The Center for Health Affairs. BRIDGING THE GAP: APRNs, PA s & THE PRIMARY CARE PHYSICIAN SHORTAGE. March 2017 Issue Brief

The Center for Health Affairs BRIDGING THE GAP: APRNs, PA s & THE PRIMARY CARE PHYSICIAN SHORTAGE March 2017 Issue Brief

THE CENTER FOR HEALTH AFFAIRS IN THIS ISSUE BRIEF Acknowledgements... 2 What are APRNs and PAs?... 4 Size and Location of the APRN and PA Workforce... 5 Scope of Practice... 9 APRN Scope of Practice... 9 HB 216... 11 Standard Care Arrangement... 11 APRNs in Other States... 12 PA Scope of Practice... 12 Access and Primary Care... 13 Current Physician Need: Health Professional Shortage Areas... 13 Future Physician Supply and Demand Projections... 14 Ohio Primary Care Projections... 15 Addressing the Primary Care Workforce Shortage... 16 Innovative New Strategies... 18 Suggestions for Stakeholders... 19 Endnotes... 20 Want this digitally? amitsch@chanet.org

LISTEN TO THE CENTER S PUBLICATIONS ON SOUNDCLOUD! ACKNOWLEDGEMENTS Directly from The Center s website at healthcare-podcast.com On the free SoundCloud app, follow NEOHospitals WRITTEN BY: Michele Fancher, HCMBA Freelance Health Writer INVALUABLE INSIGHT AND COMMENTS PROVIDED BY: Timothy L. Jarm President and CEO Laura Gronowski, FACHE Chief of Staff Lisa Anderson, MSN, RN Senior Vice President, Member Services Deanna Moore, MPA Vice President, Corporate Communications Pat Cirillo, PhD Vice President of Initiatives and Analytics, Member Services Pam Waite, MSN, RN-BC, MHSA Director of Healthcare Workforce and NEONI Operations Bob Kaliszewski Project Manager, Finance and Reimbursement THANKFUL FOR THOSE WHOSE CONTRIBUTIONS HELPED SHAPED THE FOCUS OF THIS BRIEF: Peter DiPiazza, DNP, BC-FNP Director of Advanced Clinical Practice, Riverside Methodist Hospital Meredith Lahl, MSN, APRN Executive Director / ACNO Advanced Practice Nursing, Cleveland Clinic Josanne K. Pagel, MPAS, PA-C, DFAAPA Executive Director PA Services, Cleveland Clinic Health System; Clinical Assoc. Professor, Case Western Reserve School of Medicine; President, American Academy of Physician Assistants Rebecca Patton, DNP, RN, CNOR, FAAN Lucy Jo Atkinson Scholar in Perioperative Nursing, Frances Payne Bolton School of Nursing Past President, American Nurses Association Jackie Rowles, DNP, MBA, CRNA, DAAPM, FAAN, ANP-BC Associate Professor, Leighton School of Nursing Clinical Instructor, College of Osteopathic Medicine; Director, Nurse Anesthesia Program, Marian University SPECIAL THANKS EXTENDED TO STAFF OF THE CENTER FOR HEALTH AFFAIRS: Julie Cox Director, Marketing Luisa Barone Gantt Digital Marketing Manager Rachel Brown Graphic Design Marketing Coordinator Earnest Law Facilities Assistant Christopher Nortz, CFM Director, Facilities Beverly Cash Receptionist, Facilities 2 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS BRIDGING THE GAP: APRNs, PA s & THE PRIMARY CARE PHYSICIAN SHORTAGE Primary care is a crucial component of the U.S. healthcare system. Successful management of chronic disease as well as effective preventive care are vital to ensuring good outcomes for patients and controlling healthcare spending. While there is a shortage of primary care physicians nationwide that is only expected to grow with time, other clinicians including advanced practice registered nurses and physician assistants are playing an important role in meeting the primary care needs of the population and will continue to do so in the future. This paper provides an overview of the advanced practice registered nurse and physician assistant workforce, delves into the primary care physician shortage, and discusses opportunities that these professionals have to work together to ensure the primary care needs of the population are met into the future. Issue Brief 3

WHAT ARE APRNs AND PAs? Advanced practice registered nurses (APRNs) are registered nurses with additional education and training, usually a master s degree or higher. Following completion of their education, APRNs must pass the national certification exam associated with their area of practice as well as obtain licensure in the state in which they will practice. There are four types of APRNs: certified nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. While nurse practitioners, for example, can work across a wide array of specialties, certified nurse midwives and nurse anesthetists have somewhat more focused roles. Certified nurse midwives (CNMs) provide a range of primary healthcare services to women, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, and newborn care. Certified registered nurse anesthetists (CRNAs) provide anesthesia and anesthesia-related care. 1 CRNAs work in diverse settings, including inpatient and outpatient facilities as well as physician offices and also provide pre- and post-anesthesia care as well as pain management. The differences between nurse practitioners (NPs) and clinical nurse specialists (CNSs) are somewhat more nuanced. Both require a Master of Science in nursing (MSN) and both can work in various types of healthcare settings and with diverse patient populations; however, there are some differences. For example, NPs are often found in the role of providing primary care and many work in private practices, while CNSs are more often found in acute-care settings and are not typically found in primary care roles. While NPs more typically provide direct patient care, CNSs often serve in consultative roles, assisting with complex patients or supporting care coordination or quality initiatives, for example. APRNs & PAs AT A GLANCE APRNs PAs EDUCATION Master of Science in Nursing (MSN) Master of Science TYPE OF PRACTICE Four types: certified nurse practitioner, certified registered nurse anesthetist, clinical nurse specialist, certified nurse midwife Educational foundation in