People living in the most rural areas of the United States have the least geographic access to primary care, with that access substantially tougher in states without Medicaid expansion or that maintain tight restrictions on scope of practice for nurse practitioners (NP), according to a study published in Medical Care. What's more, NPs are more likely to practice in those high-need rural areas than medical doctors, who tend to be most concentrated in urban areas, the researchers found.
In particular, the analysis of 2012 U.S. Health Resources and Services Administration data regarding medical doctors, osteopathic doctors and nurse practitioners yielded the following comparisons:
- Most rural areas of the country averaged nearly 357 uninsured people per primary care clinician compared to only 133 uninsured people per clinician in large urban areas
- The most rural areas of states that were not expanding their Medicaid programs averaged 441 uninsured persons per primary care clinician compared with 193 per clinician in similar areas in states that expanded their Medicaid programs
- In the 17 states that did not restrict NP scope of practice, 62 percent of the population had high access to primary care NPs, while, patients in the 21 states with more restrictive laws had considerably lower access
- Regardless of a state's scope of practice laws governing NPs, about 13 percent of a typical state's population has low geographic accessibility to primary care clinicians
"Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run," the researchers concluded. "Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicians."
For example, payment reforms, wider use of telehealth and changes at the medical school level can also help overcome shortages in primary care access, according to lead study author John Graves, healthcare economist at Vanderbilt University, and colleagues.
"The point is that we can do better in terms of patient accessibility to primary care," co-author Peter Buerhaus, Ph.D., a professor at Montana State University, said in a study announcement. "This is not a nurse practitioner versus physician issue. It's an issue that is driven by the question of how do we best expand access to healthcare using all available resources?"