“Some consider it the normal course of events. Try to visit your doctor and you often have to wait weeks…there is growing evidence that concerns exist with the current capacity and growth trends in Georgia’s physician workforce.”
Those words were written nearly 20 years ago in an annual report by the state agency known today as the Georgia Board of Health Care Workforce (GBHCW). Georgia has added over 2 million residents since then, mostly concentrated in Atlanta and other metropolitan areas. Meanwhile, the demographic trends that were predicted for rural Georgia have only accelerated in recent years, as its percentage of the state’s population declines and healthcare disparities continue to grow. However, it is not only rural Georgia that lacks healthcare providers, as disparities persist in pockets across the state.
In May 2020, 149 of the state’s 159 counties were designated as a primary care Health Provider Shortage Area (HPSA). Fifty-three of those 149 counties were given this designation due to their geography, with nearly all of them located in rural areas. Eighty-nine of the 149 counties were designated due to their population demographics, consisting of high levels of poverty, low income, Medicaid-eligibility, migrant populations or homelessness. Seven counties, comprising parts of the Atlanta, Augusta, and Savannah areas, were given partial county designations in which portions of the population do not have adequate access to primary care.
Similarly, 149 Georgia counties were categorized as either Medically Underserved Areas or Medically Underserved Populations. Georgia counties ranging from the most populous (Fulton) to the least populous (Taliaferro) comprised the state’s 141 Medically Underserved Areas, while the eight counties with Medically Underserved Populations included both urban and rural areas. The lack of primary care providers is consistent among both the most urban and most rural populations in Georgia.
One solution to this healthcare provider shortage that is proposed in this study is to allow physician assistants (PAs) and advanced practice registered nurses (APRNs) to practice to the full extent of their education and training. This proposed solution is not new or novel to Georgia. In 2015, the Georgia Rural Hospital Stabilization Committee recommended expanded authority for nurse practitioners and physician assistants to improve health outcomes in rural Georgia. It was determined that this change “could help bolster healthcare resources in rural communities” due to the “growing physician shortage.” As other states deregulate and allow full practice authority for physician assistants and APRNs, healthcare disparities continue to grow in Georgia. Existing research shows that many of the arguments against full practice authority for these healthcare providers are misleading or inaccurate.
First, it is necessary to define these specialties and what differentiates them, along with how they are currently regulated in Georgia. Physician assistants are licensed clinicians who practice in every medical setting and specialty. They are “educated at the master’s degree level,” and their training consists of “approximately 27 months (three academic years) and include classroom instruction and more than 2,000 hours of clinical rotations.” In Georgia, physician assistants are not allowed to see patients independently and are supervised by a physician. A physician is only allowed to supervise four or fewer physician assistants. Physician assistants are allowed to prescribe medications and order diagnostic tests and additional medical treatment as allowed by their supervising physician.
APRNs consist of four types of providers who not only offer different levels of healthcare but are educated and certified differently.
Nurse practitioners, often referred to as NPs, are the most common. Georgia requires nurse practitioners to have a master’s or other graduate degree in a nursing practitioner specialty, advanced coursework related to patient care and to be nationally certified in their field of practice. Nurse practitioners are governed by the same supervision ratio as physician assistants, in which a physician can supervise no more than four nurse practitioners. Nurse practitioners are also allowed to prescribe drugs to patients depending on the agreement with the physician. Prior to 2020, Georgia was the last state in the country that prohibited nurse practitioners from ordering diagnostic tests; nurse practitioners are now allowed to order MRIs and CT scans.
Certified nurse-midwives, or CNMs, are registered nurses who possess at least a master’s degree in nurse-midwifery and are required to be certified by the American Midwifery Certification Board. CNMs are primarily associated with prenatal and postpartum care, including natural birthing procedures and holistic care, but also offer primary care to women throughout all stages of life.
Clinical nurse specialists, or CNSs, also require at least a master’s degree in nursing but typically do not engage in direct patient care. Their primary areas of focus often include managing the care of complex populations, such as gerontology or pediatric critical care, and the training and development of plans for health systems to improve delivery and patient outcomes.
Certified registered nurse anesthetists, or CRNAs, must possess a master’s degree in anesthesia and are required to be certified by the National Board of Certification and Recertification for Nurse Anesthetists. CRNAs provide all forms of anesthesia care.
