Chapter 9.  Access to Care

This chapter summarizes the findings of the study relating the impact of increasing numbers of NPs, PAs, and CNMs and increasing professional practice options of the three professions on access to health care in the U.S. It includes the following subsections:

• Concepts and Definitions
• Limitations on Quantitative Assessments Professional Practice Index and Access to Care Anecdotal Evidence from Fieldworkclusions

Access to health care is generally related to the ability of individuals in a population group to obtain appropriate services to diagnose and treat health problems and symptoms. A variety of factors influence access to health care for an individual or family, including: availability of health insurance or means of paying for needed services, sufficient numbers of appropriate health professionals to serve all those needing services, and availability of appropriate health care organizations within reasonable travel times.

Access to health care in the U.S. is far from universal, despite programs like Medicaid which help those with limited resources obtain needed services. Many people with resources greater than the limits of public assistance programs like Medicaid do not have health insurance from their employers, and are therefore unable to obtain care. In addition, there are places in this country which do not have sufficient numbers of practitioners to care for all those that need services.

An assessment of the impact of the three professions on access to care was a fundamental objective of this study. Although the increased numbers of practitioners and visits per capita are indicators of improved access, these statistics do not identify the recipients of the services. The initial charge to the study team called for an assessment of the impact of changes in professional practice and numbers of practitioners per capita on access to care for those traditionally underserved by the health care system, e.g., those without insurance, those who are unemployed, etc.

In the discussion that follows the concern is primarily with access to care for underserved population groups. These groups are referred to as “underserved populations”. The term “underserved area” is also used in some circumstances to refer to a geographic subdivision in which a “large share” of the population is underserved. Because it is not possible to address the issue of access to care in a systematic, quantitative way, no effort has been made in this study to use precise definitions of these terms.

Superficially, it is easy to conclude that the dramatic increases in the numbers of NPs, PAs, and CNMs in the 1990s resulted in more services to the public, and increases in professional practice indices resulted in additional services provided. Unfortunately, definitive measurement of the influence of NP, PA, and CNM professional practice on access to healthcare services for underserved populations remains elusive for several reasons:

• Adequate data for NPs and CNMs are not available. Efforts to collect counts for these professions are confounded by the myriad licensing configurations that exist across States. Some State Boards of Nursing count only those licensed as nurses. In some States, the use of an NP or CNM credential is permitted if a nurse has obtained a national certification, with no additional required State certification. Recent passage of legislation in States addressing NP practice as a separate professional category should alleviate this problem. However, in many States, the census of CNMs is still embedded in NP data since nurse midwives are often licensed as a category of advanced practice nurse.
• The identification of practice location of the three professions is another confounding issue, since no national database accurately tracks the specific locations in which NPs, PAs, and CNMs work. For example, in order to determine whether a practitioner works in a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA), it is necessary to locate the practice locations of these professionals at the census tract or zip code level. In most States only a mailing address is available for identifying the geographic location of practitioners, and most mailing addresses are not the same as practice addresses. Files are even less likely to identify the location of second or third practice sites, which are more likely to be underserved areas than primary practice sites.
• It is currently impossible to identify with certainty the providers of services to underserved populations in many settings because many NPs, PAs, and CNMs provide services that are tagged with the identifiers of their supervising or collaborating physicians in insurance claims data. Although Medicaid and Medicare carriers in many States are requiring that each NP, PA, and CNM providing services to eligible populations have a separate identifier, many third party payers have different claim requirements. In addition, many HMOs/MCOs have been unwilling to empanel NPs, PAs, and CNMs, requiring the three professions to bill for services through the participating physician(s) with whom they work. These administrative practices make NP, PA, and CNM services effectively ‘invisible’ to those assessing the quantity and quality of care.

The new National Provider Identifier (NPI) required by the Health Insurance Portability and Accountability Act presents an opportunity to implement more effective tracking of the type of health providers, levels of care provided, and locations where services are offered. This will only occur if the NPIs are required by all payer organizations on billing documents. Such an initiative would still only identify services provided by the three professions to insured populations. Tracking of care provided to people without health insurance presents an even greater challenge.

