Special supplement to the Fall 2013 Quarterly from the MDH Office of Rural Health & Primary Care
MINNESOTA'S PRIMARY CARE WORKFORCE: EXPERTS RESPOND TO NEW ORHPC REPORT
In October, ORHPC released a major new report: Minnesota's Primary Care Workforce, 2011-2012. This
month, we asked individuals representing different perspectives in primary care to review the report
and respond to four questions. Below is a summary of the responses from our four "panelists": Mary
Chesney, PhD, RN, CNP, Clinical Associate Professor and Director of the Doctor of Nursing Practice
Program at the University of Minnesota's School of Nursing; Daron Gersch, MD, President, Minnesota
Academy of Family Physicians; Becky Ness, MPAS, PA-C, Professional Practice Chair of the Minnesota
Academy of Physician Assistants; and Katie Gaul, MA, research associate at the Cecil G. Sheps Center for
Health Services Research at the University of North Carolina. Many thanks to each of you!
What are the report's most important findings?
Becky Ness: Physician assistants (PAs), who are all trained in primary care and are a generally
younger workforce, can fill the need for primary care providers when given the opportunity as job
availability occurs. According to the data presented, PAs better represent the increasing ethnic
diversity seen throughout the state as well. Although PAs are “younger,” not addressed in this
report is the fact that many PA students desire to go into primary care, but many rural and
underserved sites want older and more experienced providers. Therefore, PA graduates migrate to
the specialties as their second option due to job availabilities.
Mary Chesney: A number of the findings are compelling but not surprising given national workforce
trends. Of concern is the aging of the physician and nurse practitioner (NP) workforce. Equally
concerning is the finding that none of the primary care provider groups adequately match racial and
ethnic minority distribution in Minnesota’s population. And rural Minnesota continues to have
inadequate access to primary care providers.
Data that were not surprising to me but may be to those outside of the Advanced Practice
Registered Nurse (APRN) community are those related to urban-rural distribution of Minnesota
NPs. Nationally, 17 percent of NPs practice in rural areas, where 10 percent of the national
population reside. In contrast, only 10 percent of Minnesota NPs practice in rural areas, where 17
percent of the state’s population resides. Data from a large 2012 national study using national
provider number data (Understanding APRN Distribution in Urban and Rural Areas of the U.S. Using
National Provider Identifier Data) trended close to significance (p = 0.075) showing that NPs were
more likely to be distributed in rural areas in states where NPs had full practice authority
(autonomy), compared to states like Minnesota that have restrictions on NP practice that tie them
to a specific physician or group of physicians in order to practice and prescribe. I have also received
numerous anecdotal reports from NPs who live in rural areas and are not able to practice there
because they cannot find a collaborating physician willing to sign the necessary written prescriptive
agreement required for NP prescriptive practice.
Daron Gersch: This key sentence is the most important message: “All three provider types provide
substantial amounts of Minnesota’s primary care and increasingly work together within certified
Health Care Homes and other emerging interdisciplinary, team-based models of care.”
Katie Gaul: This report suggests that, as in many places, there is a geographic imbalance of primary
care providers, with more providers practicing in urban areas and fewer practicing in small and
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isolated rural areas. The lack of diversity in the primary care workforce points to an opportunity to
develop new and/or enhance existing diversity initiatives both in the health careers pipeline and in
the workplace. The report summarizes the variation in age across region by rural status in different
ways for different providers. Further analysis on the age distribution by geographic location may
highlight areas to be targeted for recruitment and retention efforts.
Do any of the findings surprise you?
Becky Ness: There were a number of surprising findings. One is a misperception, even by MDH, that
NPs have more training than PAs. The report should have provided more emphasis on the robust
training of PA’s (27-month programming worth 90-100 credit hours & 2,000+ clinical hours of
training). Also, Certificates of Added Qualifications (CAQs) do not accurately reflect PA practice
settings, however American Academy of Physician Assistant (AAPA) data does include practice
setting/specialty information and state-specific data can easily be extrapolated from national data
and would provide more accurate information. CAQs are new to the National Commission on
Certification of Physician Assistants (NCCPA) and are not a requirement to practice or seek
reimbursement for PA services.
Another surprise was the proportionally small amount of PAs practicing in pediatrics in Minnesota
versus nationally. This is not due to PAs lack of interest, but rather reflects the job opportunities
from employers who are seeking PAs. There were also a number of misconceptions in the document
regarding PA practice and scope of training.
