The Journal for Nurse Practitioners is proud to announce the Marilyn Edmunds JNP Writing Award, which honors excellence in writing and encourages writing for publication.. Congratulations to Cinthya Sotelo, DNP, FNP-C, for her article “Ovarian Ectopic Pregnancy: A Clinical Analysis” in the March 2019 issue. Billings J. More experience with EHRs might improve net revenue by improving patient scheduling and other patient flow processes or by capturing more billable services. These areas affect more than 57 million people, and almost 16,000 additional practitioners are required to meet primary care needs.1 Moreover, Hofer et al estimated that an additional 4307 to 6940 PCPs would be required just to meet the needs of the newly insured under the Affordable Care Act.2 A study by Huang and Finegold expanded this analysis to identify geographic areas disproportionately affected by the combination of insurance expansion and the current shortage of PCPs.3 They estimated that 51 million Americans live in the areas that will experience the greatest effect of primary care shortage. 11. However, among practices employing some NPs, the ratio is 0.211, or about 1 NP per 4.7 physicians. 5. Cooper RA. Those results imply that among practices with some NPs, risk-adjusted PBPY costs are higher up to 0.32 and decline thereafter as the ratio increases. Newhouse RP, Stanik-Hutt J, White KM, et al. That variable was not significant in any analyses at the 0.05 level, and its inclusion had only a minor effect in 1 regression, as discussed in the Results section. Nurse practitioner staffing data indicate that employing 0.25 to 0.50 NPs per primary care physician increases patient-level costs and decreases quality. 1, No. While greater reliance on nurse practitioners in primary healthcare settings can improve service efficiency and accessibility, their integration is not straightforward, challenging existing role definitions of both registered nurses and physicians. The primary function of nurse practitioners is to promote wellness through patient health education. Tools for monitoring the health care safety net [AHRQ publication No. Keywords nurse practitioner, history, ... Google Scholar | Medline. 2012;50(7):606-610. New York, private philanthropy also played a major role in helping the nurse practitioner and physician assistant professions get up and running, and then expand nationwide. Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. Family nurse practitioners (FNP) earn high salaries working in a variety of settings. Manning BT, Bohl DD, Redondo ML, Gerlinger TL, Sporer SM, Paprosky WG, Levine BR. Health Aff (Millwood). Small primary care practices face four hurdles—including a physician-centric mind-set—in becoming medical homes. Results: Employing NPs in primary care practices is associated with increased risk-adjusted patient cost for up to 1 NP for every 2 physicians, but cost decreases as the number of NPs per physician increases. The Role of Nursing in Spiritual Care: Within the nursing literature, interest in spirituality has increased exponentially in the last several decades. 6. Midlevel Providers in Orthopaedic Surgery: The Patient's Perspective. Employing more nurse practitioners (NPs) to meet increased needs for primary healthcare could increase costs and have a negative effect on quality if their clinical roles are not clarified. Both are statistically significant at close to the 0.05 level. Roblin DW, Howard DH, Becker ER, Adams EK, Roberts MH. The Nurse Practitioner: June 11, 2018 - Volume 43 - Issue 6 - p 8 doi: 10.1097/ E-mail: 2011;29(5):230-250; quiz 251. Review. J Health Econ. NLM Since other practice-level attributes have been shown to be associated with cost and quality variables in our previous research, we include 5 of those as control variables in this analysis.20 Those variables, taken from the MGMA survey, are specified as follows: a) practice ownership: physician-owned, hospital-owned, other-owned (eg, community health centers, health insurance plans, local government agencies); b) net revenue: net revenue after operating costs as a percentage of total net revenue; c) rural versus urban location: rural if in a community of 5000 or fewer population; d) EHR: practice has an EHR; and e) years with EHR: number of years since implementing EHR. 2004;39(3):607-626. 2010;29(5):893-899. Practices employing NPs have higher rates of non-emergent ED visits and lower rates of CVD/LDL testing than practices not employing NPs. As of January, a record of more than 270,000 nurse practitioners (estimated) are licensed to practice in … The number of years the practice has had an EHR is positively associated with net revenue, as is rural location. Several recent studies have highlighted the pending shortage of primary care physicians (PCPs). 