primary care; can specialize later CERTIFICATION & LICENSURE SUPERVISION Certification in area of specialty and licensure in state where practicing Some APRNs can work independently of a physician, depending on their type of practice and state regulations National certification exam and licensure where practicing PAs work under the supervision of a physician Physician assistants (PAs) are educated and trained through medical, rather than nursing, programs, and most complete a Master of Science degree. A broad, generalist medical education prepares PAs to take medical histories, perform physical examinations, order and interpret laboratory tests, diagnose illness, develop and manage treatment plans for their patients, prescribe medications and assist in surgery. While their foundation is in primary care, PAs can specialize following completion of their education. Upon graduating, they are required to pass a national certification exam as well as obtain licensure in the state where they will practice. Physician assistants work closely with and must practice under the supervision of a physician. 2 While many PAs work in primary care, they can be found in a wide array of specialties and settings. 4 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS TRANSITION TO DNP In 2004, the American Association of Colleges of Nursing recommended that by 2015, APRNs be educated at the doctoral level, rather than at the master s level. While there are several pathways to a doctorate for nurses, including a PhD, the Doctorate in Nursing Practice (DNP) is a practice-focused, rather than research-focused, degree. CRNAs have been working toward the implementation of a clinical doctoral level of preparation. In 2007, the American Association of Nurse Anesthetists announced its support for doctoral education for entry into nurse anesthesia practice by 2025. In 2009, the Council on Accreditation of Nurse Anesthesia Educational Programs adopted the requirement that students accepted into an accredited program on Jan. 1, 2022, and thereafter must graduate with doctoral degrees. 3 In the interim, any new CRNA education program seeking accreditation for the first time must now be at the DNP level. SIZE AND LOCATION OF THE APRN AND PA WORKFORCE The ranks of both advanced practice registered nurses and physician assistants are growing. By far, nurse practitioners make up the largest component of this workforce. At a national level, according to the U.S. Bureau of Labor Statistics as of May 2015 there were: 136,060 people working as nurse practitioners. 4 39,410 people working as nurse anesthetists. 5 7,430 people working as nurse midwives. 6 98,470 people working as physician assistants. 7 The Bureau of Labor Statistics does not report clinical nurse specialists separately and instead includes CNSs, which make up a relatively small portion of the nursing workforce, in the count of people working as registered nurses. 8 It is important to note, these are counts of people working in these occupations, according to the Bureau s Occupational Employment Statistics, which are survey data based on a population sample. The actual number of people certified or licensed in these occupations may be greater, as some maintain their licenses when they re not in the workforce or when working in other jobs. In Ohio, data from the Bureau of Labor Statistics show that over the last few years, all categories of these practitioners are growing in numbers. The number of nurse practitioners has grown the most, increasing 62 percent from 2012 to 2015, while the ranks for nurse anesthetists grew by 45 percent, physician assistants by 33 percent, and nurse midwives by 18 percent. Issue Brief 5

OHIO APRN & PA WORKFORCE, 2012-2015 7,000 6,000 5,000 4,000 3,000 2,000 1,000-2012 2013 2014 2015 Nurse Anesthetists Nurse Midwives Nurse Practitioners Physician Assistants Source: U.S. Bureau of Labor Statistics, Occupational Employment Statistics An analysis of 2015 Ohio nurse licensure data shows there are over 11,000 working APRNs in the state, with nearly 4,500 of them in the 23-county region of Northeast Ohio. 9 Well over half are nurse practitioners. OHIO & NORTHEAST OHIO WORKING APRNs IN 2015 TOTAL APRNs NPs CNSs CNMs CRNAs OHIO 11,301 7,652 1,219 288 2,142 NORTHEAST OHIO 4,485 2,871 636 102 876 Source: Ohio Board of Nursing Licensure Data 6 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS The Bureau of Labor Statistics uses something called a location quotient to analyze the concentration of professionals among states. The location quotient for each state compares that state s concentration of professionals to the national average. States with quotients greater than one have a higher share of employment than average, while the opposite is true for states with quotients below one. Based on this information, it is evident that the geographic distribution of both NPs and PAs is uneven, with considerable variation among states. When compared to the national average, nurse practitioners are concentrated more highly in a handful of New England states along with New York, Delaware, West Virginia, Kentucky, Tennessee and Mississippi. They re found in especially low concentration in Michigan, Pennsylvania and Illinois, along with California, Nevada, Texas, Oklahoma and Rhode Island. Ohio falls close to the national average. LOCATION QUOTIENT OF NURSE PRACTITIONERS, BY STATE, MAY 2015 WA CA OR NV ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MI IN KY TN OH PA WV VA NC SC NY ME VT NH MA RI CT NJ DE DC MD TX LA MS AL GA AK FL PR HI LOCATION QUOTIENT 0.20-0.40 0.40-0.80 0.80-1.25 1.25-2.50 2.50-3.50 Source: U.S. Bureau of Labor Statistics. https://www.bls.gov/oes/current/oes291171.htm Issue Brief 7

