‘Growth is not access’ — NP growth is surging, but is it helping primary care?

The nation’s nurse practitioner (NP) workforce is growing about 10 times faster than the physician workforce.

But more NPs does not guarantee more patients are getting better access to primary care, according to a new analysis by Milbank Memorial Fund.

“Rapid Growth, Uncertain Impact: Nurse Practitioners and the Future of Primary Care Access” is a new policy report examining the state of education and practice for NPs. About 90% of NPs train in primary care, yet fewer than half appear to practice in it, according to the report. Experts who discussed the findings said closing that gap will require more consistent training standards, better data and more money for clinical education.

“Growth is not access, and every state is well positioned to make sure that their growing NP workforce delivers high quality primary care where it is needed most,” said lead author Monica O’Reilly-Jacob, Ph.D., APRN, assistant professor of nursing at Columbia University School of Nursing.

She presented the findings Oct. 14 during an online webinar with Shannon Idzik, D.N.P., professor and associate dean for the Doctor of Nursing Practice (D.N.P.) program at the University of Maryland School of Nursing, and Hovik Khosrovian, senior health policy adviser for workforce development at the California Department of Health Care Access and Information (HCAI). Diana Bianco, J.D., primary care consultant for the Milbank Memorial Fund, moderated.

Bianco noted that focusing on NPs does not mean physicians, physician associates (PAs) and other members of the primary care team are any less crucial. The discussion covered training quality, funding and the data needed to track where NPs end up.

Where are the new NPs going?

The report projects the NP workforce will grow nearly 11% annually from 2023 to 2030, compared with 1.1% for physicians. Early-career clinicians are driving the surge. The number of NPs younger than 40 grew 389% from 2010 to 2023.

NPs already carry much of the load in underserved areas. They work in 66% of primary care practices in the most disadvantaged communities, compared with 33% of practices in the least disadvantaged, according to research by O’Reilly-Jacob’s team cited in the report.

But the report describes a “primary care pipeline leak.” Medicare claims identify NPs with a generic code that does not distinguish primary care from specialty care, but recent studies estimate 31% to 45% practice primary care. Rising demand and higher pay in acute care, psychiatry and other specialties have pulled primary care-trained NPs away, according to the report.

“Primary care for all disciplines is a demanding setting, and we know that primary care providers experience burnout, and many are lured into the specialties with higher pay,” O’Reilly-Jacob said.

Postgraduate residency and fellowship programs, which emerged about 20 years ago, give new NPs a year or two of supported transition to practice, often in complex safety-net settings. Those programs have been found to reduce burnout and improve retention in underserved communities, she said.

Is NP training consistent enough?

Distance-based programs have widened access for nurses who cannot relocate because of caregiving, work or financial pressures, and graduates are likely to stay in the communities where they trained, O’Reilly-Jacob said. From 2014 to 2024, the share of fully online NP programs rose from 11% to 25%, while fully in-person programs fell from 17% to 6%, according to the report.

Online instruction is not the problem by itself, the authors wrote. The concern is a small group of what they call “high-volume, low-touch” programs, with practices such as near-universal admission, limited faculty contact and students left to find and pay their own preceptors. The largest for-profit NP program graduated 2,129 NPs in 2023, or 6.4% of all NP graduates that year.

Clinical training requirements also vary. Accreditors require 500 hours of direct patient care, while the 2022 National Task Force (NTF) for Quality Nurse Practitioner Education recommends 750. Many programs are moving to 750 hours voluntarily, but not all accreditors and certifiers require it, Idzik said.

Her own research suggests the hours matter. In a study she and colleagues conducted last year, programs with more than 750 clinical hours were eight times more likely to have a 100% certification pass rate and almost five times more likely to have a pass rate above 80%, she said.

Pass rates shape the workforce math, too. Early certification results for the first six months of this year showed pass rates of 72% for family nurse practitioners and 77% for adult-gerontology primary care NPs, Idzik said. With roughly 30,000 graduates a year and pass rates of 72% to 80%, only about 24,000 reach the workforce, she said.

“All of our colleagues in health care are producing these reports by school nationally, which is something that the nursing community isn’t doing,” Idzik said.

