NPs and PAs handling increasingly more primary care visits: New studies

When patients seek primary care, it’s becoming more likely that they’ll see a nurse practitioner or physician assistant.

Health care visits to NPs and PAs, also known as advanced practice providers, have been rising in recent years compared with doctor visits, according to the latest studies. The proportion of Medicare visits that NPs and PAs delivered nearly doubled in the 7-year period 2013-2019 (14% in 2013 to 26% in 2019), according to research published this month in the BMJ. Among study participants, 42% had at least one visit with an NP or PA. Meanwhile, primary care visits with a physician decreased by 18%, the study showed.

Medicare accounts for roughly 20% of the U.S. population and 23% of health care spending, according to 2023 data cited in the report. Study authors surveyed a random sample, 20% of Medicare recipients who sought care through in-person and telemedicine visits to outpatient and nursing facilities before the COVID-19 pandemic.

Medical clinics have turned to NPs and PAs to offset a shortage of primary care doctors, with the United States having fewer physicians per capita than other industrialized nations, according to Ateev Mehrotra, MD, MPH, professor of health care policy at Harvard Medical School and one of the authors of the BMJ report.

Nursing schools also struggle to meet the growing demand for NPs. In more than half of U.S. states, NPs can work independently without physician supervision, while PAs face more restrictions.

Another study earlier this year also found a rise in APP care. FAIR Health reported that nearly one in three patients received care between 2016 and 2022 from someone other than a physician, with NPs providing 27% of primary care visits and PAs, 15%.

The trend isn’t new. But for many years, claims data from Medicare or commercial payers masked the impact of advanced practitioners because their care was billed under a supervising physician, explained Michael L. Powe, vice president of reimbursement and professional advocacy for the American Academy of Physician Assistants, which represents PAs.

NPs and PAs are more likely to see patients with lower incomes, those who live in rural communities, or those who have disabilities, according to the BMJ study, suggesting that these providers may improve access to health care.

They already comprise about half of the primary care professionals in rural areas, said Stephen Ferrara, DNP, president of the American Association of Nurse Practitioners, citing a 2022 report by the Medicare Payment Advisory Commission.

The BMJ study also found that NPs and PAs were more likely to see patients for certain conditions. For example, they handled 42% of visits for respiratory infections and 37% of visits for anxiety, compared with only 13% of visits for eye problems and 20% of visits for hypertension.

Dr. Mehrotra said patients, in general, are still unlikely to see only an NP for many conditions, particularly chronic illness. “You might see the physician one time and then the nurse practitioner, and then the PA. And you might see another physician in the practice.”

He said health care leaders need to decide how to set up teams to best serve patients. From a health policy perspective, they should also consider whether to boost funding for NP and PA education or primary care residencies.

Meanwhile, the growth of advanced practitioners continues. The Bureau of Labor Statistics estimates that the number of NPs will increase to 359,000 in 2031 (80% growth from 2019) and the number of PAs will increase to 178,000 (48% growth).

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