The Economic Value of Nurse Practitioners in the U.S. Healthcare System

Abstract

Background: In the U.S., nurse practitioners (NPs) are rapidly transforming the provider workforce. While evidence of cost-effectiveness of NP care is emerging, less is known about the economic benefit and value of NPs to consumers, payors, and healthcare organizations.

Aims: Guided by the Nursing Human Capital Value Model, the overall aim of this dissertation was to understand the economic benefit and value of NPs. Specifically, synthesize existing evidence of the economic value of NPs to organizations (Manuscript 1), compare ambulatory cost and service volume between NPs and physicians to Medicare, a public payor (Manuscript 2), and examine whether the presence of NPs in intensive care unit (ICU) provider teams impact patient (i.e., consumer) outcomes (Manuscript 3).

Methods and Results: Manuscript 1 is a systematic review; we searched 5 electronic databases and included inferentially statistical studies conducted in the U.S. which measured organizational financial outcomes attributable to NPs. From the 28 included studies, we found that care provided by NPs was associated with reductions in both organizational production costs (n=9) and reimbursement payments (n=6). Three studies (11%) reported complete economic evaluations with contradictory results and the remaining were partial economic evaluations. Manuscript 2 is a cross-sectional observational inferential study of Medicare providers nationwide; we used 100% Medicare Part B claims to conduct provider-level adjusted regression analyses of patient annualized cost and service volume (outcomes), interacting the provider type (NP versus physician, exposure) with state-level scope of practice (SoP) regulations. We found that, compared to physicians, NP care was $136.62 (95% CI: -145.39, -127.86; p<0.001) and $185.09 (95% CI: -189.05, -181.13; p<0.001) less costly per patient and NPs provided 1.84 (95% CI: -2.91, -0.76; p<0.001) and 3.01 (95% CI: -3.43, -2.58; p<0.001) fewer services per patient annually in full and restricted SoP states, respectively. Finally, Manuscript 3 is a cross-sectional observational inferential study of ICU patient encounters from 5 ICUs in a single healthcare facility. We used linked patient-provider Electronic Health Records to conduct adjusted patient-shift-level multinomial logistic regression comparing the likelihood of patient death and patient discharge from the ICU (outcomes) in the presence or absence of NPs on the shift. We found no significant association for the likelihood of death in the ICU (p=0.562) and a 0.9% (p<0.001) higher likelihood of discharge from the ICU during shifts when NPs were present in the patient’s provider teams.

Discussion: Our systematic review (Manuscript 1) revealed, from the organization’s perspective, the economic value of NPs is currently limited and subject to conceptual and measurement limitations; thus, leaving organizations inadequately prepared to make evidence-based financial decisions in the employment and use of NPs. Yet, NPs offer significant economic advantages in the ambulatory care setting from a public payors’ perspective (Manuscript 2) and in the critical care setting from the consumer/patient’s perspective (Manuscript 3).

Conclusion: This dissertation examined the economic value of NPs in the U.S. from the organization, payor, and consumer perspective and revealed a potential misalignment between the value NPs provide to consumers and payors and their economic value to the organizations that employ them. Collectively, the three manuscripts provide evidence for (1) researchers to examine an organization’s return on investment from employing NPs, (2) policymakers to remove barriers that hinder economic advantages of NPs, and (3) administrators in hospital settings to hire and use NPs in the delivery of critical care services.