The number of nurse practitioners (NPs) in the United States more than doubled in recent years amid an expansion of online training programs, according to a study published online February 3 in Health Affairs. The new data may play into a brewing policy battle in Washington about how Medicare pays NPs.
The field of NPs had experienced "an unprecedented rate of growth for a major profession," write David I. Auerbach, PhD, and Peter I. Buerhaus, PhD, both of Montana State University, and Douglas O. Staiger, PhD, of Dartmouth College.
The number of NPs in the United States reached 190,000 in 2017 compared with approximately 91,000 in 2010. That increase far outpaced the growth for other medical specialties in the same period, according to the authors. The number of registered nurses (RNs) who were not advanced practice RNs (APRNs) rose by 22% during the same period, increasing from about 2.5 million to about 3 million. Meanwhile, the number of physicians rose just 9%, from about 870,000 to 950,000.
The expansion of the NP workforce is certain to have significant implications for medical care in the United States, especially given ongoing concern about a physician shortage, the authors note.
"Most obvious and direct is that more care will be provided by NPs," write Auerbach and colleagues. "There are projected to be two NPs for every five physicians in 2030, compared to less than one NP per five physicians in 2016."
The authors note that their estimate is significantly lower than the 240,000 licensed NPs reported in 2017 by the American Association of Nurse Practitioners.
However, Auerbach and colleagues used data from the Census Bureau's American Community Survey data, which draws on self-reported data.
Thus, the discrepancy may be due to a substantial portion of NPs who are not currently working or are employed in positions they would not characterize as NP, the authors write.
Hospitals remain the major employer for NPs, but there has been more rapid growth in other settings, according to Auerbach and colleagues.
Specifically, 74,642 NPs were employed by hospitals in 2017, a 116% increase from the 34,616 reported in 2010. During the same period, the number of NPs working in physician offices rose by 124%, from 21,844 to 48,942, and the number working in outpatient care centers rose by 142%, from 13,612 to 32,967.
This reflects a shift in the field, with nurses serving in a wide array of roles and medical specialties, said Brooke Trainum, JD, assistant director for policy and regulatory advocacy at the American Nurses Association (ANA).
"There are RNs who may never work in a hospital," Trainum told Medscape Medical News in an interview.
NPs today work across fields and are not clustered in primary care, said Gary LeRoy, MD, president of the American Academy of Family Physicians, in an interview.
"They are in virtually every specialty of medicine," he said.
LeRoy said that, while NPs are valuable members of medical teams, there is a need to recognize what physicians' extra years of training and study bring to patients. "As talented as many of our nurse practitioners are, they are not interchangeable with doctors," LeRoy said. "They are part of a team, a team that needs to be led by a knowledgeable physician who sees the big picture."
LeRoy said that one surprising result from the new study is how many NPs relied on online training to earn their credentials.
In the last 15 years, many NP training programs have adopted distance learning and online formats, Auerbach and colleagues write. Overall 175 of the 376 NP education programs are offered mostly online, according to data from the American Association of Colleges of Nursing. In many cases, nurses start these programs immediately or very shortly after they've completed their initial RN education.
"That was stunning to me," LeRoy said. "How can you learn to be a clinician by going online? It's a people-driven, relationship-driven profession."
Marion E. Mass, MD, cofounder of Practicing Physicians of America, earlier raised concerns about the changes in NP training in comments to the Centers for Medicare and Medicaid Services (CMS) last fall.
In an interview with Medscape Medical News, Mass also stressed that NPs are valuable members of medical teams. But she also said there is a "dangerous experiment" underway in medicine, citing a decline in clinical experience and easing of oversight.
"Almost half of states already allow NPs to work without physician supervision and more may follow in adopting this experimental approach," she said. "If nothing else, patients deserve the right to know the training of anyone caring for them."
In the past, nurses often had 5, 10, or even more years of clinical practice before seeing patients independently, she said.
"Now we are seeing new college graduates working full time while doing online programs and 18 months later they are a nurse practitioner," Mass said. "The seasoned nurse practitioners should be every bit as anxious with the impact on patients with this new model as we physicians are, and patients should be alarmed."
Policy Battle in Washington
The expanding role of NPs in caring for senior citizens has already sparked a policy battle in Washington.
Major nursing and physician groups in January reiterated their opposing views to the Trump administration's bid to encourage more independent practice of NPs and physician assistants (PAs).
In an October executive order, President Donald J. Trump said he wanted Medicare to pay physicians, NPs, and PAs "in accordance with the work performed rather than the clinician's occupation."
The executive order serves largely as an outline of the Trump administration's goals, but does not itself change policy. It instead sets 1-year deadlines for the US Department of Health and Human Services (HHS) to issue proposals on Medicare's payments and rules for NPs and PAs.
The question remains whether HHS will carry through on Trump's directive.
ANA has urged HHS to do so. "Medicare rules now subject APRNs, including NPs, to a variety of practice restrictions even when state laws do not impose such rules," wrote Ernest Grant, PhD, RN, president of ANA, in a January 17 letter to CMS.
Grant wrote that the changes Trump seeks would "improve patient satisfaction and health outcomes" by giving people enrolled in Medicare more access to clinicians.
However, physician groups urged CMS to reject the bid to allow more latitude for independent work by APRNs and PAs.
"While all health care professionals share an important role in providing care to patients, their skills are not interchangeable with those of a fully trained physician, and this is especially true in family medicine and primary care," wrote John S. Cullen, MD, chairman of the American Academy of Family Physicians' board, in a January 14 letter.
"APRNs and PAs should never independently deliver care without supervision from a physician."
