Public Comment

Nurse Practioners Provide Cost-Effective Care

By Matt Freeman
Thursday March 25, 2010 - 04:30:00 PM

During this month’s health care summit, President Obama pleaded for practical solutions to our healthcare crisis. During America’s ongoing debate about cost control, access to care, and healthcare quality, the role of the primary care provider has become particularly critical. The family doctor is the first line of care, a gatekeeper, and a coordinator of care in our complex healthcare structure. 


Physicians have few incentives to enter primary care: the reimbursement is low, the work is hard, and there is greater appeal to work as a specialist. Struggling to make ends meet, primary care physicians are leaving to join “boutique” practices, leaving insured patients to look elsewhere. As physicians leave the field, there has only been a one percent per capita increase in the number of primary care physicians from the mid 1990s to the mid 2000s. 


There are multiple potential solutions: increasing reimbursement to primary care physicians, offering loan forgiveness to medical students and residents who enter primary care. These measures have the potential to be expensive to patients, taxpayers, and insurers. 


Another, more cost-effective solution is available to Californians. It is the credentialing of nurse practitioners as primary care providers. 


Nurse practitioners (NPs), are registered nurses with graduate-level training. Since the 1960s, NPs have provided safe, effective primary care. Extensive research has consistently demonstrated that NPs provide care that is equivalent to that of a physician; in fact the care might actually be better. The cost per visit is five to nine percent lower, NPs offer their patients longer visits, and have higher patient satisfaction. 


A patient with a sore throat, abdominal pain, diabetes, high cholesterol, or a patient seeking a routine physical exam will do just as well with a nurse practitioner as he or she would with a physician. Nurse practitioners have and use their authority to prescribe medication, order and interpret laboratory tests, and make appropriate referrals. 


Some physician groups have alluded to concerns about patient safety. In more than 40 years of practices, no study has ever demonstrated a compromise in patient safety. A nurse practitioner—just like a physician—recognizes his or her scope of practice and limitations, and refers patients appropriately. 


Nurse practitioners do not replace physicians. They work in a collaborative environment, recognizing that medically complex patients, or those with unstable illnesses warrant collaboration with physicians or other healthcare providers. 


Given the strain on primary care physicians, we all recognize that there is no shortage of patients, and increased use of nurse practitioners will not jeopardize physician practice. 


Despite all of the convincing data, California’s insurance plans do not recognize nurse practitioners. Although they pay for the services offered by NPs, they do so as if the NP’s collaborating physician provided the care. Patients are unable to name a nurse practitioner as their primary care provider, leading to confusion, and the potential for longer wait times for appointments. 


Patients looking for a new primary care provider will only find physicians listed in their insurance company web sites and printed materials, even if well-trained nurse practitioners are available to serve them. 


Californians deserve to have an open and informed choice of primary care providers. The more than 10,000 primary care nurse practitioners in California are continuing to provide exceptional care. Now is the time for California’s insurers to recognize and credential our services, thereby opening the door for improved patient access to cost-effective, quality care. This will enhance transparency while maintaining safe, interdisciplinary care. 


It has been done before. Twenty-three states already credential nurse practitioners as primary care providers. Californians deserve the same open market for primary care. 




Matt Freeman is a nurse practitioner in San Francisco.