The most recent Health Resources and Services Administration (HRSA) report predicts a 205% adequacy of nurse practitioners (NPs) in primary care by 2035. This translates to the primary care NP workforce being 105% overmanned (HRSA, 2023). Also speculated are family medicine physicians at 90% adequacy, general internal medicine physicians at 83% adequacy, geriatric physicians at 88% adequacy, pediatricians at 98%, and primary care physician assistants at 150% (HRSA, 2023). How is such an extreme "overage" of NPs even possible? Why are we still discussing a shortage of primary care providers? Well, it is all about the lens through which the workforce is viewed.

Health Resources and Services Administration releases projections on the primary care workforce annually. These projections are a highly complex series of economic predictions based on current and past data with some trends occasionally built in as potential future health care workforce scenarios. Workforce projections are undertaken to provide a basis for policy, planning, and funding across the United States.

Health Resources and Services Administration calculates the individual provider types included in the primary care umbrella in silos. This means that data on family medicine physician practice are used to predict the number of family medicine physicians needed and are not inclusive of NPs who work in family medicine. It is the same for the other primary care physician types. Now, we as NPs understand that our role is not to be a physician substitute because we have different philosophical approaches to practice. However, we are, in many clinical situations, being expected to practice according to the traditional medical model of care. This includes rapid turnover of patients, disease-focused models, and emphasis on production.

Numerous issues contribute to inaccurate workforce projections. These include data sets based on billing that may not include all NP contributions, such as NPs being billed as "incident to" or grouped in a facility national provider identifier (NPI) versus their own. A lack of definition of primary care practice is also an issue. A large variety of new models are arising across the country in which primary care is delivered, but outdated definitions citing the standard physician-led patient medical home eliminate significant NP-led models such as retail clinics, urgent care, and home-based visits. With more of the population gravitating toward nontraditional primary care for ease of access, lower costs, and convenience (Mehrotra et al., 2008; Poon et al., 2018; Ray et al., 2020), definitions for workforce planning also need to shift.

While HRSA would lead us to believe we are still in dire straits with our primary care workforce, it is a matter of perspective. There is no "oversupply" of NPs, it is simply a matter of counting us appropriately. There are several solutions to the issue of the supposed lack of primary care providers in the United States. One is to fund the National Healthcare Workforce Commission, established by the ACA in 2010 but not yet funded by Congress (Buerhaus & Retchin, 2013), and in doing so, integrate all types of providers into this commission for accurate representation. Another helpful strategy for data purposes would be to mandate all providers to bill under their own, individual NPI, so all can be counted appropriately. The establishment of an NP Masterfile after the example of the AMA Masterfile would also be greatly beneficial for workforce projection and numerous other purposes. Finally, a recent study has proposed a means to look at primary care research differently. Instead of basing the definition of primary care on the certification of the provider or the setting in which the provider is employed, they proposed using activities of the provider as the basis for determining primary care delivery (O'Reilly-Jacob et al., 2023). Using this means of identification, primary care physician numbers are smaller than current projections while NP numbers in primary care practice are significantly larger (O'Reilly-Jacob et al., 2023).

What can we, as clinicians, administrators, academicians, and scientists, do about the lack of NP representation in current primary care workforce projections? Clinicians can be sure to work with their organizations for proper billing under their individual NPI number and continue to represent NPs on important clinical committees across the health care system. NP administrators need to advocate for NPs to be included in workforce projections at all levels. NP scientists must push for improved data sources that are representative of an integrated workforce, use more inclusive data in our studies, and emphasize the publication of workforce studies in professional journals to disseminate more accurate information on NP representation in the workforce. Academicians, and all of us, need to work with those in the policy world to shift funding where it is most needed, to those who are doing the work.

Acknowledgments:The author would like to acknowledge the College of Nursing & Professional Disciplines at the University of North Dakota as providing seed grant support for the author during the parent project. She would also like to acknowledge her contributing authors from the parent project which is in the submission process including: Barbara Wise, PhD, RN, FNP-BC; Christine Pintz, PhD, FNP-BC, FAANP, FAAN; Mary Beth Bigley, DrPH, ANP-BC, FAAN; Brenda Douglass, DNP, ANPR, FNP-C, CDCES, CTTS; Tracie Kirkland, DNP, ANP-BC, CPNP-PC, PPCNP-BC; Stefanie La Manna, PhD, MPH, APRN, FNP-C, AGACNP-BC; Donna Lynch-Smith, DNP, ACNP-BC, APRN, NE-BC, CNL; Sheryl Mitchell, DNP, APRNB, FNP-BC, ACNP-BC, FAANP; Sharon Stager, DNP, APRN, FNP-BC; and Julia Steed, PhD, APRN, FNP-BC.

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