-seven of Pennsylvania’s 67 counties saw their primary care physician workforce shrink, including 20 counties with a significant decrease. Another 8 counties experienced no increase.
By percentage, the counties that lost the most primary care physicians from 2015-to-2017 were:
By number, the counties that lost the most primary care physicians were:
Nurse Practitioners Increase
Pennsylvania State Board of Nursing (SBON) records show even more significant growth in the NP profession. According to SBON, Pennsylvania had 11,439 licensed nurse practitioners in 2017, which grew to a total of 15,391 in 2020. In order to draw a clear, apples-to-apples comparison, the animated and static graphics in this report use the same federal data source for physicians and NPs.
According to HRSA data, the number of nurse practitioners in Pennsylvania increased rapidly in recent years, most notably in underserved and rural areas. Overall the state’s NP workforce grew by 22%. The 1,613 new NPs practicing brought Pa.’s 2017 total to 9,045, according to HRSA.
NP care expanded in 57 of 67 Pa. counties. The growth was significant in all of them including 20% increase or higher in 42 counties. The remaining 10 counties saw no change. No Pennsylvania county saw a decrease in NPs.
By percentage, the counties that gained the most nurse practitioners from 2015-to-2017 were:
By number, the counties that gained the most nurse practitioners were:
What the Growth of Nurse Practitioners Means
Either today, or within a year or two, nurse practitioners will outnumber physicians as primary care providers in Pennsylvania. Policymakers should embrace the growth of the nurse practitioner profession as an opportunity to increase access to primary health care.
More than raw numbers, the growth of NPs represents an opportunity to improve access to care for all, including chronically underserved patient groups. Research repeatedly proves that NPs are more likely than physicians to provide primary care to seniors, low-income families, and rural communities.
Nurse practitioners serve seniors.
According to the Journal of the American Geriatrics Society: “NPs are now the largest type of provider delivering residence-based care and NPs provide care over the largest geographical service area.”[ii]
But, according to the Journal of the American Geriatrics Society researcher: “Regulations are hindering the profession’s growth in many states even as demand for in-home care climbs.”
Nurse practitioners serve low-income families.
According to the Journal of the American Medical Association: From 2010 to 2016, the proportion of NPs in low-income communities rose from 19.8 to 41.1 per 100,000 people, while physicians dipped from 52.9 to 52.[iii]
According to a University of Pennsylvania study: 2 in 3 primary care physicians in Pennsylvania are turning away new Medicaid patients. 82% turn away prospective patients who were uninsured.[iv]
Nurse practitioners serve rural patients.
According to the Kaiser Family Foundation: “Primary care NPs are significantly more likely than primary care physicians to practice in urban and rural areas, provide care in a wider range of community settings, and serve a high proportion of uninsured patients and other vulnerable populations.”[v]
According to the Journal of the American Medical Association: From 2010 to 2016, the proportion of NPs in rural communities increased from 25.2 to 41.3 per 100,000 people while the proportion of physicians dropped from 59.5 to 47.8. vi
According to the American Association of Nurse Practitioners and the U.S. Government Accountability Office: Nurse practitioners are twice as likely to practice in rural areas compared to physicians.[vii] [viii]
Despite the proven benefits of NP practice, outdated regulation hampers Pennsylvania’s effort to attract and retain qualified nurse practitioners. This is because every Pennsylvania NP is required to obtain signed documents, called Collaborative Agreements, with two physicians as one of many conditions of licensure. Pennsylvania is one of a shrinking number of states that mandate Collaborative Agreements.
Researchers have disproven the safety benefits used to support these mandates. As the National Academy of Medicine concluded: “What nurse practitioners are able to do once they graduate varies widely for reasons that are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work.” And: “No studies suggest that APRNs are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs.”[ix]
Meanwhile, evidence shows that Pennsylvania’s current mandate harms patients.
Researchers compared states that have Full Practice Authority to those that don’t. They found that Medicare and Medicaid patients experience 50% more unnecessary hospitalizations in states like Pennsylvania without Full Practice Authority compared to states that have it.[x]
Nurse practitioners in states with Full Practice Authority are more likely to practice in rural areas compared to nurse practitioners in states like Pennsylvania without Full Practice Authority.[xi]
In states with Full Practice Authority, NPs see more Medicare patients.[xii]
PCNP and almost every major health care stakeholder group in Pennsylvania has endorsed legislation – Senate Bill 25 – to permanently eliminate the current mandate and move to a modern process for NP licensure. This modern policy, called Full Practice Authority, has been adopted by 23 states including Maryland. Endorsements include The Hospital and Healthsystem Association of Pennsylvania, AARP Pennsylvania, the Pennsylvania Homecare Association and SEIU Healthcare Pennsylvania; free market advocates like the Commonwealth Foundation and Americans for Prosperity; the Pennsylvania Rural Health Association; newspaper editorial boards; and many, many more.
Pennsylvania should fully leverage the primary care workforce of the present. Enacting Full Practice Authority for NPs will increase access to primary health care, especially for those who need it most.
Table: Change in Primary Care Physicians and Nurse Practitioners by Pennsylvania County, 2015 to 2017
[i] Data source: The Area Health Resource File (AHRF) of the Health Resources and Services Administration, 2015, 2016, and 2017. The AHRF does not specifically segment physicians based on their status as a primary care provider. In fact, its definition for primary care physicians is significantly different from the common vernacular: “This practitioner category includes physicians who are providing hospital patient care.” In order to be as expansive as possible, this report includes any physicians (MDs and DOs) who practice in a field that includes primary care: family medicine, general practice, internal medicine, or pediatrics. Likewise, AHRF does not specifically segment nurse practitioners based on their practice environment. According to the American Association of Nurse Practitioners, 89.7% of NPs are certified in an area of primary care.
[ii] Journal of the American Geriatrics Society, “Increasing Role of Nurse Practitioners in House Call Programs,” Dec. 2016.
[iii] Journal of the American Medical Association, “Primary Care Nurse Practitioners and Physicians in Low-Income and Rural Areas, 2010-2016,” Jan. 2019.
[iv] JAMA Internal Medicine, “Primary Care Access for New Patients on the Eve of Health Care Reform,” June 2014.
[v] Kaiser Family Foundation, “Tapping Nurse Practitioners to Meet Rising Demand for Primary Care,” Jan. 2015.
[vi] Journal of the American Medical Association, “Primary Care Nurse Practitioners and Physicians in Low-Income and Rural Areas, 2010-2016,” Jan. 2019.
[vii] AANP 2009-2010 National Sample Survey.
[viii] GAO Primary Care Report, 2008. General Accounting Office Senate Testimony. Retrieved September 6, 2010, from http://www.gao.gov/new.items/d08472t.pdf.
[ix] Academy of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” Oct. 2010.
[x] Nursing Outlook, “Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients,” July 2014.
[xi] Washington, Wyoming, Alaska, Montana, and Idaho Rural Health Research Center, “Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Identifier Data,” April 2012.
[xii] Health Affairs, “States With The Least Restrictive Regulations Experienced The Largest Increase In Patients Seen By Nurse Practitioners,” 2013.