Current and projected shortages in the US health workforce have prompted policymakers to propose reforms to Medicare Graduate Medical Education (GME) and nursing programs. However, researchers have historically faced challenges in accurately predicting workforce trends; physician and nurse supply and demand all grew faster than expected over the past 2 decades. These discrepancies highlight the need for scenario-based workforce planning and projection models that estimate how a policy intervention would affect the workforce outcome of interest. In addition, policy options modeled should address not only increasing provider-to-population ratios but also improving health outcomes through innovative payment and care models.

Importance Health care delivery systems rely on a well-prepared and adequately sized registered nurse (RN) workforce. The US RN workforce decreased by more than 100 000 in 2021 during the COVID-19 pandemic—a far greater single-year drop than observed over the past 4 decades. The implication for the longer-term growth of the RN workforce is unknown. Objective To describe recent trends in RN employment through 2023 and forecast the growth of the RN workforce through 2035. Design, Setting, and Participants Descriptive analysis of recent trends since the start of the COVID-19 pandemic in RN employment using data from the US Bureau of the Census Current Population Survey and including employed RNs aged 23 to 69 years from 1982 through 2023, and retrospective cohort analysis of employment trends by birth year and age to project the age distribution and employment of RNs through 2035. Main Outcome and Measures Annual full-time equivalent (FTE) employment of RNs by age, demographics, and sector of employment; forecast of RN workforce by age through 2035. Results The final sample included 455 085 RN respondents aged 23 to 69 years. After a sharp decline in 2021, RN employment recovered, and the total number of FTE RNs in 2022 and 2023 was 6% higher than in 2019 (3.35 million vs 3.16 million, respectively). Using data on employment, education, and population through 2022, the size of the RN workforce was projected to increase by roughly 1.2 million FTEs to 4.56 million by 2035, close to prepandemic forecasts. Growth will be driven primarily by RNs aged 35 to 49 years, who are projected to compose nearly half (47%) of the RN workforce in 2035, up from 38% in 2022. Conclusions and Relevance In this study, the rebound in the total size of the US RN workforce during 2022 and 2023 indicates that the earlier drop in RN employment during the first 2 years of the COVID-19 pandemic was likely transitory. Updated forecasts of the future RN workforce are very close to those made before the pandemic.

OBJECTIVE:To evaluate trends and drivers of commercial ambulatory spending and price variation.DATA SOURCES AND STUDY SETTING:Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019.STUDY DESIGN:Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation.DATA COLLECTION/EXTRACTION METHODS:We analyzed commercial claims data from All-Payer Claims Databases in the two states.PRINCIPAL FINDINGS:Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings.CONCLUSIONS:States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

This cross-sectional study assesses a market basket price index to evaluate hospital outpatient department price levels and growth.

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

Purpose Rural registered nurses (RNs) play an integral role in providing care for an underserved population with worse health outcomes than urban counterparts. However, little information is available on the profile of this workforce, which is necessary to understand the capacity of these nurses to provide quality and demanded care presently and in the future. Methods We utilize data from the American Community Survey to provide a contemporary analysis on the supply of rural RNs in the United States. Findings While the number of physicians serving rural populations has decreased in recent years, and rural nurse practitioners (NPs) remain in short supply, rural RNs have steadily grown in numbers at a rate comparable to urban RNs. Rural RNs are markedly less diverse than the populations they serve and only half of rural RNs had a bachelor's degree or higher compared to over 70% for urban RNs. In their supply, young rural nurses appear on pace with urban nurses to adequately replace older nurses and continue to grow the workforce, based on data through 2019. Conclusions The rural RN workforce is projected to steadily grow amidst declining rural physicians and limited rural NPs. The burgeoning investments in the rural health workforce present opportunities to help diversify, increase educational access, and further rural readiness for rural RNs moving forward.

ImportanceA better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities.ObjectiveTo investigate differences in earnings and hours worked for male and female physicians at various ages and family status.Design, Setting, and ParticipantsThis retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019.ExposuresEarned income and work hours.Main Outcomes and MeasuresOutcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022.ResultsThe sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children.Conclusions and RelevanceIn this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.

