Advocates for Evidence-Based Health Policy Speakers
Advanced Practice Providers as Alternatives
The United States is expected to face a shortage of as many as 49,300 primary care physicians (PCP’s) by 2030. One potential solution to deal with this shortage is to expand the role of non-physician practitioners, namely nurse practitioners (NP’s) and physician assistants (PA’s), in primary care. However, there are concerns that NP’s and PA’s may “use more diagnostic tests, specialty referrals, and return visits than physicians”, driving up costs in a system that has already been struggling to contain costs. To determine whether these concerns are warranted, Morgan et al. investigated how having an NP or PA, rather than a physician, as a patient’s main primary care provider affected health care utilization and costs for medically complex patients.
Using electronic health records of medically complex diabetic patients receiving care from Veterans’ Affairs (VA) hospitals, they found that patients whose main primary care providers were NP’s or PA’s were less likely to be hospitalized, less likely to visit the emergency department, and had less outpatient, pharmacy, and total health care costs compared to patients whose main primary care providers were physicians. According to the authors, this difference in costs amounted to savings of $2,005 per year for patients with NP providers and $2,300 per year for patients with PA providers compared to having a physician as the main primary care provider. This study is limited by its potential lack of generalizability to hospitals that do not use the medical home model and by differences in patient panel sizes between the different type of providers.
Given the extent of the looming PCP shortage and the impacts that it is having on patients and the health care system as a whole, expanding the autonomy of NP’s and PA’s in primary care may be an effective solution. Having an NP or a PA as the main primary care provider, even for medically complex patients, will neither decrease quality of care nor increase the costs of care, thus making these frontline clinicians acceptable alternatives to physicians while ensuring that patients have access to primary care.
This Health Policy Journal Club review is written by Avilasha Sinha as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where she is a medical student.
Abstract
Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs’ and PAs’ care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012–13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6–7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.
PMID: 31158006
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