by Peter Buerhaus, PhD, RN, FAAN, January 12, 2015 – Due to a familiar set of forces – fears of physician shortages, an aging population, implementation of health reform delivery and payment systems, expansion of insurance coverage – interest in increasing the supply and the roles of nurse practitioners has grown rapidly. Policy makers, clinicians, the media and those concerned with access and quality all want to know how the primary care delivery system needs to change and what is the optimal size and configuration of the primary care workforce required for the future.

To provide timely data to help answer some of the most pressing policy questions about the contributions of NPs, beginning in 2011 Center for Interdisciplinary Health Workforce Studies (the Center) researchers have been conducting comparative analyses of primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs). These studies have used data from two sources: A 2012 national survey of PCNPs and PCMDs; and, data from national Medicare claims and other administrative data. Below we summarize key findings from two recent analyses of the 2012 national survey. Keep an eye on the Center’s website for forthcoming reports of the studies our research team are conducting using Medicare claims data.

2012 National Survey of Primary Care Nurse Practitioners and Physicians

Our survey research team, led by Dr. Karen Donelan, developed and conducted the National Survey of Primary Care Nurse Practitioners and Physicians to identify and compare PCNPs’ and PCMDs’ perceptions of NP scope of practice, workforce supply, career recommendations, clinical services provided by PCNPs, and to obtain information on the practice characteristics of PCNPs. From November 23, 2011, to April 9, 2012, we conducted a national postal mail survey of 972 clinicians (467 PCNPs and 505 PCMDs). The response rate was 61.2%.

The results of two recent analyses of these survey data are now available on-line in advance of print publication.

The first of these analyses examined the practice characteristics of these two groups of clinicians. Areas assessed include: compensation and billing practices; characteristics of patients treated; PCNPs’ use of their own National Provider Identification (NPI) number to bill services; how PCNPs spend their time; clinical and nonclinical activities performed by both clinicians; and, whether PCNPs have privileges to admit, round on patients, and write orders independently of physicians. Among other findings, results of the study (lead author Peter Buerhaus) show that:

  • PCNPs are not as ethnically diverse as PCMDs and are 5 years older on average than PCMDs
  • PCNPs are more likely than PCMDs to practice in urban and rural areas, provide care in a wider range of community settings, treat Medicaid recipients and other vulnerable populations, are also more likely to accept new Medicaid patients
  • Not only do most PCNPs work with PCMDs, but also the majority of both clinicians believe that increasing the supply of PCNPs will result in greater collaboration and team practice
  • Although PCNPs and PCMDs deliver similar services and spend their time in nearly identical ways, PCNPs work less hours and see fewer patients
  • Only a handful of PCNPs have their salary adjusted for productivity and quality performance
  • PCNPs cite government and local regulations as impeding their capacity to admit and round on patients in hospitals and long-term care facilities and write treatment orders without a physician co-signature.

 

The full study can be found on the website of the journal Nursing Outlook here.

 

Also using data from the 2012 National Survey of Primary Care Nurse Practitioners and Physicians, a second analysis focused on PCNP and PCMD job and career satisfaction and their respective career recommendations. The study can be found on the website of the journal Academic Medicine here. Among other findings, the study (lead author Catherine DesRoches) reported:

  • More than 80% of clinicians in both groups said they believed there is a national shortage of PCMDs. PCMD were significantly less likely than PCNPs to report national shortages of PCNPs: 263 PCPs (52%) versus 364 PCNPs (78%)
  • 56% (282) of PCMDs would recommend their own career, as would 88% (410) of PCNPs. However, both PCMDs and PCNPs were significantly more likely to recommend a career as a PCNP than as a PCMD (66% of PCPs versus 88% of NPs)
  • Majorities of both PCMDs and PCNPs reported being very or somewhat satisfied with their current employment (88% of PCNPs and 83% of PCPs). However, the two groups differed significantly in terms of satisfaction with their careers: 73% of PCNPs reported that they were very satisfied with their career, significantly more than the 46% of PCMDs who reported being very satisfied with their career as a primary care clinician
  • PCNPs and PCPs held different beliefs about the effect of an increased supply of PCNPs. 57% of PCMDs believed that their own income would decrease, compared with 22% of PCNPs who felt this way; and 74% of PCMDs believed that a greater number of PCNPs would lead to their replacement compared with 50% of PCNPs who agreed with this view.

 

For author comments about the study, please see http://www.massgeneral.org/about/pressrelease.aspx?id=1779

 

The above studies were preceded in 2013 by a publication in The New England Journal of Medicine that described other areas assessed by the 2012 National Survey of Primary Care Nurse Practitioners and Physicians. [see: Donelan, K., DesRoches, C., Dittus, R., Buerhaus, P. (May 16, 2013) Perspectives of physicians and nurse practitioners on primary care practice. The New England Journal of Medicine 368(20):1898-1906]. Among other findings, there was wide disagreement between PCNPs and PCMDs over whether physicians provide a higher-quality examination and consultation than do PCNPs during the same type of primary care visit (66% of PCMDs felt that PCMDs provided a higher quality examination) with 75% of PCNPs disagreeing with this view. The two groups of clinicians also disagreed about the role that PCNPs should play in leading clinical practice and in admitting and rounding on patients in hospitals and skilled nursing facilities. PCMDs also expressed reservations about whether the quality of care will be positively affected with further expansions of the PCNP workforce.

 

Studies of Specialty Care NPs and MDs, and of Care Provided by PCNPs and PCMDs to Medicare Beneficiaries Underway  

Center researchers are busy working on other studies aimed at determining the contributions of NPs in the United States. The survey team has just completed the administration of the 2014 National Survey of Specialty Care Nurse Practitioners and Physicians. This survey, among other themes, focuses on care coordination and teamwork among specialty care NPs and physicians working in in trauma, emergency, and intensive care units. Data are now being analyzed, and we look forward to reporting the results of this new survey later in 2015.

Also underway are a series of analyses using national Medicare claims data. Using 2008 claims data, the team has already assessed the number and distribution of PCNPs throughout the US billing for care provided to Medicare beneficiaries. In addition, analysis of the types, quantities, and payments of services provided by PCNPs compared to PCMDs has also been conducted. Using more recent Medicare claims data (2009 and 2010), the team is completing an analysis of the costs of care provided by both clinicians over a 12-month period, and an analysis to decompose the sources of cost differences.

Finally, Center researchers have been funded to acquire the most recent Medicare data and analyze the quality of care provided by these PCNPs and PCMDs among different sub-populations of beneficiaries. As results of these studies are published, we will post key findings on the Center’s website.