OBJECTIVE:To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics.DESIGN:Cross-sectional time series study.SETTING:National data from the traditional Medicare insurance program in the USA.PARTICIPANTS:Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken.MAIN OUTCOME MEASURES:The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis.RESULTS:From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%).CONCLUSION:The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

BACKGROUND:Policymakers are increasingly interested in using nurse practitioners to provide health care to rural populations, yet little is known about their characteristics and preparation for independent practice. METHODS:We obtained data from the 2018 National Sample Survey of Registered Nurses and compared characteristics of family nurse practitioners (FNPs) employed in rural areas versus those employed in non-rural areas. Regression analysis was used to determine the relationship between the outcome variable of interest, preparation for practice and other covariates. FINDINGS:FNPs practicing in a rural setting felt less prepared for independent practice than their counterparts in non-rural settings except for those prepared with a doctoral degree. DISCUSSION:The majority of FNPs working in rural areas believed they were not as well prepared for independent practice. Because rural FNPs often practice autonomously and without medical back up, nursing educators need to educate FNPs with the skills and knowledge necessary to practice effectively in rural settings.

Analysis of Current Population Survey data suggests a tightening labor market for registered nurses, licensed practical nurses, and nursing assistants, marked by falling employment and rising wages through June 2021. Unemployment rates remain higher in nonhospital settings and among registered nurses and nursing assistants who are members of racial and ethnic minority groups.

Nurse practitioners (NPs) and physician assistants (PAs) represent a growing share of the health care workforce, but much of the care they provide cannot be observed in claims data because of indirect (or "incident to") billing, a practice in which visits provided by an NP or PA are billed by a supervising physician. If NPs and PAs bill directly for a visit, Medicare and many private payers pay 85 percent of what is paid to a physician for the same service. Some policy makers have proposed eliminating indirect billing, but the possible impact of such a change is unknown. Using a novel approach that relies on prescriptions to identify indirectly billed visits, we estimated that the number of all NP or PA visits in fee-for-service Medicare data billed indirectly was 10.9 million in 2010 and 30.6 million in 2018. Indirect billing was more common in states with laws restricting NPs" scope of practice. Eliminating indirect billing would have saved Medicare roughly $194 million in 2018, with the greatest decrease in revenue seen among smaller primary care practices, which are more likely to use this form of billing.

Research ObjectiveTo examine the type of services that are prone to “surprise billing” and the potential increased spending for patients and payers.Study DesignOut‐of‐network billing occurs when patients receive services from providers that do not have a negotiated rate with the patient's insurer. While patients sometimes choose such providers knowingly (e.g., a preferred out‐of‐network mental health provider), out‐of‐network billing often occurs in scenarios outside of patients' control ‐ e.g., an out‐of‐network anesthesiologist participating in a surgery at an in‐network facility without patient knowledge ‐known as “surprise billing.” [Organization blinded] investigated “surprise billing” trends using the state's all‐payer claims database.Population StudiedPatients insured by three large commercial payers in Massachusetts from 2015 to 2017 that had out‐of‐network indicators in their claims. These members represent over 15% of the state's commercially‐insured lives.Principal FindingsAmong 657,140 commercially insured patients in 2017, we identified 68,342 distinct “surprise” claims, representing 30,332 Massachusetts residents (4.6%) during 44,689 healthcare encounters, in which patients most likely received care from out‐of‐network providers that they did not choose. Among these encounters, 10,590 (23.7%) were ambulance services, and 34,099 (76.3%) were professional services, primarily from ERAP providers (emergency, radiology, anesthesiology, or pathology). Among “surprise” professional services, 29.3% of encounters occurred within the emergency department (ED). Among the payers examined, 7.2 percent of ED visits in 2017 resulted in at least one “surprise” claim. The hospital outpatient department was the setting where most “surprise” professional encounters occurred, accounting for 82.6% of non‐ED out‐of‐network radiology claims, 71.2% of such pathology claims, and 65.5% of such anesthesiology claims.While claims data cannot substantiate whether a patient received a “balance bill” for any given encounter (when a patient is billed for the difference between the insurer's payment and the provider's charges on an out‐of‐network bill), we observed the potential for balance billing in more than 90% of “surprise” professional services claims. The average balance potentially billed to patients for these claims was $167 per claim but varied widely, ranging from $5 at the 5th percentile to $749 at the 95th percentile.Across a range of “surprise” procedures and ambulance services, average spending on out‐of‐network claims far exceeded average spending on in‐network claims. In addition, charges and payer‐paid amounts appeared to rise substantially over time. For example, for a moderate severity ED evaluation and monitoring (E&M) visit, the out‐of‐network charge grew 11% from $294 in 2015 to $325 in 2017.ConclusionsOut‐of‐network claims for ambulance and ERAP services continue to occur in the Massachusetts commercial market, potentially leading to higher premiums and burdening patients with unforeseen and large balance bills.Implications for Policy or PracticeWith recent federal and state legislative action to limit the practice of “surprise billing,” it is crucial to understand the practice's implications on payers, patients, and overall market functioning.

