Primary Care Delivery Changes as Nonphysician Clinicians Gain Independence

States across the United States have expanded health insurance coverage to more of their uninsured residents, resulting in at least 1 million more people having health insurance in 2007 than in 2006. These state-level health reforms should result in improved health care for a greater portion of the population. But the shortage of physicians, at least in some areas, has raised questions about whether the increased demand for care can be met. One study found that about 56 million U.S. residents do not have a regular source of health care because of physician shortages in their areas (1). Some patients now face long delays or many miles of travel to receive primary care.

A survey conducted in Massachusetts, a state with a large increase of newly insured residents, illustrates these problems. The 2007 survey by the Massachusetts Medical Society found that even before health reform was enacted, Massachusetts had shortages of primary care physicians and some specialists and that patients already had access problems, including long waits for appointments (2). “Massachusetts may be leading the nation in health care reform, but we'e falling behind in a critical aspect of patient care, and that's the supply of physicians. With an aging population, health care reform, and soaring rates of obesity and chronic diseases, such as diabetes, hypertension, and arthritis, real questions are surfacing about whether enough physicians will be available in Massachusetts to handle the increased demand for health care services,” said B. Dale Magee, MD, past president of the Massachusetts Medical Society, when the findings were published.

To help fill gaps in the generalist physician workforce, leaders of the health reform in Massachusetts have supported the expanded use of nonphysician health care providers. Increasingly, physician assistants (PAs) and nurse practitioners (NPs) are staffing clinics and providing basic care …