In the United States, the 3.1 million registered nurses (RNs) account for the largest health profession, and this is projected to grow by 33% by 2025 (from 2012). Furthermore, a growing gap between the demand for primary care and the number of physicians available to meet that demand is increasingly becoming apparent.
Nurse practitioners (NPs) and RNs are uniquely positioned to assume the role of the primary care physician (PCP) in the future, according to a recent article by Thomas Bodenheimer, MD, Professor, Family Community Medicine, University of California San Francisco (UCSF) School of Medicine, and Laurie Bauer, RN, MSPH, doctoral student, School of Nursing, UCSF (Bodenheimer T, Bauer L. N Engl J Med. 2016;375:1015-1017).
The 150 million American adults who have chronic medical conditions will receive some of their care from RNs who are operating as care managers, Dr Bodenheimer and Ms Bauer suggest.
Nurses as Primary Care Providers
“About 8000 primary care physicians (including doctors of osteopathy and international medical graduates) entered the workforce in 2015, up only slightly from 7500 in 2005….In contrast, the number of NPs entering the workforce each year has mushroomed from 6600 in 2003 to 18,000 in 2014,” the authors said, adding that the number of physician assistants (PAs) entering the workforce is also rising.
If these trends continue, Dr Bodenheimer and Ms Bauer say that the number of PCPs will drop from 71% in 2010 to 60% in 2025, with a continued decline thereafter. Alternatively, the number of primary care providers who are NPs will leap from 19% in 2010 to 29% in 2025, and will continue to rise. This trend is even more prominent in rural communities, because NPs are considerably more likely to settle in rural America than physicians.
In addition to nurses seeing an increasing role as primary care providers, burgeoning research has shown that NPs deliver care that is at least as high quality as that delivered by physicians, and receive satisfaction scores from patients similar to those received by physicians. Having nurses fulfill the role of PCPs also has cost benefits. Primary care costs were 29% lower, and office visit and in-patient costs were 11% to 18% lower, among Medicare beneficiaries who received care from an NP instead of a physician.
Nurses are also poised to fill the gap in demand for primary care. Even with the increasing numbers of graduating NPs and PAs, there will be a decline in the ratio of PCPs to the population, because only 50% of NPs and 32% of PAs are expected to choose primary care careers. According to the authors, nurses are increasingly assuming 3 functions that are key features of primary care:
- A growing number of RNs are today managing the care of patients with chronic diseases, by providing direct support for behavior change and by adjusting their medications for common conditions, such as hypertension and diabetes, using protocols for physicians
- They are leading complex care management teams to improve patient care and help to reduce the cost of care for patients with multiple comorbidities who are known to be high users of healthcare services
- Nurses are now coordinating the care provided to a patient at the primary provider center and the care provided in other institutions or services for the same patient to ensure proper care coordination, by assisting with care transitions related to a hospital, primary care settings, and the patient’s home.
Barriers to Nurses Assuming Roles in Primary Care
Although NPs and RNs are in an ideal position to help fill the increasing gap in primary care, there are obstacles they need to overcome before assuming this role.
Specifically, newly graduated NPs are reportedly uncomfortable taking responsibility for a panel of patients, and public and private insurers rarely pay for services provided by RNs.
However, these challenges are being addressed with the creation of intensive primary care NP residencies, the gradual expansion of alternative payment models that would allow for allocating more responsibilities to RNs, and the implementation of new curricula and training programs for nurses by the American Academy of Ambulatory Care Nursing.
“Despite these challenges, the shortage of primary care physicians and the increasing prevalence of chronic diseases are powerful forces pushing primary care toward stronger NP and RN participation. It’s fortunate that the growth in the supply of NPs and RNs enables us to rethink who does what in primary care,” the authors concluded.