What Works

Nurse practitioners provide quality primary care at a lower cost than physicians

The caveats: Most of the evidence involves routine care. It is uncertain whether nurse practitioners will be willing to work in rural areas to fill the primary care void.

Jan Greene
Contributing Editor

The growing need for primary care providers, particularly in rural areas, has opened the door for nurse practitioners to fill the void. Nursing students are rushing to get nurse practitioner degrees, and researchers are working to keep pace with studies. Most of the results provide evidence for expanded use of nurse practitioners in a variety of settings and perhaps especially in rural areas with a scarcity of primary care physicians.

NP presence in primary care grows

In rural areas, about one in every four primary care providers is a nurse practitioner.

Source: Barnes H et al., Health Affairs, June 2018

Most nurse practitioners (about 85%) work in primary care settings, both urban and rural. The numbers are growing. A study published in Health Affairs last year found that nurse practitioners were roughly one in four primary care providers in rural areas in 2016, an increase from about one in five eight years before. Care provided by nurse practitioners can be close to 30% less expensive than care provided by physicians, although the difference varies with the payer and the the type of service.

Advocates for nurse practitioners say that there’s no difference in the quality of care delivered by nurse practitioners and physicians when it comes to basic preventive and chronic disease monitoring tasks. A Cochrane evidence review in July 2018 found nurse practitioners spend more time with patients and are rated more highly than physicians on patient satisfaction surveys. The review—which was, granted, mainly of European studies—concluded that outcomes for patients seen by nurse practitioners were on par with those seen by physicians in several areas: mortality, blood pressure control, diabetes, and heart disease. Nurse practitioners and doctors were also similar in the number of tests and prescriptions ordered.

In this country, a 2017 study of Medicare patients looked at quality indicators for vulnerable elders. Patients seen by nurse practitioners had fewer preventable hospitalizations and adverse outcomes. The authors suggested that results might be chalked up to nurse practitioners providing care that sticks to clinical guidelines and involves less intensive use of costly health services.

Comparing the quality of primary care provided by physicians and nurse practitioners can be fraught because of a related political battle over whether nurse practitioners should be allowed to work independently of physician oversight. Currently, 22 states have allowed them to do so. Physician advocacy groups argue such laws devalue a medical degree and the years of clinical experience and depth of knowledge it conveys. But putting aside the question of licensure and independence, physicians generally support the expanded use of nurse practitioners as part of a team, which is increasingly how they are deployed in all types of settings.