Lowering Costs, Not Quality, With Nurse Practitioners

Marilyn W. Edmunds, PhD, CRNP


June 04, 2010

Nurse Practitioners as an Underutilized Resource for Health Reform: Evidence-Based Demonstrations of Cost-Effectiveness

Bauer JC
J Am Acad Nurse Pract. 2010;22:228-231

Article Summary

Recent healthcare reform initiatives were motivated by an imperative to reduce the relentless increase in spending on medical care. Solutions are focused on the application of proven principles of evidence-based practice and cost-effectiveness: in short, finding the least-expensive way to provide a specific clinical service of acceptable quality.

Written by an internationally recognized medical economist and health futurist, this article combines economic analysis and a literature review to show how the goals of healthcare reform can be accomplished by allowing independently licensed nurse practitioners (NPs) to provide a wide range of services directly to patients in a variety of clinical settings.

Some of the author's conclusions are:

  • Allowing the substitution of NPs for more-expensive health professionals can reduce the costs of producing healthcare without diminishing quality in the process.

  • Policies that constrain appropriate input substitution need to be changed as quickly as possible. Money that could be reallocated to meeting reform goals is being wasted as long as rules and regulations hinder full use of less expensive, equally qualified NPs.

  • Economic and clinical gains can be realized by allowing NPs to be independent caregivers and team leaders for a large number of health services and settings.

  • The United States is paying a high price for current policies that prevent NPs from practicing within their full, legally defined scopes of practice.

  • Cost-effectiveness analysis clearly supports reversing rules and regulations that deny reimbursement to NPs while paying more expensive health professionals for clinical services that achieve similar results.

  • Several decades of experience with NPs and dozens of published studies show that quality is not a problem with reforms that would allow NPs to provide more services. Nurse practitioners care for patients at least as well as physicians in many clearly defined areas of nursing and medical practice.

  • Every study published in peer-reviewed journals has reinforced the Office of Technology Assessment's conclusions in 1981[1] NPs can be substituted for physicians in a significant portion of medical services -- ranging from 25% in some specialty areas to 90% in primary care -- with at least similar outcomes. Not a single study has found that NPs provide inferior services within the overlapping scopes of licensed practice.

  • Those who favor restricting the use of NPs in overlapping areas of clinical competency have no data to support their position.

  • Patients like the care they receive from NPs at least as much as the care they receive from physicians. Consumers' overall appreciation of NPs is extremely high.

  • The use of NPs can save money in accordance with another important goal of health reform: reducing the direct and indirect cost of professional liability (eg, malpractice claims).

  • Collaborative, team-based approaches to care -- including teams led by NPs -- should be actively promoted to reduce overall spending on healthcare.

  • The full integration of NPs into daily practice as substitutes for other qualified health professionals in many clinical areas will also enhance access. Nurse practitioners treat patients in many settings where other qualified independent caregivers are scarce.


This is a succinct summary of the NP literature as it pertains to economic issues of healthcare. Although NP practice has been subjugated to some of the most intense research investigation of any healthcare provider group, many of the studies have been discounted because the research was performed by NPs themselves. This article should heighten the credibility of some of the earlier studies by coming to the same conclusions. The author makes the same type of recommendations that Barbara Sefreit, JD, Associate Dean and Professor, Yale Law School, did in 1992[2]: She suggested that regulations that hinder NPs from their full scope of practice should be removed.

This article should help guide state legislators who seek to create order out of chaos in the new healthcare reform movements. It should also be used as evidence for federal regulators when writing the myriad of regulations that will come out of the recently passed healthcare reform legislation. This article should make these individuals more comfortable with removing some of the barriers to NP practice. Debate about the use of NPs will surely continue, so this article is timely.



Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.