Predictions that nurse practitioners and physician assistants will help fill the primary care physician shortage may not be realistic as more NPs and PAs choose subspecialty practices, according to the American Academy of Family Physicians (AAFP).

“Some factors that influence physicians to choose subspecialty careers may have similar effects for NPs and PAs, including student debt and income gap disparities,” the AAFP reported in American Family Physician. “Relying on NPs and PAs to solve the problem of a growing shortage of primary care physicians may not be an option, and policy makers should not abandon policy solutions designed to increase the number of primary care physicians, NPs and PAs.”

Although the NP and PA professions emerged in response to physician shortages and uneven distribution of health services, inconsistent data on how many NPs and PAs are actually clinically active and where they practice limits understanding of the roles they play in delivering primary care services.

Continue Reading

So Stephen Petterson, PhD, and colleagues at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington, the research arm of the AAFP, analyzed data from the National Provider Identifier file to determine where NPs and PAs are practicing and if they are working in facilities with physicians.

Should there be more incentives for NPs and PAs to stay in primary care?

The most recent statistics from October 2011 indicate 43% of PAs practice primary care (30,402 of 70,383), whereas the proportion of NPs in primary care is slightly higher at 52.4% (55,625 of 106,073).

“This finding corroborates recent federal studies of nurse practitioners and those of physician assistant organizations,” Andrew Basemore, MD, MPH, director of the Robert Graham Center said in a press release.

Despite these findings, legislative efforts are underway to reform Medicare’s provider payment system to include nonphysician providers such as NPs and PAs. For example, an amendment in the Medicare Patient Access and Quality Improvement Act of 2013 (HR 2810) would reward all medical providers, not just physicians, for running patient-centered medical homes for chronic care management. 

Prior to the amendment only physicians who meet National Committee for Quality Assurance (NCQA) standards for medical homes qualified for such payments. The amendment, requested by NP lobbyists, replaces “physician” with “provider” in many parts of the bill.

Currently, 20 states have NP-led patient-centered medical homes recognized by the NCQA, and a 2010 Institute of Medicine (IOM) report cited expanding NP scope of practice as a solution to meeting growing demands for healthcare providers.

However, many physician groups, including the AAFP, have been vocal that NPs be required to work within a medical team lead by physicians.

PA lobbyists have also been stepping up efforts to gain better recognition in payment plans, sending a petition to Health and Human Services Secretary Kathleen Sebelius requesting an IOM study on the effectiveness and utilization of PAs.


  1. Petterson SM et al. Am Fam Physician. 2013;88(4):230.