Health systems are turning to advanced practice provider care to increase capacity and patient access.
Projections from the Bureau of Labor Statistics said that nurse practitioners are the fastest-growing occupation in the country, with employment in the profession expected to grow 46% by 2031. Physician assistant employment is also slated to increase nearly 30% in the same time period, placing it among the nation's 20 fastest-growing occupations.
Simultaneously, a physician shortage has already hit the nation and is expected to grow worse as physicians retire. About 36,000 nurse practitioners entered the healthcare workforce in 2020, alongside nearly 10,000 physician assistants and 2,600 certified registered nurse anesthesiologists. Together, they made up more than 60% of providers entering the workforce. Only 37% were physicians, according to a Kaufman Hall analysis of data from professional societies.
To address the gaps in care, systems are adjusting their care models to include more APPs.
"Regardless of the care setting or the type of APP, the NP or PA is a valued member of the provider team who is an active participant in evaluation of patients and care planning with their collaborating physician," John Heaton, MD, president and chief medical officer for New Orleans-based LCMC Health, told Becker's.
The scope of practice debate
In recent years, medical associations have butted heads over whether increasing scope of practice for APPs will improve patient care and access.
National associations for APPs and pharmacists have lobbies for increased scopes amid the nation's growing physician shortage and rising patient volumes. Some organizations also said that expanding scopes can reduce healthcare costs and that 82% of patients support having APPs provide the full extent of care.
"I don't want to replace physicians. I believe we should all be able to practice to the full extent of our education and training for the benefit of patients," Janet Setnor, MSN, CRNA, president of the American Association of Nurse Anesthesiology, told Becker's.
However, the American Medical Association, which has led the opposition against broader scopes of practice, has said that expanding APPs practices can harm patients and increase cost of care.
"There is certainly room for improvement in the U.S. health system, but allowing nonphysicians such as nurse practitioners or physician assistants to diagnose and treat patients without any physician oversight is a step in the wrong direction," the association's website says.
Becker's asked leaders if they saw or heard of tensions around scope of practice within their hospitals and medical groups, and all of them said they have not seen much tension.
"We work very collaboratively with a common goal of taking care of our patients and providing access to care," James Kravec, MD, chief clinical officer of Bon Secours Mercy Health's Youngstown/Lorain Ohio Market, told Becker's.
APP use in practice
APPs have been successful in a few models: primary care, walk-in care and specialty care.
"APPs help screen patients for medical conditions, which can then be escalated to a physician if necessary," Dr. Kravec said. "In surgery, APPs enable quicker patient access both before and after surgery while the surgeon remains focused on operating. It's a combination of improving access and ensuring follow-up care."
Bon Secours Mercy Health is one of many systems expanding their use of APPs. The system has a one- to three-year plan called the Provider Position and Provider Workforce Plan that predicts where the greatest staff needs are across the system and who best fits those roles.
"We start recruiting early, focusing on where we need physicians in primary care, advanced practice clinicians in primary care, and in which specialties physicians are required versus those that can be supported by advanced practice clinicians," Dr. Kravec said.
The plan is adjusted yearly and is created in collaboration between hospital leaders and medical groups.
Norfolk, Va.-based Sentara Health is another system leaning into APP care. It is currently working on doubling the number of advanced practice providers in its primary care facilities and anticipates a 70% increase in care capacity with each APP added. APPs in primary care will manage about 1,100 patients annually, compared to 1,500 patients for physicians.
"APPs are crucial to expanding primary care access and meeting the growing demand for healthcare services," Steven Pearman, MD, vice president of Sentara Medical Group, told Becker's. "It's vital to integrate them thoughtfully into the care team, leveraging their skills to improve outcomes and reduce burdens on physicians. A collaborative, team-based approach is the future of primary care."
Sentara is also transitioning from a 1-to-1 pairing of physician and APP to a team-based care model where physicians lead a team of APPs, registered nurses, pharmacists, counselors, educators and care managers.
The team-based approach will allow care teams to manage lower-complexity needs and provide bridging care for new patients awaiting their first primary care provider appointment. The model enables both physicians and APPs to practice at the top of their license in both primary and specialty care.
APP leadership expanding in the C-suite
A growing number of health systems are adding advanced practice providers to their executive teams.
"The value of an executive level APP leader includes a standardized reporting structure of APRN/PAs to ensure APPs are practicing at the top of their license in a positive work environment with a focus on practice, productivity, recruitment and onboarding, annual performance reviews, and quality and compliance," Meredith Foxx, MSN, APRN, senior vice president and chief nursing officer at Cleveland Clinic, told Becker's.
Over the past several months, at least four health systems have created executive APP positions or added them to their leadership structures. This includes:
- Melissa Stoudmire, MSN, APRN, Cleveland Clinic's first vice president of advanced practice providers, stepped into the role Aug. 1 and will lead more than 3,600 PAs, NPs, clinical nurse specialists, certified midwives, certified registered nurse anesthetists and certified anesthesiologist assistants.
- Lewes, Del.-based Beebe Healthcare selected Amanda Connoyer, DNP, APRN, as its first chief advanced practice clinician to oversee the system's 200 APPs.
Concerns about APP care
Within hospitals, many physicians have embraced APPs, though with some of the major changes comes a few initial concerns.
At Sentara, physicians raised concerns regarding legal exposure, training, compensation and a perceived loss of control over patient care.
"It's a cultural shift to recognize that delegating care responsibilities is essential for reducing burnout and improving outcomes," Dr. Pearman said. "APPs are viewed as colleagues, not 'helpers,' which fosters a professional environment."
To address these concerns, Sentara has enhanced its APP onboarding and mentorship programs and is transitioning to a compensation model in 2025 that balances base salary, quality metrics and productivity bonuses, and reduced the administrative burden so physicians and APPs could focus on patient care.
Advice
Across the country, leaders said the same thing: APPs are a valuable member of the care team and their work is vital.
"Our team includes physicians, APPs, pharmacists, technicians, nurses—everyone plays a different but vital role," Dr. Kravec said. "Over time, the dynamics may shift, but having a great team with a common purpose is the key takeaway."
Leaders also told Becker's that systems should reevaluate their current access, availability and patient needs and adjust their need for physicians and APPs. For systems that determine APPs are the best fit for the job, Dr. Pearman has six pieces of advice for how to expand the APP coverage:
- Create a culture: Educate stakeholders on the value of APPs and recognize them as professional colleagues.
- Define roles: Align APPs with organizational goals and clarify their scope of practice.
- Be flexible: Offer hybrid schedules and accommodate personal needs to attract and retain talent.
- Invest in training: Provide onboarding, mentorship and continuing education to support APPs' growth.
- Foster inclusion: Involve APPs in decision-making, governance and leadership opportunities.
- Utilize partnerships: Collaborate with academic institutions and training programs to develop a pipeline of skilled APPs.