One of the broad conclusions of this study drawn from the background research and fieldwork conducted as part of this study is that the professional practice indices for NPs, PAs, and CNMs are directly related to access to care. Legal requirements for practice affect both the care that is legally possible and the circumstances under which care is provided. There are several environmental and regulatory factors that inhibit or promote access by underserved populations to health services provided by NPs, PAs, and CNMs.

• Supervisory arrangements for NPs, PAs, and CNMs required in law can dramatically affect the provision of services. Impediments to care are created when statutes or regulations in a State require that a physician be physically present within an office or facility when services are provided by a NP, PA, or CNM, or that a physician must be within a certain distance of the site where services are provided. Provision of care is then limited to locations where physicians choose to practice or to locations that are proximate. This study has confirmed that NPs, PAs, and CNMs, like physicians are concentrated in urban and suburban settings. This preference places rural populations at higher risk for limited access, especially in States that require the three professions to practice in close proximity to their collaborating/supervising physicians.
• The specific services that may be provided may also be limited in law. Statutes and regulations that proscribe the tasks and services that may be provided by the three professions build barriers that directly affect the characteristics of practice and subsequently, the way in which access may be achieved. If there is a requirement that a new patient must see a physician prior to an encounter with a NP, PA, or CNM, access by the patient is limited by the availability of the physician. Similarly, requiring all medical orders written by a PA to be cosigned by a physician before execution limits access to care. Assuming that the PA is competent to provide the service without direct supervision, these legal limitations may unnecessarily impede the provision of care. The fact that such restrictions exist in some States and not in others, raises questions about the need for the restrictions.
• Prescriptive authority is an important feature of professional practice that requires legal permission and enhances care, particularly for rural populations. This privilege is legally enabled in States at various levels by allowing NPs, PAs, or CNMs to prescribe a range of scheduled drugs. If permitted by the State in which practice occurs, the Federal government assigns the professional a DEA registration to prescribe controlled substances. The ability to supply a prescription to a patient without the signature of a physician creates important possibilities for increased access to services in locations physically distant from a collaborating physician.
• Health insurance - or lack of it - is the most frequently discussed environmental impediment to access to health services. Those without health insurance have few options when seeking care and often do so only under the most serious medical circumstances. And when there is insurance, the reimbursement policies in States affect the ability of the three professions to be paid directly for services. The lack of insurance and the lack of available direct reimbursement for NPs, PAs, and CNMs were identified by study informants as significant barriers to access. The three professions are often limited to caring for those patients who have insurance from payer organizations with which the supervising/ collaborating physician has contracts to provide care. The refusal of many third party payers to empanel NPs, PAs, and CNMs limits access to patients. Physicians often act as the intermediaries between payers and NPs, CNMs, and PAs and also between patients and these professionals. Another dimension to the discussion about health insurance is that even being insured—although technically providing access—is not always a predictor of utilization. Other barriers such as transportation, provider office hours, and cultural differences can significantly affect patient utilization.

Despite the inability to assess quantitatively the impact of increased professional practice for NPs, PAs, and CNMs on access to care, fieldwork informants overwhelmingly supported the hypothesis that increases in professional practice in the 1990s improved access to care for underserved populations. The fieldwork in this study provides evidence of the manner in which these services are made available. In fact, the fieldwork suggests that demonstration projects in different States often provide pathways to broader scopes of practice for the three professions. The discussion that follows is based primarily on the fieldwork conducted as part of this study as summarized in Appendix G of this report and in the seven separate field study reports.^[35]