1. Health Serv Res. Most of these studies found the performance of advanced practice nurses to be equal to or better than that of physicians. The coefficient of no nurse practitioners per physician (NPPs) shows that on average, Medicare costs are $445 higher per patient for practices that do not employ NPs than practices that employ some NPs, but the difference is not statistically significant. The objective of this study was to determine the association of NPs with patient-level cost and quality of care. The cost-maximizing ratio is 0.32, or about 1 NP for every 2 physicians. Nurse practitioner workforce: a substantial supply of primary care providers. As in most organizational-level studies, organizational characteristics are not assigned randomly to organizations, but are “endogenously” chosen by the organization. Accessed March 2014. Nurs Inq. Perspectives of physicians and nurse practitioners on primary care practice. The descriptive statistics are shown separately for practices employing no NPs versus some NPs. These variables are calculated from the Medicare claims files and are specified as follows: HEDIS measures. 22. Clipboard, Search History, and several other advanced features are temporarily unavailable. Reinhardt U. Nurse practitioners are the principal group of advanced-practice nurses delivering primary care in the United States. Cochrane Database Syst Rev. For example, it is possible that practices with more costly patients, even after standard risk adjustment, hire more NPs. 21. In contrast, the mean ratio across the entire sample (including practices that employ no NPs) is 0.154, or about 1 NP per 6.5 physicians. Methods: A national sample of primary care medical group practices based on responses to the 2009 Medical Group Management Association Performance Survey. The data set for this analysis was created by identifying the adult primary care medical group practices that provided organizational and performance data for the Medical Group Management Association (MGMA) 2009 survey. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Online ahead of print. This is an important measure of the relationship between practice-level revenue and cost of care, and a measure of the contribution of NPs to the efficiency of the medical group practice in providing services. Liu N, D’Aunno T. The productivity and cost-efficiency of models for involving nurse practitioners in primary care: a perspective from queuing analysis. Gysin S, Meier R, van Vught A, Merlo C, Gemperli A, Essig S. BMC Fam Pract. (Including the number of patients attributed to the physician’s practice in that regression improves the precision of those estimates, resulting in a level of significance of 0.046 on the square of the ratio, even though the coefficient of the number of patients is itself not statistically significant.) Available:… Health Serv Res. Health promotion by nurses is associated with common universal principles of nursing. The evolving role of nurse practitioners (NPs) as primary care providers, especially for vulnerable populations, is central to the debate regarding strategies to address the growing need for primary care services. Brown SA, Grimes DE. While these studies provide important insights into the performance of NPs, they do not address the challenges faced by primary care medical group practices when they participate in accountable care organizations or similar programs in which patient population—level costs and quality are the main performance measures. Data on 85 practices were then linked to claims data on the Medicare beneficiaries who received a plurality of their nonhospital evaluation and management visits from the practices. Accessed March 2014. AUSTIN, TEXAS (January 28, 2019) – The American Association of Nurse Practitioners ® (AANP) released both the new national nurse practitioner (NP) count and findings from its 2018 National Nurse Practitioner Sample Survey. The potential of nurse practitioners is not being fully realized in primary care medical practices. Authorship Information: Concept and design (JK, BD, AC); acquisition of data (JK, BD, AC); analysis and interpretation of data (JK, BD, AC, MS, JT); drafting of the manuscript (JK, BD, JT, MS); critical revision of the manuscript for important intellectual content (JK, BD, AC); statistical analysis (JK, BD, JT); provision of patients or study materials (JK); obtaining funding (JK, BD); administrative, technical, or logistic support (JK, BD, AC, JT); and supervision (JK). As noted by Grumbach and Bodenheimer (2004)22 and Nutting et al (2012),23 staffing is only 1 part of team care. We recommend that nurse practice acts--the state laws governing how nurses may practice--be standardized, that equivalent reimbursement be paid for comparable services regardless of practitioner, and that performance results be publicly reported to maximize the high-quality care that nurse practitioners provide. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? However, we can say that practices that have found a way to accommodate a higher ratio of NPs to physicians exhibit the differences (or lack of differences) in the dependent variables that we find in our analyses. 