Nurse practitioner FPA, workforce diversity, and access

Explainer of Plemmons et al. (2023), Policy, Politics, & Nursing Practice. Not the journal article.

Citation: Plemmons, A., Shakya, S., Cato, K., Sadarangani, T., Poghosyan, L., & Timmons, E. (2023). Exploring the relationship between nurse practitioner full practice authority, nurse practitioner workforce diversity, and disparate primary care access. Policy, Politics, & Nursing Practice, 24(1), 26-35. Plemmons et al. (2022) Free PDF

Facts¶

Main finding¶

While nurse practitioners of color remain underrepresented in most states relative to population demographics, FPA states show higher representation of NPs from communities of color compared to non-FPA states. Notably, Black and Asian nurse practitioners in FPA states serve 2.8% more Black Medicare beneficiaries (statistically significant at 10% level), suggesting FPA may improve access to care for Medicare beneficiaries of color. However, FPA did not change the race/ethnicity of patients served by White or Hispanic nurse practitioners.

One caveat¶

Race prediction based on surnames - while commonly used in literature - may be less accurate than direct racial/ethnic classification. Additionally, the analysis is limited to Medicare beneficiaries (elderly and disabled populations), which may not be representative of all patients served by NPs. The results are correlative, not causal; establishing causality would require longer time series and more data points across the policy adoption timeline.

Policy hook¶

The U.S. faces a critical shortage of primary care physicians (expected 17,800-48,000 shortage by 2034), and physicians of color are even more scarce and more willing to work in poorly served communities. Healthcare provider shortages - particularly those from communities of color - disproportionately affect access to primary care in racially diverse neighborhoods. The study examines whether expanding nurse practitioner full practice authority (FPA) can help address this disparity by attracting a more diverse NP workforce to poorly served communities.

Data and setting¶

• Data sources: Centers for Medicare & Medicaid Services (CMS) Physician Compare Data (2014-2020), Medicare Provider Utilization and Payment Data Part D Prescriber Summary Files (2013-2017), U.S. Census annual population estimates, and FPA classifications from McMichael & Markowitz (2020)

• Population: All nurse practitioners enrolled in Medicare and the Medicare beneficiaries they serve across all U.S. states and D.C.

• Time period: 2013-2020

• Race prediction: Used R-package “predictrace” comparing NP surnames to 2010 Census surname records to infer likely racial/ethnic background

Research design (plain language)¶

Descriptive and quantitative observational study with difference-in-differences analysis. Researchers compared the racial/ethnic composition of the NP workforce to state population composition using maps and descriptive statistics. They then used a generalized difference-in-differences regression model to examine whether states that granted FPA to NPs experienced changes in the race/ethnicity of Medicare beneficiaries served by NPs, treating FPA adoption as a natural policy experiment across states.

PDF or DOI¶

DOI · Free PDF

Why it matters¶

Healthcare provider diversity matters because patients more readily seek care from and communicate better with providers from their own racial or ethnic background. With physicians in short supply - especially those of color - nurse practitioners represent a potential solution to expand access in poorly served communities. This study provides evidence that scope-of-practice restrictions may inadvertently limit workforce diversity. States with FPA demonstrate higher representation of NPs from communities of color relative to their populations, and these NPs serve more patients of color. Granting NPs full autonomy doesn’t sacrifice care quality but could be a low-cost policy lever for addressing health gaps. The findings suggest that regulatory barriers - not lack of qualified diverse providers - may be the constraint. Future diversity programs in nursing education, paired with FPA expansion, could really improve fair access to primary care.