An Advanced Practice Provider (APP) is a licensed healthcare professional who is not a physician but is educated, trained, and authorized to perform many of the same activities as physicians. APPs are increasingly integral to healthcare delivery, and include nurse practitioners (NPs), physician assistants (PAs), certified nurse midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs).
More than two decades ago, in 2002, I had an idea that putting small healthcare clinics inside drug, grocery, and big-box retail outlets that were staffed by APPs would provide consumers with easy access to high-quality, acute/episodic, and preventive care at affordable prices.
In the process of researching the viability of this idea (which turned into RediClinic), I contacted a nurse practitioner at Columbia University’s School of Nursing named Mary Mundinger (DrPH). Dr, Mundinger was one of a number of prominent nurse practitioners and other nursing advocates (including Tine Hansen-Turton, J.D., who joined me and others in co-founding the Convenient Care Association in 2006) who had pioneered independent practice for nurse practitioners in the 90’s – that is, the ability to practice at the top of their licenses without physician supervision.
My meeting with Dr. Mundinger was both pleasant and productive, as she shared an extensive amount of research establishing that the quality of care provided by NPs was comparable to that provided by physicians, particularly in primary care. More than 50 independent studies have now confirmed this conclusion. Here’s how the American Enterprise Institute put it in one of them:
Can NPs provide health care of comparable quality to that provided by primary care physicians? Our studies showed that beneficiaries who received their primary care from NPs consistently received significantly higher-quality care than physicians’ patients in several respects. While beneficiaries treated by physicians received slightly better services in a few realms, the differences were marginal. These results held when vulnerable populations of Medicare beneficiaries were analyzed separately and compared to those cared for by physicians, aligning with the findings of many other studies conducted over the past four decades.
Extensive Education and Training
I thought Dr. Mundinger would be excited by the prospect of a new model based on care delivery by NPs, and she was to some degree. However, she was quick to point out that the limited scope of practice I envisioned for NPs at RediClinic – in order to ensure that patients with routine medical needs could be treated in time periods that were predictably brief – would not allow them to practice at the top of their licenses.
For purposes of this article, I am focusing on NPs and PAs (both Master’s Prepared), and the increased role they could play in increasing access to healthcare and reducing costs if the 23 states that don’t currently allow independent NP practice and the much larger number that don’t allow the PA version of it would change course – particularly in light of the significant and growing shortage of primary care physicians.
However, you can see from the following chart that there are many different kinds of APPs, and that the one thing they share is the significant amount of education (minimum of six years, not including supervised clinical experience) required to achieve their respective licenses.
While there have been some suggestions in the media that the educational institutions that license APPs may not be rigorous enough, there is a multi-level process in place to ensure that graduates are properly prepared.
- Educational institutions must be accredited by recognized national agencies to offer advanced practice provider programs.
- State licensing boards grant licensure based on graduation from accredited programs and passing of national certification exams.
- Certification boards ensure ongoing professional competency through standardized exams and continuing education requirements.
- The U.S. Department of Education recognizes and approves accrediting agencies, such as the Consortium for Advanced Practice Providers (CAPP), to ensure national standards are met in postgraduate training.
Unnecessary and Burdensome Regulations
While acknowledging Dr. Mundinger’s position that NPs should be allowed to practice at the top of their licenses without physician supervision, I found in my home state of Texas (and many other states in which RediClinic subsequently operated) that the regulations governing NP and PA practice were much more of an obstacle to full practice authority than any I had contemplated for RediClinic.
In general, the NP and PA regulations in Texas were unnecessary, costly, and difficult to justify given the state’s well-documented shortage of primary care physicians and the resulting public health issues.
When we launched RediClinic in H-E-B grocery stores in Texas, a physician had to be on site 20% of the time our APPs were practicing, and each of these “oversight physicians” (who had to be paid but did not provide patient care) were only allowed to supervise a maximum of four NPs or PAs.
Over the next few years, we were able to convince regulators to reduce the on-site requirement to 10% and then eliminate it entirely. However, it was a waste of valuable healthcare resources in the interim, and today – more than 20 years later – the physician supervision requirement remains, in spite of extensive evidence that barriers to independent APP practice restrict access to care while doing nothing to improve the quality of it.
And Texas is not alone in unnecessarily restricting the ability of NPs and PAs to practice at the tops of their licenses without physician supervision, which, among other things, adds about $8,000 annually to the cost of NP and PA practices. In a recent ranking by the Convenient Care Association, 27 U.S. states received a grade of “D” or “F” based on their levels of NP, PA, and other APP provider autonomy.
Solving for the Primary Care Shortage
In a national survey by the Mellman Group, 31% of Americans said they had to wait an “unreasonably” long time to get an appointment with a healthcare professional. In Texas, 44% of patients said they had to wait one to two months, and 38% said they had to wait over two months for an appointment.
The main reason for these unacceptably long wait times for primary care, which has been shown to be a key driver of healthcare costs, is that our nation has a significant shortage of primary care physicians, a trend that is projected to worsen over the coming decade.
- In 2024, the Health Resources and Services Administration (HRSA) estimated a shortage of approximately 43,130 primary care physicians.
- The Association of American Medical Colleges (AAMC) projects a national shortage of between 13,500 and 86,000 physicians across all specialties by 2036, with a coincident shortage of 20,200 to 40,400 primary care physicians specifically.
- By 2036, HRSA projects a total shortage of 68,020 primary care physicians if current trends continue.
- Other projections, such as those from the AAMC, estimate the shortfall of primary care physicians in 2036 could range from 20,200 to 40,400.
- Some models predict the shortage could reach as high as 87,150 full-time equivalent (FTE) primary care physicians by 2037, with the problem being especially acute in nonmetropolitan and rural areas.
The increasing supply of NPs and PAs could offset this primary care shortfall if their capabilities were fully utilized. This means finally giving NPs, PAs, and other APPs the ability to practice at the tops of their licenses, without the need for burdensome and unnecessary physician oversight.
None of this is intended to diminish in any way the central role that primary care and other physicians play in our nation’s healthcare delivery system, or to discourage teamwork among physicians and other healthcare professionals. However, there are simply not enough physicians to go around, the shortage is projected to worsen, and we can’t afford to hang onto outmoded and inefficient care delivery models when the APP solution is staring us in the face.
Originally posted on Forbes.com