2004;291(10):1246-1251. Descriptive statistics for the variables in the analysis are shown in . While numerous studies have focused on the potential contributions of and need for more NPs,4-7 the factors influencing their roles,8-11 and the quality of their care,12-15 few have examined their association with costs; and to our knowledge, none have assessed their association with practice-level costs or the relationships between those costs and quality of care.  |  Nurse Journal: 7 Future Trends for Nurse Practitioners. Please enable it to take advantage of the complete set of features! 2010;29(5):893-899. Consequently, cost and quality gains are not being achieved. 14. NYU Wagner website. APNs are often referred to as advanced practice registered nurses (APRPs) and are among a group of healthcare provides described as advanced practice providers (APPs). 2020 Aug 13;21(1):164. doi: 10.1186/s12875-020-01240-8. The role of nurse practitioners in reinventing primary care. 2000;283(1):59-68. Naylor MD, Kurtzman ET. Perhaps there are unobserved variables that influence decisions to hire NPs and also influence patient-level cost and quality. Caring for the sick has certainly gotten more complicated. Medical administrators should evaluate the influence of NP staffing ratios on their clinical roles and subsequent cost and quality performance. In this staffing range, this suggests that the clinical role of NPs has an adverse influence on performance. New directions for nurse practitioners and physician assistants in the era of physician shortages. General health promoters. Nurs Res. Much of the effectiveness is related to organizational and cultural factors. Mundinger MO, Kane RL, Lenz ER, et al. Objectives: The employment of more nurse practitioners (NPs) is one of the most promising ways to expand the capacity of medical group practices. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. 2003;1(2):97-104. The participants’ perceptions of nurse practitioner consultation communication processes and social interactions were represented through six themes: Consulting style of nurse practitioners; Nurse practitioner – GP comparisons; Lifeworld content or lifeworld style; Nurse practitioner role ambiguity; Creating the impression of time and Expectations for safety netting. House Bill 573: An Act Relative to the Role of Certain Advanced Registered Nurse Practitioners in the State Mental Health Services System. Get the latest research from NIH: Barnes studied the relationship between ANP role transition, prior RN experience, and formal orientation. Their services include, but are not limited to: ordering, conducting and interpreting diagnostic and laboratory tests; prescribing pharmacologic agents and non-pharmacologic therapies; and teaching and counseling. We cannot say that medical practices will experience the outcomes indicated by our estimated coefficients if they alter the number of NPs they employ. Nurse practitioners are the principal group of advanced-practice nurses delivering primary care in the United States. These may include family nurse practitioners or adult gerontology nurse practitioners, for example. Citation: Puskar, K. R. (June 15, 1996). Strategy. 13. 2019 Nov 27;20(1):163. doi: 10.1186/s12875-019-1055-z.  | a comparison of primary care physicians and nonphysician clinicians in California and Washington. 18. However, little is known about the optimal use of these clinicians in primary care medical practices or the effect of NPs on the costs and quality of care. The NP staffing ratio does not appear to be related to non-emergent ED use ratios, but higher ratios are associated with higher ACS admissions (). The employment of more nurse practitioners (NPs) is one of the most promising ways to expand the capacity of medical group practices to meet the projected needs for primary healthcare created by an aging population and increased health insurance coverage under the Affordable Care Act. 2001;20(4):231-238. Nurse practitioner (NP), nonphysician clinician who is a nurse with a graduate degree in advanced-practice nursing. COVID-19 is an emerging, rapidly evolving situation. JAMA. Hofer AN, Abraham JM, Moscovice I. Kralewski JE, Wallace W, Wingert TD, Knutson DJ, Johnson CE. Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. Robert Wood Johnson Foundation: Nurses Take on New and Expanded Roles in Health Care 2011;89(1):69-89. 2010 Apr;22(4):228-31. doi: 10.1111/j.1745-7599.2010.00498.x. Certainly, more research is needed to document the factors influencing these performance measures and how the practice determines the clinical roles of the NPs once they are employed, as well as how practices bill for the time of NPs, and how the roles of NPs and physician supervision of NPs differ among practices. Address correspondence to: John Kralewski, PhD, MHA, Professor Emeritus and Senior Research Fellow, Division of Health Policy and Management, School of Public Health, The University of Minnesota. 2013 Nurse practitioner state practice environment. Review of Economics and Statistics. 17. 2008 Nov 1;138(43-44):621-8. Measures of inappropriate utilization. 