Nurse practitioners are rushing in to fill the gaps in US health care

Have you ever caught yourself squinting at the acronyms next to your health care provider’s name? MD, DO, NP, PA…

The medical workforce has changed. While the United States has long faced a doctor (MD or DO) shortage, there are now more nurse practitioners (NPs) and physician assistants (PAs) than ever before. More states are giving them a broad license to perform medical services on their own. A PA could prescribe you medication during a hospital stay. An NP could set up their own clinic in your area and run it like the family doctors of the last century.

If you’re looking for a primary care appointment, but have limited options (as many of us do), you may find more appointments with an NP next to the name than an MD. Or you might find an NP running the minute clinic at your local pharmacy.

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What do all these letters mean? How should people think about these different credentials in different contexts? These are questions with major implications for both the US health system as a whole, and for each individual seeking care. Here’s what you need to know.

Though the rules can differ depending on where you live, here are the broad strokes of what these different certifications mean:

MDs (medical doctors) and DOs (doctors of osteopathic medicine): These are the positions that we’d commonly call “doctor.” They get an undergraduate degree, attend medical school, and then go through several years of residency under the supervision of more experienced physicians. DOs have historically placed an emphasis on a “holistic” approach to treating their patients, but as medicine overall has trended in that direction, there is less of a difference in practice between these two positions as there used to be.NPs (nurse practitioners): These providers have a bachelor’s degree (as all registered nurses do) and then got a postgraduate degree (either master’s or PhD) to become an NP. Depending on your state, they can either run their own practices or they must collaborate with an MD/DO who oversees their work. According to Grant Martsolf, a nursing services researcher at the University of Pittsburgh, the NP category was originally created because there were a lot of long-serving nurses who were more experienced and frankly more knowledgeable than younger MDs and DOs. NPs can also work in specialty fields (like cardiology) and in hospitals.PAs (physician assistants): These practitioners also get an undergraduate degree with credits in relevant fields like biology or chemistry and receive postgraduate education to become a PA. They always work in collaboration with an overseeing physician — thus the name — and they can be found everywhere from the primary care clinic to the hospital. There is wide variation in how they are allowed to practice across the country: In some states, they can treat and prescribe medicines without a doctor present; in others, a doctor is required to be much more hands on.

There are other acronyms (RNs, or registered nurses; LPNs, or licensed practical nurses) but NPs especially are increasingly practicing medicine autonomously, literally changing the face of health care for many Americans.

In 1999, there were just 44,000 NPs in the United States. Today, while estimates vary, there are in the neighborhood of 400,000. A real shift in the type of provider who offers general care — and even sometimes treatment in a more specialized setting — is underway in America.

What’s driving this rapid growth in nurse practitioners?

The dramatic growth in NPs has coincided with reforms that have allowed them to practice more medicine on their own. In the 1990s, only a handful of states were allowing NPs to have full autonomy, including the ability to start and oversee their own clinic; today, more than half (27) grant them that freedom under state law (called “scope of practice” laws).

Why such a shift? The doctor shortage was the most commonly cited reason in my interviews with researchers in this field. It’s becoming harder and harder for patients to find a doctor, especially for basic primary care, because many doctors are opting for more lucrative specialties over becoming a general practitioner. Authorizing NPs specifically to do that work on their own is theoretically a way to get more providers into underserved communities. While doctors have often resisted these changes, large health systems are more supportive because it is cheaper to hire NPs than MDs.

“The health systems are experiencing shortages of workers everywhere. They just want warm bodies,” Monica O’Reilly-Jacob, a nurse practitioner and nursing health services researcher at Columbia School of Nursing, told me.

So, in theory, you can get more providers delivering the same basic medical services at a lower cost, often to patients who may not have any other options. Even if those benefits are limited, some experts still argue in favor of relaxing the rules and giving more discretion to the individual clinic or health system to decide how their providers practice medicine.

“It seems to me that these scope of practice questions are actually relatively well managed within the institution,” Martsolf said.

Is this good for patients?

The theory seems sound — but the reality is a bit more complicated.

There is some evidence that giving NPs more freedom allows them to deliver care to more patients; one study in particular looked at prescribing for opioid overdose treatment after NP laws were liberalized in some states and found that more prescriptions were being written without appearing to replace the prescriptions already being given by MDs and DOs. That would suggest the NPs were playing a complementary role and addressing an unmet need.

“We see big increases in prescribing behavior in the states where [NPs] can participate in the market compared to states where they can’t, which we interpret as an increase in market access and lower costs,” Mindy Marks, a health economist at Northeastern University and co-author on that study, told me. “There was a need there that’s now being addressed.”

But there may be a limit to how much loosening rules for NPs expands access for the people who need it most. At the same time that more NPs are allowed to start and run their own practices, those NPs are being drawn away from primary care by the same financial incentives that are luring doctors away. They can make more money working with a specialist or in a hospital than they can running their own primary care clinic.

That can also lead to people working beyond what they’ve been trained to do, O’Reilly-Jacob said. While most NPs have received training specifically for primary care, more and more of them are working in acute care settings, like hospitals. While NPs could get certification for those services, not all of them do.

This disconnect between the idea of expanding scope of practice and how it actually plays out in the real world is one of the reasons that patients should still be diligent about who’s treating them.

Should you be worried about seeing an NP?

Despite the caveats, all the experts I spoke to said yes, they would be comfortable with or even prefer getting treated by an NP, particularly for primary care.

“I will wait two months to see my primary care NP rather than the physician that she works with,” O’Reilly-Jacob said, adding that the NP has a longer waiting list but that she’s worth it. “I think NPs just look at the whole person. They focus on preventative care. They’re really patient-centered. They are great at communication. They’re not standing at the door with their hand on the knob waiting to leave. I notice a big difference between primary care in front of an NP and a physician.”

Still, there are some questions that you can ask if you’re looking for a new primary care provider and considering an NP. Ask how long they’ve been practicing and what kind of training they’ve received. If you find a NP who’s worked on their own for 10 years, you’re probably going to get as good of care as you would from a doctor, Martsolf said. Some states, like New York, actually require NPs to perform a certain number of hours with doctor oversight before an NP can practice on their own. But if they are a younger provider, it could be worth asking additional questions about their experience and education to make sure you’re comfortable with having them as your primary contact with the medical system.

Likewise, at a specialty clinic or a hospital, you could ask about how an NP coordinates with a doctor or what kind of specialized training they have received.

“If I was in the hospital, I would just say, ‘What’s your certification?’” O’Reilly-Jacob said. “And if they’re certified to be practicing where they are, I’m all on board.”

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