For the past six years, we have tracked primary care workforce numbers, comparing the annual primary care residency match data with the primary care nurse practitioner (NP) graduation rates. The trends for physicians and NPs have been striking in their contrasts, and those contrasts continue with the data presented in the latest reports. This year, the number of NP graduates continued to rise, while the number of physician graduates, both allopathic and osteopathic, remained essentially flat.

At the same time, the national emphasis on the need for primary care access and the value of primary care has grown. Patients with access to primary care live longer and healthier lives. The Office of Disease Prevention and Health Promotion reports that “people with a usual source of care have better health outcomes, fewer disparities, and lower costs.” Research indicates that individuals without a primary care source are more likely to experience delays in diagnosis, have more expensive health care costs, and die at earlier ages than those who do have primary care providers.

This year, the number of US medical school graduates entering primary care residencies—including family medicine, internal medicine primary care categories, and pediatrics—totaled 2,730 (2018, National Resident Matching Program [NRMP]; 2018, American Osteopathic Association [AOA]). Even adding in the important contribution of international medical school graduates matching into primary care specialties (discussed below), this does not come close to addressing the predicted deficit of 23,640 primary care physicians by 2025. In contrast, there were more than 22,500 NPs who graduated from primary care programs in 2017. Furthermore, only 8.0 percent of the overall NRMP matches this year occurred in primary care specialties—a sharp drop from 11.6 percent three years ago—while 84.0 percent of NP graduates are from primary care programs.

2017 And 2018 National Resident Matching Program Data

Allopathic Medical Graduates

In 2014, NRMP data disclosed that there were merely 19 more allopathic US resident matches to primary care specialties than in 2013. In 2015, there were 91 more US residency primary care matches compared to 2014, including both allopathic and osteopathic data. In 2016, there were 144 more matches than in 2015, but in 2017, there were only 24 more primary care matches than in 2016, including allopathic and osteopathic numbers. The smaller increase in 2017 reflected fewer internal medicine pediatric matches; family practice medicine matches were up by 50 in 2017.

In 2018, there were 2,044 US medical student allopathic graduates matched to primary care specialties. This represented an increase of 140 more compared to 2017. In 2018, there were 113 more US family medicine matches than in 2017 (1,631 compared to 1,518), and 22 more internal medicine matches than in 2017. There were five more US pediatrics primary care matches than in 2017, compared to four fewer matches in 2017 than in 2016.

Osteopathic Medical Graduates

Osteopathic medicine match data are a bit more challenging as increasingly more osteopathic matches are now part of the NRMP and embedded in that data. This year the AOA Resident Registration Program reported US primary care matches (family medicine and pediatrics) at 522, 128 fewer than last year. In 2017, there were five fewer than in 2016.

The 2018 combined total of allopathic and osteopathic US-trained primary care matches, 2,730, was 12 more than in 2017. We suspect that osteopathic primary care matches may be under-reported, as AOA internal medicine numbers are not organized using the same categories as allopathic medicine and are not included. Thus, the increase of 140 allopathic primary care matches in 2018, as opposed to the overall increase of 12 primary care matches, may be the most revealing number, although even the higher increase falls far short of alleviating the primary care shortage. By 2019, the NRMP system will be the sole method for tracking all osteopathic and allopathic matches, resulting in a clearer and more accurate report with one standardized set of categories.

International Medical Graduates

International medical graduates account for almost half of all primary care residency matches in 2018—nearly matching the total for US medical graduates—and continue to play a significant role in meeting the primary care positions offered in the match system. In 2016, 47.3 percent (n = 1,839) of the primary care matches were international graduates. In 2017, that percentage increased to 48.4 percent (n = 1,940), and in 2018, it increased again to 49.3 percent (n = 2,148). Without the international match numbers, the outlook for the primary care physician supply in the US would be even more troublesome.

Primary Care Nurse Practitioner Graduation Rates

The story for primary care is much more encouraging when looking at the NP graduate numbers. The American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF) reported that the 2017 primary care NP graduate ranks totaled 22,585. This is an increase of 2,285 over 2016 (n = 20,300). The 2016 NP primary care graduate numbers, reported out in 2017, were 2,400 higher than the previous year.

As noted above, primary care NP graduates represent 84 percent of the most recent group of new NP graduates. Although that is slightly lower than one year ago, when 87 percent of all NP graduates were in primary care, it is a striking contrast to the 8 percent of resident matches to primary care this year. The increases in NP primary care numbers have been quite consistent over the past five years and are expected to continue. NP graduates in 2018 were almost entirely US residents; 1–2 percent (depending on the specific primary care program) were non-US residents. Exhibit 1 demonstrates the substantial and critical part of the primary care workforce that NP education has addressed for the past five years and is based on the NRMP, AOA, AACN and NONPF data reported here and in the previous five years.

Exhibit 1: 2014–18 US Primary Care Residency Match And US Nurse Practitioner Primary Care Graduates

Sources: Authors’ analysis of primary care residency match, 2014–18 and American Association of Colleges of Nursing/National Organization of Nurse Practitioner Faculties report on nurse practitioner enrollments and graduations 2014–18.

Eighty percent (n = 18,035) of the NPs graduating in 2017 were family NPs—those prepared to treat patients across the lifespan. The next largest group of graduates are represented by the adult gerontology NPs (n = 3,141, 14 percent). About a decade ago, there was a national required change in the adult NP role (the NP role that is congruent with primary care internal medicine in terms of age and focus), and preparation requirements now include considerable educational emphasis on older adults, an enormously important development given changing US demographics.

Although not all NPs with primary care preparation end up practicing in primary care, just as not all residency matches to primary care end up practicing in primary care, 77.8 percent of all NPs deliver primary care.

