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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000372063.03942.09
AJN Reports

Rural NPs Embrace Private Practice

Presley, Susan

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Despite challenges, NPs in rural private practice are flourishing.

Recent battles over health care reform raise the question as to whether there will be enough health care providers to take care of everyone. According to the American Academy of Family Physicians and others (, only 17% of U.S. graduating physicians in 2008 opted for primary care practice. The August 3, 2009, issue of Time magazine suggested that NPs might be the ones to fill the gap, as did Michelle Andrews, writing for the New York Times health blog on November 6, 2009: "If tens of millions of new patients enter the health care system, it seems clear that nurse practitioners will be needed to perform many of the tasks now performed by physicians." And in rural America, the shortage of primary care physicians is just as desperate, if not more so. Data presented by the Texas Tech University Health Sciences Center ( show that 27 counties in West Texas, for instance, have one or no physician, and nine counties are grossly underserved, with no primary care physicians, no NPs, and no physician assistants.

Figure. Laurie Beach...
Figure. Laurie Beach...
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Meeting needs in rural America. Mary Jo Goolsby, director of research and education for the American Academy of Nurse Practitioners, said that just over 20% of NPs practice in rural areas. "This is actually about the same percentage of the U.S. population we have living in rural areas and more than twice the percentage of physicians who practice in rural areas." And the trend is moving upward, albeit slowly. Thirty years ago, a small cohort study from the Department of Health, Education, and Welfare (published in the October 1978 issue of the American Journal of Public Health) showed that only 16% of NPs worked in rural settings.

Government agencies are discovering the efficacy of using NPs, too. In 2004 Washington State launched a program that added more NPs to its workers' compensation provider system in order to address disparities in access to health care among injured workers in rural areas. The three-year pilot program, reported on in the spring 2008 Journal of Rural Health, demonstrated that rural NPs serving as primary providers increased the timeliness with which injured workers were treated and reports were filed. In addition, the numbers of patients seen by NPs in rural areas increased by 14% (and the number seen by physicians rose 1.5%).

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Laws regarding what level of connection to a physician an NP must have vary from state to state, making the exact number of NPs in business for themselves difficult to pinpoint. Goolsby says that there are many different levels of practice, including community-based private care, hospital-owned outpatient practice—and many other types of practice for NPs.

Dee Lesseig, an advanced practice nurse (APN) practicing psychiatry in rural Kirksville, Missouri, agrees, noting that it can lead to confusion. "The term "practice" is confusing because we have to have a formal collaborative agreement with a physician. At least that's the intent of the law."

Reasons for going into private practice vary. Barbara Phillips, an NP in Aberdeen, Washington (a rural area with a population of around 16,500), went into private practice so she could care for patients in a way that matched her philosophical ideals. "We focus on health and not disease. My new-patient visits are 45 minutes. A great many of my patients have multiple diseases that can't adequately be dealt with in five or 10 minutes."

Lesseig concurs, noting, "Nurses are very dissatisfied if they can't take time in a practice to take care of their patients. They don't want a system that puts pressure on them to see more patients per hour. It's why we go into nursing instead of medicine, to spend time with patients."

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A study by Lindeke and colleagues published in the spring 2005 Journal of Rural Health showed that one of the difficulties NPs had with practice in rural areas was low salaries.

Although that perception may keep many NPs from practicing in rural areas, the comparatively lower cost of living in those areas often makes up for the gap in salaries between rural NPs and their counterparts in more heavily populated regions.

"We actually do quite well," said Phillips. "I opened the practice three years ago, and I was paying my bills within two months." Spending more time with her patients does cut into her income, however. "One of the things you have to look at in your practice is your bottom line, and part of that is asking what it costs to see each patient. If the cost drops below your reimbursement, that becomes a negative."

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One frequent obstacle to going into private practice is health insurance. If an NP's office staff is small, finding a group policy can be difficult, if not impossible. And perhaps one of the biggest challenges for NPs in private practice is a combination of what Phillips calls "the red tape" of insurance authorizations and finding qualified staff to work through it. "The prior authorizations and the work that goes on behind the scenes take so much staff time," says Phillips, although she understands that regulation is essential. A patient may request an unnecessary test "just because he's always wanted one." However, most of the NP's struggles go the other way—they spend inordinate amounts of time trying to obtain approval for tests or medication that patients need.

Obtaining proper reimbursement is an ongoing issue. Lesseig says that until recently, most reimbursement groups didn't have fee schedules for NPs or other APNs, and many insurance companies fail to understand that NPs and APNs can save them money. "Medicare, for example, reimburses NPs at 85% of a physician's rate." NPs are paid the same as a counselor who has no prescribing privileges. Lesseig says that NPs and APNs "don't really get credit for being able to cover therapy and medications."

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Physicians have been the least accepting of NPs as providers with ever-expanding roles. Phillips says that primary care physicians in particular have been the biggest challenge, with their reactions to her practice "ranging from professional politeness to open hostility."

Although some physicians are clearly becoming more accepting of NPs who work with them in their practices, many still take issue with NPs in solo practice.

In Kentucky, for example, physician groups are opposing legislation that would give NPs more in dependence in prescribing. The conflict, says Jeffrey Harden, DO, of Kirksville, Missouri, comes from a feeling by physicians and osteopaths that NPs are "encroaching on their territory and trying to place themselves in the domain of physicians. Why be an NP if you wanted to be a physician?"

The rural public has been much more welcoming to NPs, both as primary care providers and in specialty fields. A 2007 study by Deonne J. Brown of the College of Nursing at Seattle University in Washington that focused on the partially rural King County showed that 90% of adults who worked for a religious nonprofit organization knew about the role of NPs. Of those who had used NP services, a strong majority were satisfied with the care they received. Lesseig says that in the last 15 years, acceptance of NPs from rural community members has greatly increased.

Although rural NPs in private practice have unique challenges, it's still well worth it for NPs to have their own businesses, says Phillips. "I'll never go back to working for someone else." Perhaps most important, she adds, NPs don't have to go it alone. A Web site started by Phillips,, is geared specifically to helping start-up and existing private practice NPs.

With U.S. health care being on the verge of radical change, NPs in private practice—particularly in rural areas—will certainly be affected. Phillips explains, "So many NPs want to get into their own practices, and I think this will be a huge part of the future of NPs. I think the more NPs who have their own offices—particularly because we're so willing to work anywhere—the more we improve access to care."

Susan Presley

© 2010 Lippincott Williams & Wilkins, Inc.


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