• Statutes enabling practice by the professions across States often have preambles that indicate that these professions were established specifically to help meet the healthcare needs of underserved populations including the poor, the elderly, and the disabled. In fact, all three professions are rooted in the principle of serving the needy, and this principle continues to be central to the current values of the three professions. The practical application of this principle is evident in the educational curricula and clinical experiences provided in training programs for each of the three professions.
• The fieldwork supports the contention that NPs, PAs, and CNMs originally practiced largely in areas where there was a lack of physician presence providing primary care. Currently, however, the health care system is drawing the three professions from their original focus on primary care to medical and surgical specialty practices. Since specialty physicians are less likely than generalist physicians to practice in underserved areas, this trend tends to counteract the initial positive impact on access of increasing the supply of NPs, PAs, and CNMs serving traditionally underserved populations.
• In some States professional practice for the three professions is expanded under special circumstances to permit a broader set of services to underserved populations. In this study this legal condition is referred to as “dual scope of practice”. NPs, PAs, and CNMs practicing in “traditional” locations with physicians are governed by one set of rules, while NPs, PAs, and CNMs practicing in jurisdictions and settings where underserved populations seek health care are permitted expanded privileges for those patients. The experience of the three professions with needy populations in these dual scope States has sometimes led to legislative initiatives that broadens scope in traditional environments. A successful pilot project in Ohio that provided NPs with prescriptive authority to increase access is an example of an initiative that was initially authorized only in limited settings, but was eventually expanded to all settings.

The fieldwork conducted as part of this study provided many illustrations of the contributions of the three professions to access to care. The following examples, drawn from observations of fieldwork informants in the seven States (California, Illinois, New York, North Carolina, Ohio, Oregon, and Texas), confirm that NPs, PAs, and CNMs contribute to health care for many population groups.

