Competition for clinical staff is heating up as healthcare companies bolster their primary-care offerings, but industry observers expect the growing supply of nurse practitioners and physician assistants to meet the ballooning demand for advanced practice clinicians.
Payers, providers, tech companies and private-equity backed ventures are building out primary-care oriented services, which rely on a steady supply of advanced practice practitioners.
Amazon recently announced a new initiative that will virtually connect patients with primary care physicians and nurse practitioners. Initially available to Amazon's workforce, it will be offered by summer to private employers across the country who want to join. Humana, CVS Health and UnitedHealth Group continue to expand their primary-care networks. Fully capitated, team-based models like Oak Street Health and Iora Health are entering new markets while health systems broaden their ambulatory footprints.
This has increased the demand for advanced practice practitioners, some of which are already among the fastest-growing jobs in the country. Nurse anesthetists, NPs and nurse midwives are projected to grow 45% from 2019 to 2029, according to the Bureau of Labor Statistics, pegging physician assistants' growth at 31% over that span.
While there was an estimated shortage of 20,400 primary-care physicians in 2020, the supply of NPs and PAs grew by 30% and 58% respectively, outstripping a 17% increase in combined demand, according to the Health Resources and Services Administration. The NP workforce more than doubled from 2010 to 2017.
"The nurse practitioner workforce has continued to grow rapidly, but wages are now flat for the last few years," said David Auerbach, an adjunct professor at Montana State University and senior director of research and cost trends at the Massachusetts Health Policy Commission who studies the healthcare workforce. "That suggests to us that there is probably not going to be a shortage of NPs anytime soon."
Demand for NPs like nurse anesthetists is also growing in the inpatient space, in addition to the urgent care, retail clinic and telehealth sectors. That is, in part, why more health systems have been investing in academic institutions.
Renton, Wash.-based Providence partnered with the University of Providence in 2017 to create a stable pipeline of clinicians. They've added programs in infection prevention and epidemiology and organizational leadership with curricula tailored to the integrated health system.
"Competition is increasing across all high-demand areas," said Justin Crowe, senior vice president of community partnerships at Providence. "(The university) isn't going to meet the demand on its own, but it's a proactive step along with our other academic partnerships."
Ochsner Health and Loyola University New Orleans launched a pre-licensure undergraduate nursing program last year.
An average of 175,900 openings for registered nurses are projected each year over the decade, largely due to the aging workforce, a dearth of teachers as well as the migration of RNs to NP roles, according to the BLS. In Louisiana, more than half of the state's nurses are at least 50 years old, a report from the Louisiana State Board of Nursing found.
"Across Louisiana, there are critical shortages in the healthcare workforce. This, combined with COVID-19, has demonstrated the significant need for more high-quality healthcare education programs," said Tracey Schiro, chief human resources manager at Ochsner. "Through existing and new partnerships with national-recognized academic institutions and available workforce programs, we continue to build a pipeline that develops and trains the next generation of healthcare leaders to address this shortage and new competition."
Attracting primary-care physicians hasn't been an issue for ChenMed, a physician-led and privately owned wraparound primary care provider, CEO Dr. Christopher Chen said.
"The problem is mostly about selection. We have about three applications for every one spot," he told Modern Healthcare last year. "Despite the primary-care shortage, there is no shortage of interest."
Some employed primary-care physicians have been leaving their health systems, which has been a boon for organizations like VillageMD, a private equity-backed primary care provider that recently teamed up with Walgreens.
"Sometimes primary-care physicians in health systems are asked to do things administratively that they don't love and don't allow them to do what they're best at—care for patients," said Paul Martino, co-founder and chief strategy officer of VillageMD. "We offer an alternative employment option."
Generally, VillageMD hasn't had trouble sourcing primary-care providers, NPs or PAs, he noted.
As for nurse practitioners, there are two significant barriers to increasing the supply, said Linda Aiken, director of the University of Pennsylvania Center for Health Outcomes and Policy Research.
Nursing schools cannot find enough physicians and fully qualified NPs to provide the requisite clinical precepting for NP students, she said. Also, many states still require NPs to operate under physician oversight, which increases the cost of hiring NPs and discourages potential candidates, Aiken said.
"Greater engagement of these national payers and employers of NPs in advocating for modernizing state scope of practice policies and Medicare graduate nursing education policy would be game-changers in ensuring an adequate supply of NPs," she said.
Scope of practice laws, in addition to telehealth regulations, are poised to adjust post-pandemic. Waivers implemented during the emergency declaration have helped increase access.
But some medical associations are opposing states' proposed expansion of NP's scope of practice laws. They claim that quality of care will decrease solely under a NP's supervision, although studies show that quality is comparable while costs drop significantly.
"In general, the growing supply of NPs and PAs will help many of these emerging models, but I expect some battles around state licensure and scope of practice laws," said Joanne Spetz, director of the UCSF Philip R. Lee Institute for Health Policy Studies.
While industry observers are hopeful that telehealth could help fill care gaps in areas like opioid treatment, low-income and rural communities will continue to feel the brunt of staffing shortages.
L.A. Care Health Plan, which has been growing its urgent care network that predominantly serves low-income communities, has had trouble finding primary-care physicians, CEO John Baackes said.
Its tuition reimbursement and loan forgiveness plans will help attract more doctors over the long term, but L.A. Care will continue to grapple with staffing issues, he said.
"Too many doctors are going into specialty care because of the money," Baackes said. "We need physicians who look like their patients because there's been so much research on if a patient sees a doctor, NP or PA who looks and sounds like them, they have better results."