Health Insurance

Amid a Physician Shortage, 51% of Primary Care Providers Are Nurse Practitioners and Physician Assistants

Amid a Physician Shortage, 51% of Primary Care Providers Are Nurse Practitioners and Physician Assistants

Nurse practitioners (NPs) and physician assistants (PAs) are filling the primary care physician gap. Here’s which states have the highest percentage of NPs and PAs in primary care.
A doctor speaks to a patient.
A doctor speaks to a patient. Source: Getty Images

The COVID-19 pandemic spotlighted America’s health care workers, as well as staffing shortages in an industry where people are increasingly overworked. Although the pandemic caused significant health care staff shortages, it also exacerbated those developing before the crisis struck — namely, an increasing lack of physicians in the U.S.

There’s an increasing demand for health care professionals. America is an ever-growing and aging nation — the U.S. Census Bureau even projects that the number of older adults will be higher than the number of children for the first time in 2034. Older adults need regular health care, particularly with 6 in 10 adult Americans having a chronic disease.

However, other health care professionals are stepping in to provide primary care. According to ValuePenguin health insurance expert Robin Townsend, the emergence of these professionals in primary care has benefits.

"Nurse practitioners and physician assistants are (at least partially) filling the primary care provider gap left by physicians," Townsend says. "That’s good for patients across the U.S. — especially those without insurance — as it gives them better access to affordable care."

Key findings

  • There are 168.7 primary care providers (PCPs) for every 100,000 Americans. The District of Columbia has the highest rate of PCPs at 464.1 per 100,000 residents. On the other hand, Washington state has just 107.9 PCPs per 100,000 residents — making it the state with the lowest rate of PCPs.
  • Nurse practitioners (NPs) and physician assistants (PAs) help fill those primary care gaps. In fact, NPs and PAs make up a larger portion of primary care providers than physicians. While 48.8% of PCPs in the U.S. are physicians (including doctors specializing in internal medicine, family medicine and pediatrics), 42.9% are NPs and 8.2% are PAs.
  • Kansas has the highest percentage of NPs and PAs in PCP roles (80.9%). That’s followed by Louisiana (77.5%) and North Dakota (72.9%). Meanwhile, the District of Columbia has the highest percentage of physicians in PCP roles (76.3%), followed by Hawaii (68.2%) and Pennsylvania (63.1%).
  • Since 2016, the number of nurse practitioners has jumped by 56.2%. Similarly, the number of those in PA roles has increased by 27.8%. Meanwhile, physicians in the combined specialties of internal medicine, family medicine and pediatrics have dropped by 0.21%.
  • NPs and PAs are among the 10 fastest-growing professions, according to U.S. Bureau of Labor Statistics (BLS) projections. From 2020 to 2030, NP jobs are predicted to grow by 52.2%, while PA roles are expected to grow by 31.0%. At the same time, the predicted growth for all occupations is 7.7%.

Rate of primary care providers varies widely by state

For every 100,000 Americans, there are 168.7 primary care providers (PCPs), but those figures vary extensively by state. Washington state ranks lowest, at 107.9 PCPs per 100,000 residents.

Following that, the states with the lowest rates include:

  • Nevada: 114.2 PCPs per 100,000 residents
  • Oregon: 115.6 PCPs per 100,000

On the other hand, the District of Columbia has the highest rate of PCPs at 464.1 per 100,000 residents. That’s followed by:

  • Alaska: 281.2 PCPs per 100,000 residents
  • Tennessee: 260.1 PCPs per 100,000

Many states with the lowest rate of PCP providers have more countywide primary care shortages than the states with the highest rates. An earlier ValuePenguin study on health care workforce shortages found that 41% of counties within Washington state have a lack of PCPs — the third-highest. Meanwhile, Nevada ranked first, with 63% of counties in the state facing a shortage of PCPs.

Primary care health professional shortage areas (HPSAs) are determined using the following factors:

  • Population-to-provider ratio
  • Percentage of population below 100% of the federal poverty level
  • Infant Health Index, which factors infant mortality rates or low birth weight rates
  • Travel time to the nearest source of care outside the HPSA area

On the opposite end of the list, just 8% of counties in Tennessee have a PCP shortage. And while the District of Columbia wasn’t included in the original study, three of the next four states with the highest rate of PCPs had deficiencies in 20% or less of their counties.

Still, there are some exceptions. Oregon (third-lowest PCP rate) had a notably smaller shortage of PCPs — affecting just 25% of counties in the state — while Alaska (second-highest PCP rate) ranked notably higher, with 79% of counties facing a PCP shortage.

