Research highlights major role of nurse practitioners in rural areas

Primary care is a critical piece of the healthcare puzzle because, for many people, it is the first point of contact with the healthcare system. Primary care is the early line of defense for screenings for major health conditions. Primary care providers also help patients with chronic conditions manage their disease and improve quality of life.

Despite the critical importance of primary care physicians (PCPs), the United States is facing a shortage of those doctors. The number of up-and-coming PCPs is nowhere close to the amount who are late in their careers or retiring. This shortage creates a challenge for some urban and rural areas, where primary care physicians are notoriously harder to recruit.

A key way to combat this shortage is to tap highly skilled nurse practitioners (NPs), who are choosing primary care at a much higher rate than physicians. Of the 248,000 NPs in the country, about 87 percent are trained in primary care and more are in the pipeline.

The University of Delaware's Hilary Barnes, an assistant professor in the College of Health Sciences' School of Nursing, recently published a research article in Health Affairs about primary care's increased reliance in nurse practitioners in rural and nonrural areas. They now account for 1 in 4 medical care providers in practices in rural areas – a 43.2 percent increase overall from 2008 to 2016.

However, legislation in many states does not permit nurse practitioners to fully serve as primary care providers. Barnes is studying state-specific legislation on NP's scope of practice, which vary greatly.

"Some states are very restrictive," Barnes said. "An NP has to maintain written agreements with a physician to practice and prescribe medication. In the most extreme examples, the law states that an NP must talk about every patient with a physician. Or that the physician has to sign for prescriptions."

States with restrictions at the highest level include Pennsylvania. Such regulations are challenging given the dwindling number of physicians in the field, and those rules also greatly undervalue an NPs' ability deliver primary care safely and at a high level, Barnes described.

Barnes also pointed to what she described as "mid-level" states regarding regulation (including New Jersey), which provided additional latitude, but not autonomy for NPs.

"There's an in-between where an NP needs a collaborative agreement to prescribe medication," Barnes said. "The provider can practice independently of a physician, but, without prescriptive authority, you are limited on the services that you can provide to patients."

Barnes said that at the fully autonomous level, such as Delaware, states allow NPs to practice primary care without supervision of a physician. In 2015, UD's STAR Health Sciences Complex played host to the signing of a pair of Senate bills – SB57 and SB101 – that give Delaware advance practice nurses more independence. Through these and similar laws, NPs are nationally certified and can practice independently -; known as full practice authority.

Not surprisingly, states with more modern laws have more NPs providing primary care services to residents.

"In the states with more restrictive laws, say you are a trained NP in a rural area who wants to practice primary care," Barnes said. "Because there is no physician in town, you can't have a collaborative agreement. Therefore, you can't practice at the advanced practice level. Or, say you live in Mansfield, Pennsylvania; you might have to sign a collaborative agreement with a physician in Harrisburg -; a two and half hour drive."

If the physician collaborator moves away or retires, the NP loses the ability to practice. Additionally, more research is needed, but anecdotal evidence suggests that many NPs have to pay physicians to sign a collaborative agreement.

Evidenced-based research has shown that more restrictive laws don't improve patients care.

Barnes added, "In states where the restrictions have been removed, care has not diminished. These restrictive laws don't do anything to improve patient safety or quality of care. All that they are really doing is putting up barriers to primary care. Removing the practice restrictions can really only be a benefit."

States like Pennsylvania are currently evaluating proposed legislation to reduce restrictions, including NPs becoming independent primary care providers after a certain number of hours under a primary care physician.

"These transition-to-practice hours are kind of a compromise," Barnes said. "You are supervised by a physician for two or three years, an arbitrary number, before you can become independent. These laws are new, so we don't have data on whether they are helpful or not. But, on the surface, they seem like another restriction."

Employment of advanced practice clinicians

Barnes and several collaborators recently published a research study in JAMA Internal Medicine entitled "Employment of Advanced Practice Clinicians in Physician Practices." The researchers investigated levels of and changes in advanced practice clinician employment across different physician practices -; comparing 2008 and 2016. Advanced practice clinicians include physician assistants and NPs.

The study paid particular attention to specialty practices, finding that approximately one in four specialty practices employ advanced practice clinicians (compared with one in three primary care practices). Historically, the NP role was developed to focus on primary care; most advanced practice clinicians are NPs. Hence, the expectation is that advanced practice clinicians would have a greater presence in primary care practices. Yet, the proportion of practices with advanced practice clinicians grew modestly over the past eight years.

This sort of shows the growing willingness/interest/importance of NPs to all segments of healthcare delivery – more practices are hiring them and using them to deliver care.

"We concluded that overall growth may be driven by number of factors," Barnes said. "Factors include recent increases in graduates from advanced practice clinician programs, the emergence of value-based purchasing models that incentivize team-based care and downward price pressure from public and private payers, which makes the lower costs of advanced practice clinician employment more attractive."