According to the 2019-2020 GBHCW licensure renewal data, there are 24,914 total physicians comprising all specialties practicing statewide, at a rate of 230 physicians per 100,000 residents. There are 3,810 total physician assistants at a rate of 36.2 residents per 100,000 residents. There are 141,117 total registered nurses (RN) in the state, not including the specialties that comprise APRNs, at a rate of 939 per 100,000 residents. Among the four specialties which comprise APRNs, there are rates of 103 nurse practitioners, 13 certified registered nurse anesthetists, 4 certified nurse-midwives, and 2 clinical nurse specialists, all per 100,000 residents.
Given the higher rate of nurse practitioners in comparison to the other specialties that comprise APRNs, much of the existing research and this study focuses on their contributions to primary care. However, certified nurse-midwives also provide an important contribution to women’s primary care in many underserved areas and their contributions are noted where the research exists.
How underserved is most of Georgia?
Out of Georgia’s 150 counties:
- 9 Georgia counties do not have any type of physician at all
- 18 Georgia counties do not have a family medicine physician
- 40 lack an internal medicine physician
- 65 Georgia counties do not have a pediatrician
- 82 Georgia counties do not have an OB-GYN
- 90 do not have a psychiatrist
Unfortunately, this reflects an alarming trend in which Georgia’s healthcare disparities continue to widen. This is demonstrated by the previous license renewal period, in which eight Georgia counties did not have a physician, 11 did not have a family medicine physician, 37 did not have an internal medicine physician, 63 did not have a pediatrician, 75 did not have an OB-GYN, and 84 did not have a psychiatrist.
By expanding the ability of healthcare professionals to practice to the full extent of their training, Georgia can close its widening provider gap. Research from comprehensive studies assessing the effects of full practice authority for physician assistants and nurse practitioners is clear—unlocking the potential of these providers improves access to quality care for patients and does not expose patients to any new harms. States that grant full practice authority, allowing physician assistants and nurse practitioners to operate independently and without physician supervision, have increased healthcare access to underserved populations including rural residents, mental health patients and Medicaid recipients. The research has also indicated positive economic benefits for the community.
Several research studies have provided evidence that full practice authority for physician assistants and nurse practitioners can help address physician shortages—particularly in rural areas and Health Provider Shortage Areas (HPSAs). An analysis of healthcare providers in California and Washington state showed that physician assistants, nurse practitioners, and certified nurse-midwives were more likely to provide care for patients residing in rural areas and HPSAs. As more states allowed nurse practitioners to work to the full extent of their training between 2008 and 2016, the percentage of rural primary care practices employing nurse practitioners increased by 10 percentage points nationally. Further, allowing nurse practitioners and physician assistants to do the work that they are trained to perform is found to increase the supply of nurse practitioners and physician assistants in areas with physician shortages by approximately 60%.
Full practice authority for nurse practitioners, in addition to being associated with an increase in the likelihood of nurse practitioners residing in HPSAs, has also been found to be associated with higher self-employment for nurse practitioners. This increase in entrepreneurship has implications for local economic development and employment. One recent study found that the average NP-owned clinic employed seven full-time workers and served 325 patients each year. Reducing barriers to small business is as important in Georgia as it is nationally—62% of net new job creation is generated by small businesses.
Full practice authority for physician assistants and nurse practitioners has also been found to positively affect the most vulnerable members of society. One study finds that moving toward full practice authority for physician assistants reduces the dollar amount of outpatient Medicaid claims by 11%. Additional research suggests Medicaid patients received 8% more total days of patient care in states that granted nurse practitioners full practice authority, all without increasing cost. A national survey found that nurse practitioners are more likely to treat Medicaid patients than physicians. In Georgia, the most recent physician survey data finds that only 64% of physicians accept Medicaid patients and only 60% of physicians accept new Medicaid patients.
Full practice authority for nurse practitioners has also been shown to correlate with increased diversity of the nurse practitioner workforce. Research shows that minority patients prefer to receive care from minority doctors. For Black and Asian nurse practitioners, full practice authority is associated with higher caseloads of black Medicare patients. In addition to declining Medicaid acceptance rates among physicians, the Medicare acceptance rate in Georgia also continues to decline. This is important, considering an aging and increasingly diverse population statewide.
Georgia has taken steps in recent years to address its maternal mortality rate by expanding postpartum coverage through Medicaid. Medicaid is the largest payer of maternity care in the United States and finances over 40% of all births, and also covers a higher proportion of births with pregnancy complications. Women with incomes up to 220 percent of the federal poverty level are now eligible for increased postpartum coverage through Medicaid after legislation was passed in 2022 that extended medical coverage from six months to a year. Given the overall shortage of physicians including OB/GYNs, and the significant number of physicians statewide that do not accept Medicaid, certified nurse-midwives can play an important role in improved maternal health outcomes. States that allow certified nurse-midwives to practice to the full extent of their training and education have observed lower rates of labor inductions and C-sections than states that do not allow full practice authority for CNMs. These states have also seen slight improvements in infant health metrics, such as birth weight and gestation. An overall reduction in the number of C-sections could also result in significant cost reduction for the state, with one estimate of more than $100 million in savings.
