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Within the next decade or so, the US is expected to experience a primary care shortfall of up to 86,000 physicians. Though the impact will be felt throughout the nation, socioeconomically disadvantaged communities are likely to bear the brunt.

In rural areas especially, a perfect storm of lower incomes, limited insurance coverage and access, insufficient public transportation, and dwindling healthcare provider numbers has translated into significant disparities in preventable chronic diseases, hospitalizations, and elevated mortality rates. Given proposed cuts to Medicaid, which 1 in 7 Americans living in rural areas rely on, and an aging population, gaps in outcomes are likely to widen even further.

An important key to addressing and possibly eliminating these current and future gaps — especially in the care of chronic diseases — lie with nurse practitioners (NPs).

“NPs are becoming more and more critical points of access to care in really poor neighborhoods,” Monica O’Reilly-Jacob, PhD, assistant professor at the Columbia University School of Nursing’s Center for Healthcare Delivery Research and Innovation in New York City, told Medscape Medical News. “So even though primary care supply is low, NP presence is even greater.”

O’Reilly-Jacob is the lead author of a cross-sectional analysis examining the distribution of primary care practices across communities of varying socioeconomic characteristics in the US. Not only did her team find that in 2023, 53.4% (42,601 of 79,743) of primary care practices employed NPs, but these practices were also significantly likely to be located among communities classified as low income and rural. What’s more, as numbers of primary care clinics declined in areas with the highest levels of socioeconomic disadvantages, the proportion of independent NP practices appeared to increase.

A Niche of Innovators

Lorraine Bock is a dual-certified family NP and emergency NP. Owner of two direct primary care practices operating in rural areas — one in Carlisle, Pennsylvania, and the other in North Brookfield, Massachusetts — Bock said that NPs inherently embody the concept of “meeting patients where they are.”

“NPs are innovators,” Bock said. “We’re trained to look at the whole person, the whole environment, everything that impacts the patient and not just the disease process. So when it comes to delivering care, we go where the patients are.”

Bock shared that she recently did a house call on a homebound patient with diabetes, instructed her on injecting insulin, and got her on a continuous glucose monitor.

“As NPs, we treat chronic diseases for a number of reasons,” said Bock. “One is that there aren’t enough specialists. In our area, a newly diagnosed diabetic cannot get in to see an endocrinologist if they aren’t already an established patient. You can’t wait to treat your diabetes or your high blood pressure for 3-6 months.”

Providing patients with consistent access to diabetes education, tools, and treatment regimens is where NPs can make a real difference, said K.C. Arnold, an NP and owner of The Diabetes Center in Ocean Springs, Mississippi.

“We’re a boots-on-the-ground niche caring for patients,” said Arnold. “For example, I start with a patient where they’re at and help them make little changes to get them to their A1c goals. It doesn’t happen overnight, but that’s where NPs are best at what we do, whether it’s primary care or a specialty practice like mine.”

Addressing Practice Constraints

Though NPs are currently one of the fastest growing occupations, they face formidable challenges in many of the areas where their services are most needed. Otherwise known as scope of practice regulations, state laws bucket NPs into three practice categories: the right to conduct full professional activities (without physician supervision or collaboration), reduced activities (inability to operate independently or prescribe certain treatments), or restricted activities (required to work under physician supervision for all scope of practice).

Today, NPs face reduced practice authority in six of the poorest US states (Alabama, Kentucky, West Virginia, Arkansas, Mississippi, and Louisiana) and restricted in one (Oklahoma).

Pointing to her study findings, O’Reilly-Jacob noted despite having some of the worst health outcomes in the country and being most dependent on practices with NPs on staff, “the southeast has the most restrictive scope of practice laws.”

“Imagine what could be happening if we reduced some of these restrictions and increased capacity,” said O’Reilly-Jacob.

“I can’t, as a nurse practitioner, order medical nutrition therapy or refer to a dietician due to federal Medicare rules for example,” said Arnold. “I can be a prescribing provider for diabetic shoes, but I can’t be a certifying provider. So if my patients have neuropathy and need diabetic shoes, I have to work in collaboration with their primary care doctor.”

Both Arnold and Bock said that the inability to afford to run an independent practice has also been challenging. Bock explained that Medicare currently reimburses NPs at 85%, or the amount physicians receive, while Medicaid ranges from 75% to 100%.

Collaboration Is Key

Western North Carolina’s Mountain Area Health Education Center (MAHEC) is working hard to ensure that health professionals and workforce are trained and encouraged to practice where the needs are greatest.

“Every one of our 16 western-most counties has a health professional shortage by some definition,” said Brian Hodge, MD, family physician and MAHEC’s chief academic officer. “So we’re continually and actively looking at both health outcomes of these different counties and also what primary care access looks like, what the population to primary care ratios or physician density look like,” he said.

This is where NPs can fill the gap, especially in light of pending federal policies.

“How we work together, how we coordinate care across professions, how we lean into opportunities for physicians, NPs, and pharmacists so they work collaboratively to ensure that all of the population has an opportunity to have their preventive care and chronic disease needs met is important,” said Hodge.

“I really hope we can continue to come to the table collaboratively and work toward better solutions. We owe it to our neighbors and rural communities to provide better access.”

The study was funded by a grant from the National Institute of Nursing Research.

O’Reilly-Jacob reported having no relevant financial relationships. Bock reported being the owner of Peace and Balance Health and Wellness Services in Carlisle, Pennsylvania, and Bright Star Health in North Brookfield. Arnold reported being the owner of The Diabetes Center. Hodge reported being an employee of MAHEC. 

Liz Scherer is a health and medical journalist. She frequently covers US, EU, and Canadian news on behalf of Medscape Medical News.