Nurse practitioner geographic distribution. underserved areas in the US. Steiner, R., Bumbach, M., Yoon, S., &L Lutz, B.

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1 Nurse practitioner geographic distribution and scope of practice in medically underserved areas in the US Neff, D.F., Harman, J., Bejliri,I., Steiner, R., Bumbach, M., Yoon, S., &L Lutz, B.

2 Funded by Robert Wood Johnson, The Future of Nursing: Campaign for Action Research Initiative Thank you Jeff Harman, PhD, UF Department of Health Services Research, Administration and Policy Michael Bumbach, RN, APRN, UF PhD student Dr. Ilir Bejliri and Sunny Yoon UF PhD student UF Department of Urban & Regional Planning and GeoPlan Center Dr. Ruth Steiner, Director of the Center for Health and the Built Environment Dr. Barbara Lutz, McNeill Distinguished Professor, School of Nursing, College of Health and Human Services, University of North Carolina-Wilmington

3 Patient Protection and Affordable Care Act Latest Numbers 8 million signed up for private insurance in the Health Insurance Marketplace 3 million adults gain coverage staying on their parents plans 3 million more people were enrolled in Medicaid and CHIP 5 million enrolled that meet ACA outside Marketplace 5.7 M will be uninsured 24 states have not expanded Medicaid. (retrieved at

4 Problem In just 3 years, we will have tens of thousands fewer primary care providers than we need, a shortage that will be felt disproportionately in rural and underserved urban environments.

5 Solution IOM: The Future of Nursing: Leading Change, Advancing Health nurses are poised to help bridge the gap between coverage and access, to coordinate increasingly complex care for a wide range of patients, to fulfill their potential as primary care providers to the full extent of their education and training, and to enable the full economic value of their contributions across practice settings to be realized. ed

6 Problem: State regulations of NP practice, institutional and other practice barriers may hinder NPs from providing services in these areas.

7 American Association of Nurse Practitioners

8 Purpose The AIM of this study was to compare the distribution and variability of: 21,100 licensed and nationally certified nurse practitioners (NP) practice location between states with and without restrictions on independent practice and overlay 241,618 primary care physician practices (PCPs) and medically underserved areas (MUAs) across the US to determine whether states which allow for independent NP practice are more likely to have NPs practicing in MUAs.

9 Methods Databases American Association of Nurse Practitioner National NP Database - 21, NPs addresses (proxy for practice location) American Medical Association database - 241,618 primary care physician (PCPs) practice sites US Dept. of Health & Human Services MUA at zip code tabulation area level. Rural-Urban Commuting Areas (RUCA) rural/small town and urban area codes classified by Census Track

10 Geographic Information System (GIS) methods Pinpoint descriptive locations to a spatial mapping surface Geo-locate NPs and physician Geocoded d 99.76% of NPs 99.99% of PCP

11 Chi Square Provider X type of state regulation type X MUA Logistic regression analysis: Examined odds of having an MUA with no provider (primary care physician or nurse practitioner) by level of nurse practice restriction Restricted Practice (reference) Reduced d Practice Full Practice

12 Findings

13

14

15

16

17 In states where NPS practice independently, d 71% of MUAs have NO primary health care providers (NPs and PCPs) In states t where NP practices are supervised dby a physician specifically for prescribing, 83% of MUAs have NO providers In states where NPs have the most restrictive practices, 79% of MUAs have NO providers

18 The odds of having a MUA with no PCP or NP practice was 33% lower in states that allowed for full NP practice compared to restricted states (OR=0.67, p<.001) 36% greater in states that had reduced NP practice compared to restricted states (OR=1.36, p<.001)

19 Policy, Delivery and Practice Implications Unequal distribution of primary health care providers (NPs and PCPs) in the US such that some geographic areas (MUAs) have few or no providers. Few medically underserved areas have available access to any primary care providers and are less likely to have access if there are state restrictions on NP practice. In addition, we found that when compared to PCPs, NPs are In addition, we found that when compared to PCPs, NPs are more likely to work in rural areas and MUAs.

20 Key point: State regulations negatively impact the NPs authority to provide primary care to the full extent of their education, certification, and training, including their ability to prescribe medications and order tests, to be reimbursed, and to be primary care providers of record. Leads to greater likelihood of having no primary care providers in MUAs

21 Future research To provide context to geocoding findings Conduct survey of a large sample of NPs Barriers and facilitators to practice Qualitative interviews with NPs Collect more data about NP practice environments though ARF and Census data and conduct more sophisticated analyses to account for differences in population and health care provider supply

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