Health News: Rural health care likely to be provided by nurses

BOZEMAN - New research by Montana State University professor Peter Buerhaus and others has found that nurse practitioners are more likely than medical doctors to practice in rural areas.

The study is published in the January issue of Medical Care, the Journal of the American Public Health Association.

As part of the study, the researchers identified the geographic location of people in the United States who were newly eligible for health insurance coverage under the Affordable Care Act. They also identified the geographic locations of where primary care clinicians practice just before the launch of the insurance expansions in 2014. Finally, the researchers investigated whether geographic accessibility to primary care clinicians differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws that affect nurse practitioners.

The researchers found that people living in the most rural areas of the country had the least geographic access to a primary care clinician (primary care doctors, nurse practitioners and physician assistants). People living in states that were not expanding their Medicaid program were even more likely to experience geographic access problems.

“The most rural areas of the country averaged nearly 357 uninsured people per primary care clinician compared to only 133 uninsured people per clinician in large urban areas,” according to lead study author John Graves, healthcare economist at Vanderbilt University.  He also explained that there were differences across states expanding and not expanding Medicaid as of January 2015.

“The most rural areas of states that were not expanding their Medicaid programs averaged 441 uninsured persons per primary care clinician compared with 193 per clinician in similar areas in states expanding their Medicaid programs,” Graves said.

The researchers found that physicians who provide primary care services made up the largest share of the workforce, but those doctors were more concentrated in urban settings. However, nurse practitioners were relatively more likely to practice in rural areas than in urban areas.

Further, the percentage of individuals with access to primary care differed depending on the state’s scope-of-practice laws, Buerhaus noted.

“For the 17 states that did not restrict scope-of-practice laws governing nurse practitioners at the time of the study, 62 percent of the state’s population had high geographic accessibility to a primary care nurse practitioner,” Buerhaus said. “In contrast, in the 21 states that fully restricted the practice of nurse practitioners, the percent of the population with high accessibility to a primary care clinician decreased considerably.” Montana does not impose restrictions on nurse practitioners.

Despite this finding, Buerhaus added that regardless of a state’s scope of practice laws governing nurse practitioners, about 13 percent of a typical state’s population has low geographic accessibility to primary care clinicians.

“Across the country, there is considerable effort aimed at expanding the capacity of the primary care workforce, in part by removing state-level restrictions placed on nurse practitioners. Our findings suggest that eliminating these restrictions would indeed help increase geographic access to primary care, but this benefit would not occur immediately and would take some period of time. More importantly, even with the removal of restrictive regulations, there will still be between 12 percent and 15 percent of the population that will continue to have low geographic access to primary care,” Buerhaus said.

As a consequence, Buerhaus added, removing restrictions placed on nurse practitioners will not, by itself, guarantee geographic access to primary care for all.

“Other actions, including payment reforms, greater use of tele-health care, innovations in the way care is delivered by organizations and by teams of clinicians and non-clinicians, locating medical schools in rural areas, and exposing physicians and nurses to rural health early in their education, are needed to overcome the persistent problem of inadequate access to primary care,” Buerhaus said.

For the study, the researchers used 2012 U.S. Health Resources and Services Administration data regarding medical doctors, osteopathic doctors and nurse practitioners.

Buerhaus co-authored the research with Graves and Pranita Mishra, Robert Dittus and Ravi Parikh, all of Vanderbilt, and Jennifer Perloff of Brandeis University.

The findings come as implementation of the Affordable Care Act is expected to increase the demand for primary care services due to an expansion of health insurance coverage and because the act requires an increased number of services to be provided at no cost to insured patients.

The researchers noted that these factors, as well as an aging population, “have heightened concerns over clinician workloads and patient access-to-care, and have fueled a longstanding debate over whether the United States faces an acute shortage of primary care physicians.”

Added Graves, “Our findings further suggest that the well-documented trend toward physicians specializing in fields other than in primary care is likely occurring among nurse practitioners as well. This is a significant headwind to efforts to expand primary care system capacity.”

By providing a comprehensive portrait of the primary care workforce in the U.S., the researchers hope to demonstrate that primary care workforce planning could be improved by efforts that recognize where physicians and nurse practitioners tend to locate, Graves said.

“The point is that we can do better in terms of patient accessibility to primary care,” Buerhaus said. “This is not a nurse practitioner versus physician issue. It’s an issue that is driven by the question of how do we best expand access to health care using all available resources?”

Funding for the study was provided by the Robert Wood Johnson Foundation’s State Health Access and Reform Evaluation Program

Buerhaus is working with other researchers on studies examining factors that affect the location of where physicians practice, and on studies of the costs and quality of primary care provided to Medicare beneficiaries by physicians and nurse practitioners.”