2017 Survey of Nurse Practitioners (NPs) and Certified Nurse-Midwives (CNMs)

Joanne Spetz, PhD

Lisel Blash, MA

Lela Chu, BS

Matthew Jura, MPH, MS

Preliminary Findings - November 2017

Background

▪ Last BRN NP-CNM survey conducted 2010

▪Small numbers of NPs and CNMs in Biennial RN Surveys

▪What changes have occurred over the past 7 years?

NP/CNM Survey

▪ 12-page survey for NPs & CNMs

• Education

• Employment, clinical practice & patient population

• Barriers to practice

▪ 2,500 surveys mailed

▪ 66% response rate (1,664 completions)

▪ 1,616 valid responses

• 1,269 NPs

• 177 CNMs

• 170 dual-certified

3

How many NPs & CNMs live & work in California?

NPs CNMs Both

NP & CNM

# living in California 17,287 511 505

# working as NPs/CNMs 14,145 364 437

% working as NPs/CNMs 81.8% 71.2% 86.5%

4

83% 85%

68%

14%15%

27%

4% 0% 5%

NP CNM Both

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Has 3+ NP/NM jobs

Has 2 NP/NM jobs

Has 1 NP/NM job

How old are employed NPs and CNMs?

5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2017 2010 2017 2010 2017

NP CNM NP+CNM

<35 35-44 45-54 55-64 65+

Diversity of employed NPs & CNMs

6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2017 2010 2017 2010 2017

NP CNM NP+CNM

Mixed

Native American

Pacific Islander

Other Asian

Asian Indian

Filipino

Hispanic

Black

White

Gender diversity of employed NPs & CNMs

7

7.5%11.7%

0.8% 1.2% 0.8% 2.1%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2017 2010 2017 2010 2017

NP CNM NP+CNM

Male

Highest education of employed NPs & CNMs

72.1% 73.3%

58.1%

69.8%

8.5%10.8%

7.4%

6.8%

18.0% 9.1%

34.2%20.5%

1.4%6.3%

0.2% 1.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 NPs 2017 NPs 2010 CNMs 2017 CNMs

Other

Doctoral

Certificate Program

Post-master's certificate

Master's Degree (MSN,non-ELM)

8

Initial RN education of NPs & CNMsInitial APRN education NPs CNM NP+CNM

Diploma 7% 10.7% 10.4%

AT + 30-unit 27.8% 14.2% 25.4%

BSN 57.5% 73.4% 57.1%

MSN + ELM 6.9% 1.7% 7.2%

Doctoral 0.8% 0% 0%

9

63.5%41.0%

66.1%

29.9%55.3%

30.6%

0%

20%

40%

60%

80%

100%

NP CNM NP+CNM

Internationally educated

Educated in other state

Educated in CA

Employment rate by age group, 2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<35 yrs 35-44 45-54 55-64 65+

Dual NP & CNM

NPs

CNMs

10

Work settingsNPs NMs NP+NM

Hospital setting 25.8% 43.6% 50.8%

Clinic setting 60.2% 48.9% 43.0%

Hospital acute 10.2% 1.3% 1.1%

Hospital outpatient clinic 10.5% 0.7% 3.5%

Community Health Center 11.3% 11% 11.7%

Private MD/DO Practice 16.0% 8.7% 13.0%

Private primary care group 23.3% 12.4% 13.4%

HMO/Managed Care 1.1% 6.1% 1.7%

Veterans Administration 5.9% 2.8% 5.8%

Academic education 1.9% 0 % 1.4%

11

Job titles of NPs & CNMs employed in these roles

NPs CNMs NP+CNM

Nurse Practitioner 94.8% 0.0% 19.8%

Certified Nurse Midwife 0.0% 97.1% 74.9%

Middle management position 0.4% 1.8% 0.0%

12

Estimated shares of patients with types of payment (% reporting share in principal position)

10.5% 10.5%

28.7%

50.8%

24.3%14.7%

37.0% 40.0%

36.3%

32.6%

55.8%

45.4%

28.5% 21.0%

18.1%

4.9% 11.8%

25.9%

11.9%11.6%

8.0% 1.9%2.7% 3.6%

8.6% 12.3%7.2%

1.1%1.3% 5.8%

3.7% 4.5%1.6%

8.7% 4.1% 4.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Medicare Medicaid PrivateInsurance

