Preface

The numbers of nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs) increased dramatically in the 1990s. As of 2000 there were an estimated 95,000 NPs^[1], 40,000 PAs^[2], and 8,000 CNMs^[3] practicing in the U.S., an increase of about 160 percent from 1992. Over this period the three professions were also becoming more widely accepted by physicians, patients, and the general public as key members of the health care delivery team.

To document the extent to which the three professions experienced increased responsibilities over this period, and were helping to meet the health care needs of underserved populations, the Health Resources and Services Administration (HRSA) commissioned this study of the professional practice of NPs, PAs, and CNMs in the 50 States by the Center for Health Workforce Studies at the School of Public Health at the University at Albany. The study involved the compilation of a variety of data to explore these issues, including statutes and regulations from the 50 States, estimated numbers of practitioners, numbers of education programs and graduates, etc. These data were supplemented by field work and interviews conducted in seven States. This report represents a synthesis of all the components of the study.

The Center for Health Workforce Studies is a not-for-profit research center operating under the auspices of the University at Albany of the State University of New York and Health Research, Incorporated (HRI). The views expressed in this report are those of the authors and do not necessarily represent the views or positions of the State University of New York, the School of Public Health, HRI, HRSA, or the subcontractors.

This chapter presents an overview of the study and this report. It includes the following sections:

• Introduction
• Key Findings
• Discussion

Physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs) play increasingly important roles in the health care system in the U.S.  The three professions now combine to form a group of practitioners that is rapidly approaching 20 percent of the size of the physician workforce. 

Since many of the NPs, PAs, and CNMs are recent graduates of their respective education programs and few are near retirement age, barring a major unexpected reduction in the respective education programs, the supply of new practitioners is almost certain to continue to grow substantially relative to both population and the supply of physicians for the foreseeable future.

A 1994 article on State practice environments of NPs, PAs, and CNMs by Sekscenski et al, concluded that the professional practice of NPs, PAs, and CNMs varies widely across the 50 States, and that favorable practice environments for the three professions are strongly associated with larger supplies of practitioners [1]. This report revisits this situation and

• documents changes in professional practice of the three professions between 1992 and 2000;
• creates new statistical professional practice indices for each of the three professions that more accurately reflect the respective practice environments across the 50 States in 2000;
• examines the nature of the relationship between the three professions, the professional environment in which they operate, and their physician counterparts;
• identifies salient factors that are related to changes in the three professions and their physician counterparts; and
• assesses the extent to which the three professions improved access to care for underserved populations in the 1990s.

The professional practice indices described in this report were designed to quantify the professional practice options, structural identity, and market recognition of the three professions in each of the 50 States. Higher scores on a professional practice index are generally associated with broader sets of tasks, more autonomous practice environments (i.e., less direct oversight by physicians), and greater opportunities to prescribe controlled substances.

No effort was made to develop an index that could be used to compare the professional practice across the three professions. Although there are similarities among the three professions, each has developed independently with different sets of legal, organizational, and clinical parameters, and it would be inappropriate to compare any single index across the three professions.

The study included: a review of the relevant literature, a systematic review of professional practice statutes and regulations in the 50 States, analysis of data on the three professions and related practice and environmental characteristics, field work in seven States (California, Illinois, New York, North Carolina, Ohio, Oregon, and Texas), and interviews and discussions with a wide range of informants and stakeholders.

