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Adjunct Providers and Complex Patients

By June 19, 2019Commentary

One way to lower health spending is to decrease the unit cost of providing a service.  Another way is to more effectively manage care, especially for sicker patients, by eliminating unnecessary utilization or finding lower cost treatment methods.  These two approaches are covered in research in Health Affairs.   (HA Article)   The use of physician assistants and nurse practitioners has grown in recent years.  They have significantly lower unit costs than do physicians and research so far suggests that the outcomes they produce are just as good.  Many states now give them wide scope of unsupervised practice, although there are still often conflicts with physician organizations seeking to protect their turf.  This particular study sought to track utilization and costs in a cohort of diabetes patients treated by NPs and PAs, comparing costs to those for similar patients treated by doctors.  Diabetes is a chronic disease which requires careful management to avoid acute episodes which might require emergency room or inpatient hospital use.  The patients came from the Veterans Administration health system, which allowed for clear attribution of care management to a physician, physician assistant or nurse practitioner.  Utilization and cost were tracked for 2012 and 2013 for a set of complex diabetes patients.  A variety of typical adjustments were made to the analyses to assure consistent comparison, given patient demographic, social, economic and health status differences.

Of the total group of patients, 78% had a doctor as the primary care provider, 16% had a nurse practitioner and 6% had a physician’s assistant.  The patients were quite complex and high users of health care.  The nurse practitioner and physician assistant patients were less likely to have a hospitalization during the study period, including those for ambulatory care sensitive conditions.  Patients of physicians also had a higher rate of ER visits.  Patients of physician assistants had more primary care visits than did patients of either doctors or nurse practitioners.  There were no significant differences in rates of specialty visits.  Physician patients had higher outpatient, pharmacy and total health spending than did patients of nurse practitioners or physician assistants.  Physician patients also had higher inpatient spending than did NP patients.  Annual total medical spending for NP patients averaged $32,645; for PAs it was $32350 and for doctors $34,650.  So seeing an NP or PA saved 6-7% on medical costs.  And nurse practitioners and physician assistants are paid substantially less than the typical physician, so the cost of service is lower as well.  The results of studies like this should encourage policymakers and payers of all types to continue to expand the scope of practice for non-physician clinicians and to encourage their use for managing the care of even complex chronic disease patients.

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