Comparatively, the concentration of physician assistants looks a bit different. There are very few in Mississippi and Alabama, and they are in low concentration in another 13 states, including Ohio. They are in higher-than-average concentration in 17 states plus the District of Columbia. LOCATION QUOTIENT OF PHYSICIAN ASSISTANTS, BY STATE, MAY 2015 WA OR ID MT WY ND SD MN WI MI NY ME VT NH MA RI CA NV UT CO NE KS IA MO IL IN KY OH WV PA VA CT NJ DE DC MD AZ NM OK AR TN NC SC MS AL GA TX LA AK FL PR HI LOCATION QUOTIENT 0.20-0.40 0.40-0.80 0.80-1.25 1.25-2.50 2.50-3.50 Blank areas indicate data not available. Source: U.S. Bureau of Labor Statistics. https://www.bls.gov/oes/current/oes291071.htm 8 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS There a variety of factors that can affect the distribution of these providers among states. Some of these might include the number, location and size of education programs, for example. Scope of practice, which is determined at the state level, can also have an impact. SCOPE OF PRACTICE Scope of practice describes the tasks and responsibilities healthcare practitioners like nurses, physicians and PAs are allowed to perform. There are a variety of factors that determine scope of practice. Professional organizations generally outline what they see as appropriate; educational institutions, along with the organizations that accredit these institutions, also influence scope; credentialing requirements and state regulations include rules and guidelines; and the healthcare facilities that employ these professionals also, through their bylaws, have a hand in determining scope. APRN SCOPE OF PRACTICE The professional organizations representing APRNs have developed scopes of practice that loosely define what these professionals, based on their education and experience, are qualified to do. However, the actual laws and regulations that specify this occur at the state level. All 50 states have enacted nurse practice acts, which are laws intended to oversee and ensure the safe practice of nursing. 10 Although state nurse practice acts vary in their specifics, they all generally cover: 99 Authority, power and composition of a board of nursing. 99 Education program standards. 99 Standards and scope of nursing practice. 99 Types of titles and licenses. 99 Requirements for licensure. 99 Grounds for disciplinary action, other violations and possible remedies. 11 The Nurse Practice Act in Ohio dates back to 1915, and has since been amended and updated numerous times to reflect the evolving practice of nursing. Initially, the governing body for nurses fell under the state medical board, but in the 1940s a separate board of nursing was established. 12 A modification to Ohio s Nurse Practice Act in 2013 included changing the title of advanced practice nurses to advanced practice registered nurses. 13 Issue Brief 9

Under the Ohio Nurse Practice Act: Certified nurse-midwives are authorized to provide, in collaboration with a physician, healthcare to women before, during and after childbirth. They are prevented from delivering complicated births, such as when the baby is in a breech position. Certified registered nurse anesthetists, with the supervision and in the immediate presence of a physician, podiatrist, or dentist, may administer anesthesia as well as provide pre- and post-anesthesia care. Certified nurse practitioners, in collaboration with a physician or podiatrist, may provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness within the nurse's specialty. Clinical nurse specialists, in collaboration with a physician or podiatrist, may provide and manage the care of individuals and groups with complex health problems and provide healthcare services that promote, improve, and manage healthcare within the nurse's specialty. Previously, in order to prescribe medications, certified nurse practitioners, midwives and nurse specialists in Ohio were required to obtain a separate certificate to prescribe. However, Ohio HB 216, which was passed at the end of 2016, eliminated the need for a separate certificate to prescribe. Under the new law, these nurses will be granted the authority to prescribe and furnish most drugs as part of their APRN license. CERTIFICATION Following completion of their education, APRNs must become certified in their area of practice. There are numerous national organizations through which APRNs can earn their certification. Under the state s Nurse Practice Act, the Ohio Board of Nursing has the authority to determine the certifications that qualify nurses for licensure in the state. These include the American Academy of Nurse Practitioners Certification Program, American Midwifery Certification Board, and National Board of Certification and Recertification for Nurse Anesthetists, among others. 14 10 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS HB 216 Ohio House Bill 216, the latest legislative initiative to modify the state s nursing laws, was passed in December 2016 by the General Assembly, signed by Governor Kasich Jan. 4, and becomes effective in April. In addition to eliminating the separate certificate to prescribe as mentioned above, it made numerous other changes. These include: The establishment of an exclusionary drug formulary for APRNs. Rather than specifying the drugs an APRN is permitted to prescribe, as under the previous formulary, an exclusionary formulary will specify the drugs APRNs are not authorized to prescribe. An increase from three to five in the number of APRNs with whom a physician or podiatrist may collaborate at the same time in the prescribing component of an APRN's practice. Allowing an APRN to continue to practice under an existing standard care arrangement without a collaborating physician or podiatrist for a period of up to 120 days if the physician or podiatrist terminates the collaboration. HB 