Nurse Practitioners: The Growing Solution in Health Care Delivery
As managed care and falling inpatient volumes move more health care beyond the hospital to other sites around the community, policymakers are looking to one type of advanced registered nurse -- the nurse practitioner (NP) -- to help meet the escalating need for high-quality and accessible health care.
Under growing pressure to balance quality and cost, health planners are relying increasingly on nurse practitioners as the providers of choice for a range of front-line health services, such as primary and preventive care, managing chronic health conditions in older people, and teaching patients how to avoid injury and the expense of hospitalization and nursing home care. Mounting studies show that the quality of NP care is equal to, and at times better than, comparable services by physicians, and often lower cost.
This backgrounder describes the expanding use of nurse practitioners in a health system that is redefining how and where basic health care is delivered. The following pages highlight the roles, cost-effectiveness, and educational preparation of NPs, and present the recommendations of the American Association of Colleges of Nursing (AACN) and other nursing and health care organizations for ensuring that federal funding of nurse practitioner education is sufficient and effectively targeted.
- Who NPs Are...What NPs Do
- Documented Cost-Effectiveness
- Nurse Practitioner Education: Facts and Stats
- Funding NP Education
WHO NPs ARE....WHAT NPs DO
Preparation / Scope of Practice
As registered nurses whose education and clinical practice experience extend beyond basic RN training, nurse practitioners provide basic health care for infants, children, and adults in a wide range of settings such as health maintenance organizations, hospitals, primary care clinics, schools, community health centers, workplaces, and homes. Most NPs work in clinical specialties such as pediatrics, family practice, adult acute care, neonatal care, oncology, ob-gyn/women's health, occupational health, school health, and gerontological care.
Though the vast majority of nurse practitioners are prepared in master's-degree programs, a smaller number have received training in certificate programs that require up to two years of additional clinical training beyond the master's degree in nursing.
In their primary care roles, nurse practitioners perform physical exams; diagnose and treat common acute illnesses and injuries; provide immunizations; manage high blood pressure, diabetes, and other chronic problems; order and interpret X-rays and other lab tests; and counsel patients on disease prevention and health care options.
In emergency rooms, critical-care units, and other departments at hospitals nationwide, the growing ranks of acute-care nurse practitioners not only provide direct care for patients, but also help ensure continuity of care by following patients within the hospital and post-discharge. Although not replacements for physicians, acute-care NPs also perform a variety of invasive therapeutic procedures -- such as inserting and removing arterial lines and pulmonary artery catheters -- and carry out roles once reserved for medical residents, such as treating acute health problems and managing chronic illnesses.
NPs not only meet basic health care needs in rural areas and inner cities -- sites not adequately served by physicians -- but deliver quality primary care to other underserved populations, such as children in school settings and the elderly. Some NPs have independent practices and can be reimbursed by Medicare, Medicaid, or other third parties.
In 1996, an estimated 53,753 RNs were nationally certified as nurse practitioners or held state recognition as nurse practitioners or advanced practice nurses. (1)
Every state and the District of Columbia have granted nurse practitioners authority to prescribe medications. Twelve states and D.C. allow NPs to write prescriptions independent of physician involvement. In 21 states plus the District, NPs can practice independently without physician collaboration or supervision. (2)
In 1999, nurse practitioners nationally earned salaries ranging between $50,000 to $70,000 across a range of specialties, with an average of $60,000. (3)
Compared to physician training, the education of a nurse practitioner costs four-to-five times less and can be completed at least four years sooner. Such figures buttress claims that relying solely on physicians to deliver primary care would not only seriously delay the availability of critically needed providers, but incur excessive expense as well.
