Nurse Practitioners and sexual and reproductive health services: An analysis of supply and demand

By Diana Taylor

I recently had the pleasure of serving as co-author to a new report from the RAND Corporation, titled Nurse Practitioners and Sexual and Reproductive Health Services: An Analysis of Supply and Demand.

A brief summary: Current trends in supply and demand for sexual and reproductive health (SRH) services, particularly for low-income individuals, suggest a growing gap in the next decade, with demand outstripping supply of competent health professionals. The reasons for this gap are tied less to the production of clinicians overall and more to a reduced production of Nurse Practitioners (NPs) trained to deliver SRH care.

Although this report focuses on NPs, many of our findings and recommendations are relevant to other providers of SRH services, including registered nurses, physician assistants, nurse-midwives, primary care physicians, and obstetrician-gynecologists. We analyze the impact of the evolving health care delivery system and expanding health insurance coverage, which offers an opportunity to integrate the currently “siloed” system and bring it closer to the comprehensive system of SRH services integrated across public health and primary care that the World Health Organization recommends.(See page 60 of the report.)

Multiple data sources and methods were used to address questions related to the future gap between demand for SRH services and the supply of SRH services. Quantitative analyses used existing data sources (Centers for Disease Control National Survey of Family Growth, U.S. Department of Health and Human Services National Sample Survey of Registered Nurses, the American Academy of Nurse Practitioners, theOffice of Family Planning Title X annual reports, and the National Certification Corporation Women’s Health Care Nurse Practitioner (WHNP) certification data). Additional quantitative and qualitative information not available from the aforementioned data sources included interviews with more than 20 experts and clinic personnel and surveys of a professional organization of WHNPs and of clinic administrators.

We propose a range of short and intermediate policy options and interventions spanning education, federal/state policy, and emerging models of care delivery that have the potential not only to close expected supply-demand gaps but to improve the quality and efficiency of SRH service delivery, expand the provider base delivering SRH services, and better integrate these services with other parts of the health care system.

A few highlights from the report

1. Demand for SRH services (e.g., contraception, STI treatment, and preventive services) is projected to grow modestly (10-20%) by 2020. Service demand is driven largely by changes in the racial/ethnic makeup of the population of women of reproductive age and by changes in insurance coverage under the Affordable Care Act. Regardless of where services are provided, these increases portend a need for more clinicians competent to provide a range of SRH services. (See pages 7-22.)
2. Estimating the supply of health professionals prepared to provide SRH care is more complex. Combined with likely shortages of primary care physicians, including ob-gyn physicians, there is a shrinking proportion of NPs prepared to provide women’s health, and even fewer WHNPs providing services in public health, community clinics, and family planning. The number of primary care NPs is growing rapidly and is expected to continue to grow in the next decade, on the order of 5,000 NPs per year, or roughly 50% growth. This supply would be more than adequate to meet growing demands for SRH services if NPs (and other primary care clinicians) were competent in SRH care and if there were incentives to choose this area of practice in proportion to their overall numbers. (See pages 23-37.)
3. Clarifying the definition of sexual and reproductive health as used by the World Health Organization (WHO). Sexual and reproductive health care is sometimes thought of narrowly as maternal-child, family planning, or women’s health care. However, to produce optimal health outcomes, many experts believe SRH care should include the reproductive health of men and women throughout their lifespan and adolescents of both sexes. Under a definition accepted by the WHO and implemented in a number of national health systems, a minimum package of SRH care accessible to all would include preconception care, contraception, pregnancy and unplanned pregnancy care, women’s health/common gynecology care, genitourinary conditions of men, assessment of specialty gynecology problems including infertility, and sexual health promotion, all delivered within a system of public health and primary care services. (See page xiii and page 60.)
4. Barriers to increasing and utilizing health professionals in SRH care. The results of our interviews with experts and with SRH clinic personnel suggest that a variety of structural factors in the NP supply pipeline and work environments may be working to constrict the supply and use of NPs and other primary care clinicians in SRH care: (1) multiple features of the education system that work to minimize the number of NPs who are provided with adequate education in SRH, (2) limited options for clinic-based training in SRH care both before and after licensure or certification, (3) professional certification barriers that further restrict who is certified in SRH, (4) structural features of the health care delivery system that discourage optimal utilization of NPs in SRH care, and (5) federal and state policies on regulation and financing that make it difficult to optimally utilize and retain NPs in SRH care. (See pages 40-50.)
5. Policy options for education, clinical training, accreditation, and credentialing. Options include standardizing curricula and training, as has been achieved in other cross-cutting fields of health care such as gerontology, psych-mental health, and genetics. A core set of standards and competencies will enable development of a standard curriculum. This will allow programs to better integrate SRH and primary care training and clarify the opportunity for clinicians with a potential interest in SRH. Development and expansion of clinical practice training programs in SRH care can quickly build and consolidate skills of students, residents and post-graduate clinicians. Basing certification requirements on competencies rather than other criteria could replace the restrictive pathways to certification that currently impose barriers to obtain certification in SRH care. (See options 1-3, pages 52-54.)
6. A standardized, interprofessional curriculum for teaching core competencies in SRH. A standardized curriculum for teaching core competencies has been developed in gerontology, women’s health, behavioral health and genetics, but does not exist for SRH care in the United States. Fortunately, the WHO has created a standard set of domains and core competencies for SRH. We describe the model implemented by the United Kingdom National Health Service, which aligns competency-based SRH education, practice and credentialing standards within a coordinated system of primary care and public health. (See pages 60-63.)
7. Responding to emerging models of care delivery. New models of health care delivery create new policy options for increasing primary care clinician engagement in SRH service delivery. First, as accountable care organizations and other integrated models develop, several enabling actions could promote greater integration of SRH care into these models. These might include co-location of SRH-competent providers in primary care clinics such as federally qualified health centers or community health centers; expansion of retail clinics and nurse-managed health centers with SRH services; and setting payment rates based on services rather than provider type.(See options 10-12, pages 58-59.)
8. Innovative models currently under development in the United States. Based on interviews with multiple experts across education, service delivery, workforce and SRH policy, we highlight three models for delivery of SRH services. At the Arizona State University College of Nursing and Health Innovations, clinical practice and education are aligned in areas of primary care, women’s health and family planning. A public health nurse-NP team model of family planning and maternal child health, integrated into a statewide system of public health service delivery, has been in existence for 15 years. In a third model, two approaches to adolescent reproductive health service delivery integrate education, technology and clinical care within an integrated health care system that includes primary and specialty care, community hospitals, academic medical centers, community health centers across an interprofessional collaborative. (See pages 63-68.)