This paper examines the potential for nurse practitioners (NPs) to deliver cost-effective, high-quality primary care in the context of rising U.S. healthcare expenditures and the Affordable Care Act. Drawing on two major systematic literature reviews, the paper evaluates whether NP-provided care is equivalent to physician care across key clinical indicators, including patient satisfaction, health outcomes, and disease management. It further considers the financial implications of expanded NP practice, particularly for costly chronic conditions such as diabetes and coronary atherosclerosis, concluding that NPs represent a credible source of healthcare savings without compromising care quality.
With passage of the Patient Protection and Affordable Care Act (ACA) of 2010 and its stated agenda for controlling the cost of healthcare in America, many are advocating for expansion of the nurse practitioner (NP) workforce and its scope of practice (Poghosyan, Lucero, Rauch, & Berkowitz, 2012). The concerns about current and projected healthcare costs are warranted. In 2009, the U.S. allocated just over 17% of its gross domestic product to healthcare spending — at least 5% above that spent by other Western nations (Squires, 2012). Half of this was spent through Medicare and Medicaid, which provide coverage for retirees, the disabled, and those living in poverty. This is important because these latter two patient populations are those traditionally served by NPs (Poghosyan, Lucero, Rauch, & Berkowitz, 2012).
While many NP workforce advocates have highlighted the limitations that several states have placed on NPs' scope of practice — and the lost healthcare savings thus incurred (Poghosyan, Lucero, Rauch, & Berkowitz, 2012) — the potential savings mean little unless the care provided is at least equivalent to that of physicians. Horrocks and colleagues (2002) conducted a systematic literature review of empirical studies that had investigated quality-of-care issues surrounding NPs and found no difference in health status, prescriptions written, return consultations, or referrals. However, NPs tended to spend significantly more time with patients and conduct more tests. This likely explains why patients reported greater satisfaction with NP care.
A more recent systematic review of the literature encompassed 37 studies, many of which had been published after Horrocks and colleagues (2002) conducted their study (Newhouse et al., 2011). Based on this analysis, NPs are equivalent to physicians in terms of patient satisfaction, health status, hypertension control, emergency department visits, hospitalizations, ventilation duration, length of hospital stay, and mortality. Notably, however, NP patients tended to control their serum glucose and lipid levels better. These findings suggest that primary care provided by NPs is at least equal to that provided by physicians.
"Financial impact of diabetes and heart disease costs"
Many advocates for expanding the NP workforce have cited lower fees as the primary source of healthcare savings; however, if the quality of care is not equivalent to that provided by physicians, then the savings benefit would be doubtful. Two systematic literature reviews — one conducted in the United Kingdom and the other in the United States — both found that the quality of care is essentially equivalent across a number of indicators, if not better. The healthcare cost savings attributable to lower fees is therefore a valid claim.
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