Nurse Practitioners

Improving Access to High-Quality, Cost-Effective Health Care

As the U.S. population ages and expands, and millions of previously uninsured individuals gain access to health coverage, the demand for primary care physician services is projected to outstrip supply. Nurse Practitioners can play a key role and fill these gaps in primary care services by providing greater access to high-quality care.

What is a Nurse Practitioner? Nurse Practitioners (NPs) are registered nurses with advanced education and training who provide a broad scope of health care services, to patients living in urban and rural settings across the nation.

• There are about 205,000 licensed NPs in the U.S, and this number is expected to grow to 244,000 by 2025.i • Over 98% of NPs have either a Masters or Doctoral degree, and nearly all are nationally certified.ii • More than 86% of NPs are prepared in primary care, and almost half of NPs engage in family practice.iii • Depending on their area of practice and degree of specialization, NPs offer health promotion, patient evaluation, treatment, diagnosis, education, counseling, case management, and coordination of care. The most common clinical specializations among NPs are family health, adult health, women's health, and pediatric health.iv Many NPs also specialize in geriatric health.

How do Nurse Practitioners and Doctors Differ? Nurse practitioners and doctors differ in the scope of their professional licensure and level of clinical education.

• A physician’s medical license and scope of practice are more general, while the scope of services NPs can provide is narrowly defined in state law. • While both NPs and doctors typically attend six to eight years of post-secondary education, doctors also typically take part in a two year residency program.v Currently, NPs do not participate in formal residency training, although NP residencies are becoming more common and there is national attention on the Graduate Nurse Education (GNE) demonstration projects that are blazing the trail for advance practice nurse residencies.vi

Why are levels of satisfaction so high among patients of Nurse Practitioners? Despite the differences in clinical education, research shows that the quality of care delivered by nurse practitioners and physicians is equivalent.

• The National Governor’s Association (NGA), concluded that, “none of the studies we reviewed raised concerns about the quality of NP care.” The NGA went on to say that, “the research suggests that NPs can perform many primary care services as well as physicians do and achieve equal or higher patient satisfaction rates among their patients.”vii • High levels of satisfaction stem from the nursing model of care that NPs follow. Nurses historically adopt a person-centered, rather than disease-centered view of health care. Thus, rather than focusing on the symptoms of disease, the nursing model emphasizes patient centered, whole person care.

Nurse Practitioners are Filling Gaps in Care • According to the National Center for Health Workforce Analysis, aging, population growth and insurance coverage expansion will cause an increase in demand for primary care services, resulting in a projected shortage of 20,400 primary care physicians by 2020.viii

• In a 2012 study, researchers estimated that the total number of office visits to primary care physicians will increase from 462 million in 2008 to 565 million in 2025.ix

• Nurse Practitioners can help fill gaps in care left by the physician shortage. The overall number of trained NPs is predicted to increase by 30%, from 55,400 NPs in 2010 to 72,100 by 2020. And, according to the American Association of Nurse Practitioners, 89% of NPs are trained in primary care and more than 75% practice in primary care settings.x

Nurse Practitioners Deliver High-Quality Care • NPs are capable of managing 80-90% of the care provided by primary care physicians without referral or consultation.xi

• Where NPs “had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients’ outcomes were comparable.”xii

• A comprehensive literature review of 118 studies that took place between 1998 and 2008 made three significant conclusions: (1) NPs working in collaboration with physicians provide effective, high-quality patient care that is the same or better than the care provided by physicians alone; (2) NPs have an important role to play in improving the quality of patient care; and (3) NPs can safely augment the physician supply as part of efforts designed to expand access to care.xiii

• A 2011 study of patients served by nurse practitioner-led nurse-managed health centers (NMHC) found that, “overall, quality measure findings for nurse-managed health centers compared favorably with national benchmarks, with particularly high-quality demonstrated for chronic disease care management.”xiv

• Another 2011 study looking at outcomes for 500 children treated for viral infections at an NP-led NMHC in Indiana concluded that the quality and efficiency of care provided by the NMHC exceeded expectations and surpassed the benchmark for each NCQA HEDIS measure.xv