Full rankings: States with the fewest primary care providers per capita

Rank
State
Population
Total PCPs
Rate of PCPs per 100,000 residents
1Washington7,738,6928,350107.9
2Nevada3,143,9913,590114.2
3Oregon4,246,1554,910115.6
4Hawaii1,441,5531,700117.9
5Alabama5,039,8776,090120.8
6Illinois12,671,46915,510122.4
7Utah3,337,9754,520135.4
8Texas29,527,94140,110135.8
9Louisiana4,624,0476,350137.3
10Kansas2,934,5824,050138.0
11New Mexico2,115,8772,930138.5
12California39,237,83654,750139.5
Show All Rows

Source: ValuePenguin analysis of U.S. Bureau of Labor Statistics (BLS) and U.S. Census Bureau data

51.1% of PCPs are nurse practitioners and physician assistants

When thinking about primary care, a doctor likely comes to mind. And that may be the case for some Americans — internal medicine, family medicine and pediatrics are primary care specialties in which physicians practice.

But a PCP doesn’t necessarily need to be a physician — in fact, more than half of PCP providers aren’t physicians at all. Rather, when comparing the number of physicians specializing in PCP roles with the number of nurse practitioners (NPs) and physician assistants (PAs) in the U.S., ValuePenguin researchers found:

  • 48.8% of PCPs are physicians
  • 42.9% are NPs
  • 8.2% are PAs

Townsend believes that varying levels of education likely play a role in the difference between the type of providers in PCP roles.

"NPs and PAs finish school and become licensed more quickly than physicians, which means they can start practicing sooner," Townsend says. "Educational costs are lower, too, making the NP and PA fields open to more people. And fewer medical school graduates are choosing primary care as their specialty."

Only 29.2% of U.S. physicians practice in a primary care specialty, according to a ValuePenguin analysis of a 2019 report from the Association of American Medical Colleges (AAMC). This rate has been declining over the past decade. Though many factors may contribute to the decline in physicians in primary care specialties, pay, burnout and an increasing number of physicians leaving likely contribute.

Primary care is among the lowest-paid specialties at an average of $255,000 annually, according to a 2022 Medscape report. In comparison, those in plastic surgery earn an average of $576,000 — the highest among those examined. Although primary care physician salaries are still well above the national median salary of $45,760, many physicians may prefer working within a higher-earning specialty — particularly those with hefty medical school debt.

Meanwhile, an analysis of studies on PCP burnout — emotional exhaustion and reduced feelings of accomplishment at work — found that the prevalence of self-reported burnout among PCPs range from 13.5% to 60%, according to a study published in the Medical Care Research and Review journal. Coupled with that, 1 in 3 primary care clinicians reported in March 2021 that they expected to leave primary care within five years, according to a survey from the Larry A. Green Center, a Richmond, Va.-based research, development and advocacy firm.

Which states have the lowest percentage of physicians in primary care roles?

The percentage of physicians in PCP roles varies by state, too. Overall, Kansas has the lowest percentage of physicians in PCP roles. Of the PCP providers in the state, just 19.1% are physicians, while 72.0% are NPs and 8.9% are PAs. That’s followed by:

  • Louisiana: 22.5% of PCPs are physicians
  • North Dakota: 27.1%

Meanwhile, the District of Columbia has the highest percentage of physicians in PCP roles (76.3%), followed by:

  • Hawaii: 68.2% of PCPs are physicians
  • Pennsylvania: 63.1%

With NPs and PAs earning significantly less than physicians, cost of living may have something to do with the varying percentages of physicians in primary care. The states with the lowest percentage of physicians in PCP roles generally have a lower cost of living. In comparison, those with the highest percentage of physicians in PCP roles generally have a higher cost of living.

Full rankings: States with the lowest percentage of physicians in PCP roles

Rank
State
Percentage of PCPs who are NPs
Percentage of PCPs who are PAs
Percentage of PCPs who are physicians
1Kansas72.0%8.9%19.1%
2Louisiana70.5%7.1%22.5%
3North Dakota63.1%9.8%27.1%
4West Virginia61.3%8.7%29.9%
5Alabama67.4%2.4%30.2%
6Mississippi67.0%2.1%30.9%
7North Carolina52.8%15.5%31.7%
8New Jersey56.9%11.0%32.2%
9Utah54.6%12.3%33.2%
10Tennessee61.8%4.7%33.5%
11Washington48.9%11.3%39.8%
12Georgia47.0%13.1%40.0%
Show All Rows

Source: ValuePenguin analysis of BLS and Census Bureau data

While NP and PA roles are growing, physician roles are shrinking

Since 2016, the number of people employed as nurse practitioners has jumped from 150,230 to 234,690 — an increase of 56.2%. PA roles have grown, too: The number of PAs has risen 27.8%, jumping from 104,050 in 2016 to 132,940 in 2021.