• The numbers of NPs, PAs, and CNMs increased significantly in virtually every State between 1992 and 2000. The overall increase was 160 percent over this 8 year period.
• The professional practice for all three professions expanded significantly between 1992 and 2000, that is, practitioners in each of the three professions were permitted to perform more procedures and were permitted to work with less direct supervision from physicians in 2000 than they were in 1992.
• None of the 50 States achieved an index score of 100 on the new professional practice indices for any of the three professions in 2000, indicating that even States with the most expansive practice environments have not yet achieved all practice options viewed as 'optimal' by the respective professions.
• While there remain differences in the scope index scores among the 50 States, the variation of the index  scores has declined since 1992, suggesting that the 1990s was a period of 'standardization' or 'convergence' of professional practice across the 50 States for all three of the professions.
• The professional practice indices were significantly positively correlated with the numbers of practitioners per capita for the respective professions in 2000. This suggests that a more positive legal environment for the professions encourages both improved practice options and greater number of practitioners in a State.
• The professional practice indices were significantly positively correlated with managed care penetration in the States in 2000. This suggests that managed care strategies do impact the regulatory environment of NPs, PAs, and CNMs. This is consistent with the significant increases in the numbers of graduates from professional education programs for NPs, PAs, and CNMs in the decade of the 90s, and the continuing success of new graduates in finding employment.
• No other exogenous factor (e.g., aggregate health care expenditures, health insurance rates) was significantly correlated with the new professional practice indices for the three professions in the States. It may be that a study of individual practitioners would reveal additional relationships, but the State-level analysis in this study did not.
• Despite anecdotes about tensions between physicians and the three professions, significant positive correlations between practitioner per capita ratios for NPs, PAs, CNMs, and physicians indicate that States with more physicians per capita also have more NPs, PAs, and CNMs per capita. This is an indication that the three professions supplement or support physicians rather than substitute for or supplant them.
• A critical factor for the three professions related to access to care is the distribution of practitioners. Although the three professions do provide services in areas in which physicians cannot set up viable practices, the penetration of NPs, PAs, and CNMs into shortage areas is often limited by the practice locations of their collaborating physicians.
• Although a majority of new NPs and PAs trained in US entering practice in the 1990s were trained in primary care specialties, many of them entered non-primary care specialties. Many NPs and PAs in specialty practices are assigned tasks generally considered to be 'primary care', e.g., histories and physicals.
• Study informants reported that the attraction of NPs, PAs, and CNMs in different clinical settings and organizations is driven by two key factors: the salary difference between physicians and the three professions, and the ability of the three professions to handle effectively a wide range of clinical tasks. If salaries of the three professions continue to increase relative to those of physicians, the demand for the three professions may fall off. This may be the case for primary care practices as the salaries of primary care physicians in many parts of the U.S. are only slightly higher than those of NPs, PAs, and CNMs.
• Whereas in the early 1990s the major professional practice concerns of NPs were prescriptive authority and legal relations with physicians, the key issue for NPs in recent years has been empanelment by managed care organizations and insurance carriers, that is, the ability to contract with and obtain their own provider numbers for reimbursement from third party payers. This issue is related to both access and visibility. Empanelment provides a major impetus for NPs to seek out patients in traditionally underserved communities and neighborhoods. Empanelment also permits appropriate counting of the services provided by NPs, which now are often reported as being provided by supervising physicians.
• Although the observed increases in both numbers of practitioners and professional practice indices are the basis for prima facie arguments that access to services increased, reliable estimates of the numbers of NPs, PAs, and CNMs practicing in shortage areas are not available in most States. Thus, definitive statistical evidence of improved access for underserved populations is not available. However, qualitative research conducted as part of the field work in this study strongly supported the claim that the three professions do improve access to care for underserved populations.
• The processes by which legal scopes of practice change in the 50 States are far from uniform, but the field work indicates that the following steps are present in most States: practice teams of physicians and one or more of the three professions work out ‘locally acceptable practice arrangements’, often based on local demonstration programs that permit innovative practices; then the practitioners seek changes in professional practice to permit these procedures and arrangements for all practitioners. If access to services is limited, public constituent groups and coalitions (e.g., Primary Care Agencies, advocacy groups) often lobby for changes in professional practice to improve access to needed services. The professional associations for the NPs, PAs, and CNMs also lobby actively for changes in professional practice.
• Reimbursement, i.e., compensation or remuneration for different professional activities and procedures, is critical to the acceptance of different practice and supervision arrangements. There will always be some practitioners who provide pro bono services to underserved populations, but provision of services to broad segments of the population that are underserved will happen only if appropriate compensation is available.

The analyses, interviews, and meetings conducted as part of this study identify potential follow-up activities that could be pursued at some point.

1. Many informants suggested revisiting the professions every 4 or 5 years to track changes in professional practice of NPs, PAs, and CNMs, the growth in the numbers of practitioners, their demographic characteristics, their legal scopes of practice, their practice patterns, and their contributions to care, especially for underserved populations.
2. A pilot study in one or two States to count/estimate the numbers of NPs, PAs, and CNMs who work in Health Professional Shortage Areas and Medically Underserved Areas, and assess their roles in providing care to underserved populations in rural communities, urban neighborhoods, community health centers, and institutions serving special populations would permit a careful assessment of the contributions of the three professions to care for the underserved.
3. Improved financial incentives for NPs, PAs, and CNMs to practice in HPSAs and other shortage areas could significantly improve access to care for underserved populations. Options for these incentives include increased Medicare incentive payments (as with physicians) and educational loan forgiveness/repayment programs.
4. Increased Medicare reimbursement levels for CNMs from 65 percent of physician rate to 85 percent (as is the case for NPs and PAs) would and help to increase access to CNM services for populations with mental and physical disabilities who are insured by Medicare .
5. Evaluation of State programs that permit practice with remote supervision in more non-traditional settings, including schools, nursing homes, home health agencies, and prisons could ultimately improve access to care for the people in these settings, many of whom are underserved.
6. Practitioner data bases for NPs and CNMs comparable to those maintained by PAs and physicians would significantly enhance the possibilities of assessing the practice patterns of the professions and their contributions to access for underserved populations.
7. If managed care organizations were encouraged to empanel properly qualified NPs, PAs, and CNMs, so that they can provide services to their patients with greater professional autonomy, the result would be improved access to services and reduced costs of care. Empanelment would also provide a basis for more accurately counting the services of the three professions, whose services are often now significantly underestimated because they are recorded as being provided by their collaborating physicians.