Duke Professor Highlights Health Care Cost Savings for PA Patients at the VA

Experts Discuss Care for High-Need Patients

June 13, 2019

By Jenni Roberson

The need to expand the U.S. healthcare workforce to ensure care for the aging population living with chronic conditions – and the associated costs for patients – was the topic of a recent briefing hosted by the journal Health Affairs in Washington, D.C.

Perri Morgan, PhD, PA-C, professor and director of research for the PA Division in the Department of Family Medicine and Community Health at Duke University Medical School, joined a panel of experts to discuss research that underscores how PAs and NPs can continue to be a part of efforts to address the growing need for high-quality healthcare professionals.

[Reforming American’s Healthcare System Through Choice and Competition: Statements Relevant to the PA Profession]

During her presentation, Morgan discussed research conclusions that used U.S. Department of Veterans Affairs (VA) data on a cohort of 47,236 medically complex patients with diabetes to compare health services use and costs over one year depending on whether the primary care provider was a physician, NP, or PA.

An article about this research, “Impact of Physicians, Nurse Practitioners, and Physician Assistants on Utilization and Costs for Complex Patients,” was recently published in Health Affairs, a peer-reviewed journal of health policy thought and research.

The VA is a unique health care system that functions as a patient-centered medical home and in which PAs, NPS, and physicians lead their own teams responsible for patient care. In addition, PAs and NPs are granted a permissive scope of practice. The similar roles of physicians, PAs, and NPs in this care model allows researchers to accurately compare the outcomes of the three types of care teams. The research in question looked specifically at the most complex patients with diabetes within the VA system; the average patient within this study was three and a half times more medically complex than the average Medicare patient and had over six chronic conditions.

Using EHR data and controlling for differences in patient demographics and medical and social complexity, the researchers found that physician patients had statistically significantly higher overall costs than patients of NPs and PAs. The higher costs were driven by more emergency department visits and more inpatient admissions for patients with physician primary care providers. Patients of NPs and PAs had nearly identical mean per patient expenditures in all categories. Patients of PAs and NPs incurred lower annual per patient pharmacy expenditures than patients of physicians (9%, 95% CI: 4, 13%; 8%, 95% CI: 1, 14, respectively), translating to a mean per patient annual difference of approximately $300 in pharmaceutical expenditures. Smaller differences were seen in outpatient expenditures between provider types: Compared to patients of physicians, patients of NPs incurred 3% lower (95% CI: 0.04, 6) outpatient expenditures in the year, and patients of PAs incurred 5% lower (95% CI: 1, 9) outpatient expenditures.

The cumulative effect led to a reduction in total per patient health care costs for patients of NPs and PAs, compared to those of physicians. Overall, patients of NPs incurred 6%  lower expenditures compared to those of physicians (95% CI: 3, 9), while patients of PAs incurred 7% lower expenditures (95% CI: 2, 11). This translated to a difference of $2,005 and $2,300 in per patient annual total health care costs, respectively.1

While both patients of both PAs and NPs had had more primary care visits, they had less utilization of inpatient visits, and had fewer days with an emergency department visit. The work of the researchers demonstrates that PAs and NPs, when practicing under permissive scopes of practice, can provide primary care services for the most medically complex patients with diabetes mellitus, without raising costs.

More Resources
AAPA Research
Diabetes is Daunting. Finding a Quality Provider Shouldn’t Be.
PAs Can Bring Cost-Effective Care to Complex Patients
Care Costs 6-7% Lower for Complex Patients Treated by NPs, PAs


    1. Health Affairs. Impact of Physicians, Nurse Practitioners, and Physician Assistants on Utilization and Costs for Complex Patients. Health Affairs website. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00014

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