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How Healthcare Reform Is Impacting Primary Care


The current primary care provider workforce will not be able to meet the growing demands driven by recent healthcare reforms. What is the solution?

Over the past 5 years, an estimated 27 million Americans have gained health insurance coverage as a result of the Affordable Care Act (ACA). While widespread coverage is good news overall, this trend has had one unfortunate consequence: It has exacerbated our nation’s primary care physician shortage. In fact, the Health Resources and Services Administration predicts that the US will have a shortfall of 20,400 primary care physicians (PCPs) by the year 2020.

It is clear that the current primary care provider workforce will not be able to meet the growing demands driven by recent health care reforms. That is why an increasing number of health policy experts are encouraging state and federal governments to broaden the role of family nurse practitioners (FNPs) and other advanced practice nurses in the primary care setting.

A Growing Emphasis on Nurse Practitioners

In 2012, approximately half of all NPs in the United States were practicing in primary care settings. Since then, NP graduation rates have been steadily rising, with 14,400 primary care NPs graduating in 2014. While the number of practicing NPs is currently at around 205,000, this figure is expected to double by the year 2025.

Nearly 90% of all nurse practitioners are prepared to provide primary care, which includes preventive and chronic illness care. NPs have the advanced education and training to carry out many traditional physician tasks, including writing prescriptions. Moreover, studies show that NPs deliver safe and effective patient care that is on par with care provided by physicians.

In anticipation of the provider shortage, the ACA has implemented a number of initiatives designed to advance the role of NPs in primary care practice. These programs include the Graduate Nurse Education (GNE) demonstration, which was set to provide up to $200 million in funding to 5 hospital systems from 2012 through 2016 to educate and train greater numbers of NPs. The government has also increased funding to allow National Health Services Corps (NHSC) programs to add more NPs.

Obstacles to NP Practice

However, barriers to NP practice continue to prevent these practitioners from achieving their full potential. The most challenging of these is undoubtedly the scope-of-practice regulations established by Medicaid agencies, state licensing boards, and hospitals themselves. A 2012 study found major differences in NP scope-of-practice requirements across US states. In some states, NPs are fully authorized to evaluate, diagnose, and initiate and manage patient treatment. Yet while certain states allow NPs the freedom to work independently of physician oversight, others place tight restrictions on select activities (eg, diagnosing a patient’s condition or prescribing medications).

Another obstacle facing NPs is reimbursement. In many states, the amount of Medicaid reimbursement for NP services is considerably less than those services provided by a physician—up to 25% less. Additionally, a quarter of HMOs do not recognize nurse practitioners as primary care providers, which also impacts coverage.

Looking to the Future

If effectively integrated into the healthcare delivery system, greater use of nurse practitioners could provide much-needed respite in the midst of our dire primary care physician shortage. In this scenario, the percentage of primary care services provided by NPs and physician assistants (PAs) could grow to 28% by 2020.

While the barriers are significant, there are some glimmers of hope on the horizon. More states are working to expand the role of NPs in primary care, including granting full practice authority and improving reimbursement. Currently, 21 states and the District of Columbia allow NPs to practice without a supervision requirement, with similar legislation pending in many other states. Still, there is a long road ahead. We must work collaboratively to break down costly and unnecessary barriers, move away from restrictive regulations, and drive the changes needed to support a healthy future for our primary care system.

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