Nurse Practitioners – Shortage or Surplus?

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    Is there an NP surplus or a shortage? This controversial topic has been hotly debated, and is of great interest to current and future NPs, so I conducted some research to help our community.

    Nurse Practitioners – Shortage or Surplus?

    Nurse Practitioners – Shortage or Surplus?

    This controversial topic has been hotly debated, and is of great interest to current and future NPs, so I conducted some research to help our community. So, is there a surplus or a shortage? It depends. (Note: this article is not in perfect APA format).

    The Case for an NP Surplus

    In 2014, Edward Salsberg published an analysis of the NP pipeline in Health Affairs. Based on data provided by AACN and the National Organization of Nurse Practitioner Faculties (NONPF), Salsberg reported new NP graduation rates had “increased from 6,611 in 2003 to 16,031 in 2013, an increase of 142 percent (Salsberg, 2014).” [He also noted that not all of these graduates would actually become practicing NPs – so estimates of new NPs entering the workforce have been rounded to 15,000 in some analyses], In addition, “the number of newly certified PAs went from 4,337 in 2003 to 6,607 in 2013, an increase of 52 percent. The annual number of new PAs will certainly continue to grow (Salsberg, 2014).”

    Salsberg reports that while there is currently a shortage of NPs, he is concerned that the high growth rates in NPs and PAs could lead to a large surplus by 2020. He gives two examples of similar phenomenon: the nurse shortage and the MD shortage. “In the early 1980s and 1990s, the nursing job market became saturated and new RNs had a very difficult time finding jobs; as a result, applicants and enrollment plummeted significantly over a 5 to 7 year period. Some programs ended up closing. This in turn contributed to new rounds of [RN] shortages.” There was also a boom and bust cycle in physician supply. There was an MD shortage from 1950-1980, then an MD surplus from 1980-2000, and then another shortage persisting to the present. “However, [these cycles do] not necessarily mean that the forecasters got it wrong: in some cases, the educational community not only responded, but over-responded (Salsberg, 2014).”

    A 2013 HRSA projection, updated in 2016, also raised fears of an NP surplus by 2020 (note the HRSA projections are only for primary care):

    · The supply of primary care NPs is projected to increase by 30 percent, from 55,400 in 2010 to 72,100 in 2020. The supply of primary care PAs is projected to increase by 58 percent, from 27,700 to 43,900 over the same period.

    · Assuming that NPs and PAs provide the same proportion of services in 2020 that they did in 2010, the combined demand for NPs and PAs would increase by only 17 percent (HRSA, 2016a).

    HRSA also published state-level projections of the primary care provider workforce in 2016. This report indicates a current shortage of NPs and PAs, but also projects a possible future surplus of primary care NPs and PAs by 2025. The surplus or shortage would vary by state. “In 2025, no state is projected to have a shortage of primary care NPs. Projected surpluses range from less than 100 FTE NPs (4 states and the District of Columbia) to 5,350 FTE NPs (Texas). Thirteen states are projected to have a primary care NP surplus in excess of 1,000 FTEs in 2025 (HRSA, 2016b).”

    A less dire situation is projected for primary care PAs: “Differences between each state’s 2025 primary care PA supply and its 2025 PA demand range from a projected shortage of 560 FTE primary care PAs in Ohio to a projected surplus of 2,260 FTE PAs in California. A total of nine states are projected to have a primary care PA shortage in 2025, while five states are projected to have a surplus in excess of 1,000 FTEs (HRSA, 2016b).

    After reading these reports, it is reasonable to conclude that there is cause for concern over an NP surplus in the near future.

