Defining the Primary Care Workforce in Kansas

Key Points

• • There were 5,435 licensed clinicians in the primary care workforce in Kansas in 2019, of which 1,976 were physicians, 3,101 were nurse practitioners and 358 were physician assistants.
  • Kansas had a total of 86 residency positions in primary care in 2019. However, some physicians who complete a primary care residency go on to complete additional training in a sub-specialty.
  • Physician assistants and nurse practitioners in Kansas cannot practice or prescribe in a location separate from a physician without an agreement with a physician.
  • The median salary in Kansas was $143,380- $203,270 for a primary care physician (depending on specialty); and the median was $97,310 for a nurse practitioner and $103,120 for a physician assistant in 2018, although it may be less for those in primary care.

This issue brief is the first of a two-part series examining the primary care workforce in Kansas. It describes the clinicians who comprise the primary care workforce in Kansas. The second brief, Implications of an Aging Primary Care Physician Workforce in Kansas, describes the age and geographic distribution of primary care physicians.

Introduction

Kansas, like the U.S. as a whole, is experiencing a shortage of primary care physicians. In 2018, the Health Resources and Services Administration (HRSA) indicated that 180 physicians were needed to eliminate the current primary care Health Professional Shortage Area (HPSA) designations in Kansas. While primary care physicians are not the only clinicians who provide primary care, Kansas statute requires nurse practitioners (NP) and physician assistants (PA) to practice according to an agreement with a physician.

What is Primary Care?

According to the National Academies of Sciences, Engineering, and Medicine (National Academies), primary care is “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” This definition also could apply to dental primary care and behavioral health, including in an integrated care setting.

Primary Care Workforce

According to the National Academies, the major types of primary care clinicians are physicians, PAs and NPs. In this issue brief, physician refers to individuals who attended an allopathic medical school (MD) or an osteopathic medical school (DO), and primary care physician specialties include family medicine, general internal medicine, geriatrics, general pediatrics and general practice. Hospitalists and other specialists, such as cardiologists or obstetricians/gynecologists, are not considered primary care physicians. While they might provide primary care for some populations, according to HRSA, “they are not engaged in activities that meet the [National Academies] definition of primary care.”

PAs specialize similarly to physicians, and in Kansas an estimated one-third of PAs specialize in primary care. Among advanced practice registered nurses (APRN), NPs most commonly practice primary care and are considered primary care clinicians in this issue brief. Nationally more than 75 percent of NPs specialize in primary care, and aggregate Kansas licensing data indicates the rate is similar, and potentially higher, in Kansas. Other APRNs in Kansas, including clinical nurse specialists, nurse anesthetists and nurse-midwives, are not considered primary care clinicians in this issue brief.

Licensure data from the Kansas State Board of Healing Arts and the Kansas State Board of Nursing, the best available data, was used to estimate the primary care workforce in Kansas in 2019. Currently, clinicians are not required by statute to report data such as secondary practice locations, how many hours per week they work and how many patients they treat. Consistent collection of this information is critical to better understanding the workforce in Kansas.

Clinicians were included in the estimate if their practice state was Kansas and if they reported one of the primary care specialties described earlier. Physicians with a primary care specialty were excluded if a web search revealed that they were a hospitalist. APRNs were included if they were licensed as an NP. Because PA specialty information was not available in the licensure data, the number of primary care PAs was estimated using the proportion of PAs in Kansas practicing primary care published by the National Commission on Certification of Physician Assistants (NCCPA). According to the NCCPA, 35.7 percent of PAs in Kansas were practicing primary care in 2018.

As of April 2019, there were 5,435 licensed clinicians in the primary care workforce in Kansas, of which 1,976 were physicians, 3,101 were NPs and 358 were PAs. More than half (55.1 percent) of all licensed physicians, PAs and APRNs in Kansas do not practice primary care (Figure 1).

Physician Training in Kansas: Kansas has one medical school, the University of Kansas (KU) School of Medicine, with campuses in three locations: Kansas City, Salina and Wichita. Since 2017, each KU class has 211 medical students. According to the Association of American Medical Colleges (AAMC), 37.7 percent of medical students who completed medical school in Kansas were actively practicing in any specialty in the state in 2018. See Figure 2 for a comparison of Kansas retention rate to the median retention rate across all U.S. states. Based on available data, most Kansas physicians attended medical school at the University of Kansas School of Medicine. A smaller number graduated from the Kansas City University of Medicine and Biosciences and the University of Missouri—Kansas City School Medicine, while many others graduated from medical schools in bordering states.

