High Turnover Among APCs Highlights Need for Better Retention Strategies

About 30% of advanced practice clinicians (APCs) who first billed Medicare between 2010 and 2021 moved practices within 3 years, according to a research letter published today in JAMA Network Open.¹

APCs, who include nurse practitioners, physician assistants, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists, are projected to join the US health care workforce in 5-fold greater numbers than physicians between 2023 and 2033.² Despite the growing literature on the quality and cost-effectiveness of APCs, the researchers noted that job turnover among this population remains underexamined.¹

Because of fewer formal subspecialty training or certification requirements, APCs have lower barriers to job and specialty changes than physicians.³ As their employment increases, the researchers explained that understanding APC job turnover is critical for workforce planning, hiring, and retention.¹

Because of this, they conducted a retrospective cohort study using Medicare Data on Provider Practice and Specialty files to identify APCs who first billed Medicare Part B between 2010 and 2021. The researchers tracked the first month each APC billed Medicare, and every month, assessed whether the clinician began billing under a new tax identification number, indicating a practice change. A time-to-event analysis measured the duration from initial billing to the final billing within the first practice.

The study population consisted of 217,487 APCs who first billed Medicare between 2010 and 2021, comprising132,670 nurse practitioners; 62,491 physician assistants; 15,934 certified registered nurse anesthetists; 5066 certified nurse midwives; and 1236 clinical nurse specialists. The mean (SD) age of APCs was 37.1 (10.0) years, and most (83.0%; n = 180,442) were women.

Among the study population, 26.8% (n = 58,337) moved practices (median [IQR] time to event, 13.0 [6.0-26.0] months), while 73.2% (n = 159,150) did not and were right censored (median time to event, 27.0 [11.0-55.0] months). Compared with nurse practitioners (24.6%; n = 53,502), turnover was highest among certified registered nurse anesthetists (34.9%; n = 75,902) and physician assistants (30.7%; n = 66,768).

Cumulatively, 14.4% (n = 31,218) of APCs moved practices within 1 year of first billing, and 29.8% (n = 64,811) did so within 3 years. Turnover was most common in hospital-based specialties, where 20.7% (n = 45,019) moved within 1 year and 43% (n = 93,519) within 3 years. In contrast, movement was least common in medical subspecialties (14.4% [n = 31,318] at 1 year; 30.2% [n = 65,681] at 3 years) and obstetrics and gynecology (12.1% [n = 26,316] at 1 year; 23.3% [n = 50,674] at 3 years).

Lastly, the researchers acknowledged their study’s limitations, one being that these data are limited to APCs who independently bill Medicare. Also, movement within a tax identification number, like changing specialties within a large multispecialty group, was not captured. Despite these limitations, they expressed confidence in their findings and suggested areas for further research.

“The high turnover rate we observed has significant implications for hiring and training investments made by APCs and medical practices,” the authors concluded. “Further work should investigate practice characteristics, specific tasks, remuneration, and other potential factors associated with practice turnover.”

References

1. Hyman MJ, Litwack K, Qualich SA, Schram AW, Skolarus TA, Modi PK. Turnover among early-career advanced practice clinicians. JAMA Netw Open. 2025;8(5):e258638. doi:10.1001/jamanetworkopen.2025.8638
2. Occupational Outlook Handbook. Bureau of Labor Statistics. 2024. Accessed May 5, 2025. https://www.bls.gov/ooh/
3. Hooker RS, Cawley JF, Leinweber W. Career flexibility of physician assistants and the potential for more primary care. Health Aff (Millwood). 2010;29(5):880-886. doi:10.1377/hlthaff.2009.0884