    The Case for an NP Shortage

    Currently, there is high demand for NPs on a national level. In a 2017 report on healthcare recruiting, Merritt Hawkins found that PAs and NPs (combined) “represent Merritt Hawkins’ third most requested search in the 2017 Review, up from fifth in 2016. This is the highest position PAs and NPs have held on the list, though neither was in the top 20 singly or combined six years ago. PAs and NPs are playing a growing role in team-based care (many were trained in this model), in some cases handling 80 percent or more of the duties physicians perform, allowing doctors to focus on the most complex patients and procedures . . . PAs and NPs provide the bulk of care at the growing number of urgent care and retail centers and also have been a fixture at FQHCs for years. Given these considerations and the continued physician shortage, demand for PAs and NPs can be expected to accelerate. A significant recruiting challenge is arising in this area as many PAs and NPs are choosing to specialize though demand remains pronounced in primary care (Merritt Hawkins, 2017).”

    All of the projections reviewed in the NP surplus section above indicated a current shortage of NPs and PA, especially in primary care and in locations such as inner cities, smaller cities and town, and rural areas, but raised concerns over possible future surpluses. However, all of these sources included important caveats and limitations to their surplus projections, which can be grouped into the following categories:

    1) Inability to predict full impact of ACA and any future healthcare policy changes
    2) Inability to predict future changes in scope of practice for NPs and PAs (more states are likely to authorize full practice authority for NPs)
    3) Estimates of an NP and PA surplus did not factor in greater utilization of NPs and PAs to offset the primary care MD shortage

    For example, while projecting a future NP surplus, Salsberg concluded: “If these practitioners [NPs and PAs] are fully integrated into the delivery system and allowed to practice consistent with their education and training, this growth can help assure access to cost effective care across the nation.”

    The 2013/2016 HRSA and 2016 HRSA reports, while raising concerns over a future NP and PA surplus, also points out that “If today's system for delivering primary care remained fundamentally the same in 2020, there will be a projected shortage of 20,400 primary care physicians.” The report concludes:

    · Under a scenario in which the rapidly growing NP and PA supply can effectively be integrated, the shortage of 20,400 physicians in 2020 could be reduced to 6,400 PCPs.

    · If fully utilized, the percent of primary care services provided by NPs and PAs will grow from 23 percent in 2010 to 28 percent in 2020. Physicians would remain the dominant providers of primary care, only decreasing from 77 percent of the primary care services in 2010 to 72 percent in 2020 (HRSA, 2016a).

    A 2013 Rand study hypothesized the future NP and PA surplus will help offset MD shortage:

    · New roles for nurse practitioners and physician assistants may cut a predicted shortage of physicians by about 50%, according to a new study released Monday.

    · The surge in new patients covered by health insurance that will be sparked by the Affordable Care Act has led to predictions that there will be a shortage of 45,000 primary care physicians by 2025, about 20% less than the predicted demand, said David Auerbach, a policy researcher at the Rand Corp., a non-profit policy think tank that conducted the study published Monday in the journal Health Affairs (Kennedy,2103).

    A new report presented at a 2017 American Association of Medical Colleges provides additional insight from a different perspective. Instead of numbers of providers, the researchers analyzed labor supply and demand in terms of visits and full-time equivalent hours because many NPs and PAs are currently handling work typically assigned to doctors. “Researchers applied the FutureDocs Forecasting Tool, showing a 15% increase in physician FTE labor from 2013-2030 and 18% increase in number of physicians. They found an 11% increase in demand for visits per 10,000 and -- evaluating physicians only -- a shortage of 4,700 visits per 10,000 by 2030 (based on an average 2,500 visits entertained per each physicians). The authors concluded: “The continuation of recent surges in nurse practitioner and physician assistant workforces could alleviate much of the potential overall physician shortage in the U.S., [but] . . . the researchers' projections still forecast shortages of primary care labor in rural areas and too few available provider hours to treat conditions such as those in the nervous system (a shortage of 21 million visits overall).”

    Conclusion

    Studies agree that there is currently an NP shortage at a national level (this may not be true of all locations), but that we may be heading into an NP surplus period. However, these same studies agree this could change if NPs were successfully integrated into the medical environments and utilized at a greater level. Other projections indicate that NPs and PAs could successfully be used to offset the primary care MD shortage, thus reducing or eliminating any NP/PA surplus. In other words, we don’t know for sure if there will be an NP surplus in the future, due to countervailing factors.