Meanwhile, the number of physicians in primary care specialties has dropped 0.21% in the same period.

Growth rate of U.S. physicians, NPs and PAs (2016 to 2021)

Year
Physicians
NPs
PAs
2016195,220150,230104,050
2017197,710166,280109,220
2018180,440179,650114,710
2019183,720200,600120,090
2020176,740211,280125,280
2021194,810234,690132,940
Growth rate (2016-2021)-0.21%56.2%27.8%

Source: ValuePenguin analysis of BLS data

However, the demand for physicians is growing. The BLS predicts that the U.S. will need 91,400 physicians by 2026, according to a 2020 report from Human Resources for Health — a 13% increase from 2016. And as the physician shortage worsens, some areas in the U.S. will be more impacted than others. By 2030, the regions with the largest estimated shortage ratios — according to the same report — will be:

  • The West (69 unfilled physician roles per 100,000 people)
  • The South (62 unfilled physician roles per 100,000 people)
  • The Midwest (41 unfilled physician roles per 100,000 people)

On the other hand, the Northeast will have a surplus of 50 physicians per 100,000 people.

In light of this, Townsend says NPs and PAs will play an increasingly vital role in primary care — but that’s not necessarily a bad thing.

"More and more NPs and PAs are caring for patients in all stages of life, including older Americans, and this trend will continue," Townsend says. "NPs and PAs are well-equipped to manage chronic diseases with outcomes similar to medical doctors. In fact, NPs and PAs provide health care at a lower cost than medical doctors and are more likely to treat patients directly, rather than refer them for unnecessary follow-up health services. This is good for the patient and saves on health care costs, especially for Medicare."

Plus, notably, a study published in 2020 in the journal Medical Care suggests that patients of NPs and PAs have lower odds of inpatient hospital admissions and require less frequent emergency department visits. Not only does that indicate a higher level of care, but it suggests millions of dollars saved in patient care.

NP and PA jobs are among the 10 fastest-growing professions

While there’s a stark discrepancy between the growth rates of NPs and PAs compared to physicians, it’s only projected to get wider. In fact, NP and PA jobs are among the 10 fastest-growing jobs in the U.S. From 2020 to 2030, the BLS predicts that NP jobs will grow by 52.2%, while PA roles will grow by 31.0%.

Meanwhile, all physicians and surgeon jobs are projected to grow just 3.0% from 2020 to 2030, slower than the average of 7.7% for all occupations. Notably, it’s also slower than the predictions for employment in health care occupations overall, which are projected to grow by 16.0%.

With physicians growing at a much slower rate, Townsend says NPs and PAs will play a vital role in preventing a shortage of PCPs.

"With fewer medical doctors choosing the primary care field, it’s important that NPs and PAs continue filling their role," Townsend says. "Primary care providers act as medical ‘gatekeepers.’ Without them, patients are more likely to go directly to the hospital for their medical needs. This puts a greater burden on the U.S. health care system."

Top factors to consider when choosing a new provider

Whether you visit a physician, NP or PA, having a PCP is vital to your long-term health. To determine the PCP that’s right for you, Townsend offers the following advice:

  • Keep your needs in mind. For example, those with a heart condition should look for a primary provider who can meet those needs and is connected with specialists and facilities in the field. You should also ensure that the provider accepts your insurance — including Medicare or Medicaid.
  • Determine your compatibility. Townsend recommends calling the office to get a first impression of the practice your potential PCP runs. Do you feel comfortable and welcomed as a potential new patient? How far in advance do you have to make appointments? Is this a group or individual practice?
  • Use the government resources available to you. Townsend recommends using the Physician Compare tool to find primary care providers in your area, which also allows you to read about quality issues that may have been reported. It’s a Medicare tool, but anyone can use it.

Methodology

Researchers determined the number of primary care providers ("PCPs") by analyzing May 2021 data from the U.S. Bureau of Labor Statistics (BLS) to determine the number of employed physicians in the primary care specialties.

Specifically, researchers looked at the number of physicians specializing in internal medicine, family medicine and pediatrics. Researchers then determined the number of people employed as nurse practitioners (NPs) and physician assistants (PAs) in each state.

To calculate the rate of PCPs per 100,000 residents, researchers compared the number of PCPs in each state with population data from the Census Bureau 2020 American Community Survey (with five-year estimates).