Indeed, a recent estimate projects that underutilization of nurse practitioners costs the nation nearly $9 billion annually due to practice restrictions in state laws and other "denied access" for consumers that is keeping the cost of basic health care inflated. (4)
In addition, recent studies have reported that, compared to physicians, NPs scored higher on patient satisfaction and on resolving conditions such as high blood pressure and high blood sugar levels. Patients of NPs also were more compliant than physicians' patients in taking medications, keeping appointments, and following recommended behavioral changes. (5)
Moreover, even after acknowledging the methodological flaws of some of the studies it reviewed in 1986, the congressional Office of Technology Assessment (OTA) concluded that nurse practitioners can deliver as much as 80 percent of the health services, and up to 90 percent of the pediatric care provided by primary care physicians, at equal to or better quality and at less cost. (6) In 12 studies, OTA found that the quality of care by NPs -- including communication with patients, preventive actions, and reductions in the number of patient symptoms -- was higher than that for physicians. (7)
Although NPs can prescribe medications in most states, they are more likely than physicians to suggest non-prescription drug approaches to therapy, such as changes in diet or counseling to relieve stress. In a 1991 study in the Archives of Internal Medicine, nurse practitioners were far less likely (20 percent compared to 63 percent of MDs) to recommend a prescription drug in a hypothetical case of a patient with gastrointestinal distress. (8)
Elsewhere, researchers at the University of Rochester reported that intensive-care babies cared for by neonatal nurse practitioners averaged 2.4 fewer hospital days and more than $3,400 less in charges than those cared for by medical residents, despite the fact that the NPs' infants were younger and had significantly lower birthweight. Unlike residents, nurse practitioners don't rotate, are "more consistent caregivers" who can follow infants through their entire stay, and need to rely less on support services to stay apprised of a patient's progress, the authors suggest in explaining the findings of the 1994 study. (9)
In Massachusetts, Worcester-based Fallon Healthcare System, an HMO, found that the average cost to care for nursing home patients was 42 percent lower when care was provided by a team of a physician and geriatric nurse practitioner than by a physician alone. Costs were kept trim largely because patients received "good episodic care" by NPs on site and were followed so closely by the teams that fewer referrals to specialists were needed, according to a 1992 study in HMO Practice. (10)
Although physicians provided 66 percent of visits during one period in 1994 at another Massachusetts HMO, Boston-based Harvard Community Health Plan, only 28 percent required the services of an MD, according to an analysis by plan managers. More than half (52 percent) of their visits, plan physicians said, could have been handled by a nurse practitioner or physician assistant. (11) In New York City, under an agreement between Columbia Presbyterian Medical Center and Oxford Health Plans, a leading managed care company, patients covered by certain Oxford plans can choose a nurse practitioner instead of a physician as their principal primary care provider, a move encouraged by the prospect of cost-savings from NPs' emphasis on prevention and health promotion. (12)
In line with such findings, the Pew Health Professions Commission has urged doubling the number of nurse practitioner graduates by the year 2000 to offset the shortages of primary care physicians in major metropolitan centers, rural sites, and inner cities. (13)
NURSE PRACTITIONER EDUCATION: FACTS AND STATS
The vast majority (more than 90 percent) of nurse practitioner education programs at colleges and universities confer the master's degree.(14) A smaller number confer a certificate requiring up to two years of additional clinical training beyond the master's degree in nursing.
Since 1991, the U.S. Public Health Service has contracted with the American Association of Colleges of Nursing (AACN) to organize nurse practitioner faculty into a nationwide advocacy network to attract candidates to the National Health Service Corps (NHSC) -- the sole source of health care for many Americans in outlying rural and other areas underserved by health professionals. Faculty advocates are the primary links providing nurse practitioner students who are completing their master's degree with information on the Corps' training and clinical practice opportunities.
NHSC's health care providers agree to serve in a shortage area in exchange for student financial assistance through NHSC scholarships and loan repayment programs.
According to AACN data:
Number of NP Programs
-- Nationwide, 323 universities and colleges offered master's-degree or post-master's nurse practitioner programs in fall 1999. (15) Of these, 262 are participating in the faculty advocate network.
Enrollments / Graduations
-- Of all master's-degree students enrolled at responding schools in fall 1999, 60.8 percent (19,635 students) were pursuing study as nurse practitioners. (16) Within nurse practitioner programs, enrollments in fall 1999 were led by students in family nurse practitioner tracks (52 percent), followed by -- among other NP specialties -- adult health (15.2 percent), pediatric (9 percent), adult acute care (5.2 percent), women's health (3.8 percent), gerontological (2.8 percent), psychiatric/mental health (3.2 percent), neonatal (1.5 percent), oncology (0.4 percent), and school (0.2 percent) tracks. (17)
-- Between August 1998 and July 1999, NP or combined NP/clinical nurse specialist programs produced more than half (64.9 percent, or 6,559) of master's-degree graduates at responding schools. (18)
FUNDING NP EDUCATION
Nurse Education Act
For FY 2001, AACN and other organizations of the Tri-Council for Nursing have urged funding of $78 million -- an increase of 15 percent over FY 2000 levels -- for the Nurse Education Act (NEA), the single largest source of federal appropriations for nursing education. (The Tri-Council for Nursing is comprised of AACN, the American Nurses Association, American Organization of Nurse Executives, and National League for Nursing.) Although the NEA (Title VIII of the Public Health Service Act) supports nursing programs at both the baccalaureate and graduate levels, it focuses primarily on training for nurse practitioners, clinical nurse specialists, certified nurse-midwives, and nurse anesthetists -- RNs who perform at the critical advanced practice level.
