CMS Reports APRNs Could Solve Primary Workforce Shortage

A recent report to Congress on the first government initiative to test funding of graduate clinical education for advanced practice registered nurses showed such a measure could help fill the nation’s need for primary healthcare providers.

The Centers for Medicare and Medicaid Services Graduate Nurse Education Demonstration generated APRN growth and was instrumental in transforming APRNs clinical education at participating nursing schools, according to the Graduate Nurse Education report to Congress released October 2017.

The report’s findings show significantly greater APRN enrollment and graduation growth in demonstration schools versus comparison schools. The majority of clinical training hours took place in community settings, where care is most needed. APRN growth from the demonstration was primarily in nurse practitioners. The cost to clinically train an APRN to graduation in the demonstration was estimated to be less than $30,000, with community-based primary care physician residency training costing about $150,000 a year.

Other findings from the demonstration show hospitals’ affiliations with schools of nursing result in lower average costs for APRN education, and APRNs trained under the demonstration have entered practice in a variety of rural and urban settings, including federally qualified health centers, nurse-managed clinics, ambulatory medical practices, retail clinics and hospitals.

The result, according to an independent CMS evaluation, is a significant increase in primary care providers.

Originally a four-year project, the demonstration was extended to six years (ending in 2018), with a price tag of $200 million, according to Linda Aiken, PhD, RN, FAAN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

Linda Aiken - APRNs
Linda Aiken, RN

“The report to Congress suggests that if Medicare provided a modest amount of additional funding to support clinical training of APRNs that we could substantially increase the number of new primary care providers, which, of course, is important for solving the national shortage of primary care,” said Aiken, whose flagship teaching hospital is one of the hospitals selected for the demonstration.

Goal is to have Medicare cover clinical education costs for APRNs

By 2025, the U.S. will be short 23,640 primary care physician provider full-time equivalents needed to meet swelling healthcare demand due in large part to more access to insurance and aging, according to the report.

The goal now is to convince Medicare that it should consider factoring in the cost of clinical training for APRNs — a cost borne by providers, including hospitals, community-based physicians and others, according to Aiken.

If passed, Medicare would pay providers, including physicians and nurses, for being involved in clinical education, which generally isn’t covered in tuition costs.

“That is the biggest problem that is constraining the ability of nursing schools to accept more students,” Aiken said. “They can’t find enough clinical preceptors.”

If Medicare dollars go to funding clinical preceptors, more practicing physicians and APRNs would be able to participate in clinical training, which then would allow the nursing schools to up their enrollments.

“Right now, there’s a big demand among prospective nurses and existing RNs to become APRNs, but there is not enough capacity to enable all of them to be admitted to a program,” Aiken said.

Memorial Hermann-Texas Medical Center, which is participating in the demonstration and set out to graduate an additional 400 APRNs in four years, had graduated 1,695 APRNs, of which 98% are now employed in community care settings, as of August 2016.

Memorial Hermann reports that enrollments in APRN programs at Graduate Nurse Education schools is working — schools working in the demonstration with the health system have seen a 180% increase in enrollment since its start.

Lori Hull Grommesh - APRNs
Lori Hull-Grommesh, RN

Lori Hull-Grommesh, DNP, RN, ACNP-BC, director of the Texas Gulf Coast Graduate Nurse Education Demonstration at Memorial Hermann-Texas Medical Center, said the demonstration offers other benefits, including strengthening Memorial Hermann’s relationships with Texas nursing schools.

“When we first started and received the demonstration grant in 2012, we had to do a number of things,” Grommesh said. “We had to immediately get with the schools of nursing and get them on board because, of course, that’s where the students come from. We had to find clinical preceptor sites, especially in our community and at other hospitals in Houston. We all work so well together now.”

Many of the healthcare facilities that had agreed to help train nurse practitioners as part of the demonstration had never done so prior to the demonstration, according to Grommesh.

“They were unclear about what we do and how nurse practitioners could even help their practices,” she said. “One of the biggest benefits is the providers are hiring our graduates and are seeing the benefits of what a nurse practitioner can do and the value that nurse practitioners can bring to the practice.”

HonorHealth, a Scottsdale, Ariz-based health system, has experienced much the same, according to Melanie Brewer, DNSc, RN, FNP-BC, executive director of the demonstration project at HonorHealth in Scottsdale.

“Through increasing the numbers of students enrolled and the numbers that graduate, the demonstration project has increased the number of highly qualified APRNs practicing in the state of Arizona,” Brewer wrote in an email to “Our nursing school colleagues were able to increase the number of APRN students who receive training each year from an average of 175 for the four schools to 1,117 in the fourth year of the demonstration project. Through this program, the number of APRN graduates for the four partner universities has increased 146%.”

What’s needed next to fund more APRNs?

There’s a large national coalition of stakeholders who are promoting that Medicare make the modifications and modernize their funding of nursing education to include these costs, which have been shown to affordably produce more APRNs, according to Aiken.

“The main proposal is to advocate for Medicare modernizing their policies to train nurses, sort of analogous to what they’re doing for physicians with a great deal more money. Medicare is investing about $15 billion a year in physician residencies, but very little in the equivalent part of training of APRNs,” Aiken said.

Many hospital employers are paying those costs, currently. But there’s an extent to which they can shoulder the costs.

“The issue is that, if more money was available in the future, hospitals and other providers would be more likely to volunteer to be engaged in nurse practitioner (and APRN) training because some of the costs would be offset,” Aiken said.

Aiken’s research and that of others suggests advanced practice nurses are a solution to the long-standing primary care provider shortage and can contribute to improving the quality of inpatient care. The demand for nurse practitioners is expected to exceed the growth rate for any other health professional occupation in the next decade, according to recent U.S. Bureau of Labor Statistics.

Nurse leaders, according to Grommesh, need to recognize that a lot of RNs are going back to school, embrace it and promote higher education, retaining those nurses and using them in advanced practice roles.

“I think some of the hesitation is we’re losing our bedside nurses, but there is a way to help those nurses go back to school and bring back that learning to the institution,” Grommesh said.