This is part of the May 2013 issue of Sharing Nursing's Knowledge.

“National Nurses Week gives us a chance to recognize the contribution of the health care providers at the heart of our health care system.  Every day, nurses provide leadership, innovation and advocacy to meet the health care needs of Americans… The health care law’s emphasis on keeping people healthy, preventing illness, and managing chronic conditions, opens new opportunities for nurses to shape and lead the future delivery of healthcare and capitalizes on the expertise of the nursing profession… Please join me in thanking our nation’s nurses for the critical work they do in bringing better care and better health to all Americans.”
-- Health & Human Services Secretary Kathleen Sebelius, HHS Secretary Kathleen Sebelius on National Nurses Week, HHS.gov, May 6, 2013

“There are just over 180,000 APRNs [Advanced Practice Registered Nurses] in the United States, most of them in primary and long-term care ... extensive research finds they are able to handle 80 percent to 90 percent of primary care cases — and achieve outstanding results. APRNs can handle the vast majority of primary and preventive care needs and leave the more complex cases to physicians. This is a win-win situation, that frees nurses and physicians to spend more time with the patients who need them most. Utilizing APRNs provides the fastest and most cost-effective strategy for meeting the health and health care needs of millions more Americans … Millions of Americans need help maintaining healthy lives or managing chronic conditions. Millions of older people need care in their homes. And millions of soon-to-be-insured patients need a health care provider with the time and training to listen, diagnose and educate. Unleashing the skills of nurse practitioners will improve health care. It is the right thing to do and it is the right time to act.”
-- Sheila Burke, Malcolm Wiener Center for Social Policy, Harvard University, and Future of Nursing: Campaign for Action strategic advisory committee (SAC); and Bill Novelli, McDonough School of Business, Georgetown University, and Future of Nursing: Campaign for Action SAC, Advanced Nurses Lower Costs, Improve Care, Politico, May 6, 2013

In light of concerns about the nation’s shortage of primary care providers—which is likely to be exacerbated as health reform takes effect—many have argued that nurse practitioners (NPs) can help increase capacity. But because state laws about NPs’ scope of practice vary widely, in some places NPs may not be able to help fill the gap and satisfy demand for primary care services.

A new report from the National Institute for Health Care Reform examines the scope-of-practice laws and payment policies that affect how and to what extent NPs can provide primary care. The report examines laws across six states (Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan) that represent a range of restrictiveness. The National Institute for Health Care Reform is a nonprofit, nonpartisan organization that conducts health policy research and analysis.

Rather than spelling out specific tasks NPs can perform, scope-of-practice laws generally determine whether NPs must have physician supervision. Requirements for documented supervision—collaborative agreements—are seen “as a formality that does not stimulate meaningful interaction between NPs and physicians,” according to the report. Collaborative agreements can limit how NPs are used in care settings or prohibit them from acting as the sole care provider, and can limit NPs’ range or number of practice settings, which can have serious consequences for underserved rural communities, the report says.

This is part of the March 2013 issue of Sharing Nursing's Knowledge.

For three years, Congress has failed to fund a federal panel that was created to address a dire shortage of health care professionals—and now the news media is beginning to take note.

The unfunded panel broke through the media silence in January when Politico, an inside-the-Beltway publication that covers Congress and the White House, ran a story about it. In February, the New York Times followed up with its own piece.

Officially called the National Health Care Workforce Commission, the panel was created in 2010 under the health reform law to address concerns over a short supply of health care providers at a time when demand is growing, thanks to the aging population and an influx of newly insured people expected to enter the health care system next year.

A leading nurse researcher, Peter Buerhaus, PhD, RN, FAAN, a professor of nursing at Vanderbilt University, was tapped to chair the commission and 15 members were appointed. But Congress never appropriated funds for it—a phenomenon that was noted at a recent hearing before a U.S. Senate subcommittee.

“It’s a disappointing situation,” Buerhaus told the New York Times. “The nation’s health care work force has many problems that are not being attended to. These problems were apparent before health care reform, and they will be even more pressing after health care reform.”

When insurance coverage expands under health reform next year, dramatically increasing demand for primary care services, approximately 51 million Americans will be living in primary care shortage areas, according to a study published online in Health Affairs. Seven million people will be in hard hit areas, where the expected increase in demand for providers is nearly twice that of other regions (10% greater than their current supply, as compared to 5%).

The researchers predict the states most likely to have dire physician shortages because of increased demand are (in order) Texas, Mississippi, Nevada, Idaho and Oklahoma. They estimate the nation will need an additional 7,200 primary care providers, or 2.5 percent of the current supply.

The researchers “also found that small areas with a greater need for primary care services and providers, although concentrated in certain states, can be found in forty-seven states,” the study says. “The results of this study suggest that promoting and refining policies related to the distribution of primary care providers and community health centers may be as important as policies aimed at increasing the overall supply of primary care providers.”

The study was conducted by Elbert S. Huang (School of Medicine, University of Chicago) and Kenneth Finegold (Division of Health Care Financing Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services).

Read the abstract.
Read a Becker’s Hospital Review article about the study.

A regional analysis of the nursing workforce finds that the South and Midwest have a greater supply of registered nurses (RNs) available to fill positions when nurses retire or leave the workforce than other regions. The study, published in Nursing Economic$, found the South and Midwest have more young nurses to replace fewer older nurses than the Northeast and West.

“Expanding the size of the future RN workforce requires the number of entrants flowing into the workforce to exceed the number of nurses flowing out of the workforce,” the authors write.