In addition, NEA provides vital seed money for the nation's nursing centers -- primary care facilities operated by nursing schools and managed by nurse practitioner faculty. Nursing centers not only serve as clinical training sites for NP students, but also deliver basic health services to their surrounding communities, including high-risk, vulnerable, and underserved populations.
The Role of Medicare Support
As front-line primary care and outpatient treatment become more dominant and hospitals focus more on acute care for the sickest patients, the demand for skilled nurse practitioners continues to climb. Despite this need, Medicare -- the largest single source of federal funding for nursing education -- currently does not support training for NPs and most other advanced practice nurses while, at the same time, continuing to subsidize hospital diploma programs that have been out of the mainstream of nursing education for decades.
Since its creation in 1965, Medicare has reimbursed hospitals for a portion of their clinical, classroom, and other costs to train nurses, physicians, and other health personnel with the aim of providing high-quality inpatient care to Medicare recipients.
In FY 1998, Medicare provided an estimated $410 million for nurse and allied health training. Yet 70 percent of every Medicare dollar for nursing education continues to go to hospital diploma programs that not only produce less than 10 percent of the nation's registered nurses, but are geared to the needs of a dwindling in-patient population and fail to produce the more sophisticated RN required for today's patient care. (19)
In addition, diploma programs are concentrated in three states (New Jersey, Ohio, and Pennsylvania) that received nearly half (48 percent) of Medicare funds for diploma nursing education in 1991, according to a study in the Journal of the American Medical Association. (20)
When Medicare was created, most categories of advanced practice nursing had not yet emerged. Moreover, across the last several decades, nursing education has shifted almost entirely from its early roots in hospital diploma schools into the college and university system. As a result, diploma education is no longer needed in most areas, while the health system's demand for skilled nurse practitioners, certified nurse-midwives, and other advanced practice nurses continues to escalate.
Medicare's current restrictions not only exclude 90 percent of all nursing education programs, but perpetuate an emphasis on training physicians and other health professionals in hospitals just as health care delivery is moving beyond the hospital to a diversity of settings throughout the community. Indeed, in FY 1998, the federal Bureau of Health Professions received $293 million for health professions education -- including training for needed primary care providers -- compared to the more than an estimated $7 billion spent by Medicare in FY 1997 for graduate medical education to support physician residencies in hospitals, often in specialties in oversupply.
The Drive to Redirect Medicare Funding
In the 106th Congress, AACN and other nursing organizations support the establishment of an all-payer trust fund to provide broad-based and stable funding of clinical education of advanced practice nurses, physicians, and other health professionals. Contributions to the fund would come from existing Medicare monies as well as from a combination of other sources, such as an excise tax or health plan assessment, to ensure that the financing burden is distributed fairly. In a 1997 report to Congress, the Institute of Medicine (IOM), an arm of the National Academy of Sciences, urged the creation of such a trust fund.
Moreover, AACN, together with other nursing and health care groups, has urged Congress to redirect Medicare monies for diploma nursing education towards training for nurse practitioners and other advanced practice RNs. Such a redirection, which AACN and other backers have proposed be phased in over three years, would require no new funding and result in faster production of advanced RNs for an increasingly outpatient world where more needs of Medicare patients will lie.
The Medicare funds would be provided from a stable, on-going source not subject to the uncertainties of annual appropriations decisions. Among other benefits, the move would give hospitals, HMOs, and other facilities an incentive -- reimbursement -- to take on additional numbers of advanced practice nursing students for on-site training. The monies also would allow hiring additional faculty, thus helping schools to ease the growing waiting lists at programs that prepare advanced practice nurses.