• In all seven States, informants reported that access to care is enhanced by the use of the three professions in many settings. All three professions were originally conceived because of national policy concerns about meeting the health care needs of underserved populations. In fact, informants suggested that for many years NPs, PAs, and CNMs worked in underserved settings in proportionately greater numbers than physicians. For instance, in North Carolina, NPs and PAs originally practiced only in health clinics and public health settings. They have subsequently moved into more mainstream practice environments as the professions have become more recognized.
• Initially, Federal reimbursement policies encouraged practice in underserved settings by permitting public reimbursement for services provided in special public health, institutional, and clinic settings that serve the underserved. The 1997 Balanced Budget Act (BBA) equalized reimbursement across all settings providing less of an incentive to remain in locations designated as underserved. The BBA extended a 10 percent bonus for physicians practicing in identified underserved locations but did not extend that same benefit to NPs, PAs, and CNMs practicing in the same settings. Informants suggested that this was counterproductive to Federal policy, which was to encourage NPs, PAs, and CNMs to work with populations with limited access to health services.
• The current increase in specialization by PAs and NPs was cited by some informants as a reason for concern. As these professions move into specialty and sub-specialty care, their opportunities for practice with underserved populations are reduced. Since specialist physicians are not found in great numbers in HPSAs and MUAs, the NPs, PAs, and CNMs with whom specialist physicians collaborate are also less likely to be found in those settings.
• Determining if care is being provided to the underserved by NPs, PAs, and CNMs is a complex task, which often has less than satisfying results. Informants suggested that underserved populations can be found in almost any medical setting. For example, PAs in New York discussed institutionally-based care in a non-HPSA certified facility. This is not identified as care to the underserved even though there is a significant provision of care to underserved individuals in such settings. There are many “needy” patients who would be classified as underserved who receive treatment in community hospitals, major medical centers, and even private physician offices. Care to patients who are uninsured or publicly insured is provided by medical professionals who work in settings not traditionally identified as serving underserved populations. However, the care provided is often considerable and should be identified as contributing to access. Assessing to whom, by whom, where, and how such care is provided is difficult and may require tracking patients on public assistance rather than providers. In any case, when considering the issue of how to increase access, traditional care settings should not be ignored.
• Many informants reiterated that reimbursement of providers has a major impact on access to care. Uninsured and publicly insured populations do not always have the same access as privately insured patients. One informant described the Balanced Budget Act of 1997 as “a house of cards”. Rural health was greatly affected by its implementation since clinics with greater than 50 beds were no longer supported. Without support, many larger clinics closed causing some professionals in underserved areas to leave their positions.
• In Texas, informants indicated that reimbursement is an especially difficult issue in rural areas. Lack of funding for services to needy populations is a disincentive to practice in locations where those populations are located. Reimbursement policies impact both utilization by patients and recruitment of professionals since payment for services is a fundamental issue for all medical professionals.
• Some informants suggested that many newer graduates are not interested in working with underserved populations. They are more interested in practicing where the money is. Students were viewed as being savvier and more aggressive than they had been in the past. This change in orientation affects the pool of providers who traditionally might have sought work with the underserved.
• According to informants, public initiatives that encourage professionals to work in health professions shortage areas encountered difficulty because decisions about where to practice are often driven by personal preferences. Individuals make decisions about where they will practice based on personal background, individual goals, family obligations, and practice opportunities. Economics is an important factor for new graduates who have loans to repay. Educational indebtedness may cause new graduates to take positions based on remuneration rather than professional satisfaction. These are exogenous factors over which policymakers have little control.
• Informants also noted several policy initiatives that encourage professionals to practice in underserved areas, including: expanded loan repayment programs, more clinical rotations for student professionals in underserved settings, and targeted efforts to recruit new professionals into underserved areas. These were considered important strategies for increasing the numbers of NPs, CNMs, and PAs available to provide primary care to underserved populations.
• An example of a successful collaborative effort to increase the numbers of NPs, PAs, and CNMs in underserved settings is an educational initiative called Partnerships in Training, funded by the Robert Wood Johnson Foundation. The objectives of this program are “the development and implementation of a regional educational system for nurse practitioners, physician assistants, and certified nurse midwives involving a culturally competent interdisciplinary curriculum, distance learning modalities, and shared resources among the education partners.”^[36] The program presently operates in eight States: Arkansas, California, Colorado, Michigan, Minnesota, New Mexico, North Carolina, and Wisconsin.^[37] In California, the partnership consortium is operated in collaboration with several area health education centers as well as several college and university programs. Potential NPs, PAs, and CNMs are recruited from underserved communities and then educated in or near those same communities. The program encourages students to remain in their home communities after training. A survey in 2000 by the California Center for Health Workforce Studies, found that 39 percent of NPs, 39 percent of PAs, and 47 percent of CNMs surveyed in the State presently practice in underserved settings.^[38] Informants credit the program with encouraging new providers to locate in underserved areas which has increased access to care.