Nurse Practitioner Care is Cost-Effective • A worksite clinic run by a single NP resulted in direct medical care cost-savings of nearly $2.18 million over a two- year period, without including indirect savings related to lost productivity and absences.xvi

• After insurance reform in Massachusetts, the state determined that it could save $4.2 to $8.4 billion over a 10-year period from increased use of NPs.xvii

• A 2015 study examining Medicare claims data found that evaluation and management costs were 29% less for NP patients when compared to other providers; NP inpatient visits costs were 18% less and office visits 11% less.xviii

• Within six months of establishing an NP-led NMHC, one municipality experienced a cost savings of more than $26,000 due to reductions in calls to police and paramedics.xix

• Another NP-led NMHC providing care to persons living with HIV reduced hospital charges for patients by $785,744 over one year.xx

• Between 1990 and 2000, one NP-led NMHC was able to reduce emergency room visits by uninsured patients by 25%. This led to an estimated cost savings of $13.9 million.xxi

For more information, contact National Nurse-Led Care Consortium Law and Policy Manager, Brian Valdez at (215) 731-7146 or [email protected].

i American Association of Nurse Practitioners, NP infographic available at: https://www.aanp.org/all-about-nps/what-is-an-np-2 ii American Association of Nurse Practitioners, NP Factsheet available at: https://www.aanp.org/all-about-nps/np-fact-sheet iii American Association of Nurse Practitioners, NP Factsheet available at: https://www.aanp.org/all-about-nps/np-fact-sheet and NP infographic available at: https://www.aanp.org/all-about-nps/what-is-an-np-2 iv American Association of Nurse Practitioners, NP Factsheet available at: https://www.aanp.org/all-about-nps/np-fact-sheet v The Physician Assistant life, Physician Assistant vs. Nurse Practitioner vs. Medical Doctor, Profession Comparison Chart (updated September 2015), available at http://www.thepalife.com/physician-assistant-vs-nurse-practitioner-vs-medical-doctor/ vi Ibid. vii Maria, Schiff et al. The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care, National Governors Association, (2012). viii U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Rockville, Maryland: U.S. Department of Health and Human Services, 2013. ix Patterson, Stephen M., et al. Projecting US Primary Care Physician Workforce Needs: 2010-2025. Annals of Family Medicine 10 no. 6 (2012). x Nurse Practitioners in Primary Care. American Association of Nurse Practitioners. Available at: http://www.aanp.org/aanpqa2/images/documents/publications/NPsInPrimaryCare.pdf xi Mary O. Mundinger, Advanced Practice Nursing – Good Medicine for Physicians, 330 New Eng. J. Med. 211, 211-14 (1994). xii Mary O. Mundinger et al., Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial, 283 JAMA. 59, 59-68 (2000). xiiiRobin P. Newhouse, et al., Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review, 29 Nurs. Econ. 230, 230-50 (2011), available at http://www.nursingeconomics.net/ce/2013/article3001021.pdf. xiv Violet H. Barkauskas et al., Quality of Care in Nurse-Managed Health Centers, 35 Nurs. Admin. Quart. 34, 34-43 (2011). xv Jennifer A. Coddington & Laura P. Sands, Cost of Health Care and Quality Outcomes of Patients at Nurse-Managed Clinics, 26 Nurs. Econ. 75, 75-83 (2008), available at http://www.nursingeconomics.net/ce/2010/article26075083.pdf. xvi David Chenoweth et al., Nurse Practitioner Services: Three-Year Impact on Health Care Costs, 50 J. Occup. Environ. Med. 1293, 1293-98 (2008). xvii Christine E. Eibner et al., Controlling Health Care Spending in Massachusetts: An Analysis of Options, RAND Corp. (Aug. 2009), available at http://www.rand.org/pubs/technical_reports/2009/RAND_TR733.pdf. xviii Jennifer Perloff et al., Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians, Health Services Research. Published online (2015). xix Jennifer A. Coddington & Laura P. Sands, Cost of Health Care and Quality Outcomes of Patients at Nurse-Managed Clinics, 26 Nurs. Econ. 75, 75-83 (2008), available at http://www.nursingeconomics.net/ce/2010/article26075083.pdf. xx Ibid. xxi Ibid.