    My personal advice to NP students and new grads is to be flexible with regard to location. Research the areas with the greatest demand for NPs and don’t overlook a job search on these locations and populations. “Prime” areas like the major cities also have NP opportunities, but there will be more competition for these positions. Of course, top notch candidates will still get jobs in such areas.


    References (not in perfect APA format)

    NP, PA Workforce Growth Could Address Physician Shortage | Medpage Today

    Projecting the Supply and Demand for Primary Care Practitioners Through 22 | Bureau of Health Workforce

    State-level projections of supply and demand for primary care practitioners: 2013-2025.

    Doctor shortage may not be as bad as feared, study says

    Physician Salary Surveys and Articles: Average Salaries by Specialty, Physician Compensation and Physician Practice Data

    Sharp Increases In The Clinician Pipeline: Opportunity And Danger


    Bibliography

    Interesting Forbes article: Nurse practitioners are more in demand than most physicians as states allow direct access to patients for these increasingly popular health professionals.

    This is the Merrit Hawkins report referenced in the Forbes article. It is provides a wealth of information on MD, NP, and PA compensation. Use this link and then select “2017 Review of Physician and Advanced Practitioner Recruiting Incentives”
    Physician Salary Surveys and Articles: Average Salaries by Specialty, Physician Compensation and Physician Practice Data

    This is an excellent resource to identify areas with a primary care or mental health provider shortage.
    HPSA Find

    This a good resource for California NPs - you can find shortage areas in the state

    Best states for NPs

    Fascinating article on how there can seem to be both a shortage and surplus of labor in an industry, based on queuing theory, in STEM professions: STEM Crisis or Surplus
    Last edit by traumaRUs on Aug 16
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  2. Visit shibaowner profile page

    About shibaowner, MSN, NP

    Primary care AGNP who graduated in 2016. Prior to becoming an NP, I was a high tech management consulting executive with 20 years experience. I live in California.

    From 'California'; Joined Mar '17; Posts: 476; Likes: 559.

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    10 Comments

  3. by   BSNRN2010
    I am a new grad NP in metro Atlanta, GA area and on average, if you haven't been doing much networking in school, it is tough to find a job. And in some cases, you find one but the compensation is terrible. I feel that it is a surplus in our area. People finding it tough in school to get preceptors and jobs. I am learning that it is very valuable to know your worth as a midlevel provider and definitely know and understand your scope of practice for your state. It's a lot and its important.
  4. by   seattleite188
    I just wanted to add another dynamic that may not have been considered in many of these studies, as they were completed a few years back. It is no longer possible to practice as a new ARNP now without getting a doctorate first. I think almost every school has transitioned their model to the dnp model and don't offer master's in nurse practitioner studies. This will undoubtedly curb future arnp supply and possibly enable a higher standard of performance.
  5. by   ICUman
    Quote from seattleite188
    It is no longer possible to practice as a new ARNP now without getting a doctorate first. I think almost every school has transitioned their model to the dnp model and don't offer master's in nurse practitioner studies. This will undoubtedly curb future arnp supply and possibly enable a higher standard of performance.
    What on earth?
    It is completely possible to practice as a new APRN without a doctorate degree.
    There are far more master's awarding NP programs than there are doctorate at this time. Not "every school" has transitioned, in fact, most have not. And with what incentive? To be in school an extra year, and typically no additional earning potential upon possession of such a degree?