216 also created a new type of licensure. Previously, APRNs maintained a registered nurse license and in addition obtained a certificate of authority to practice as an APRN. HB 216 establishes an APRN license that includes designation as a certified registered nurse anesthetist, clinical nurse specialist, certified nurse midwife, or certified nurse practitioner. STANDARD CARE ARRANGEMENT In order to practice in Ohio, NPs, midwives and nurse specialists are required to have a formal relationship, called a standard care arrangement, with a collaborating physician or podiatrist. A standard care arrangement is a written, formal guide for planning and evaluating a patient's healthcare. It documents how the APRN and physician will work together and includes, for example, the criteria the APRN will follow in determining when the patient should be referred to the collaborating physician, the process for obtaining a consultation with the physician, and the process for resolving disagreements between the APRN and physician regarding patient management. Under Ohio law, the collaborating physician must be continuously available for communication but need not be on site. 15 CRNAs are not required to have this standard care arrangement because, rather than working collaboratively with a physician as do NPs, midwives and nurse specialists, CRNAs in Ohio require direct supervision. This means that when administering anesthesia, a CRNA must be in the immediate presence of a physician, dentist, or podiatrist. 16 APRNs IN THE VA The U.S. Department of Veterans Affairs (VA) announced in December that it will begin allowing three types of APRNs certified nurse practitioners, certified nurse midwives and clinical nurse specialists who are employed by the VA to practice to the full scope of their license regardless of limitations or regulations imposed by state law. There is one exception: VA-employed APRNs will still follow any state restrictions on their authority to prescribe and administer controlled substances. As of July 2016, the VA workforce of roughly 93,500 nurses included approximately 5,769 APRNs. 17 Issue Brief 11

APRNs IN OTHER STATES Given that the specifics of what APRNs are permitted to do under their license are determined at the state level, there is considerable variation among states regarding APRN scope of practice. As of June 2016, about two-thirds of states and the District of Columbia require some sort of collaborative agreement between APRNs and physicians. 18 Specifically looking at the scope of practice for certified nurse practitioners, NPs in the Northwest region of the country generally have the most independence, while those in the Southeast have the least. In the Midwest, this varies. States like Nebraska, North Dakota and Iowa have afforded their NPs more independence whereas Michigan NPs are among the least independent. Ohio is somewhere in the middle. 19 Ohio is one of 18 states that require some sort of collaborative agreement with a physician for an NP to diagnose and treat patients and it is one of 27 states that do not allow NPs to prescribe independently, without a collaborative agreement with a physician. 20 PA SCOPE OF PRACTICE Many of the first state laws for physician assistants passed in the 1970s were simple amendments to the medical practice act that allowed a physician to delegate to a PA patient care tasks that were within the physician s scope of practice. These were followed by more stringent regulatory lists of tasks in some states, but these detailed methods of regulation proved impractical and unnecessary. Although there is still some variation in state law, the majority of states have abandoned the concept that a medical board or other regulatory agency should make decisions about scope of practice details for individual PAs. Most states now allow the details of each PA s scope of practice to be decided at the practice level. 21 PA SCOPE OF PRACTICE IN THE 50 STATES PLUS THE DISTRICT OF COLUMBIA, AS OF JULY 2015 WHAT DO STATES ALLOW? WHAT DOES THIS MEAN? WHAT S HAPPENING IN OHIO? PAs in 42 states have full prescriptive authority. Scope of practice is determined on site in 34 states. 28 states have adaptable supervision requirements. In these states, PA prescriptive authority is determined at the practice level by the supervising physician. In most of the other nine, the restrictions in state law concern Schedule II drugs, which are controlled substances, like opioids, that have a high potential for abuse. This means the supervising physician and PA jointly establish a written agreement outlining the PA's scope of practice. In these states, the specifics regarding physician supervision of PAs are determined at the practice level. In the other states, this is determined by state law. Ohio PAs have full prescriptive authority. In Ohio, scope of practice is not determined on site. State law lists the specific services PAs can provide. Ohio is one of 23 states that does not have adaptable supervision requirements. Co-sign requirements are determined at the practice level, rather than by state law, in 26 states. These requirements refer to what the supervising physician is required to sign off on. In Ohio, co-signing requirements are determined at the practice level. The maximum number of PAs a physician can supervise at one time is not limited in 40 states. While in these states the number is unlimited, the remaining 11 do have limits, ranging from two to six. An Ohio physician is limited to supervising up to four PAs at one time. Source: The Henry J. Kaiser Family Foundation. State Health Facts: Physician Assistant Scope of Practice Laws. 12 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS As with APRNs, healthcare facilities, like hospitals, nursing homes, surgical centers and others, have a role in determining the scope of practice for PAs in their institutions. In order to provide patient care services within an institution, PAs request clinical privileges, which must be approved by the medical staff, and ultimately, the institution s governing body. This process defines a scope of practice that each individual is qualified to provide within that organization. Institutions assess PA requests for privileges just as they do for physicians, including verification of professional credentials and documentation of additional relevant training, experience and skills. 