Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans
Nurse practitioners (NPs) account for about one-fifth of the primary care workforce in the United States, and VA is one of the largest employers of NPs with more than 5,000 serving in 142 VA medical centers. While several studies have identified current and future shortages of primary care physicians, NPs may provide a cost-effective alternative with an average annual salary of $107,480 compared to $198,370 for an MD general internist (2017 numbers). Investigators in this retrospective cohort study assessed patient outcomes between primary care NPs and MDs, including utilization, costs, and quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA) from 2010 to 2012. This study included three disease-specific cohorts: diabetes (180,934 Veterans assigned to MDs and 26,363 assigned to NPs); hypertension (312,181 Veterans assigned to MDs and 45,806 assigned to NPs); and ischemic heart disease (98,847 Veterans assigned to MDs and 14,413 assigned to NPs). Three types of outpatient care were assessed – primary care, specialty care, and mental health visits. Two cost measures were assessed – total outpatient costs and total cost. Investigators also examined eight process and outcome measures routinely used by VA to measure the quality of primary care. Investigators controlled for potential adverse selection of the sickest patients to MDs by making use of the natural experiment that occurs when primary care MDs leave VA and their patients are re-assigned to other MDs and NPs.
- Compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar quality of care in the management of chronic disease compared to those assigned to MDs.
- Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant.
- Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
- Investigators did not measure patient satisfaction in NP versus MD patients, nor requests to be reassigned to another primary care provider.
This study was funded by HSR&D (IIR 14-054), and Dr. Wong was supported by an HSR&D Career Development Award. All authors except Dr. Sales are with HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle and Denver. Dr. Sales leads the Long-Term Care QUERI program in Ann Arbor, MI.
Liu C-F, Hebert P, Douglas J, Neely E, Sulc C, Reddy A, Sales A, and Wong E. Outcomes of Primary Care Delivery by Nurse Practitioners: Utilization, Cost, and Quality of Care. Health Services Research. April 2020;55(2):178-189.