The Country Nurse

A recent study published in Medical Care examined the relationship of geographic accessibility to primary care providers. Data derived from the 2013 Area Health Resource File, which provides a comprehensive data on a broad range of health resources and socioeconomic indicators, and the U.S. Census Bureau county travel data. Accessibility was defined as low if the population-to-provider ratio was in the top third of counties, medium if this index fell in the middle third, and high if it fell in the lowest third. The analysis contained 323,902 primary care physicians (PCMDs), 149,784 , 94,209 physician assistants, and 1,336 certified nurse midwives.

PCMDs comprised the largest proportion of the primary care workforce across all settings, but were more concentrated in urban areas (92.1 providers per 100,000 citizens in urban areas vs. 69.7 in rural areas). There were also more than double the number of uninsured individuals per physician in rural vs. urban areas (350 vs. 150, respectively). Accessibility to primary care nurse practitioners (PCNPs) was highest in rural areas, even in states with restricted scope of practice. While in some areas, among the overall NP workforce, PCNPs made up only 27% of all NPs in urban areas and up to 53% in rural areas.

This nurse concludes three things: First, incentive programs such as student loan repayment for service in underserved areas seem to be accomplishing the goal of increasing the amount of NPs in rural areas. Let’s keep these up. Second, we should continue to . It was interesting to note that some states with restricted scope of practice laws are also those synonymous with rural poor: Kentucky, Tennessee, West Virginia, and North Carolina. Third, we should re-double efforts to entice both physicians and advanced practice nurses into primary care. States with a high number of rural poor should consider a strategy that encompasses these three features.

For many Americans, health care is only as as it is affordable. The ACA will produce a decline in the uninsured; it can’t not do this. Other issues with access such as transportation and cultural competency have yet to be addressed. Telehealth in rural communities is promising, but I wonder if home visits might not be even more effective by eliminating the need for travel and integrating the caregiver into the community they serve.

commentary by Megan Doede

Abstract

BACKGROUND: Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians-particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured.

OBJECTIVE: We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws.

RESEARCH DESIGN: An observational study.

SUBJECTS: 2013 Area Health Resource File (AHRF) and US Census Bureau county travel data.

MEASURES: The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC.

RESULTS: We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations.

CONCLUSIONS: Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains. PMID: 26565526

Graves, JA, et al. Med Care. 2015 Nov 12; epub ahead of print.