22 It is worth noting, however, that there are some hospitals that operate under a different model, in which physicians and physician assistants are more like employees of the hospital, rather than independent practitioners with privileges. ACCESS AND PRIMARY CARE One of the important roles of APRNs and PAs in the nation s healthcare system is their ability to improve access to care, especially in places where access to physicians is limited. Certified nurse midwives and nurse anesthetists, for example, can alleviate access problems in rural areas, where there may an absence or shortage of physician gynecologists or anesthesiologists. One of the most significant areas where APRNs and PAs are improving access is in the area of primary care. With documented primary care shortages in many areas of the country, and with predictions that access to primary care physicians is only expected to get more difficult in the future, nurse practitioners and physician assistants can fill a vital need. CURRENT PHYSICIAN NEED: HEALTH PROFESSIONAL SHORTAGE AREAS One way of understanding unmet needs with respect to primary care is through the federally designated Health Professional Shortage Areas (HPSA). The HPSA designation is used to identify geographic areas and population groups within the United States that are experiencing a shortage of health professionals. There are three categories of HPSA designation based on the health discipline experiencing a shortage: PRIMARY MEDICAL DENTAL MENTAL HEALTH The principal factor used to determine an HPSA designation is the number of health professionals relative to the population. Federal regulations stipulate that, in order to be considered as having a shortage of providers, an area s ratio of population to providers must be above a certain threshold. For primary medical care, the population-to-provider ratio must be at least 3,500 to 1 (3,000 to 1 if there are unusually high needs in the community). 23 Across the United States, there are 6,626 designated primary care HPSAs. A total of 9,376 additional practitioners are needed to remove these HPSA designations. 24 Ohio has 141 HPSAs and would require 145 practitioners to fill the unmet need. In terms of the percent of total primary care need that is being met, Ohio is the ninth best. Ohio ranks 21st when it comes to the number of practitioners it needs, meaning that in terms of sheer numbers of practitioners, there are 20 states that need more primary care practitioners than Ohio. With 607, California has the largest number of HPSAs, but at 1,010, Florida needs the most practitioners to eliminate its HPSA designations. 25 Issue Brief 13

U.S. & OHIO PRIMARY CARE PROFESSIONAL SHORTAGE PRIMARY CARE HPSAs PRIMARY CARE PRACTITIONERS NEEDED 6,626 9,376 141 145 FUTURE PHYSICIAN SUPPLY AND DEMAND PROJECTIONS Predicting future workforce supply and demand is, of course, not an exact science. Organizations that perform these projections for physicians analyze factors such as the numbers of medical students who graduate each year and in what specialties, the aging of the physician workforce and retirement rates, and a whole host of demographic factors aimed at estimating how many patients there likely will be in the future and what their healthcare needs will be. Two entities that have performed these projections the Health Resources and Services Administration (HRSA), which is a division of the U.S. Department of Health and Human Services, and the Association of American Medical Colleges (AAMC) have both predicted primary care physician shortages to worsen over the next few years. The latest HRSA report on primary care, released in November 2016, predicts a nationwide shortage of 23,640 full-time equivalent primary care physicians by 2025. This is based on an anticipated growth of 22,880 primary care physicians between 2013, the study s baseline year, and 2025. As a result, the total supply of 239,460 primary care physicians nationwide falls short of the projected demand of 263,100 in 2025. According to HRSA, the growth in demand will largely result from the aging and growth of the U.S. population. 26 PROJECTED 2025 U.S. PRIMARY CARE PHYSICIAN WORKFORCE PRIMARY CARE PHYSICIAN SUPPLY 239,460 PRIMARY CARE PHYSICIAN DEMAND 263,100 PRIMARY CARE PHYSICIAN SHORTAGE 23,640 Source: Health Resources and Services Administration 14 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS These results are consistent with AAMC predictions. That organization s most recent study, published in 2015, also projected significant shortages for both physicians overall, and for primary care. By 2025, the study anticipates a nationwide shortfall of between 46,100 and 90,400 physicians, with projected shortfalls in primary care ranging between 12,500 and 31,100 physicians. The lower ranges of the projected shortfalls reflect the rapid growth in supply of advanced practice clinicians and the increased role these clinicians are playing in patient care delivery. However, even in these scenarios, physician shortages are projected to persist. 