Work comp. Other govt. Uninsured

0% 1-25% 26%-50% 51-75% 76-99% 100%

13

Types of patient currently accepted by practices in which NPs & CNMs work

NPs CNMs NP+CNM

Medicare 80.0% 49.5% 63.7%

Medicaid 69.8% 71.1% 61.5%

Private Ins 76.9% 77.2% 86.9%

Work comp

Other gov

Uninsured

25.6%

38.5%

54.1%

8.6%

28.3%

38.5%

5.6%

34.4%

46.0%

14

Medicare/Medicaid national provider numbers & payment

15

29.9% of NPs are primary care providers for private plans

20.5% of CNMs are primary care providers for private plans

28.5% of NP+CNMs are primary care providers for private plans

78.0% 81.0% 82.0%92.9% 94.6% 88.9%

0%

20%

40%

60%

80%

100%

NPs CNMs NP+CNM

Has a Medicare/Medicaid National Provider Identifier

2010 2017

Medicare/Medi-Cal billing

NPs CNMs NP+CNM

Medicare billing 2010 2017 2010 2017 2010 2017

Bill directly 20.8% 25.1% 27.9% 10.9% 24.6% 18.5%

Incident to physician 29.9% 18.8% 13.6% 7.4% 24.7% 11.8%

Don’t know 49.2% 41.8% 58.6% 60.9% 50.7% 53.3%

Medi-Cal billing

Bill directly 22.9% 24.9% 34.4% 18.2% 30.9% 28.6%

Incident to physician 25.2% 18.1% 15.8% 9.9% 24.5% 11.7%

Don’t know 51.9% 40.2% 49.8% 60.7% 44.6% 49.3%

16

What share of NPs & CNMs provide primary care?

NPs CNMs NP+CNM

2010 2017 2010 2017 2010 2017

First APRN job 66.1% 59% 68.9% 47.5% 68.3% 50.1%

Second APRN job 60.1% 50.2% 43.9% 42.9% 49.5% 41.1%

17

66.1% 68.9% 68.3%59.0%

47.5% 50.1%

0%10%20%30%40%50%60%70%80%

NPs CNMs NP+CNM

First APRN job

2010

60.1%

43.9%49.5%50.2%

42.9% 41.1%

0%

10%

20%

30%

40%

50%

60%

70%

NPs CNMs NP+CNM

Second APRN job

2010

Scope of practice

18

To a

AlwaysAlmost

always

consider-

able

Occasion-

allySeldom Never

degree

Using your NP/CNM

skills fully?58.5% 23.8% 12.6% 2.2% 1.7% 1.1%

Allowed to practice the

fullest extent of the 57.7% 21.4% 15.6% 3.3% 1.6% 0.5%

legal scope of practice.

Barriers to providing high-quality care reported by NPs and CNMs

19

Not a Minor Major

Inadequate time with patients

problem

29.6%problem

43.2%problem

25.1%

Denial of coverage/care decisions by insurance companies 27.2% 39.4% 22.7%

Too little involvement in decisions in your organization 42.8% 33.9% 17.7%Patients’ inability to receive needed care because of

inability to pay

Lack of administrative support

33.1%

45.2%

41.5%

34.2%

16.9%

16.8%

Quality issues outside of your control 32.5% 46.6% 15.5%

Lack of qualified specialists in your area 51.7% 29.0% 15.3%

Lack of ancillary clinical support (such as MAs) 49.1% 32.3% 14.6%

Lack of access/support for educational advancement 53.9% 28.2% 13.7%Not getting timely reports from other providers and

facilities38.5% 44.1% 12.2%

Percent of NPs/CNMs working in non-NP/CNM RN jobs

20

28.0%

23.0%

15.5%16.0%

5.0%

12.0%

0%

5%

10%

15%

20%

25%

30%

NP CNM NP+CNM

2010

All Employed as NP/CNM

20.0%18.2%

5.9%

11.6%

7.7%

3.5%

0%

5%

10%

15%

20%

25%

NP CNM NP+CNM

2017

All Employed as NP/CNM

Reasons for not working as NP/CNM (% saying “very important”)

21

Not at all

important

Somewhat

important

Very Important

important

Lack of NP/CNM jobs/practice opportunities in 16.8% 5.5% 14.5% 31.4%desired location

Childcare/family responsibilities 14.4% 9.0% 6.4% 31.2%Lack of NP/CNM jobs in desired type of facility 17.3% 7.6% 10.6% 30.4%Lack of NP/CNM jobs in desired specialty 15.8% 7.0% 19.0% 25.9%Retired 12.2% 5.6% 4.3% 22.2%

Dissatisfied with benefits/salary 15.8% 9.7% 12.4% 21.3%Lack of good management/ leadership 16.2% 10.2% 14.5% 21.3%

Overall lack of NP/CNM jobs 18.8% 10.7% 14.8% 21.2%Inconvenient schedules 18.4% 13.3% 9.9% 19.2%

Overall satisfaction with NP/CNM practice

22

NP CNM NP+CNM

Very dissatisifed 6.9% 3.7% 3.2%Dissatisfied 3.7% 6.4% 5.0%Neither satisfied nor dissatisfied 8.1% 0.4% 0.2%Satisfied 43.6% 57.2% 42.4%Very satisfied 37.7% 32.2% 49.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NP CNM NP+CNM

Very satisified

Satisfied

Neither satisified nor dissatisfied

Dissatisfied

Very dissatisifed