By the year 2030, the expected shortfall of primary care physicians ranges between 14,800 and 49,300.¹ Under the influence of a growing and aging population, the next decade promises to put extraordinary pressure on the physician workforce. To make matters worse, physician reimbursement remains stagnant or in decline. While there remains modest growth in the total number of physicians in the U.S., demand is outpacing supply, and the gap between primary care and specialty care growth is widening. Independent practices are already confronted with increasingly unsustainable business economics, and soon, only subsidized primary care will be able to survive. While most urgent care models already rely heavily on advanced practitioners, the limited supply of physicians and the upside-down business case we expect over the next decade will necessitate a deliberate and strategic approach to the utilization of nonphysician providers in urgent care.
Nurse practitioners and physician assistants have widely been viewed as a potential stop-gap for the growing shortage. This has fueled an unprecedented expansion of advanced practice training programs and a reinforced provider work-force when it is most desperately needed. What’s more, NPs and PAs choose primary care as their practice interest more often than physicians. In fact, 78% of NPs choose a primary care discipline vs only 33% of physicians.² With more schools, shorter training requirements, and more primary care interest, NPs practicing in primary care are slated to increase by 47% in the next 6 years, with primary care PAs increasing by 38%.2 Yet, scope of practice laws are an obstacle to independent practice for NPs and PAs, and most states require some level of physician supervision. These practice restrictions also have unintended consequences, including the potential of medical liability for the practices that rely heavily on advanced practitioner staffing models. Such is the case for many urgent care centers. In an effort to reduce risk, ensure quality, and provide the necessary support for NPs and PAs in urgent care, a well-structured supervision policy and oversight are critical. Here are a few suggestions:
- Regulatory: Scope of practice, prescriptive authority, supervision, and chart sign-off requirements vary considerably by state. Make sure you understand your state’s statutes.
- Credentialing: Internal credentialing and privileging are critical when integrating advanced practice providers (APPs) into urgent care. Do not assume that all APPs are created equal. Some are more prepared than others for the urgent care scope of practice. Experience in a family practice, urgent care, and/or emergency department setting along with a core competency assessment is a good way to narrow the candidate pool.
- Supervision: Supervision policy is as much a matter of quality as risk management. Improper and/or inconsistent supervision exposes the practice and the providers to liability if there is a bad outcome, regardless if the actual care was appropriate. These policies should be clear, easy to understand, and signed off on by the APPs and their physician supervisors.
- High-risk complaints and conditions: Given the increased risk and challenge of high-risk clinical presentations, it is highly recommended that the urgent care define what they are and require some level of oversight and consultation with a supervising physician. Examples include chest pain, confusion, shortness of breath, abnormal vital signs, and patients at the extremes of age.
An organized and disciplined approach to supervision can help reduce the risk and exposure caused by training and experience gaps that are inherent to an advanced practice staffing model. However, be aware that a written policy not followed is perhaps worse than no policy at all. Thus, it is critical to enforce and audit your supervision program for appropriate and consistent application. This protects the practice, the practitioners, and the patients alike.
Clearly, the primary care workforce is changing, and urgent care is already at the cutting edge for provider models utilizing advanced practitioners. With sustained attention to credentialing, oversight, and supervision, urgent care practices can maintain quality and manage risk while expanding the provider workforce in the face of declining physician availability.
- Dall T, West T, Chakrabarti R, et al. The complexities of physician supply and demand: projections from 2016 to 2030. American Association of Medical Collages. March 2018.
- UnitedHealthGroup. Addressing the nation’s primary care shortage: advanced practice clinicians and innovative care delivery models. September 2018.