Data from the 2018 National Sample Survey of Registered Nurses is compared with national and other surveys to illustrate how estimates from the 2018 survey overestimate the percentage of registered nurses (RNs) who are Hispanic/Latino and likely underestimate the percentage who are Black/African American or Asian. Because the nation's racial and ethnic composition is projected to become increasingly diverse, ensuring accurate estimates of the racial and ethnic population of RNs is essential to improving access to care for racial and ethnic minority patients, providing greater patient choice and satisfaction, improving patient-nurse communication, and enriching the educational experiences for all students.

W ith the onset of the COVID-19 pandemic and the immediate shutdown of economic activity in March 2020, overall employment in health care dropped precipitously in all sectors (exhibit 1). As employment gradually resumed (except in nursing facilities), the prevailing dynamic in the health care labor market shifted from furloughs to reports of burnout and nurse shortages. Amid this shifting landscape, there has been no systematic analysis of workforce data to increase understanding of the economic impacts on nurses. Using national data from federal government surveys, we provide a snapshot of the pandemic’s impacts on employment and earnings across categories of the nurse workforce by major employment setting and by race and ethnicity over the course of the first fifteen monthsof thepandemic.Althoughweareunable to definitively attribute these impacts to changes in supply of or demand for nurses, the observed trends shed light on broader workforce dynamics affecting this critical workforce.

The growing demand for mental health services, together with current and increasing shortages of mental health professionals and increasing adoption of integrated models of care delivery, suggest nurses will become increasingly needed to provide mental health services. Analysis of a national survey finds registered nurses and nurse practitioners working in outpatient mental health settings are older than those in other settings. Most would benefit from additional training. Provision of team-based care was associated with higher job satisfaction.

Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.

Concerns about physician shortages have led policy makers in the US public and private sectors to advocate for the greater use of nurse practitioners (NPs). We examined recent changes in demographic, employment, and earnings characteristics of NPs and the implications of those changes. In the period 2010-17 the number of NPs in the US more than doubled from approximately 91,000 to 190,000. This growth occurred in every US region and was driven by the rapid expansion of education programs that attracted nurses in the Millennial generation. Employment was concentrated in hospitals, physician offices, and outpatient care centers, and inflation-adjusted earnings grew by 5.5 percent over this period. The pronounced growth in the number of NPs has reduced the size of the registered nurse (RN) workforce by up to 80,000 nationwide. In the future, hospitals must innovate and test creative ideas to replace RNs who have left their positions to become NPs, and educators must be alert for signs of falling earnings that may signal the excess production of NPs.

This Viewpoint summarizes the distribution of physicians and registered nurses aged 55 years and older in US cities caring for COVID-19 patients and proposes roles they can play in health systems that preserve their ability to apply their experience over the long-term course of the pandemic.

A survey of health care providers reveals significant adverse effects on the ability to serve patients and sustain the practice. Without policy solutions and financial support, practice sales and closures may be imminent.

Abstract As the US population ages, primary care is expected to be the health care “home” for older adults, and several initiatives are aimed at helping to transform primary care practice to care for this population. Wide variation in staffing has been observed. Meyers et al proposed ideal models of primary care staffing for a general population and for a frail elderly population (2018). We developed the 2018 Survey of Primary Care and Geriatric Clinicians to measure optimal team configuration in clinical practices caring for older adults. A majority employed NPs, MDs and PAs, with [r = -.53] between % of clinician labor of NPs and physicians). High-NP practices are more likely located in states with full scope of practice, perform well for frail elders and are less expensive. Meyers' models, with fewer physicians, more SW and CHWs, more RNs, perform better for frail elders, and are less expensive.