In its 1997 report, the Institute of Medicine recommended that Medicare monies for diploma nursing education be phased out and redirected to support graduate-level clinical training for advanced practice nurses, much as Medicare supports physician residencies now. As AACN has urged for several years, the IOM also called for Medicare training dollars -- now restricted to hospitals and other inpatient facilities -- to be extended to HMOs and other outpatient centers where many advanced practice nurses are trained. (21)
AACN has won backing for the redirection from other groups, including the Association of Academic Health Centers, American Nurses Association, and American College of Nurse Practitioners. Supporters also include the American Association of Nurse Anesthetists, National Association of Pediatric Nurse Associates and Practitioners, and the National Organization of Nurse Practitioner Faculties.
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CONTACT: Robert Rosseter
(202) 463-6930, x231
1. Division of Nursing. (March 1996). The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses, p. 19, Washington, DC: U.S. Department of Health and Human Services.
2. Pearson, Linda J. (January 2000). "Annual Update of How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice," Nurse Practitioner, Vol. 25, No. 1, p. 18, 19.
3. Running, Alice et al. (June 2000). "A Survey of Nurse Practitioners Across the United States," Nurse Practitioner, Vol. 25, No. 6, p. 116.
4. Nichols, Len M.. (September-October 1992). "Estimating Costs of Underusing Advanced Practice Nurses," Nursing Economics, Vol. 10, No. 5, pp. 343-351.
5. Brown, Sharon A. and Deanna E. Grimes. (November-December 1995). "A Meta-Analysis of Nurse Practitioners and Nurse Midwives in Primary Care," Nursing Research, Vol. 44, No. 6, pp. 336-337.
6. U.S. Congress, Office of Technology Assessment. (December 1986). Health Technology Case Study 37: Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis [OTA STUDY], Publication No. OTA-HCS-37, p. 39. Washington, DC: U.S. Government Printing Office.
7. Office of Technology Assessment, OTA STUDY, see note 6, p. 21.
8. Buppert, Carolyn Knight. (August 1995). "Justifying Nurse Practitioner Existence: Hard Facts to Hard Figures," Nurse Practitioner, Vol. 20, No. 8, p. 44, citing Avron, J. (1991). "The Neglected Medical History and Therapeutic Choices for Abdominal Pain: A Nationwide Study of 799 Physicians and Nurses," Archives of Internal Medicine, Vol. 151, pp. 694-698.
9. Schultz, Jaclyn M. et al. (October 1994). "Nurse Practitioners' Effectiveness in NICU," Nursing Management, Vol. 25, No. 10, pp. 50-53.
10. Burl, Jeffrey B. et al. (December 1994). "Demonstration of the Cost-Effectiveness of a Nurse Practitioner/Physician Team in Long-Term Care Facilities," HMO Practice, Vol. 8, No. 4, pp. 157-161.
11 Frampton, Judith and Susan Wall. (December 1994). "Exploring the Use of NPs and PAs in Primary Care," HMO Practice, Vol. 8, No. 4, pp. 165-170.
12. Winslow, Ron,. (February 7, 1997). "Nurses to Take Doctor Duties, Oxford Says," The Wall Street Journal, p. A3.
13. Pew Health Professions Commission. (April 1994). Nurse Practitioners: Doubling the Graduates by the Year 2000, p. 1, San Francisco: University of California, Center for the Health Professions.
14. National Organization of Nurse Practitioner Faculties. (1994). National Directory of Nurse Practitioner Programs. Washington, DC: Author.
15. American Association of Colleges of Nursing. (2000). 1999-2000 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing [SURVEY], p. 3. Washington, DC: Author.
16. American Association of Colleges of Nursing, SURVEY, see note 15, p. 3.
17. American Association of Colleges of Nursing, SURVEY, see note 15, p. 36.
18. American Association of Colleges of Nursing, SURVEY, see note 15, p. 3.
19-20. Aiken, Linda H. and Marni E. Gwyther. (May 17, 1995). "Medicare Funding of Nursing Education: The Case for Policy Change," Journal of the American Medical Association, Vol.. 273, No. 19, pp. 1528, 1530.
21. Institute of Medicine. (1997). On Implementing a National Graduate Medical Education Trust Fund, pp. 29, 31-32. Washington, DC: National Academy Press.