27 While there is some uncertainty regarding future healthcare demand, based on the fate of the Affordable Care Act and the rate of insurance among the future population, the AAMC study found that only a portion of the projected demand is attributed to health reform. Expanded medical coverage achieved under the ACA once fully implemented is expected increase demand by about 16,000 to 17,000 physicians over the increased demand resulting from changing demographics. 28 The AAMC study also found that, given the number of nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists graduating each year, if labor force participation patterns remain unchanged, the supply of APRNs will grow more rapidly than is needed to keep pace with growth in demand for services at current APRN staffing levels. This suggests an additional 114,900 APRNs could be available to other areas of the healthcare system, both to expand the level of care currently provided to patients and to help offset shortages of physicians. Similarly, AAMC expects the supply of physician assistants to increase substantially between 2013 and 2025, though additional research is needed to quantify the impact. 29 Study authors point out the physician shortage itself has the potential to limit the degree to which APRNs and PAs can meet demand. All PAs and many APRNs depending on what type of APRN they are and in what state they practice are required to have a supervisory or collaborative arrangement with a physician in order to practice. And in several states the number of APRNs and PAs a physician can supervise is limited. As a result of these factors, the existing physician workforce can only absorb a limited number of APRNs and PAs. While the rapid growth in supply of APRNs and PAs could help reduce the projected magnitude of the physician shortage, the extent to which some specialties, for example, surgery specialties, can continue to absorb more APRNs and PAs given limited physician supply growth is unclear. 30 OHIO PRIMARY CARE PROJECTIONS The national shortage of primary care physicians is not expected to be distributed evenly among the states, according to the HRSA study. In fact, it found substantial variation among states. In Ohio in 2013, the report indicates a supply of 8,170 primary care physicians compared to a need for 8,660, which resulted in a shortage of 490. This is predicted to worsen by 2025, with a shortage of 1,200, based on a predicted supply of 7,990 and demand for 9,190. The HRSA report predicts that the shortage of NPs in 2013 will reverse and become an over-supply in 2025 and the 2013 PA shortage will improve but still leave unmet need. 31 OHIO PRIMARY CARE PRACTITIONER SUPPLY: 2013 & PROJECTED 2025 2013 2025 SUPPLY DEMAND DIFFERENCE SUPPLY DEMAND DIFFERENCE PRIMARY CARE PHYSICIANS 8,170 8,660-490 7,990 9,190-1,200 PRIMARY CARE NURSE PRACTITIONERS 1,960 2,210-250 3,470 2,350 1,120 PRIMARY CARE PHYSICIAN ASSISTANTS 450 1,290-840 810 1,370-560 Source: Health Resources and Services Administration Issue Brief 15

ADDRESSING THE PRIMARY CARE WORKFORCE SHORTAGE There are a variety of factors affecting the mismatch between demand for primary care services and the supply of primary care physicians. Some of these have to do with the patient population, which is demanding more healthcare services due to aging, high incidence of chronic conditions like cardiovascular disease and diabetes, and more patients with comorbidities, meaning they are being treated for more than one illness or disease. Other factors influencing the gap between supply and demand have to do with physician side. Primary care is less lucrative than many other specialties and primary care physicians report high levels of burnout, which are factors that steer medical students away from primary care and toward other specialties. An analysis of primary care physician and NP data reveals that over the last few years, the number of medical school graduates matching with primary care residencies has grown only slightly, from 1,919 in 2012 to 1,965 in 2015. In contrast, in 2012 there were more than 11,700 NP primary care graduates and this grew to 14,400 in 2015. 32 U.S. PRIMARY CARE RESIDENCY MATCHES & NURSE PRACTITIONER PRIMARY CARE GRADUATES: 2013-2015 16,000 14,000 12,000 13,568 14,400 10,000 11,764 8,000 6,000 4,000 2,000-1,919 1,938 1,965 2013 2014 2015 Medical Students Nurse Practitioners Source: Pohl, Joanne, et. al. Primary Care Workforce: The Need To Lower Barriers For Nurse Practitioners And Physicians. Health Affairs Blog. July 1, 2015. 16 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS One study looked at the relationship between a projected primary care shortage and the roles of various primary care practitioners in the healthcare system and found that much of the projected primary care physician shortage could be mitigated with changes to the primary care model and the roles of NPs and PAs. The study examined four scenarios: Maintaining the status quo with respect to primary care delivery; Increasing to 45 percent in 2025 from 15 percent in 2010 the proportion of the nation s primary care that is provided through the medical home model; Increasing to 5 percent in 2025 from 0.5 percent in 2010 the proportion of the nation s primary care provided through nurse-managed health centers; and The combined increase of both medical homes and nurse-managed health centers. 33 71% 60% Because of much stronger expected growth in the numbers of NPs and PAs relative to those of physicians, the share of primary care providers who are physicians is expected to shrink from 71 percent to 60 percent by 2025. 