    It would be nice to see a higher standard of preparation and education, but we can surely count on many, many master's prepared NP's to be exiting the pipeline now, and in the future.
  6. by   ALRN1908
    This is definitely not true as many programs continue to offer the MSN for NP's and post graduate MSN certificates. The DNP is not the only entry level into practice as of yet.
  7. by   ALRN1908
    Quote from seattleite188
    I just wanted to add another dynamic that may not have been considered in many of these studies, as they were completed a few years back. It is no longer possible to practice as a new ARNP now without getting a doctorate first. I think almost every school has transitioned their model to the dnp model and don't offer master's in nurse practitioner studies. This will undoubtedly curb future arnp supply and possibly enable a higher standard of performance.

    This is definitely not true as many programs continue to offer the MSN for NP's and post graduate MSN certificates. The DNP is not the only entry level into practice as of yet.
  8. by   staphylococci
    Quote from seattleite188
    I just wanted to add another dynamic that may not have been considered in many of these studies, as they were completed a few years back. It is no longer possible to practice as a new ARNP now without getting a doctorate first. I think almost every school has transitioned their model to the dnp model and don't offer master's in nurse practitioner studies. This will undoubtedly curb future arnp supply and possibly enable a higher standard of performance.
    This is completely untrue. I am a master's prepared FNP (May 2017 grad) and was able to secure an amazing position in a large metropolitan area with many local top NP programs. I had no issues getting interviews either. Employers were more interested in my previous experience as an RN, volunteer work, clinical rotations during NP school, and what type of person I am. Level of education was never brought up; they only wanted to know if I was board certified and licensed to practice by the board of nursing.

    NP positions are in my local area are few and far between (the ones available have poor compensation and do not value NP's), so I am having to relocate across the country to start my first NP job. Most of the residents that I worked with as an RN have had to move long distances for fellowship training after completing their residencies. I don't see this as an odd thing for new NPs like so many of my newly graduated peers. If someone really wants to be an NP and function well in the provider role, then he/she should put in the work to make that happen.
  9. by   Jedrnurse
    Quote from staphylococci
    This is completely untrue. I am a master's prepared FNP (May 2017 grad) and was able to secure an amazing position in a large metropolitan area with many local top NP programs. I had no issues getting interviews either. Employers were more interested in my previous experience as an RN, volunteer work, clinical rotations during NP school, and what type of person I am. Level of education was never brought up; they only wanted to know if I was board certified and licensed to practice by the board of nursing.

    NP positions are in my local area are few and far between (the ones available have poor compensation and do not value NP's), so I am having to relocate across the country to start my first NP job. Most of the residents that I worked with as an RN have had to move long distances for fellowship training after completing their residencies. I don't see this as an odd thing for new NPs like so many of my newly graduated peers. If someone really wants to be an NP and function well in the provider role, then he/she should put in the work to make that happen.
    Thank you for this. I shake my head when a very strongly worded assertion is presented as fact and it's patently wrong... (fake nurse news, maybe? :-)
  10. by   Owlgal
    As someone had previously mentioned, new NPs may need to exhibit a willingness to move in order to practice in a way that fits their professional goals. This is no different than physicians who move for medical school or residency programs (and often jobs). If one chooses to stay local, then they may have to compromise on some aspect of their preferred job.
  11. by   RunnerNurse09
    Quote from seattleite188
    I just wanted to add another dynamic that may not have been considered in many of these studies, as they were completed a few years back. It is no longer possible to practice as a new ARNP now without getting a doctorate first. I think almost every school has transitioned their model to the dnp model and don't offer master's in nurse practitioner studies. This will undoubtedly curb future arnp supply and possibly enable a higher standard of performance.
    This is not true at all. I have yet to find ANY job listing for an np in any setting that has stated that they require a DNP. And I have been reviewing job listings in 2 states.
  12. by   myelin
    I'd say in my market (psych) there is still a huge shortage. That shortage is projected to get worse as psychiatrists retire in droves (majority of psychiatrists are over 55 years old) for the next few decades. However, it does seem like primary care NPs have caught wind of the high salaries in psych and I'm seeing more and more FNP/AGNPs going back to school for the PMHNP license. So that could potentially tighten things up. Only time will tell.

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