By Jackie Miller

The long-term care (LTC) industry faces a troubling landscape. The Wall Street Journal recently reported on the industry's financial crisis, which is largely due to actuarial analyses underestimating the number of claims that would be filed over a longer than expected lifetime of beneficiaries. In many cases, policyholders are forced to pay much higher premiums or walk away from their coverage.

In addition to financial hardship, LTC faces what may be considered an even more fundamental issue: a lack of providers to deliver care. Geriatricians, for example, are presently and projected to be in short supply. According to the American Geriatrics Society, there are currently 13,000 fewer geriatricians in the workforce than what are needed to meet care needs. This shortage is expected to increase; the Health Resources & Services Administration projects an increased demand of geriatricians of 45% between 2013 and 2025, which would result in a provider gap of 26,980 geriatrician full-time equivalents (FTEs) by the year 2025. These shortages, coupled with a geriatrician consensus that the profession should focus on the most vulnerable populations with the most complex cases, will create a provider gap for patients that require LTC. 

As the baby boomer population continues to age and drive increased demand for long-term care, there is an opportunity for physician assistants (PAs) and nurse practitioners (NPs) to fill the jobs that would otherwise go unmet by physicians alone, according to a recent Healthforce Center report. The Bureau of Labor Statistics projects 35% growth for NP jobs and 37% growth for PA jobs in the next ten years. Given this predicted growth and NP/PA education, which equips them to care for the aging population, there is an opportunity for more NPs and PAs to join the LTC workforce. However, LTC professionals face challenges upon entering the field: PAs encounter a lack of job demand and availability, and NPs find inadequate organizational and institutional structures to support career longevity.

Definition of LTC and the Importance of Primary Care in its Delivery  

LTC encompasses a variety of services that support aging and/or disabled persons' health or personal care needs for a time period specific to individual clients, where aging refers to a person 60 years of age or older. Services to support activities of daily living in patients’ homes or facilities can be provided by paid aides, unpaid caregivers (such as friends and family members), or a combination of both.  However, primary care settings are also integral to providing long-term care. About half of the available LTC positions in the US, 55% for NPs and 43% for PAs, fall into the primary care setting. With 20% of the population projected to reach age 65 years or older by 2030, the increasingly aged population creates a demand for more professionals with LTC expertise, and subsequently, a demand for more LTC professionals in the primary care setting. 

PA Positions Dominated by Specialty Care 

PAs are especially underutilized in primary care, which could exacerbate current and forthcoming challenges related to long-term care. Demand for PAs, in particular, is higher in specialty care versus primary care. One study, for example, demonstrated discrepancies between employer demand and occupied PA positions for both specialty and primary care. It found that 82% of job postings were for specialty positions, while only 73% of occupied positions were in a specialty setting. Conversely, only 18% of job postings were for primary care positions, while 27% of occupied PA positions were in primary care. This demonstrates a gap in perceived versus actual demand for PAs in the primary care setting; there are more PAs working in primary care than what job postings alone would suggest. 

One potential explanation for a lack of employer demand of PAs in primary care may be employers’ inability to fully recognize or understand PA education; this may lead them to fall short in realizing PAs’ potential to fill employment gaps in primary care, resulting in a failure to create PA positions in their practices. 

NPs Face Structural Barriers 

The status of NP positions differs from PAs in that there is already an increased demand for NPs in LTC. Compared to 7% and 8% of LTC postings advertised for either a “PA only” or “PA or NP”, respectively, 85% of LTC postings required the position to be filled by an “NP only”. Unlike the role of PAs, NPs do not face as significant of a challenge in terms of lack of demand. Rather, despite the large role that NPs play in the delivery of long-term care within the primary care workforce, NPs face many organizational and institutional barriers. 

Lusine Poghosyan, PhD, MPH, RN, FAAN is working to understand the barriers that NPs face in primary care. Inconsistent scope of practice (SOP) laws across the US, narrow interpretation of SOP laws among organizations (even in states that do allow NPs more freedom), and the lack of understanding of NP roles and proper communication from primary care physicians has led to underutilization of NPs across the country, according to Poghosyan’s research. In addition to these negative forces, stressors associated with an individual NP can also contribute to job dissatisfaction. All of these factors play a role in and affect a NPs’ decision to stay in their position for both the short or long term. 

Without changes in these areas, NPs will continue to be underutilized and will fail to meet LTC needs, Poghosyan warns. In addition, turnover will be more prevalent, nurses will be more inclined to migrate to organizations and states that allow for more NP autonomy, and quality of care may deteriorate. 

Policy Implications and Next Steps

Overall, PAs and NPs will have an important, yet challenging role in the delivery of LTC, particularly within the primary care setting. Several policy factors on varying levels can promote the increased use of PAs and NPs to fill the provider gap for LTC in primary care: 

• Lawmakers should change state SOP laws to allow NPs the full permissions, resources, and capabilities available to any other primary care provider.
• Educators should develop and promote curricula that expose NPs and PAs to older and disabled adults, even if this exposure is brief or targeted. 
• Practices and employers should become educated and familiar with NP and PA competencies, and then provide NPs and PAs with permissions and resources accordingly.  

In addition to these policy changes, it is important that NPs and PAs be empowered by their coworkers. NPs should be viewed as providers and not burdened with other care responsibilities that a primary care physician would not take on, including clinical tasks that would normally be performed by an RN or MA. PAs do not face this challenge as often, but the same rules should apply. Cumulatively, policy changes and culture shifts can promote effective utilization of NPs and PAs in delivering long-term care, an issue we can no longer afford to ignore.

About Jackie 

Jackie Miller is a research analyst with the Institute for Health Policy Studies and Healthforce Center. Her projects focus on a range of research including community health workers, workforce policies and workforce supply and demand.