1, Manuscript 2. Both ratios are below the cost-maximizing ratio. BMJ. Our inability to give a causal interpretation to our coefficients makes them less useful for practices or policy makers who are attempting to change practice outcomes by changing the level of NP staffing. Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO. Consequently, it is difficult to interpret these results. Med Care. This article examines the background to the development of the advanced nurse practitioner role. Updated September 2003. 2013 May 16;368(20):1898-906. doi: 10.1056/NEJMsa1212938. Findings and Conclusions. 2020 Oct;58(10):853-860. doi: 10.1097/MLR.0000000000001364. Accessed March 11, 2013. The NP staffing ratio is unrelated to practice net revenue despite the (nonlinear) relationship of NPs to Medicare costs and the obvious reduction in patient-care costs to the practice if NPs are substituted for physician labor. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours. A production function for physician services. The role of nurse practitioners in reinventing primary care. Google Scholar. : How to collaborate effectively with psychiatric nurse practitioners. Findings. Per beneficiary per year total costs and quality of care were calculated from Medicare claims data. Our risk-adjusted cost variable represents a cost to the Medicare program, but it is revenue to the practice, and thus one might expect the NP staffing ratio to exhibit the same nonlinear relationship to the practice’s net revenue, but that is not the case. Sacha Ferguson, Sacha Ferguson ... An alternative approach is to maximize utilization of non-physician providers, including nurse practitioners (NPs) and other advanced practice nurses (APNs), physician assistants and midwives in primary care delivery. Use of physician assistants and nurse practitioners in primary care, 1995-1999. Differences in payment rates are adjusted using the Medicare Geographic Practice Cost Index. 4. An extensive recent review of the contributions of advanced practice nurses to primary care conducted by Laurant et al (2014)16 identified over 1100 publications, but only 3 studies assessed resource utilization such as consultation rates and prescription drug use, and 2 addressed direct costs, including labor costs per patient visit. 16. Practices in the other ownership category (owned by a community health center, the government, or a health plan) have higher A1C and mammography rates. This is an important area for future research if the full potential of these nonphysician clinicians is to be achieved. Increased ACS admissions may be one of the ways that use of NPs is associated with higher costs up to the ratio of 0.32. J Am Acad Nurse Pract. Practice organizational variables. Rural practices have lower CVD/LDL rates but do not differ on the other measures. For these reasons, the occupation is among the most popular specialized nursing roles.According to the American Association of Nurse Practitioners, about 67% of nurse practitioners across the nation hold the FNP credential.. FNPs work with families to implement healthcare plans and provide preventative … The evolution of advanced practice nurses to care for women and newborns has its roots in public health nursing of the latter decades of the 19th century. NP staffing ratios are not statistically related to performance on any of these measures. It is important to remember that the net revenue variable is based on all the practice’s patients, whereas the risk-adjusted PBPY cost variable is computed only for the practice’s Medicare patients. We compiled data on the number of FTE physicians in the practice, but dropped these data from the analyses at the suggestion of a reviewer who pointed out that it could be a mediator between the NP variables and the outcome variables. Nurse Practitioners: The first nurse practitioner training program was conceived in 1965 at the University of Colorado The advanced nurse practitioner is but one model and is sometimes described as a hybrid role because, although it holds true to the underpinning philosophy of nursing practice, it also encompasses a skillset traditionally considered to be that of doctors. Online Journal of Issues in Nursing.Vol. They are authorized to perform physical examinations, order and interpret diagnostic tests, provide counseling and education, and write prescriptions. Advanced Clinical Practitioners (ACPs) are a rapidly growing workforce worldwide with the USA showing the highest absolute number and rate per population, followed by the Netherlands, Canada, Australia, Ireland, and New Zealand (Maier, Barnes, Aiken, & Busse, 2016).Whilst many practitioners are nurses by background, the development of the role has encouraged the inclusion … A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus … The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review. 1972;54(1):55-66. As pointed out by Roblin et al (2004),17 while labor costs per patient visit decline in managed care organizations as more PAs and NPs are employed, more research is needed on delivery system cost savings and cost-effectiveness. A meta-analysis of nurse practitioners and nurse midwives in primary care. American Association of Nurse Practitioners website. The resulting per beneficiary per year (PBPY) adjusted costs represent dollar-weighted resource use to provide and manage care for similar patients. 