Nurses, Primary Care & Shortage Designation

HHS Sec. Kathleen Sebelius was at Duke on Monday announcing a program funded by the ACA to train more advanced practice nurses to expand the supply of primary care providers. The role of nurses in primary care figured heavily in the attempts by the negotiated rulemaking committee created by sec 5602 of the ACA to redefine the HPSA and MUA methods that are used to make areas eligible for federal monies designed to ameliorate provider shortages and/or underservice.

The most radical aspect of the proposal that we approved 21-2 is the “counting” of non physician primary care providers in the calculation of a population to primary care provider ratio.

Counting Providers: The Committee’s proposal recognizes that nurse practitioners,physician assistants, and certified nurse midwives provide significant primary care services in our Nation. Therefore, for the first time, these clinicians will appropriately be included in the count for purposes of developing the population-to-provider (P2P) ratio.

The current designation methods–essentially unchanged since the mid-1970s–do not include non-physician providers in the supply of primary care. Deciding to count non physician providers was one step, but the next was at what weighting relative to what type of physicians?

We counted primary care Nurse Practitioners, Physician Assistants and Certified Nurse Midwives at 0.75 FTE, along with physicians (MDs and DOs) in primary care specialties, defined as General Practice, Family Practice, General Internal Medicine, General Pediatrics, Geriatrics and Adolescent medicine counted as 1.0 to develop a total primary care supply measure for a service area. Certain providers were “backed out” of counts, such as those completing National Health Service Corps placements.

There is a variety of evidence base on which to make some of these judgments, but there are plenty of subjective and political decisions lurking just below the water. For example, advanced practice nurses have long been key providers of primary care in rural areas, so “counting” them as primary care providers seems obvious to many (most) persons who look at the evidence. However, by doing so, you place rural areas at a disadvantage by increasing their “supply” of primary care and making them less likely to be designated as a HPSA, that makes them eligible for resources. This put those who were often in a coalition (rural advocates and nurses) at odds on this issue because they now had different perspectives (impact on designation v. professionalism).

This is only one such issue. There are many others, which is why both the Clinton and Bush II administrations tried to revise the HPSA and MUA methodologies and failed to do so (they were blown up in the rule making process).

Most anyone looking objectively at the issues realizes that HPSA and MUA need to be updated and changed. Getting an agreement on how to do so is exceedingly difficult.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

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