COVID-19 and associated lockdowns took a significant toll on the mental health of Americans. A recent Kaiser Family Foundation study found that more than 40% of adults reported symptoms of anxiety or depression in January 2021—up from 11% in 2019. The problem is particularly acute in Georgia. A recent national analysis ranked Georgia last in access to mental healthcare. Nurse practitioners can do more, but restrictions on practice authority limit their potential. A recent research paper found that full practice authority for nurse practitioners increases patient-reported mental health and reduces mental health-related mortality, notably finding that “these improvements are concentrated in areas that are underserved by physicians and among populations that have difficulty accessing physician-provided care.”
Opponents of full practice authority often claim that nurse practitioners are satisfying their master’s requirement through online degrees, lacking the type of training and clinical hours that physicians possess. While nurse practitioners may not have completed medical school, the typical master’s degree program is designed to combine practical nursing experience with specialty training in their chosen field. The American Association of Colleges of Nursing describes potential master’s tracks in nursing as follows:
Entry-Level Master’s Degree: Developed for those with a bachelor’s or graduate degree in a discipline other than nursing, entry-level master’s degrees are also referred to as generic or accelerated programs. These offerings generally take about two to three years to finish with baccalaureate-level content and initial RN licensure completed during the first year. These programs, many of which prepare Clinical Nurse Leaders, are paced for students who have proven their ability to succeed at a four-year college or university. More than 60 entry-level master’s programs are available at schools nationwide.
RN to Master’s Degree: Designed for nurses with associate degrees, RN to MSN programs take about two to three years to complete with specific requirements varying by institution and based on the student’s previous course work. Though most programs are offered in classroom settings, many are delivered largely online or in a blended classroom/online format. The baccalaureate-level content missing from associate degree curricula is built into the front end of these degree completion programs. The number of RN to MSN programs has more than doubled in the past 25 years with more than 200 programs available today.
Baccalaureate to Master’s Degree: The traditional post-baccalaureate master’s is the most prevalent option offered to those seeking graduate preparation. Course work builds on undergraduate competency and allows students to concentrate their learning on a focus area. Program requirements and credit load vary by institution, though most programs may be completed in 18-24 months of full-time study. Though the majority of schools grant the Master of Science in Nursing (MSN) degree, some offer the Master of Nursing (MN) or MS in Nursing in keeping with university policy. The MSN, MN, and MS in Nursing are comparable degrees and prepare students at the same level of competency.
Despite common misconceptions, these programs often require years of training and education to complete and are built on previous work experience as a prerequisite. They are also intended to prepare APRNs for primary care specialties such as family medicine, women’s health or pediatrics, which would help address the coverage gaps that currently exist in Georgia.
One argument made against full practice authority for nurse practitioners is that independent NPs will overprescribe opioids. Objections are raised using statistics from one cross-sectional study that is unable to provide a clear picture of the effects of full practice authority. A more recent study using larger datasets over several years clearly shows that full practice authority does not result in a net increase in opioid prescribing. Another recent working paper confirms that full practice authority for nurse practitioners is not associated with increases in opioid prescribing to Medicare patients.
Legislative Activity in Other States
Georgia will not be going out on a limb if it allows full practice authority for nurse practitioners. In fact, Georgia is now among the minority of states that continue to impose restrictions on nurse practitioners. Earlier this year, Kansas became the 26th state to allow full practice authority for nurse practitioners. Although less common, two states have taken significant steps to also permit physician assistants to work to the full extent of their training. In 2019, North Dakota became the first state to provide pathways for physicians assistants to work without written agreements with physicians in several facilities and also own their own medical practices. Utah became the second state to move closer to full practice authority for physician assistants in 2021.
The last significant change to Georgia’s practice authority for APRNs and physician assistants occurred in 2020. This law resulted in physicians being allowed to enter into supervision agreements with four physician assistants, whereas they were previously only allowed to supervise two physician assistants. The same law also allowed APRNs to order MRIs and CT scans for the first time in non-emergency situations, in accordance with their nurse protocol agreement. These recent actions show that legislators are willing to ease practice restrictions, but much more can be done to address the widespread provider shortages affecting rural and urban communities across the state. Allowing full practice authority for nurse practitioners and physician assistants not only contributes to improved healthcare outcomes, but allowing them to practice independently is associated with improved economic outcomes for these underserved populations.