Expanding Access to Primary Care in Free Clinics
Population growth and a growing elderly population, accompanied by an increasing prevalence of chronic diseases associated with aging, places the greatest demand on primary care services. Expanded health insurance coverage under the Affordable Care Act and Medicaid expansion is also widening the supply and demand gap. A deficit of more than 23,000 PCPs is projected by the Health Resources and Services Administration National Center for Workforce Analysis by 2025. This finding is consistent with recent projections developed by the Association of American Medical Colleges, which suggest that PCP shortfalls may range as high as 35,000 by 2025.
In addition to the PCP workforce shortage, there is a maldistribution of physicians in rural and medically underserved areas. In Virginia, there are 105 designated health professional shortage areas for primary health care affecting a population of 1,559,609. Virginia is also challenged with a significant uninsured rate of 10.3% between 2016 and 2017 for nonelderly (ages 0-64), representing about 719,000 individuals, 87.6% of whom were adults. This estimate does not account for Virginia's Medicaid expansion, available to residents earning up to 138% of the poverty level. As of October 2019, approximately 325,000 Virginians had gained coverage. Despite Medicaid expansion, there remains a significant number of uninsured adults who are much more likely than insured to have unmet health needs and are less likely to receive preventive services.
Virginia's free and charitable clinics serve as an important safety net resource in meeting the unmet health care needs of the uninsured, Medicaid and other vulnerable patients. Safety net clinics provide a variety of services including, chronic care, specialty care, dental care, pharmaceutical care, vision care, women's health, mental health, health education, case management, care coordination, and various supportive services. Harnessing the new autonomous licensure law for nurse practitioners (NPs) will expand access by allowing NPs with five or more years of clinical experience to practice without the restriction of a mandated collaborating physician and can help mitigate the shortage of PCPs by increasing provider capacity in safety net clinics.
Leveraging the New Nurse Practitioner Autonomous Practice Licensure Law
The autonomous practice licensure law for Virginia NPs became effective January 7, 2019. The new law, reforms scope-of-practice permitting qualified NPs to be licensed to practice independently. Elimination of the career-long collaborative agreement with a team physician following a transition to practice period is a significant public policy change projected to increase the primary care workforce across the state.
Eligible NPs must meet a five-year full-time clinical practice experience equivalent and file an attestation from their collaborating physician with the Board of Nursing. Clinical practice experience is delineated as the post-graduate delivery of healthcare directly to patients, which unfortunately excludes administrative and faculty teaching time. The five-year full-time equivalent is based on a 36-hour work week and is defined as 1,800 hours per year for a total of 9,000 hours. The application requires a signature by the patient-care team physician(s) affirming that:
- The physician served as the NP collaborator pursuant to a practice agreement;
- The physician routinely practiced with a patient population and in a practice area for which the NP is certified and licensed; and
- The time period practiced with the NP pursuant to the practice agreement.
If circumstances inhibit the NP from obtaining an attestation from the collaborating physician, “other evidence” meeting the qualifications for autonomous practice licensure may be submitted. A one-time administrative fee of $100 per certification category in which the NP is licensed and certified is required. Upon verification that requirements have been met, a new “autonomous practice license” is issued and the NP may practice autonomously.
Since implementation of the new autonomous practice licensure law, 639 NPs have obtained autonomous licensure. This represents approximately 16% of an estimated 4,000 eligible NPs. These numbers are expected to grow with uptake of the new law and development and diffusion of innovative service delivery models.
The autonomous practice licensure law for Virginia NPs, has the potential to mitigate the primary care workforce shortage and increase access to care across the state. With delivery system changes and full utilization of NP and physician assistant services, the projected shortage of 23,640 PCPs by 2025 can be effectively mitigated. Although NPs and PAs do not replace physicians, studies have shown that NPs and PA practitioners can augment and expand physician capacity in many care settings. NPs can manage 80 to 90% of care provided by primary care physicians such as, take medical histories, conduct exams, order and interpret tests, develop treatment plans, and provide preventive care. Leveraging use of autonomous licensed NPs in free and charitable clinics is a strategy to increase primary care capacity to address the health care needs of Virginia's uninsured, Medicaid and other vulnerable patients.
Article provided by Cynthia Fagan, DNP, RN, FNP-BC with the Virginia Council of Nurse Practitioners.