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.
Executive Summary
This
chapter presents an overview of the study
and this report. It includes the following
sections:
- Introduction
- Key
Findings
- Discussion
Introduction
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.
Key
Findings
- 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.
Discussion
The
analyses, interviews, and meetings conducted
as part of this study identify potential
follow-up activities that could be pursued
at some point.
- 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.
- 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.
- 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.
- 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 .
- 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.
- 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.
- 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.
|