Schools can choose among three accreditors, students can choose among competing certification exams and only half of state boards of nursing directly oversee NP education, according to the report. That competition discourages certifiers and accreditors from enforcing tougher standards, O’Reilly-Jacob said. Asked whether the system is moving toward consistency, Idzik said it is becoming less consistent. Only one accreditor still requires the NTF standards, although one certifier recently moved to 750 hours, she said.

Who pays to train NPs?

Asked to pick one of the report’s five policy recommendations, O’Reilly-Jacob and Khosrovian both chose funding. In 2019, federal Health Resources and Services Administration (HRSA) programs supporting NP education totaled about $69 million. That was less than 1% of the $16.2 billion Medicare spent the following year on graduate medical education (GME) for physician residencies, according to the report.

O’Reilly-Jacob called the gap “really striking” and said the money could compensate, incentivize and recruit preceptors. The report also suggests state or federal tax incentives for clinicians who serve as NP preceptors.

California illustrates the imbalance at the state level. HCAI’s Song-Brown Healthcare Workforce Training Program receives about $3.9 million a year for family NP and PA training grants, shared between the two professions, compared with $31 million a year for primary care residencies, Khosrovian said. Since 2021, Song-Brown has supported 880 family NP and PA students and about 31 postgraduate fellows, he said.

“Ultimately it’s the funding that drives the outcomes in many ways. And without funding, it’s very little you can do besides, you know, kind of hope for the best,” Khosrovian said.

Song-Brown’s residency grants also prioritize physician training programs that integrate NPs and PAs, so residents gain experience in team-based care, he said.

What don’t we know?

Idzik chose data transparency as her top priority.

“I think we can’t really effectively improve what we can’t measure, and if we don’t have the data, it’s really hard to look at where we would even think about spending that money,” Idzik said. “Having more of something doesn’t always mean it’s better.”

The report recommends that states require NP programs to publicly report first-time certification pass rates, the share of instruction delivered online and the number of graduates. Minnesota already publishes pass rates by institution and NP track. Other recommendations:

• Board of nursing oversight of NP education in every state
• Stable clinical training funding
• Postgraduate residencies at federally qualified health centers (FQHCs) and other safety-net sites

One relatively simple solution: When NPs renew their licenses, ask if they practice primary care.

“We just have really basic gaps in what we know. We don’t even know the percentage of NPs that are providing primary care,” O’Reilly-Jacob said.

California is working to fill some of those gaps. HCAI recently added National Provider Identifier (NPI) numbers to its licensing data so it can track where grant recipients end up practicing, and it is expanding its workforce survey to capture who works in primary care, Khosrovian said. The department expects to have a primary care supply and demand model in early 2027. California has about 48,000 NPs, and the state’s problem may be a shortage and maldistribution of the health care workforce, he said.

Can team-based care keep NPs in primary care?

Retention data are thin. In California’s scholarship and loan repayment programs, retention runs around 50% after five years, Khosrovian said. Clinicians recruited from and trained in a community are more likely to stay, while those brought in from out of state or from dense urban areas to work in rural communities tend to leave, he said.

“They’re just not going to stick around after their time is done,” Khosrovian said.

Team-based, interprofessional care can help, O’Reilly-Jacob said.

“Team-based care and interprofessional care has actually been shown to reduce burnout when we’re sort of sharing the load, which is then increasing retention in those communities,” she said.

Paying for those teams remains a challenge, she added.

“As we move away from fee-for-service, right, and we’re talking about value-based care, that’s when these team-based models can work really well to be reimbursed in a value-based system,” O’Reilly-Jacob said.

Speed or quality?

Bianco asked how policymakers should balance urgent access needs with consistent, high-quality training. Khosrovian said California’s accreditation process and its Board of Registered Nursing provide checks and balances as programs expand. Idzik said the goals need not conflict if guardrails and clear outcome measures are in place.

“I don’t see them as competing priorities. I think we need both, and I think we can have both,” Idzik said. “I think if we always kind of keep our eye on the prize, you know, what’s going to happen at the end of this academic education program is they’re going to be taking care of someone’s mother, grandmother, child, neonate.”