34 That study found that if the status quo were maintained meaning, if the primary care model and roles of practitioners were to remain unchanged there would be in 2025 a projected nationwide shortage of 45,000 primary care physicians (rendering supply 20 percent below demand), a surplus of 34,000 nurse practitioners (a supply 48 percent higher than demand), and a surplus of 4,000 physician assistants (a supply 10 percent higher than demand). However, increased usage of medical homes and nurse-managed health centers, both individually and combined, were predicted to alleviate the primary care physician shortage, as well as decrease the projected surplus of NPs. The PA workforce would also be affected, with increased usage of medical homes contributing to a change from surplus to slight shortage. 35 PROJECTED PRIMARY CARE PRACTITIONER SUPPLY IN 2025 PRIMARY CARE PHYSICIAN SURPLUS / SHORTAGE NURSE PRACTITIONER SURPLUS / SHORTAGE PHYSICIAN ASSISTANT SURPLUS / SHORTAGE STATUS QUO -45,000 34,000 4,000 INCREASED MEDICAL HOME USAGE INCREASED NURSE-MANAGED HEALTH CENTER USAGE INCREASED MEDICAL HOMES & NURSE-MANAGED HEALTH CENTERS -35,000 28,000-3,000-34,000 19,000 6,000-24,000 12,000-1,000 Source: Auerbach, David, et. al. Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage. Health Affairs. November 2013. Issue Brief 17

This study demonstrates the utility of leveraging higher numbers of NPs and PAs to offset a worsening primary care physician shortage. INNOVATIVE NEW STRATEGIES While the value and utility of APRNs and PAs in the healthcare system is well recognized, some in the field have envisioned innovative approaches that go one step further in using all of the various resources in the healthcare system and maybe even some new ones to better meet the demand for primary care, and to do so in ways that can achieve further cost savings. One study suggests that primary care practices could greatly increase their capacity to meet patient demand if they reallocate clinical responsibilities to non-physician team members and even, in some instances, to patients themselves. The study advocates taking a closer look at the tasks involving primary care physicians and identifying which of those could be adequately carried out by other properly trained professionals, such as registered nurses, pharmacists and medical assistants. Tasks involved in assisting patients with chronic conditions, such as helping them engage in behavior change and improve medication adherence, as well as certain activities associated with preventive care could be provided successfully by these other professionals. The study points out, however, that changes in scope of practice would be required to accomplish some of this reorganization, which can be a complicated and contentious process. 36 Yet another study suggests the creation of a new type of health professional a primary care technician that functions similarly to emergency medical technicians (EMTs) and paramedics. Like EMTs and paramedics, these primary care technicians (PCTs) would be trained but through a less costly and timeintensive program than physicians or even APRNs or PAs. PCTs would operate out in the community, either making house calls or through neighborhood storefronts. They would rely heavily on technology, using a tablet computer to access patient medical records and to input diagnostic information, as well as to access the treatment protocols that are determined by an algorithm based on the patient s symptoms. The PCT would be in communication with a supervising physician, who would provide additional guidance and care as necessary. 37 Properly trained and equipped PCTs, the study authors argue, could promote health; treat minor illnesses and injuries; screen for mental health problems; and manage patients with stable chronic diseases, such as diabetes and asthma. In the short term, deploying PCTs in underserved neighborhoods and communities could reduce overuse of emergency departments and decrease preventable hospitalizations. In the long term, timely and consistent management of chronic health problems could delay or forestall their progression to serious disease. Of course, the implementation of this innovative model would first require the development of an education curriculum as well as the supportive technologies PCTs would utilize, and both scope of practice and payment models would require modification. 38 18 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

THE CENTER FOR HEALTH AFFAIRS SUGGESTIONS FOR STAKEHOLDERS As the American population ages, the healthcare system will experience a variety of pressures while working to ensure patients have access to the care they need. Primary care and its ability to achieve good outcomes while saving the healthcare system money, both now and in the long run, through prevention and effective care management is a vital component of the system. Those in a position to lead and affect change, from policymakers to educational institutions to healthcare providers, will need to continue the work of determining the most efficient and effective way to deploy healthcare professionals in order to achieve the ideal balance of reasonable cost, adequate access, and high quality. Healthcare institutions should ensure their bylaws allow APRNs, PAs and other professionals to practice to the full scope of their license. Policymakers in state governments should assess their laws related to scope of practice to ensure unnecessary regulations are not limiting the ability of healthcare practitioners to fully utilize their skills. Many healthcare providers increasingly are using a team approach, where groups of various types of practitioners work together to care for patients. This approach can maximize the efficiency of staff by ensuring each individual is working at the top of their license and allowing team members to take on appropriate tasks and responsibilities. This is a highly effective model that should be implemented as much as possible across the healthcare system. In order to ensure clinicians fully understand their colleagues training and capabilities, educational institutions should work to better integrate education and training of physicians, nurses, APRNs, PAs and others. Allowing these professionals to sit side by side as students would enhance their mutual trust and collaboration as professionals working together. Issue Brief 19

