Do the Math: Nurse Practitioner Scope of Practice Must Multiply

The expanding role of nurse practitioners will have to expand to fill the gap created by a physician shortage and to release some of the pressures on a system that's over-priced, over-burdened, and under-resourced.

The average primary care physician today carries an annual caseload of approximately 2,400 patients, requiring physicians to see patient after patient throughout the day at a breakneck pace. Even though there are many more diagnostic codes and therapies than ever before, the average patient spends far less time with his or her physician than at any time in the past.

In the next 20 years, both the number of people aged 65 and older, and the percentage of the U.S. population they represent, will increase substantially. Chronic illness affects over 80 percent of older adults and consumes disproportionate resources. Almost a quarter of older adults have five or more chronic conditions, regularly visit 13 different physicians, and fill over 50 prescriptions annually.



To meet the demand for primary care in 2030, each PCP would have to see 33 percent more patients than today. To avoid that, we will need 40,000 more physicians than we expect to have. Otherwise, 95 million patients -- over one in every four people -- will go without access to a physician simply because of the lack of providers to handle them. And the problem can only get worse once we bring another 32 million uninsured patients into an already stressed system.

Over the past 20 years, the number of NPs per capita in the U.S. has risen seven times faster than the number of MDs. In 2011, 16 states and the District of Columbia allow nurse practitioners to practice and prescribe independently of physicians, and 28 more states are now considering regulations that would allow NPs to practice a full range of responsibilities.

Within the Veterans' Administration, Kaiser Permanente, and Geisinger Health Systems, the expanded role of NPs has been linked to improved quality and patient satisfaction, as well as to cost reduction. Training programs across the country are moving toward curricula that will prepare NPs in gerontology as well as adult health, to ensure that graduates are ready to contribute to the care of older patients.

A debate and a political tug-of-war is now raging over whether nurse practitioners should be allowed to assume responsibilities that have historically been granted only to physicians. On one side of the rope is a coalition of four physician specialties, which includes the American Academies of Family Physicians (AAFP) and Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA), along with the Accreditation Association for Ambulatory Health Care. On the other is the National Committee for Quality Assurance (NCQA) and the American Academy of Nurse Practitioners.

But there is rarely a clear perch from which to make predictions about the future than demographics. And the demographics are clear: There will not be enough primary care physicians to serve U.S. demand for primary care.