• Informants were concerned about the move by various States and the Federal government to increase educational requirements for the professions and the concomitant impact on the professional workforce. New York informants suggested that a requirement for graduate education for the professions would change the complexion of the professional programs and place these professions out of the reach of some qualified candidates. Concern was expressed that the cost of the elevated educational requirements would adversely affect the diversity of graduates from programs and further impede the creation of a culturally competent workforce. Liberal loan repayment programs or scholarship support for diverse students were suggested as partial remedies for this problem.
• The environment in which the professional is educated and trained affects employment opportunities and prospects. Changes in educational models may also affect choice of work after graduation. PAs in New York indicated that current educational models affect practice patterns. PA education in New York was initially provided mostly in community college programs with clinical rotations provided in community settings. This encouraged graduating PAs to work in community settings by acquainting them with those workplaces. Many PA programs in the State have now turned to the medical training model in which clinical training occurs in hospitals and large medical centers. Graduates from these programs are not as likely to have connections to a community health provider and may be less inclined to return to community healthcare settings when seeking employment.
• At Duke University in North Carolina, which housed the first PA training program in the country, the PA program uses Title VII funding to support clinical rotations in medically underserved areas. Several informants suggested that providing clinical rotations in a variety of environments was critical to the process of placing the professions in settings where they are exposed to needy populations. Students sometimes discover that they particularly enjoy working in those environments and will choose to work in them after graduation because of their exposure to the opportunity during training.
• Legislation affects access to care in very direct ways. For instance, individual State requirements for the professions to have supervisory relationships with physicians affects practice in rural locations. In Ohio, a PA or NP with prescriptive authority must work within 60 minutes travel time of his/her supervising physician. This requirement significantly limits practice opportunities for PAs and NPs in the far reaches of Appalachia where supervising physicians are largely unavailable. PAs and NPs might contribute more to care for those populations if the distance limitations did not exist.
• Special circumstances tend to influence CNMs and the locations where they choose to practice. CNMs are especially constrained in rural areas because of their need for backup physicians in case of obstetrical emergencies. In many areas of rural North Carolina there are no physicians to provide on-call services, so CNMs are prevented from working in such places. Although the relationship with physicians constrains the NPs and PAs, most patients of NPs and PAs are able to travel to a physician to whom they have been referred for more complex care, even if distance is great. However, obstetrical patients are limited by their emergent medical situations from traveling long distances to any provider. Collaborating physicians must be available to come to the obstetrical patient for delivery rather than having the patient come to them. CNMs, therefore, encounter very particular professional difficulties.
• In Oregon, informants suggested that CNMs are rarely available in rural practice even though Medicaid guarantees coverage for services provided for the poor in underserved areas in the State. CNMs in Oregon suggested that opportunities to work in rural areas are scarce largely due to opposition from rural physicians who face an oversupply of obstetricians in the State. Some CNMs in Oregon have even chosen not to provide obstetrical services and instead provide only well-woman gynecological services in their practices.
• Informants viewed provision of health care in rural environments as a special issue since the physical aspects of the rural environment affect practice. The example of prescriptive authority was provided to illustrate how location can influence practice. Expanded prescriptive authority for nurse practitioners is of no use in a location where there is no pharmacy available to fill the prescription, unless the NP also has the ability to dispense samples or to dispense medications. These conditions require rural providers to be creative and collaborative. A rural provider must establish extensive networks and negotiate a variety of cooperative agreements with other providers including pharmacies in order to operate effectively and provide all needed services. Dispensing authority for nurse practitioners in such locations is one possible solution. Clinics could then stock many needed medications to meet the needs of the served population.
• The unique circumstances of rural communities require and inspire unique responses to limiting situations. In upstate New York, for instance, emergency rooms in very small, qualifying hospitals (under 15,000 visits per year) are staffed solely by PAs. This is effective in providing rural populations with access to care in emergency situations.
• Another example of creative collaboration in rural New York State is a health care cooperative which involves the participation of a variety of stakeholders. A family physician conceived and implemented a creative model for delivery of care to small rural communities in the Adirondack Mountains. Town governments in a variety of locations participate in cooperative arrangements with a medical network, the Hudson Headwaters Health Network (HHHN), by providing buildings and other support services for the medical practices. HHHN staffs the facilities with providers on an ongoing basis. The resulting health consortium provides a range of physician, NP, PA, and CNM services in each practice location. This strategy has resulted in an effective delivery system that manages a broad network of providers working cooperatively in an extensive geographic area. Several locations are staffed strictly by one or another of the three professions with physicians traveling to a clinic only on particular day(s) of the week to see complicated cases and to review caseloads with the staff providers. A network of specialist physicians and local hospitals has been developed to provide referral mechanisms for more complicated care for patients living in these remote areas. The consortium covers a wide geographic area and serves a large number of patients.
