Filling the Primary Care Shortage Gap: Who Provides the Care?

The gap between the demand and the supply for primary care services is well documented. The Affordable Care Act expanded access to care and further exacerbated an existing primary care shortage of physicians. Using 2005-2015 Medical Expenditure Panel Survey (MEPS) data, this study examines changes in the role nurses play in primary care provision.

The MEPS is a nationally representative survey of individuals that focuses on health care access and utilization. Each year of the data includes comprehensive information for respondents’ primary care office-based visits for specific medical conditions. Medical conditions are defined by Clinical Classification Codes based on the ICD-9-CM. We restricted our analytic sample to conditions that are associated with at least 100 visits in each year of the data since some of the conditions are associated with only few primary care office-based visits. The final sample included 794,577 primary care visits associated with 93 medical conditions representing 11 years of data. For each condition we calculate and analyzed the share of visits seen by nurses, advance practice nurses, and primary care physicians.

The analysis indicates that there are several important changes in primary care provision. First, the role of advance practice nurses in care provision increased, particularly among chronic conditions commonly treated by primary care clinicians. For instance, between 2005 and 2015 the share of visits for hypertension performed by nurses increased from 4.2% to 9.8%. Similarly, during this time period the share of visits performed by nurses increased for diabetes (from 10.6% to 17.5%), upper respiratory infections (from 5.2% to 13.3%) and asthma (from 7.4% to 16.8%).

Second, we find that the share of visits performed by nurses decreased for more clinically complicated and specialized cardiac conditions. For instance, during 2005-2015 time period the share of cardiac dysrythmia visits performed by nurses decreased from 20.0% to 10.7%. Similarly, the share of visits performed by nurses decreased for coronary atherosclerosis (from 10.5% to 4.2%), heart valve disorder (from 12.3% to 6.7%), and congestive heart failure (from 9.4% to 4.0%).

Third, we find that the shift toward greater role of advance practice nurses in care provision affected patients of different age, gender and socio-economic class. However, some of these effects were uneven. For instance, the median share of visits performed by nurses increased to a greater degree for poor patients (income less than 100% of FPL) than for high income patients (income at least 400% FPL).

Based on our analyses, it appears that advance practice nurses are providing need cared in primary care physician shortage in that the share of nurse visits in primary care service provision has increased. This is evidenced by the shift of visits toward primary care conditions and away from more clinically specialized conditions. Another important finding is that the increases in role of nurses in primary care provision do not concentrate on a particular patient population group. Men, women, pediatric patients, older adults, low income patients and high income patients – all experienced an increased role of nursing in primary care.