2008;17(8):1044–50. Roles of a Nurse Practitioner Working directly with patients, NPs can diagnose and manage most common and many chronic illnesses. 7. Acad Med. Because practices are choosing their NP staffing levels in addition to many other practice characteristics, it is likely to prove difficult to estimate the true causal effect of NPs or other endogenous practice characteristics on healthcare costs.  |  Introducing Advanced Practice Nurses / Nurse Practitioners in health care systems: a framework for reflection and analysis. Shortage designation: health professional shortage areas & medically underserved areas/populations. All rights reserved. With regard to the presence of nurse practitioners in nonrural settings, there was an increase from 15.9% in 2008 to 23% in 2016. Ratios higher than 0.32 are associated with lower patient costs, but practically not at all with quality. However, the extremely poor overall fit of the ACS regression results in a negative r2 after making the adjustment for the number of explanatory variables. HHS website. 1995;44(6):332-339. Published 2013. De Geest S, Moons P, Callens B, Gut C, Lindpaintner L, Spirig R. Swiss Med Wkly. Only 2 of the differences are statistically significant at the 0.05 level. 03-0027]. Ann Fam Med. 15. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Lower staffing has no effect on costs or quality, but employing two NPs per physician reduces costs and improves quality. evidence from nurse practitioners and physician assistants. This annual award was established in 2019 in recognition of … In essence, the nurse practitioner role is multifaceted, requiring independent and interdependent decision making and direct accountability for clinical judgment in managing the care of children with cancer and their families. Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. 2012;47(2):594-613. © 2020 MJH Life Sciences™ and Clinical Care Targeted Communications, LLC. 1999;44(3):167-182; Discussion 182-183. 15. The coefficient of the NP staffing level in the risk-adjusted cost equation is 9374.440 and the coefficient of the squared term is —14,939.620. Source of Funding: Funding provided by the Robert Wood Johnson Health Care Financing and Organization initiative. 2013;32(3):614-621. Find NCBI SARS-CoV-2 literature, sequence, and clinical content: Current Psychiatry 11:49–53, 2012 Google Scholar. Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study. 23. Milbank Q. BMC Fam Pract. Agency for Healthcare Research and Quality website. McGivern, D. (1986). Substitution of doctors by nurses in primary care. Advanced practice nurses (APNs) are nurses who have obtained advanced training and certification, often including a masters degree or a doctorate in nursing. Nutting PA, Crabtree BF, McDaniel RR. 3. The nursing role is rapidly evolving as nurses are tasked with an even wider range of health care responsibilities. Huang ES, Finegold K. Seven million Americans live in areas where demand for primary care may exceed supply by more than 10 percent. Our data indicate that Medicare costs for primary care medical group practices are associated with the ratio of NPs to NPs plus physicians, but this relationship is nonlinear. Unfortunately, little is known about the configuration of these clinical roles or how they influence costs and quality of care. Article PubMed Google Scholar For example, on the research site PubMed, in the decade 1982-1991 there were only seven articles addressing ‘spirituality & nursing,’ and three ‘religious & nursing’. The NP variable is entered into our analyses as the ratio of FTE NPs to FTE physicians and NPs in each practice. 2008 Jun;15(2):116-26. doi: 10.1111/j.1440-1800.2008.00404.x. NPs perform a variety of clinical roles ranging from replacing a physician to assisting the physician. 2005;(2):CD001271. The Health Resources and Services Administration identified more than 5000 primary care shortage areas as of January 2013. Author Affiliations: Division of Health Policy and Management, School of Public Health, University of Minnesota (JK, BD), Minneapolis, MN; Medica Research Institute (JK, AC, MS, JT), Minnetonka MN. All of these analyses used ordinary least squares regression equations to estimate the association of the explanatory variables, including the NP/physician staffing ratios with patient-level cost and quality and practice-level economic efficiency. HHS The field is growing, and so are opportunities for nurse practitioners, DNP and PhD nurses, nurse educators, nurse-anesthetists, and nurse researchers. It also explores the various factors that may affect nurse leadership and the role of the advanced nurse practitioner, including professional identity, gender, nursing's strategic influence, clinical outcomes, and recruitment and retention. 8. J Clin Nurs. Current ratios for all practices and those employing some NPs lie below that level.