Mary Chesney: It was surprising to see a higher proportion of younger primary care NPs (those
younger than 34 years of age) planned to stop practicing in Minnesota within the next five years, as
compared to those in the 35-44 and 45-54 year-old age range. I direct the Doctor of Nursing
Practice (DNP) Program at the University of Minnesota, where all of our APRN programs reside. I am
deeply concerned by this finding. Anecdotally, I have heard from a number of our students that
eventually they plan to move their families to states where NPs have full practice authority and
where they will be able to fully utilize the skills and knowledge acquired during their APRN
education. These younger graduates are not interested in continued battles with organized
medicine over scope of practice battles. Some have expressed concern during their student clinical
training they are seeing more and more institutional restriction on NP practice within Minnesota’s
health care settings. I think this workforce report finding warrants in-depth study to see if
Minnesota’s restrictive practice environment is causing some of our ‘best and brightest’ young NP
graduates to leave the state for practice in less restrictive states.
Daron Gersch: I think the report overestimates the people in primary care and therefore doesn't
make the shortage seem as bad as it is. I was specifically interested in the numbers of NPs working
in primary care, which was less than I expected at 43 percent. It was also surprising that 21 percent
of NPs work in rural compared to about 40 percent of FP/Internists. I think the report shows that the
NPs and PAs are not going into rural areas to "fill the need." Sadly, it also shows that physicians are
not going there either.
Katie Gaul: The PA workforce seems very young and very urban. How likely will this cohort be to
move to more rural areas in the future? Also, the number of young family physicians (<35 years)
seems low and is a bit worrisome, given that a significant proportion of internists and pediatricians
go on to subspecialize and family physicians are more likely to practice in rural areas.
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Does anything in the report suggest action needed for the state’s primary care workforce, and if so,
what action do you recommend? Who needs to be involved?
Becky Ness: [Strategies should include:] a) Increasing funding for housing in rural and underserved
areas to allow for improved access to PA students during training, as well as a requirement for rural
clinical sites to accept students, even if owned and operated by a larger health organizations.
b) Improving tuition reimbursement opportunities for primary care in rural and medically
underserved areas to offset salary differences. Look at loan forgiveness programs and potential
expansion to allow for inclusion of a greater percentage of rural and medically underserved primary
care providers.
c) Communication between educational institutions and health care organizations could promote
strategic plans to increase access to primary care through providing PA students interested in
primary care employment after graduation.
d) Include physician assistants in future analyses. This would be beneficial in providing expertise on
the profession as well the preparedness of PAs and PA students in fulfilling the needs for primary
care throughout Minnesota.
Mary Chesney: I would like to address two major concerns. The first is the disproportionate racial
and ethnic representation among NPs. Minnesota RN workforce data show a higher number of
racially and ethnically diverse nurses receive associate degrees as compared to those who receive
baccalaureate degrees in nursing. This finding means that many racially and ethnically diverse RNs
who wish to become NPs face a steeper more costly educational trajectory. They must complete and
fund an AD-to-BSN completion program before being qualified to apply to a graduate program to
become an NP. We need to find ways to financially support a greater number of diverse students
enrolling in baccalaureate nursing programs to obtain their RN degree so the move to graduate NP
education can be a smoother transition.
A second issue is the restrictive practice environment for NPs in Minnesota. If we want to keep our
young best and brightest NPs in our workforce and encourage more NPs to practice in rural areas,
the Minnesota Legislature needs to enact the APRN Consensus Model in Minnesota. This model is
one in which APRNs practice to the fullest extent of their education and training. The model calls for
removal of collaborative management and supervisory prescriptive agreements in Minnesota’s
Nurse Practice Act.
Daron Gersch: The Minnesota Medical Association (MMA) has a Primary Care Physician Task Force
that is currently working to examine and address shortage issues. The Minnesota Academy of Family
Physicians (MAFP) has been an active participant and we encourage the ORHPC to review their
results and recommendations. We also suggest tuition incentives for all primary care providers in
training, encouraging primary care NPs/PAs who work together in collaboration with physicians to
share their experiences and increasing financial support for the teaching of team-based medicine in
schools.
The Robert Graham Center identifies these potential ways to bolster the primary care pipeline:
physician payment reform, dedicated funding for primary care graduate education funding, and
increased funding for primary care training and medical student debt relief.
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Katie Gaul: It is difficult to attract health care professionals to rural and underserved areas for a
variety of reasons. Suggestions for action include evaluating the efficacy of current recruitment and
retention efforts, evaluating training programs to determine how many graduates stay in state,
practice in primary care and practice in rural areas, and investigating new training and policy
strategies.