According to data from the National Resident Matching Program, Kansas had 86 residency positions in primary care in 2019, although some physicians who complete a primary care residency may go on to complete additional training in a sub-specialty. According to the AAMC, four in 10 (39.4 percent) physicians who completed residency in Kansas were actively practicing in Kansas in 2018. Of physicians who completed both medical school and residency in Kansas, six in 10 (59.0 percent) were practicing in Kansas in 2018.

PA Training in Kansas: Kansas has one existing PA program, which is at Wichita State University (WSU). Each PA class at WSU has 48 students, and 47 percent of PAs who graduated from the program work in primary care. The Accreditation Review Commission on Education for the Physician Assistant placed the WSU PA program on probation in March 2018 and will review the program in March 2020. Probation status does not impact the ability of PA graduates to sit for the national PA exam, which is required in order to be licensed in Kansas. Starting in January 2021, Kansas State University is accepting students into a new PA program that will start with 36 students each year and expand to 44 students.

APRN Training in Kansas: APRN graduate programs typically include Master of Science in Nursing (MSN) and Doctor of Nursing Practice (DNP). In the 2017-2018 school year, 46 individuals graduated from Kansas APRN programs, although not all graduates may go on to provide primary care. The number of graduates in 2017-2018 declined from previous years, which may be due in part to multiple Kansas graduate programs switching from offering MSN degrees to DNP degrees. The following schools confer MSN or DNP degrees in Kansas: Fort Hays State University, MidAmerica Nazarene University, Pittsburg State University, University of Kansas, University of Saint Mary, Washburn University and Wichita State University.

Workforce Licensing

While most training programs are nationally certified, physicians and PAs who want to practice in Kansas must apply for licensure through the Kansas State Board of Healing Arts (BOHA) after they have completed their training. APRNs must apply for licensure through the Kansas State Board of Nursing. Licensing requirements outlined in Kansas statute or regulation — including education, exams and continuing education (CE) — are summarized in Figure 3.

Scope of Practice

Provider scope of practice is outlined in state statute and regulation. While licensed physicians can practice within the full scope of the healing arts, APRNs and PAs in Kansas must practice according to agreements with physicians, although requirements for these agreements differ for APRNs and PAs.

PA: PAs may perform acts that constitute the practice of medicine and surgery if ordered by a supervising physician, or according to an active practice agreement with a supervising physician. After 80 hours of direct supervision by a physician licensed in Kansas, PAs may practice in a separate location than their supervising physician if additional supervision requirements are met, including that the supervising physician must remain available at all times to consult with the PA. The supervising physician must review and authenticate all patient charts of the PA for the first 30 days and then review the PA’s patient care on an annual basis. PAs may prescribe according to their agreement with a physician.

APRN: APRNs may independently develop and manage the medical plan of care for patients as authorized via a collaborative practice agreement established jointly with one or more physicians. APRNs can practice in a different location from their authorizing physician according to the terms of the collaborative practice agreement, which vary according to the discretion of the APRN and physician. Agreements must be reviewed by the APRN and physician on an annual basis. APRNs may prescribe according to their agreement with a physician.

Clinician Salaries

According to the Bureau of Labor Statistics, in 2018 the median salary for a primary care physician in Kansas ranged from $143,380 to $203,270, depending on specialty. The median salary for a NP in Kansas was $97,310, and the median salary for a PA was $103,120, although it may be less for those in primary care.

Future Considerations

Addressing the primary care provider shortage in Kansas is contingent on increasing the supply of primary care physicians, NPs and PAs, as well as other clinicians that provide primary dental care and behavioral health services. Some states have modified the scope of practice for non-physician primary care clinicians. For example, 22 states (not Kansas) and the District of Columbia allow NPs to practice without an agreement with a physician, sometimes referred to as “full” scope of practice. In the 2019 legislative session, the Kansas Legislature considered — but did not pass — a bill that would allow APRNs to practice and prescribe without being supervised by or having a collaborative practice agreement with a physician.

A new osteopathic medical school in Wichita, the Kansas Health Science Center, was approved by the Kansas Board of Regents in May 2019. This new school, along with future increases in enrollment at the KU medical school campuses, create the potential for increasing the number of undergraduate medical students trained in Kansas. The number of primary care residency slots available in Kansas also impacts how many physicians will later practice primary care in the state, which will be explored further in the second issue brief in this series.