The Map That Scores DPC on Shortage Areas Counts Only Physicians. A 2026 Study Says Counting Nurse Practitioners Drops 80% of the Counties It Matched Below the Threshold.

Analysis by DPC Insider — Research Desk
#HPSA#primary care workforce#nurse practitioners#research#physician shortage#health equity
Sources: Including Nurse Practitioners in the Calculation of Primary Care Health Professional Shortage Areas · Including Nurse Practitioners in the Calculation of Primary Care Health Professional Shortage Areas (journal record) · Are Direct Primary Care Practices Located in Health Professional Shortage Areas? · Q&A: Is the Growth of Direct Primary Care Expanding Health Care Access Where It's Needed Most?

Among direct primary care practices that sit inside a federal primary care shortage area, 14% are in the highest band of HRSA’s need score, as the study grouped them. Among non-DPC primary care physicians inside those areas, 20% are. That six-point gap is the strongest version of the case against DPC, and it surfaces every time someone argues the model pulls doctors away from the patients with the least access.

A 2026 study published in Medical Care Research and Review in May says the map those percentages come from leaves the nurse practitioner workforce out of the count entirely.

L. David Wittkower, Katharine W. V. Bradley and Alicia Plemmons recalculated the shortage designations with nurse practitioners counted as primary care providers. Under conservative assumptions about how many of them work full time and how many carry a patient panel of their own, 80.2% of the 970 counties they could match changed to a score of zero and stopped meeting the shortage threshold.

Those 970 are the counties the authors could merge with county-level nurse practitioner counts, out of 1,109. The other 139 dropped out of the merge, either because no active nurse practitioner listed the county as a primary location or because their identifiers could not be matched to licensure data, so they sit outside the recalculation rather than inside it as survivors.

How the recount works

A Geographic Primary Care Health Professional Shortage Area designation runs on a ratio of population to providers. The provider side of that ratio counts physicians, and other primary care providers are left out of the calculation.

The authors linked the October 2025 National Plan and Provider Enumeration System file with state licensure data collected between May and July 2025 from all 50 states and Washington, D.C., built county-level nurse practitioner counts from it, then recalculated each county’s score against the HPSA threshold with those clinicians in the ratio. The cross-sectional design does what a redesignation exercise would do on paper, one county at a time.

Their framing of the problem is blunt. Designations drive where government resources go, and a count built on one profession obscures the workforce that is already there.

The number DPC gets scored on

The 14% figure traces back to Neal Goldstein and Paul Yerkes, writing in the Annals of Family Medicine in November 2024. They mapped 2,125 DPC practices against HRSA designations and found 44% of them inside shortage areas. Among those, 14% were in high-priority HPSAs, against 20% of the non-DPC primary care physicians inside shortage areas that the paper used as its comparison group.

Both figures are conditional on a practice already being in a shortage area, and they get repeated as though they weren’t. The 14% is a share of the 44%, so as a share of every DPC practice on the map it is smaller again. Drexel’s own Q&A about the study drops the condition, and so did our May piece on whether DPC worsens the shortage.

The same paper found DPC practices more likely to sit in rural or partially rural shortage areas than the non-DPC physicians it compared them with, which is the half of the finding critics tend to leave out. Its own conclusion points at high-priority urban shortage areas as the gap.

Both halves are measured against the physician-only map.

What a designation actually buys

A shortage designation does more than describe a county. The authors frame it as driving the allocation of government resources, with eligibility for incentive programs attached, which makes the definition of “provider” a budget decision wearing a methodology’s clothes.

That cuts in directions nobody should pretend are simple. Counting nurse practitioners would shrink the map, and fewer counties would qualify through a geographic designation. You might read the same finding as an argument for recounting, or as an argument for leaving a working instrument alone.

For DPC the consequence is narrower. Supporters and critics have spent years trading percentages that both sides treat as fixed measurements of who serves whom. If the denominator is contested, the scoreboard is contested with it.

The Counterargument

Two of the three authors work for the American Association of Nurse Practitioners, which calls itself the association for all NPs. The paper declares no conflicts of interest. A finding that counting nurse practitioners drops 80% of the counties the study could match below the threshold is still the finding you might expect from that address, so read the magnitude as an estimate produced by people with a position.

There’s a second objection that has nothing to do with who wrote it. A licensed clinician located in a county is not the same thing as an appointment a patient can get, and a designation that shrinks on paper staffs nobody.

The measurement objection survives both. Cut the estimate in half and the map still changes shape, because the current count treats one profession as the entire supply of primary care. You might disagree about what the right number is. It’s harder to argue that 14% against 20% settles anything when both figures are conditional and both come from a count with an entire profession missing from it.