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Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity

Health Reform and the Primary Care Workforce

Graves, John A. PhD*; Mishra, Pranita MPP; Dittus, Robert S. MD, MPH; Parikh, Ravi MD, MPH§; Perloff, Jennifer PhD; Buerhaus, Peter I. PhD, RN, FAAN

doi: 10.1097/MLR.0000000000000454
Original Articles

Background: Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians—particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured.

Objective: We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws.

Research Design: An observational study.

Subjects: 2013 Area Health Resource File (AHRF) and US Census Bureau county travel data.

Measures: The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC.

Results: We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations.

Conclusions: Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.

*Department of Health Policy, Institute for Medicine and Public Health

Health Systems Data Analyst I, Department of Health Policy

Population Health Sciences, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN

§Department of Ophthalmology and Visual Sciences, Yale University, New Haven, CT

Heller School for Social Policy and Management, Brandeis University, Waltham, MA

Center for Interdisciplinary Health Workforce Studies, College of Nursing, Nashville, TN

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Initial funding for this project was provided by the Robert Wood Johnson Foundation’s State Health Access and Reform Evaluation Program.

The authors declare no conflict of interest.

Reprints: John A. Graves, PhD, Department of Health Policy, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1200, Nashville, TN 37203-1738. E-mail:

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