Nurse Practitioners: Shortage or Surplus

shibaowner, MSN, RN, NP

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:

Inability to predict full impact of ACA and any future healthcare policy changes
Inability to predict future changes in scope of practice for NPs and PAs (more states are likely to authorize full practice authority for NPs)
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

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

Nurse Practitioners: Shortage or Surplus

The Case for an NP Surplus

The Case for an NP Shortage

The report concludes

Conclusion

About shibaowner, MSN, RN, NP

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