Are nurse practitioners easing shortages in underserved areas?

No matter if a state supports physician-led care or allows nurse practitioners to care for patients without any physician involvement immediately after graduation, the answer is the same.

Data just doesn’t support the argument that changing laws to allow nurse practitioners to practice without physician supervision increases access to health care for patients in rural and other areas underserved by limited access to health care.

Research from the AMA—backed up by others’ studies—shows that regardless of scope of practice laws nurse practitioners tend to practice in the same areas of the state as physicians.

Check out these salient statistics.

About one-quarter of advanced practice registered nurses (APRNs) who graduated from the Centers for Medicare & Medicaid Services’ (CMS) Graduate Nurse Education Demonstration Project went on to practice in underserved areas, a study of the program showed. However, most worked in urban areas.

Just 9% of the program’s graduates worked in rural areas and only 2% of APRN alumni from the program went on to work in federally qualified health centers.

Moreover, regardless of state scope of practice laws this practice pattern remained the same even when nurse practitioners were legally permitted to practice without physician supervision. In such circumstances, nurse practitioners generally chose to practice in the same areas that physicians did, according to an AMA issue brief on scope of practice and access to care (PDF). And the trend has stayed the same for nearly a decade.

For each of the 50 states, the AMA took data from 2013, 2018, 2020 and 2022 and mapped primary care physicians’ practice locations and nurse practitioners’ locations. The data came from the AMA Masterfile and from CMS.

Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.

Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.

It can help to look at the matter on a state-by-state level. Wyoming, for example, since 2007 has allowed nurse practitioners to practice independently. They had 382 nurse practitioners in the state compared with 441 primary care physicians in 2018. The number of nurse practitioners has increased, but the data shows they are practicing in the same areas that physicians are.

On the other end of the country in West Virginia, legislation enacted in 2017 permits nurse practitioners to diagnose and treat patients without physician involvement, but they are required to have a collaborative relationship with a physician for three years to be able to write prescriptions. While the state saw an increase in the overall number of nurse practitioners in the state, again those new professionals continued to practice in the same area as the state’s physicians, the AMA’s analysis showed.

And down South, in Georgia, nurse practitioners must practice pursuant to a protocol agreement with physician supervision and delegation.  As is the case in Wyoming, West Virginia and pretty much across the country, there has been tremendous growth in the number of nurse practitioners. There were 10,291 nurse practitioners in 2020, up from 4,275 in 2013. They practice with physicians in urban and rural areas of the state, demonstrating “that changes in nurse practitioner scope of practice laws are not the sole reason for growth of nurse practitioners in a state or where they practice,” the AMA issue brief notes. 

Another argument often advanced for expanding nurse practitioners’ scope of practice is that doing so would help address primary care physician shortages, which are severe and expected to worsen dramatically as more Baby Boomer physicians retire and the U.S. population gets older and sicker. 

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Yet research shows that, in addition to setting up practice in the same geographic locations as physicians, many nurse practitioners also are opting to pursue non-primary care specialties.

For example, the Oregon Center for Nursing found that just 25% of nurse practitioners practiced in primary care. And a study by researchers from the State University of New York, Albany, School of Public Health Center of Health Workforce Studies found that newly graduated nurse practitioners in the Empire State were more likely to go into a specialty or subspecialty than they were to go into primary care.

As data continues to show that inappropriately expanding nonphysicians’ scope of practice fails to improve health care access, there are other avenues that have proven effective in helping offer underserved areas better access to care that officials could focus their energy on.

These steps include:

• Expanding telehealth, which is critical to the future of health care.
• Increasing the number of physician residency positions. The AMA supports (PDF) the bipartisan Resident Physician Shortage Reduction Act of 2023 (H.R. 2389; S.1302) that would provide 2,000 new Medicare-supported graduate medical education positions each year over a seven year period.
• Supporting state funding for graduate medical education.
• Providing loan-forgiveness programs for physicians who practice in rural and other areas underserved by limited access to health care.
• Creating programs that encourage students from underserved areas to pursue medical school.

Dive deeper on what distinguishes physicians from nurse practitioners.