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Publication Briefs

VA Nurse Practitioners and Physician Assistants Lower Cost of Care for Complex Primary Care Patients with Diabetes

One-fourth of all Americans have two or more chronic conditions, but they account for about two-thirds of U.S. healthcare spending. The burden of managing complex patients with chronic conditions in community settings further strains a primary care system already stretched by an aging population and growth in chronic disease prevalence, including diabetes. Due to shortfalls of primary care physicians, nurse practitioners (NPs) and physician assistants (PAs) are taking on a larger role in caring for complex patients in the primary care setting. Previous studies demonstrate that quality of care is maintained with the use of NPs and PAs, but research on their effect on costs of care is less consistent and robust. Therefore, this study compared health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Using VA data, investigators identified 47,236 medically complex, pharmaceutically-treated Veterans with diabetes who received care from the same VA primary care provider in FY2012 and FY2013. Utilization was examined for inpatient hospitalizations, number of days with emergency department (ED) visits, primary care visits, endocrinology visits, and non-endocrinology specialty care visits. Cost outcomes included inpatient, outpatient, pharmacy, and total healthcare expenditures for care provided or paid for by VA.


  • Veterans in this study were medically complex, averaging almost seven chronic conditions each and 3.5 times the complexity of the typical Medicare patient.
  • After controlling for important patient- and facility-level factors, investigators found greater rates of hospitalizations and ED visits and higher healthcare expenditures among primary care patients of physicians compared to those of NPs or PAs. Mean per patient inpatient costs were $1,328 and $914 less for NPs and PAs, respectively, and pharmacy costs were about $300 less, compared to physicians. In sum, NP and PA patients had about $2,000 lower annual total care costs than patients of physicians.


  • This study addressed a long-standing concern that NPs and PAs might practice in ways that increase total costs of care and found no evidence to support this concern. Findings suggest that NPs and PAs can effectively manage primary care for medically complex patients with diabetes without increasing total care costs. Findings also provide further evidence that NPs and PAs may be appropriately used as primary care providers for complex patients, as opposed to being limited to supplementing the care of physicians within primary care settings.


  • Despite extensive statistical adjustments made by investigators, some differences in outcomes might be due to the patients of physicians being sicker in some way than those of NPs or PAs.

This study was funded by HSR&D (IIR 13-063). Drs. Smith, Berkowitz, and Jackson are part of HSR&D's Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC.

PubMed Logo Morgan P, Smith V, Berkowitz T, et al, and Jackson G. Impact of Physicians, Nurse Practitioners, and Physician Assistants on Utilization and Costs for Complex Patients. Health Affairs. June 2019;38(6):1028-1036.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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