In addition to surveying the age structure of the RN workforce, researchers used projection models to predict the nurses per capita in each region through 2030. They predict the South and Midwest will continue to see higher growth of RNs to U.S. residents than the Northeast and West.

The findings can help guide national and state health workforce planners, employers, educators, and others who are developing policies and initiatives to address nursing supply in their states, the study says. States in relatively slower RN growth regions might consider actions to recruit more entrants into the nursing workforce, increase efforts to educate policy-makers about their RN age structure, and examine their nursing education capacity.

The research was conducted by Peter Buerhaus, PhD, RN, FAAN, David Auerbach, PhD, MS, Douglas Staiger, PhD, and Ulrike Muench, PhD, RN.

Read the study.

A report completed this month by the Congressional Research Service (CRS), which conducts analysis for members and committees of Congress, examines how the Affordable Care Act (ACA) will affect the nation’s supply of physicians. In particular, the report focuses on the workforce’s size, composition and geographic distribution.

Size
The health care system cannot work effectively or efficiently without a physician workforce of appropriate size. Too few physicians means delayed care, and too many physicians can mean unnecessary or duplicate care. But measuring the size of the physician workforce—and the future physician population—is challenging, and estimates vary. The CRS report notes that “predicting the timing, content, and effect of policy change is difficult, which adds to the uncertainty of the projections.”

The ACA authorizes funding for additional medical residency training programs through the Health Resources and Services Administration (HRSA) and the ACA’s own Prevention and Public Health Fund. It requires that Medicare-funded residency training slots be redistributed from hospitals that are not using them or that have closed, to hospitals seeking to train additional residents. It also includes provisions designed to increase physician productivity and the volume of physician services available. The law encourages care coordination—in medical homes and accountable care organizations, for example—and expands the non-physician workforce that can augment or substitute for physician services.

Two newly published studies examining different aspects of physician workforce trends suggest that the long-expected shortfall in primary care physicians could be averted or lessened.

A study in Pediatrics finds pediatric residents are more likely to consider primary care or hospital practice––rather than a subspecialty that requires additional training––if they have more educational debt. The researchers found that residents with at least $51,000 in debt were about 50 percent more likely to be planning a primary care or hospitalist career than residents who owed less or no money, Reuters reports. They also found that educational debt rose 34 percent from 2006 to 2010 for pediatric residents.

While an unintended consequence of student loan debt may be that it helps relieve the primary care shortage, another recent study in Health Affairs casts some doubt on the severity of that shortage. Most existing estimates of the primary care physician shortage are based on a simple ratio of one physician for every 2,500 patients, the study says, which does not take into account changing patient demographics and alternative care-delivery methods. The researchers found that the use of health care teams and non-physicians, as well as improved information technology and data-sharing have “the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.”

Read the study in Pediatrics.
Read the study in Health Affairs.

The United States will need 52,000 additional primary care physicians by 2025 to meet demand that is growing due to three trends: population growth, population aging and insurance expansion. That is a key finding from a study published in the November/December issue of the Annals of Family Medicine. The researchers estimate that population growth will account for the majority of the needed increase in primary care doctors.

Given the current number of visits to primary care physicians and an expected population increase of 15.2 percent, the researchers predict that office visits to primary care physicians will increase from 462 million in 2008 to 565 million in 2025. This trend will be especially evident among people 65 and older, a segment of the population that is expected to grow by 60 percent. Population growth will require an additional 33,000 physicians, the study says, and aging another 10,000.

Insurance expansion under the Affordable Care Act will also require additional physicians, the researchers find. Eight thousand physicians will be needed to meet that growth.

The 52,000 additional primary care physicians would represent a 3 percent increase in the workforce.

Read the study.

New data from the Association of American Medical Colleges (AAMC) finds a 3.1 percent increase in the number of students applying to medical school this year. First-time applicants also increased (3.4 percent), which helped bring first-time enrollment at the nation’s medical schools up to an all-time high.

AAMC’s enrollment and applicant data also finds that this year’s entering class of medical students is more diverse than last year. There was an increase in applications and enrollees in all major racial and ethnic groups, and record high numbers for African American and Latino students.

If this year’s trends continue, medical schools are on track to increase total enrollment 30 percent by 2016, AAMC says.

“Medicine continues to be a very attractive career choice for our nation’s best and brightest,” Darrell G. Kirch, MD, AAMC president and CEO, said in a news release. “Given the urgent need our nation has for more doctors to care for our growing and aging population, we are extremely pleased with the continued growth in size and diversity of this year’s entering class of medical students.”

Read the news release.
See the data.

Large population centers like Las Vegas and Detroit are feeling the effects of the nation’s physician shortage, Bloomberg News reports, which is no longer limited to rural areas. Patients in populous urban areas are waiting weeks—or even months—or traveling to find the care they need.

Many factors are contributing to the shortage, including an aging physician workforce that is reaching retirement, and not enough new doctors in the pipeline to replace them and care for an influx of patients with increasingly complex health care needs.

Doctors also tend to stay near where they train, the story reports, creating poor distribution in states like Nevada that don’t have large medical schools or training hospitals. Census Bureau data shows that Nevada has the fifth-lowest ratio of doctors to patients in the country, behind Wyoming, Mississippi, Oklahoma and Idaho.

One possible solution: other health care professionals. “In a bid to address the shortage, the medical community has embraced the greater use of nurse practitioners and physician assistants, who can prescribe medicines and diagnose and treat many illnesses,” the story reports.

What do you think? What steps will convince physicians to practice in underserved areas? Register below to leave a comment.

Read the Bloomberg News story.