• The characteristics of rural practice dictate different responses to provider resources. In Oregon, informants suggested that rural practices have more difficulty predicting the need for providers and for assuring that they can afford them since patient caseload and insurance is unpredictable and the pool of potential patients is smaller.
• In Ohio, which has particularly strict rules about the supervision of PAs, physicians in a rural area suggested that employing other providers creates special challenges. A physician must review a PA’s medical orders for patients on an ongoing basis. One rural physician suggested that, although hiring a PA had increased opportunities for his patients to see a medical provider, his caseload had effectively doubled because of record review requirements. He was not only required to document the records of his patients on a daily basis, but he was also required to review his PA’s notations on her patients. The severity of his patient caseload also increased since his PA was assigned many of the patients with routine illnesses. The physician’s schedule now includes a higher proportion of patients with complex, chronic problems. Although it is helpful that he is more available to these patients, the time required from him for their medical management has also increased. As a result, the physician was finding his practice more burdensome even though he had more help. When considering whether to hire another provider for his practice in the future, the informant felt he would give serious consideration to hiring a physician who would be more independent in practice and not require ongoing supervision.
• Rural populations are also seen as having different characteristics. In Texas, informants indicated there are illegal aliens in the State afraid to seek care for fear of deportation. Farm and migrant workers are also unable to take time off from work to see a health care provider. In fact, many border workers travel to Mexico for care since medical services are available in that country at more convenient hours for the working poor. Getting to medical appointments is also an issue for people without private transportation. In Texas, mobile health care clinics or clinicians who can travel to the colonias in the evening to provide care and medications enable access.
• Cultural competency among providers is also an issue. There are not enough providers and there are even fewer who are culturally diverse or culturally competent. Texas informants cited the shortage of physician providers in underserved areas as a reason for the absence of NPs, PAs, and CNMs who must be supervised in practice. If doctors are not available for supervised practice, then NPs, PAs, and CNMs are not able to practice.
• Some States have implemented special statutory and regulatory provisions that create exceptions for professionals who wish to practice in underserved areas. For purposes of this study, we have identified these States as “dual scope of practice environments”. The legal requirements for supervision or collaboration by a physician and the parameters for prescriptive authority and reimbursement are expanded in defined locations to encourage practice with medically underserved populations or in health professional shortage areas. Texas and Oregon are States where such dual scope provisions exist.
• In Oregon, PAs are permitted to apply for remote supervision by a physician, which is intended to extend provision of care to medically disadvantaged areas. PAs must apply for this privilege and must have the ability to directly communicate with a supervising physician in case of need. Additionally, the ratio of physician-to-physician assistants is expanded in the State to allow every physician in an underserved area or facility to supervise up to four PAs, rather than the two PAs allowed in traditional practice settings.
• In Texas, physician assistants can practice with underserved populations under special circumstances that permit the PA and supervising physician more latitude. The physician must visit the clinic site every 10 days, perform a review of at least 10 percent of the medical records on a timely basis, and be available by telecommunication on a continuing basis.
• Government programs dedicated to improved access are important. In rural upstate New York, a prenatal program which initially provided care only in the early stages of pregnancy was successful and has now expanded to include a full range of obstetrical services. CNMs and NPs provide much of the care to pregnant and parenting women in this program, which reaches some of the more remote communities of the State.
• Increasing provider incentives to work in rural areas is also important. Oregon provides a $5,000 yearly income tax credit to rural providers, including NPs, PAs, and CNMs. Financial incentives might create an inducement  to practice in underserved areas.

Many informants to this study indicated that care for underserved populations is enhanced by the three professions. NPs, PAs, and CNMs contribute significantly to increased access to healthcare in the urban and rural settings where healthcare services are provided.

Opportunities exist to increase those contributions through increased scopes of practice which provide more professional autonomy, more direct access to reimbursement from a variety of payers, increased Federal incentives for those working with the underserved, scholarship grants to encourage new professionals and other initiatives to recruit a diverse workforce or train existing workforce to understand diversity and provide care in culturally competent practice. These initiatives are geared to the professions who provide care. There are also environmental initiatives that would permit greater access including monetary support for care to the uninsured and financial incentives to establish or maintain facilities that provide health services to populations with marginal access.

It was clear from the fieldwork that future initiatives to increase access should not be one-dimensional. All constituents—providers, payers, regulators, and patients—will be required to help find and create solutions to make progress towards a goal of universal access to healthcare.