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Yiqun Chen discusses the productivity of nurse practitioners (NPs) and physicians, two professions performing overlapping tasks but with stark differences in background, training, and pay.

Image courtesy of interviewee. December 7, 2023

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The paper examines the productivity of physicians and nurse practitioners (NPs) in the U.S. healthcare system, where there is rising demand for healthcare services but a relatively fixed supply of physicians. This video video context has increased the reliance on NPs as substitutes for physicians, particularly in emergency department settings. The study utilizes data from the Veterans Health Administration, which in 2016 allowed NPs to practice independently.

The findings reveal that NPs generally treat healthier patients compared to physicians, which complicates direct comparisons of their outcomes. To address this, the research employs quasi-random variation in the number of NPs on duty to assess treatment outcomes and resource use. The results indicate that while NPs incur higher medical costs for patients, they often achieve poorer treatment outcomes on average. Nonetheless, there is considerable variability in productivity within both occupations, with some NPs outperforming average physicians.

The paper suggests that experience may contribute to this productivity gap, as NPs with more experience tend to perform better. The findings recommend that healthcare systems should focus on optimal patient assignments between physicians and NPs, especially for less complex cases where NPs can perform comparably or even better than physicians. Additionally, it emphasizes exploring collaboration between the two roles to maximize patient care efficiency. Overall, the study contributes to ongoing discussions around the roles of NPs in healthcare delivery and the impact of occupational licensing on professional quality.

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X-TIMESTAMP-MAP:LOCAL=00:00:00.000,MPEGTS=900000

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In this paper, we look at the productivity of,

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physicians and, nurse practitioners.

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Um, in the US there's a increasing demand for healthcare,

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but physician supply is relatively inelastic.

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So this leads to the increased use of nurse practitioners

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as substitute for physicians, nurse practitioners,

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they are type of mid-level practitioners.

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They are trained to diagnose patients

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and also treat patients.

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And in this paper we look at,

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in the emergency department setting,

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which is an important setting,

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that is nurse practitioners whether there are differences

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between physicians

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and nurse practitioners in the, medical resource use

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and patient treatment outcomes,

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whether there are difference in these dimensions.

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So we look at this question at the

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Veterans Health Administration in the us, the VA,

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which is often just called va, the va, allow,

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they have a policy, they passed a policy in 2016

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that allowed nurse practitioners

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to practice independently without physician supervision.

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Nurse practitioners can, for example, diagnose patients,

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order treatments

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and prescribe drugs as independently

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as physicians at the va.

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The data, we are using the VA's

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Administrative Health records.

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So basically it record the patients we the

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who treat the patient,

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and, all the treatments the patients

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received during the visit.

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In the data, we can track whether the pa the provider treats

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the patient, is a nurse practitioner

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or physician, what, what type of,

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treatments the patient, received.

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And we can also track patient outcomes like,

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their mortality and hospital readmissions.

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Uh, our identification is the instrumental variable.

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H we use the, number of,

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nurse practitioners on duty at the ED on a day.

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The patient visited as an instrument

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for whether the patient is treated

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by a nurse practitioner or not.

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So if we, compared the average characteristics

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of patients treated

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by nurse practitioners versus the average characteristics

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of patients treated by physicians, we see

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that nurse practitioners on average treat healthier

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patients than physicians.

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For example, patients treated

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by nurse practitioners are younger

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and have fewer comorbidities.

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This suggests that we cannot simply compare, patient

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outcomes of patients treated

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by physicians versus nurse practitioners

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to see their productivity differences.

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We therefore uses quasi random variation in the number

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of nurse petitioners on duty at ed,

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on a data patient visited.

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So the, the eds in our setting, they use both physicians

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and nurse practitioners to treat patient,

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and they use physicians

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And nurse practitioners as substitutes.

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On days when there are more nurse practitioners,

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there are fewer physicians.

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And when there are fewer nurse practitioners,

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there are more physicians.