Diversity is another key area for action. Studies have shown that racial and ethnic diversity in the
health workforce is important in maintaining accessible, equitable and culturally competent health
care. There are many potential strategies, including expanding loan repayment, pipeline initiatives,
fostering cultural competence in education programs, attracting more diverse faculty, strengthening
student support programs, tracking and evaluating pipeline data to monitor trends. Good sources
include
•
For literature citations and suggested solutions, see
•
McGee V and Fraher E. The Diversity of North Carolina’s Health Care Workforce. Cecil G.
Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
August 2012. http://www.shepscenter.unc.edu/hp/publications/Diversity_Aug2012.pdf;
•
McGee V, Fraher E. The State of Racial/Ethnic Diversity in North Carolina’s Health
Workforce. North Carolina Medical Journal. 2012;73(5):337-345.
http://www.ncmedicaljournal.com/archives/?73501.
State agencies involved in recruitment/retention, training institutions, AHEC (Area Health Education
Center), ORHPC and those involved in health careers pipeline initiatives are some of the parties who
should be involved.
Do you see any trends regarding the availability and distribution of primary are, or models that are
working elsewhere?
Becky Ness: In Michigan, the Department of Health chose to use tobacco settlement funds for
student scholarships to help offset housing and travel expenses for rural training experiences. It was
a win-win for students and communities to expose more students to rural practice settings.
Concerning trends in Minnesota include the number of rural health clinics being merged with larger
health care organizations. These organizations are looking at productivity measures for these sites,
as well as self-imposed screening measures for potential students, which limits exposure and access
to educational partnerships for future workforce needs. There is also a common misconception
among health care administrators on the role and scope of practice for new PA graduates, who are
very well equipped to meet and provide quality health care in primary care areas, especially in rural
Minnesota.
Mary Chesney: Eighteen states plus the District of Columbia allow NPs full practice authority to
diagnose, treat, manage patient conditions and prescribe. These states’ prescribing and practice
quality and safety data remain strong. These same states tend to have higher numbers of NPs
working in rural areas (Understanding APRN Distribution in Urban and Rural Areas of the U.S. Using
National Provider Identifier Data) and “had a 2.5-fold greater likelihood of patients receiving their
primary care from NPs than did the most restrictive states” (States With the Least Restrictive
Regulations Experienced the Largest Increase in Patients Seen by Nurse Practitioners).
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Daron Gersch: I am seeing fewer providers going into primary care. Ten to 15 years ago it would
take six months to a year to recruit someone to our clinic, now it is two to three years. Even in
family medicine, more people are going into emergency or hospital medicine than into clinical
medicine. PAs and NPs are working more with other specialties versus going into primary clinical
care.
Everyone talks about getting more money to primary care, but it is not happening. Until this infusion
of money occurs there will continue to be a shortage. Some states have a per-patient-per-month
payment that has been very successful in getting money to primary care clinics - we need to do the
same.
Katie Gaul: Under the Affordable Care Act (ACA), the health care system is transforming, and many
people are wondering how this will affect our health workforce needs. The Centers for Medicare
and Medicaid Services recently said, “A transformed health care system will require a transformed
workforce … he people who will support health system transformation for communities and
populations will require different knowledge and skills….in prevention, care coordination, care
process re-engineering, dissemination of best practices, team-based care, continuous quality
improvement, and the use of data to support a transformed system.” The ACA’s emphasis on
preventive care, as well as changes in payment policy are likely to shift care from inpatient settings
out to ambulatory, community and home-based settings. This will require new and existing workers
to fill new roles, and may affect how existing workers practice in teams to deliver care.
Project Echo has been held up as a best practice. This model, through the University of New
Mexico’s School of Medicine, promotes care in underserved areas. Minnesota’s own community
paramedic training initiative is another model, extending specific primary care services to patients in
their home, working through a physician’s order.
From Nitika Moibi, Supervisor of ORHPC’s Health Workforce Planning and Analysis program:
Thanks to each of you for sharing your perspectives. As we reviewed the data for this report, every
number told a story of lack of geographic access and diversity, aging providers and primary care
deserts. Addressing these challenges is complex, as your thoughtful answers confirm, but more
important than ever. The success of health reform rests on what the Institute on Medicine stated so
well back in 1996: “Primary Care is the logical basis of an effective health care system.”
Our collective challenge is to bend the curve, so that the right mixes of providers are in the right
places to serve Minnesotans. Here at ORHPC and MDH, we will continue to share data responsibly,
inform dialogue, and forge partnerships to accomplish that. We look forward to working with you,
and thanks again.
More information about ORHPC's Health Workforce Planning and Analysis Program, as well as additional
publications and workforce data, are available on the Office of Rural Health and Primary Care website.
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