ENDNOTES 1 National Council of State Boards of Nursing. APRNs in the U.S. https://www.ncsbn.org/aprn.htm. Accessed Feb. 7, 2017. 2 American Academy of Physician Assistants. PA Scope of Practice. Last updated: Jan. 2017. https://www.aapa.org/workarea/downloadasset.aspx?id=583 3 American Association of Nurse Anesthetists. Saturday Hearing to Highlight Major Revisions to Accreditation Standards. Convention Daily 2012. http://www.aana.com/conventiondaily2012/pages/draft-standards-hearing.aspx. Accessed Feb. 7, 2017. 4 U.S. Bureau of Labor Statistics. Occupational Employment Statistics, Occupational Employment and Wages, May 2015, 29-1171 Nurse Practitioners. https://www.bls.gov/oes/current/oes291171.htm. Accessed Feb. 7, 2017. 5 U.S. Bureau of Labor Statistics. Occupational Employment Statistics, Occupational Employment and Wages, May 2015, 29-1151 Nurse Anesthetists. https://www.bls.gov/oes/current/oes291151.htm. Accessed Feb. 7, 2017. 6 U.S. Bureau of Labor Statistics. Occupational Employment Statistics, Occupational Employment and Wages, May 2015, 29-1161 Nurse Midwives. https://www.bls.gov/oes/current/oes291161.htm. Accessed Feb. 7, 2017. 7 U.S. Bureau of Labor Statistics. Occupational Employment Statistics, Occupational Employment and Wages, May 2015, 29-1071 Physician Assistants. https://www.bls.gov/oes/current/oes291071.htm. Accessed Feb. 7, 2017. 8 U.S. Bureau of Labor Statistics. Occupational Employment Statistics, Occupational Employment and Wages, May 2015, 29-1141 Registered Nurses. https://www.bls.gov/oes/current/oes291141.htm. Accessed Feb. 7, 2017. 9 The counties included in the Northeast Ohio region are: Ashland; Ashtabula; Carroll; Columbiana; Coshocton; Cuyahoga; Erie; Geauga; Harrison; Holmes; Huron; Jefferson; Lake; Lorain; Mahoning; Medina; Portage; Richland; Stark ; Summit; Trumbull; Tuscarawas; Wayne. 10 National Council of State Boards of Nursing. Nurse Practice Act, Rules & Regulations. https://www.ncsbn.org/nurse-practice-act.htm. Accessed Feb. 7, 2017. 11 Ibid. 12 Ohio Board of Nursing. The First Nurse Practice Act Passes April 27, 1915! http://epubs.democratprinting.com/article/the+first+nurse+practice+act+pa sses+%e2%80%93+april+27,+1915!/2232928/0/article.html. Accessed Feb. 7, 2017. 13 Ibid. 14 Ibid. 15 Ohio Admin. Code 4723-8-04. 16 OhioAPRN.com. COLLABORATION vs. SUPERVISION. http://www.ohioaprn.com/collaboration-vs.-supervision.html. Accessed Feb. 7, 2017. 17 U.S. Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA Grants Full Practice Authority to Advance Practice Registered Nurses. News Release. Dec. 14, 2016. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847. 18 Stokowski, Laura. APRN Prescribing Law: A State-by-State Summary. Medscape Nurses. June 3, 2016. http://www.medscape.com/viewarticle/440315 19 Barton Associates. Nurse Practitioner Scope of Practice Laws: Interactive Nurse Practitioner (NP) Scope of Practice Law Guide. https://www.bartonassociates. com/interactive-tools/nurse-practitioner-scope-of-practice-laws/. Accessed Feb. 7, 2017. 20 The Henry J. Kaiser Family Foundation. State Health Facts: Nurse Practitioner Scope of Practice Laws, as of July 24, 2015. http://kff.org/other/stateindicator/total-nurse-practitioners/?currenttimeframe=0. Accessed Feb. 7, 2017. 21 American Academy of Physician Assistants. PA Scope of Practice. Last updated: Jan. 2017. https://www.aapa.org/workarea/downloadasset.aspx?id=583 22 Ibid. 23 The Henry J. Kaiser Family Foundation. State Health Facts: Primary Care Health Professional Shortage Areas (HPSAs), as of Jan. 1, 2017. http://kff.org/other/ state-indicator/primary-care-health-professional-shortage-areas-hpsas/. Accessed Feb. 7, 2017. 24 Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services. Designated Health Professional Shortage Area Statistics. As of Jan. 1, 2017. Accessed Jan. 30, 2017. 25 The Henry J. Kaiser Family Foundation. State Health Facts: Primary Care Health Professional Shortage Areas (HPSAs)., 26 Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services. State-Level Projections of Supply and Demand for Primary Care Practitioners: 2013-2025. Nov. 2016. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/ projections/primary-care-state-projections2013-2025.pdf 27 Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. March 2015. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf 28 Ibid. 29 Ibid. 30 Ibid. 31 Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services. State-Level Projections of Supply and Demand for Primary Care Practitioners: 2013-2025. 32 Pohl, Joanne, et. al. Primary Care Workforce: The Need To Lower Barriers For Nurse Practitioners And Physicians. Health Affairs Blog. July 1, 2015. http://healthaffairs.org/blog/2015/07/01/primary-care-workforce-the-need-to-lower-barriers-for-nurse-practitioners-and-physicians/ 33 Auerbach, David, et. al. Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage. Health Affairs. November 2013. http://content.healthaffairs.org/content/32/11/1933.full.pdf 34 Ibid. 35 Ibid. 36 Bodenheimer, Thomas and Smith, Mark. Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians. Health Affairs. November 2013. http://content.healthaffairs.org/content/32/11/1881.full.pdf 37 Kellermann, Arthur, et. al. Primary Care Technicians: A Solution To The Primary Care Workforce Gap. Health Affairs. November 2013. http://content.healthaffairs.org/content/32/11/1893.full.pdf 38 Ibid. 20 BRIDGING THE GAP: APRNs, PAs & THE PRIMARY CARE PHYSICIAN SHORTAGE

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