Why more NPs, PAs may not save us from the primary care shortage

There's been plenty of worry about the impending primary care shortage, but the solution has always seemed fairly obvious - get more nurse practitioners (NPs) and physician assistants (PAs) delivering routine primary care services while allowing physicians to work at the top of their training.

Except maybe it's not that easy.

A new policy paper from a research group affiliated with the American Academy of Family Physicians (AAFP) suggests that more NPs and PAs may not be ready to step in for primary care physicians to relieve the shortage.

The reason? Just like doctors, NPs and PAs may increasingly be seeking subspecialty careers that come with better pay and less hassle.

Just 43% of the nation's 70,000 PAs, and 52% of the nation's 106,000 NPs practice in primary care, according to data cited by the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

Somewhat similarly, a study earlier this year in the Annals of Family Medicine found that the percentage of PAs working in primary care fell to 31% in 2010 from 51% in 1996.

Unlike that study, he Graham Center's policy paper doesn't address whether the numbers have been trending up or down in recent years, but the researchers suggest that simply depending on more NPs and PAs to assume more primary care duties isn't wise policy. (It's probably fair to note here that the AAFP is generally opposed to expanding NPs' scope of practice.)

"Relying on NPs and PAs to solve the problem of a growing shortage of primary care physicians may not be an option, and policy makers should not abandon policy solutions designed to increase the number of primary care physicians, NPs, and PAs," the researchers write.

Pronouncements like that aren't likely to greeted warmly by some legislators in California, home to what's currently the nation's most high-profile scope-of-practice debate. Earlier this month, the bill's sponsor watered down the legislation pertaining to NPs' scope of practice after it failed to get enough votes in committee.

The latest version of the bill allow NPs to operate independently from physicians only if they practice at a hospital, clinic or other medical facilities. A prior version of the bill would've allowed NPs to operate completely independent of physician oversight after completing 6,420 hours of supervised work.

As is typical in scope-of-practice tussles, the state's most prominent lobbying group for physicians fiercely opposes bill - even the watered-down version, arguing that it could compromise patient safety.

But California is just the tip of the iceberg in the national scope-of-practice debate. Last year 827 scope-of-practice bills were proposed nationwide, with 124 of them passing in 29 states, California Healthline reported. (Some of those bills apply to occupations other than PAs and NPs, such as pharmacists and optometrists.)

While nurses' and physicians' groups are likely to battle over scope of practice across the nation for years to come, each side can certainly agree that they need each other for the often-touted team-based care concept to fully achieve its potential.

“In order for America to realize the promise of team-based care, we all have to come to a better and shared understanding of what it means for medical providers to work together,” AAFP President-Elect Reid Blackwelder, MD, recently said. “As with any team structure, we must define roles. Each team member is critical but they’re not interchangeable.”

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