Since COVID-19, there has been a notable decline in medical school admissions among applicants of color. With a short fall of 17,899 to 48,000 primary care physicians predicted by 2034, policy makers are looking beyond the physician workforce to the growing number of nurse practitioners (NPs). This has led to more than half the states to grant Full Practice Authority to nurse practitioners.

The implementation of Full Practice Authority (FPA) policies may improve the availability of health care services for Medicare beneficiaries of color, especially if the provider has similar racial or ethnic background to the patients, said Edward Timmons, PhD, of West Virginia University John Chambers College of Business and Economics, and his coauthors in an article published in SAGE  Journals.

The nursing workforce, including NPs, has a higher representation of people of color than physicians, the authors noted. “Studies have shown that a diverse health care workforce is associated with improving access to care in communities of color, ensuring greater patient choice and satisfaction, as well as quality of care,” they said.


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To study how FPA affects the racial and ethnic diversity within the NP workforce, the researchers used data from the Centers for Medicare & Medicaid Services (CMS) on practitioner enrollment in Medicare from 2014 to 2020. The racial and ethnic composition of the US population was collected from annual state resident populations estimates of the US Census.

Ethnic Diversity Amongst the General Population

From 2014 to 2019, the ethnic diversity landscape in the US remained relatively stable, with the most notable change involving the growth of the Hispanic population. The largest ethnic group in the United States remains White, representing 69.4% of the population in 2014 and 67.7% in 2019. This is followed by Hispanic, which has gradually increased, growing from 22.7% in 2014 to 24.5% in 2019. The Black population remained relatively stable, accounting for around 11% in 2014 to 11.2% of the general population in 2019. The Asian population represents approximately 4% to 4.4% of the general population during 2014 to 2019.

These trends offer valuable insights into the evolving demographic composition of the country and have far-reaching implications for different sectors of society, including policy, culture, and health care, noted the study authors.

Importance of Provider Diversity

Even among NPs there is an underrepresentation of NPs of color, which may have a direct impact on patients of color, particularly those who are Medicare beneficiaries. Ensuring the presence of racial and ethnic minority health care providers is vital for fostering patient comfort, effective communication, and trust in the health care system. When patients feel at ease, they are more inclined to actively participate in preventive health care and adhere to treatment plans, wrote the authors. By increasing the number of physicians of color practicing in underserved areas and promoting FPA for NPs, providers can enhance access to primary health care for vulnerable populations, the authors said.

Between 2014 and 2020, the total number of NPs in the US grew by 86,806, noted the study. The percentages of Asian, Black, and Hispanic NPs have all shown upward trends. The presence of Asian NPs has consistently risen, increasing from 2.6% in 2014 to 3.7% in 2020. The proportion of Black NPs has shown an upward trend, growing from 1.9% in 2014 to 2.9% in 2020. The study also found that the proportion of Hispanic NPs saw a notable rise, growing from 3.4% in 2014 to 4.9% in 2020. This gradual progression signifies a positive movement towards greater inclusion of Asian and Black individuals in the NP workforce.

Effect of Full Practice Authority on Racial Diversity

To date, 27 states, 3 territories, and the District of Columbia have implemented FPA for NPs, with Utah becoming the latest state to adopt the measure in March 2023.  Full Practice Authority policies have the potential to enhance health care access for Medicare beneficiaries of color, the authors said. States that grant FPA to NPs demonstrate better diversity and inclusion, with a higher representation of NPs from communities of color. Consequently, in FPA states, Black and Asian NPs are able to provide a greater proportion of care to Black Medicare beneficiaries, thereby improving accessibility and quality of care for these individuals, noted the authors.

In states where FPA is implemented, Black NPs exhibit a significant increase of 2.8% in the number of Black Medicare beneficiaries they serve.  This finding was considered significant at 10%, indicating that FPA plays a positive role in enhancing the diversity of patients cared for by Black NPs.

There was little evidence to indicate that FPA contributed to increasing racial and ethnic diversity among the Medicare beneficiaries treated by Hispanic NPs, suggesting that FPA may not have a significant influence on diversifying the patient population. There is little evidence of significance to suggest that FPA has a discernible effect on the racial and ethnic makeup of Medicare beneficiaries treated by White NPs.

The study highlighted a varied landscape of FPA implementation across US states, with a significant number of states granting NPs full practice and prescriptive authority. The timeline of FPA adoption indicates a gradual transition towards increased autonomy for NPs  in providing health care services.

FPA’s Impact on Diversity and Access

The study found “evidence that Black nurse practitioners have greater representation in full practice authority states. Further, we find that black nurse practitioners are able to serve more Black and Asian Medicare beneficiaries in full practice authority states,”Dr Timmons explained.

The proportion of NPs in the “Others” category remained relatively consistent, making up approximately 12% to 13% throughout the period. In contrast, there was a gradual decline in the proportion of White NPs, from 79.2% in 2014 to 75.5% in 2020, indicating a shift towards increased diversity in the profession.

“Our results provide suggestive evidence that nurse practitioner full practice authority can help improve access to care in communities of color,” Dr. Timmons concluded.

Limitations of the study include the methodology for predicting race, which is commonly used with the literature but may not be accurate at classifying registered individuals directly. Part D Files used to identify patient race only include Medicare beneficiaries and may differ from the makeup of a NP practice. “More accurate data sources, such as those that better identify and record incidents of the incident to billing, should be collected and investigated before claiming any causal relationship,” wrote the authors.

Reference

Plemmons A, Shakya S, Cato K, Sadarangani T, Poghosyan L, Timmons E. Exploring the relationship between nurse practitioner full practice authority, nurse practitioner workforce diversity, and disparate primary care access. policy, politics, & nursing practice. 2023;24(1):26-35. doi:10.1177/15271544221138047