Care Redesign 2016

Rethinking the Primary Care Workforce — An Expanded Role for Nurses

Article · November 28, 2016

Interview with Dr. Thomas Bodenheimer on the evolving roles of physicians and nurses in the provision of primary care.

 

The adult population of the United States will soon have a different primary care experience than we’ve been used to. In the primary care practice of the future, the physician’s role will increasingly be played by nurse practitioners (NPs). In addition, the 150 million adults with one or more chronic conditions will receive some of their care from registered nurses (RNs) functioning as care managers.

Workforce experts agree on the growing gap between the population’s demand for primary care and the number of primary care physicians available to meet that demand. About 8,000 primary care physicians (including doctors of osteopathy and international medical graduates) entered the workforce in 2015, up only slightly from 7,500 in 2005. And in fact, the number of yearly entrants is expected to plateau at around 8,000. But the number of primary care physicians who retire each year is projected to reach 8,500 in 2020 — in other words, the number of retirees may exceed that of new entrants. And the size of the primary care physician workforce will be declining even as the U.S. population grows, ages, and becomes more adequately insured.1

In contrast, the number of NPs entering the workforce each year has mushroomed from 6,600 in 2003 to 18,000 in 2014. The number of primary care NPs is projected to increase by 84% between 2010 and 2025. The number of physician assistants (PAs) entering the workforce is also growing, though not as rapidly. If these trends continue, the proportion of primary care practitioners who are physicians will drop from 71% in 2010 to 60% in 2025 and will continue to decline thereafter. The proportion of practitioners who are NPs will jump from 19% to 29% during those years and will continue to rise.2 In rural communities, this trend is even more pronounced, since NPs are considerably more likely than physicians to settle in rural America.

Clearly, more and more patients will see an NP or a PA as their primary care practitioner. Physicians will probably focus on diagnostic conundrums and lead teams caring for patients with complex health care needs. A large and growing body of research demonstrates that care delivered by NPs is at least as high quality as that delivered by physicians. In addition, patient-satisfaction scores are similar for NPs and physicians.3 Moreover, care may cost less when it’s provided by NPs rather than physicians: Medicare beneficiaries assigned to an NP had primary care costs that were 29% lower and office-visit and inpatient costs that were 11 to 18% lower than those of beneficiaries assigned to a primary care physician.

Even with the increased numbers of NP and PA graduates, the ratio of primary care practitioners to population will decline, because only 50% of NPs and 32% of PAs choose primary care careers. Thus, other professionals will be needed to care for the growing number of U.S. adults with chronic conditions and geriatric syndromes. Enter the enhanced role of the RN.

While the NP role begins to approximate that of the physician, RNs are assuming three important emerging primary care functions: managing the care of patients with chronic disease by helping them with behavior change and adjusting their medications (e.g., for hypertension and diabetes) according to physician-written protocols; leading complex care management teams to help improve care and reduce the cost of care for patients with multiple diagnoses who are high users of health care services; and coordinating care between the primary care home and providers of other health care services — in particular, assisting with transitions among hospital, primary care settings, and home.4

RNs are well on their way to filling the gap. In 2015, a total of 43% of U.S. physicians worked with nurse care managers for patients with chronic conditions. The 3.1 million RNs in the United States represent the country’s largest health profession, and its numbers are projected to grow by an astonishing 33% between 2012 and 2025. Government data show that the number of RN graduates per year has increased from 69,000 in 2001 to 155,000 in 2013 (see graph); a separate analysis put the number of RN graduates at 200,000 in 2014. Thus, primary care practices are likely to benefit from a pool of RNs who could be hired to serve as chronic care managers.

Numbers of Nursing Graduates, 2001-2013

Numbers of Nursing Graduates, 2001-2013. Click To Enlarge.

Several studies indicate that RNs are qualified to perform these enhanced roles. For example, in a randomized, controlled trial, patients with diabetes and elevated blood pressure who received care from RN care managers (including initiation of medications and titration of doses) were more likely to reach their blood-pressure goals than patients whose care was managed by physicians alone.5

Some state boards of registered nursing have created a mechanism by which RNs can change medication doses using standardized procedures authorized by their physician leadership.4 Using these procedures, RNs who’ve been trained as health coaches could provide most of the care for patients with uncomplicated diabetes, hypertension, and hyperlipidemia, thereby adding considerable primary care capacity. And RN coordination of transitions from hospital to home has resulted in improved patient self-management and reduced hospital readmissions.

Although NPs and RNs are increasingly central to primary care, there are still obstacles to their performing these roles that need to be overcome. Physicians report that new NP graduates are not initially comfortable taking responsibility for a panel of patients. To address this problem, intensive 1-year primary care NP residencies are springing up. Thus far, 37 such programs exist. Doctor of Nursing Practice degree programs were designed to supplant master’s level NP programs, but they are growing more slowly than expected.

As for an enhanced role for RNs, one barrier is that public and private insurers rarely pay for RN services, but that barrier is beginning to crumble. Even under the fee-for-service payment model, practices can receive payment for Medicare wellness visits and chronic care management encounters, both of which can be conducted entirely by RNs. As alternative payment models gradually expand, primary care payment will become less visit-based, which will allow practices to reallocate more and more responsibilities to RNs and other team members.

The inadequacy of primary care training in nursing schools presents another obstacle to RNs’ becoming chronic care managers. The focus of nursing education on inpatient care skills has left some primary care RNs unprepared for the care manager role. The American Academy of Ambulatory Care Nursing and nursing leaders are addressing this problem with new curricula and training programs.

Finally, although RNs may be attracted to primary care’s regular work hours, its focus on prevention, and long-term relationships with patients, the fact that salaries are lower in primary care than in hospitals could also be a barrier.

Despite these challenges, the shortage of primary care physicians and the increasing prevalence of chronic diseases are powerful forces pushing primary care toward stronger NP and RN participation. It’s fortunate that the growth in the supply of NPs and RNs enables us to rethink who does what in primary care.


SOURCE INFORMATION

From the Center for Excellence in Primary Care (T.B.) and the School of Nursing (L.B.), University of California, San Francisco, San Francisco.

1. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med 2015;13:107-114. CrossRef | Web of Science | Medline
2. Auerbach DI, Chen PG, Friedberg MW, et al. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff (Millwood) 2013;32:1933-1941. CrossRef | Web of Science | Medline
3. Stanik-Hutt J, Newhouse RP, White KM, et al. The quality and effectiveness of care provided by nurse practitioners. J Nurse Pract 2013;9:492-500. CrossRef | Web of Science
4. Bodenheimer T, Bauer L, Olayiwola JN, Syer S. RN role reimagined: how empowering registered nurses can improve primary care. California Health Care Foundation, 2015 (http://www.chcf.org/publications/2015/08/rn-role-reimagined).
5. Denver EA, Barnard M, Woolfson RG, Earle KA. Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. Diabetes Care 2003;26:2256-2260. CrossRef | Web of Science | Medline

This Perspective article originally appeared in The New England Journal of Medicine.

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