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Also, because of the institutional features

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of providers on duty scheduling,

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there is quasi random variation in a number

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of nurse petitioners on duty.

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But patient probability of being treated

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by nurse petitioners increases with the number

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of nurse practitioner on duty.

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So we use the number of nurse petitioners on duty

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as the ED on the day the patient visited as instrument

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for whether the patient is treated by a nurse practitioner.

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We show that conditional on the baseline controls like hos,

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ed by day of the week, ed by month, and ed by year.

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Fixed effects,

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patient eristics are very well balanced across the number

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of nurse practitioners on duty.

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We found that on average,

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there are productivity differences between physicians

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and nurse practitioners.

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On average nurse practitioners,

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make patients spend more on healthcare

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but get worse treatment outcomes.

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But we also find

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that there's very large productivity variation within

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each, each profession.

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Among the physicians, there are also low quality physicians,

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and among the nurse practitioners,

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there are also high quality nurse practitioners.

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There's very large productivity overlap

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between the two professions,

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and some nurse practitioners can perform even better than

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an average physician.

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Uh, for the mechanisms, we found some,

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mechanisms suggesting differences in human capital

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between the two professions.

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On average, nurse practitioners,

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have shown lower productivity than physicians,

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and we found that, experience might play a role here.

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When providers experience that, is higher, the nurse,

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nurse practitioners, physicians' performance gap become,

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lower in some outcomes.

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So we found that nurse practitioners tend to be more likely

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to use, treatments like, dag diagnostic tests

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and also like consults, which may help

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with their treatments and a diagnosis.

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This may also contribute to the higher medical spending

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of nurse practitioners.

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Um, we also find that the performance difference

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between physicians

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and nurse practitioners,

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become higher when the patient's

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conditions are more complex.

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This suggests that it could be important to think about

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what could be the optimal patient assignments

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between physicians and nurse practitioners.

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I think there are a couple related res.

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One, directly related ation will be the role

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of nurse practitioners in, healthcare delivery.

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Given that the nurse practitioners are increasingly used in

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the US healthcare system,

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There is a growing number of papers looking at the role

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of nurse petitioners in expanding

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healthcare supply capacity.

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In addition to looking at the effects

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of nurse petitioners on expanding healthcare,

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supply capacity, I think it's also very important for us

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to understand the productivity of nurse petitioners.

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A second related literature is occupational licensing.

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This is quite an important literature in labor economics.

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Uh, the general findings of this literature is that,

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in modern contests,

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occupational licensing typically has little effect on

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improving workers', quality,

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although it increased workers' wage.

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But there are a couple, papers found

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that in early error, a def formation

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of professional standards.

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Occupational li occupational licensing has some improving

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effects on workers' quality.

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Uh, a third related literature, I think it will be the,

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worker human capital and productivity.

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Uh, this literature mainly focus on productivity variation

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within professions.

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In our paper, we also look at productivity differences

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between professions.

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One interesting finding of this paper is

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that there could be important productivity difference

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between, professions, in our case,

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nurse practitioners versus physicians training.

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And the selectivity of a, of a profession could be po

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positively correlated with its productivity.

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On the other hand, our results also show

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that there could be very large productivity variation within

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each profession, and a large overlap bet in productivity

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between professions.

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So this also suggests

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that profession may be a highly imperfect

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proxy for productivity.

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And in terms of health policy implications,

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I think the question may not be as simple

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as whether we should use nurse practitioners or not.

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I think here the more natural question could be like,

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what might be the opt optimal patient assignments

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between physicians and nurse practitioners?

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Because for less complex patients,

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nurse practitioners may perform as good

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as physicians or even better.

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And also I think,

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another question we could think about would be

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how we can make physicians

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and nurse practitioners collaborate for the,

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for even patient and

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what might be the optimal task assignments

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to each different types of workers.

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So they, there could be a good, skill,

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there could be a good, skill task matching.

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