Long story short: As a percentage of GDP, the US spends almost twice as much on healthcare as other developed countries, on average. Why is US healthcare so expensive? Partly because our doctors are paid very well and partly because we use specialists too much. Controlling access to specialists via primary care “gatekeepers” could help, but most gatekeepers in the US are physicians, aka general practitioners, or GPs. Problem is, our GPs are the highest paid in the world. Check it out:
If we really want to put a dent in healthcare spending, relying on GPs as gatekeepers won't get us very far. We need cheaper but just as good gatekeepers. Enter Nurse Practitioners! Say who? Here's who:
Nurse practitioners are registered nurses with advanced preparation and education [Masters or Doctorate] who provide primary, acute and specialty health care services. They can evaluate patients, make diagnoses, prescribe medications and initiate and manage patient treatment. - Columbia University School of Nursing
"Managing patient treatment" basically means gatekeeping. In some states and countries, nurse practitioners have been working for years as "full practice" primary care providers and gatekeepers, a status that allows them to work independently of a physician's clinical oversight. In other words, a GP is no longer required to sign-off on their professional opinions, prescriptions, and referrals. Tons of studies have found their quality of care to be as good or better than GP gatekeepers. Here are a few:
Horrocks, S., E. Anderson, et al. (2002): The authors reviewed 11 randomized controlled trials and 23 observational studies. Results: patients were more satisfied with care by a nurse practitioner. No differences in health status were found. Nurse practitioners had longer consultations than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations.
Lenz, E. R., M. O. N. Mundinger, et al. (2004): This was a 2-year follow-up of a randomized study of 406 adults comparing outcomes of patients assigned to a nurse practitioner or a physician primary care practice. The results are consistent “with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians.”
Van Der Biezen et al (2016): The authors analyzed 6,040 patients in the experimental team, of which 987 received primary care from nurse practitioners and 5,053 received care from GPs, as well as 6,052 patients in the control team. Results: There were no significant differences in health outcomes between teams. Nurse practitioner care resulted in lower resource use and cost savings than GP care.
Despite all the evidence supporting nurse practitioners as full practice primary care providers, the American Medical Association continues to oppose the practice. Most recently, in response to a VA proposal to allow full practice status to nurse practitioners, the AMA issued a statement saying it was “disappointed” by the VA’s “unprecedented proposal to allow advanced practice nurses (APRN) within the VA to practice independently of a physician's clinical oversight, regardless of individual state law…. All patients deserve access to physician expertise….” Luckily, the VA went ahead and granted full practice authority to certified nurse practitioners in December 2016.
Slowly but surely the US is catching on to the advantages of using nurse practitioners as independent primary care gatekeepers. A big factor in the gradual acceptance of this expanded role for nurse practitioners is the shortage of GPs, which has left millions of Americans without access to primary care providers. Currently, 23 states and the District of Columbia have approved full practice status for nurse practitioners. Removing physician supervision from the picture saves money and reduces the regulatory burden of tracking and enforcement. All this without compromising quality of care!
References:
Horrocks, S., E. Anderson, et al. (2002). "Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors." BMJ 324(7341): 819-823. http://www.bmj.com/content/324/7341/819.short
Lenz, E. R., M. O. N. Mundinger, et al. (2004). "Primary Care Outcomes in Patients treated by Nurse Practitioners or Physicians: Two-Year Follow-Up." Medical Care Research and Review 61(3): 332-351. DOI: 10.1177/1077558704266821
Van Der Biezen M, Adang E, Van Der Burgt R, Wensing M, Laurant M. The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasi-experimental study. BMC Fam Pract. 2016 Sep 13;17(1):132. https://www.ncbi.nlm.nih.gov/pubmed/27619968