Physician Assistants

We found no method to track primary care trends for physician assistants (PAs) with the same detail and timeliness as is possible for NPs and physicians. What we can report is that their numbers are growing and reached 115,547 as of the end of 2016.

PAs practice under the license of a physician, and their actual practice areas are reported to be 20.6 percent in family medicine and general practice, 5.0 percent in general internal medicine, and 2.0 percent in pediatrics, with the remainder in specialty practices, emergency departments, and hospital medicine.

Implications For Primary Care Delivery In The US

The striking differences in the annual growth of primary care NPs and physicians not only continue but become more extreme each year. Yet, outdated national and state policies continue to restrain NP practice and negatively impact access, efficiency, quality, and cost, while contributing to the geographic maldistribution of primary care providers. These unnecessary regulations fly in the face of evidence and best practices.

Not only are the numbers of NPs who are prepared as primary care providers surging, their numbers in practice, in both rural and non-rural settings, are increasing. In 2016, 25.2 percent of rural providers were NPs, while 23.0 percent of providers in non-rural areas were NPs, compared to 17.6 percent and 15.9 percent, respectively, in 2008. While NP growth is occurring in all states, states with Full Practice Authority under which NPs have licensure independence and are authorized to practice within the full scope of their profession under their own license without required physician oversight or physician contracts—have the highest NP presence. This demonstrates that favorable NP licensure laws influence state NP workforce numbers.

For example, within the first five years of adopting Full Practice Authority, the “the number of Arizona licensed NPs in the state increased 52 percent from 2002 to 2007…with the largest percent increase of NPs occurring in the rural-rural classified counties.” The Nevada State Board of Nursing has reported a near doubling of the number of NPs licensed in the state since the state adopted Full Practice Authority in 2013. In a just-released summary of the literature and research on NPs, Peter Buerhaus states, “It is unrealistic to rely on the physician workforce alone to provide the primary care Americans need.”

Currently, 22 states and the District of Columbia have Full Practice Authority for NPs. The Department of Veterans Affairs agreed to remove barriers to practice, allowing Full Practice Authority for NPs, certified nurse midwives, and clinical nurse specialists employed in their system. However, other states continue to require unnecessary physician oversight, without any consistent evidentiary basis. In Indiana, for instance, an NP must have a regulated contract with a physician to legally provide advanced nursing care; in Pennsylvania, dated law requires that NPs have contracts with two physicians before practicing their profession; and in Missouri it’s illegal for an NP to treat a patient located more than 30 miles away from the physician named in that state’s mandated physician/NP contract. None of these regulations improves safety, but all negatively impact access, cost, and patient choice.

Two economists estimated the causal impact of Full Practice Authority on population health care utilization rates and health outcomes. They found that it increases access and the frequency of routine checkups, improves care quality, and decreases emergency visits for ambulatory care sensitive conditions and diagnoses. The authors state, “These effects come from decrease in administrative costs for physicians and NPs and patients’ indirect costs of accessing medical care.” They suggest that the primary mechanisms for these changes are the removal of unnecessary physician and NP time spent on supervision and “decreases in indirect costs of receiving medical care such as better appointment availability and lower patient travel costs, rather than changes in provider supply or composition.”

Buerhaus, in his review of the research, found that scope of practice restrictions did not protect the public from “subpar health care.” It appears that outdated restrictive policies actually prevent both physicians and NPs from working to their fullest capacity and educational preparation, while unnecessarily increasing costs in an already stretched health care system. The number of medical students entering primary care is at its lowest ebb and cannot meet the primary care needs of the nation without fully empowered NPs.

The highest-ranking states in national health rankings—based on metrics such as access to primary care, early intervention, chronic disease hospitalization, and costs—are predominantly states with Full Practice Authority licensure for NPs, while states that restrict NP practice consistently rank the lowest. In 2018, 10 of the top-ranked 13 states identified by the Commonwealth Fund authorize Full Practice Authority licensure for NPs, and 12 of the 13 bottom-ranked states restrict NP practice. In a UnitedHealth Foundation report, eight of the top-10-ranked states have Full Practice Authority for NPs, while all 10 of the lowest-ranking states restrict NP practice. Compounding the challenges facing states ranking at the bottom is that these states also tend to have the lowest per capita number of primary care physicians. This makes bottom-ranked states without Full Practice Authority for NPs even more vulnerable to primary care shortfalls because in these states the legal permission of an NP to meet primary care needs is dependent on maintaining a regulated contract with a physician.

The Federal Trade Commission (FTC) has urged state legislators to avoid unnecessary restrictions on NPs practice. It reports substantial evidence that NPs are safe and effective “independent” providers within their scope of practice and that “extended layers of mandatory physician supervision may not be justified.” The FTC suggests that supervision requirements may actually “impair the abilities of health care professionals and provider institutions to develop new models of health care delivery in response to consumer preferences, health care needs, and new technologies.”

Of course, the need for Full Practice Authority for NPs is not the sole issue that needs to be addressed in our current primary care system. Yet, the data and numbers we report here are most compelling and warrant immediate attention. Of all the solutions currently proposed for addressing challenges in primary care workforce development, modernizing NP licensure is the only option with no added costs, no delay, and nearly half a century of evidence to support improved health care access without compromising quality or patient safety. With the continued increase in primary care NP enrollment and graduation rates, the issue before us is using the providers we have to their fullest extent. That can only happen when policies change and every state has Full Practice Authority for NPs. That evidence is clear.

As we said two years ago and repeat in 2018: “The challenge remains to maximize the practice potential of physicians and NPs so that they both are practicing to the fullest extent of their education and training. Only then will the nation reap the full benefit of expanded access to quality primary care services and a reduction in unnecessary costs to the health care system.”