al., 2009) described the results of analysts’ assessment of 12 high-priority policy options, including upper- and lower-bound estimates of potential cost savings from these options over 10 years.23 In addition, the report identified “what has to happen to implement a change” for each of the options. Under the general heading of “Redesign[ing] the Healthcare Delivery System,” the most promising cost containment options included two24 of particular relevance to APNs—“Encourag[ing] Greater Use of Nurse Practitioners and Physician Assistants,” and “Promot[ing] the Growth of Retail Clinics.”25 (These options are significant, for purposes of this paper, because nurse practitioners [NPs] are a major cohort within the larger class of APNs, and the analysis that applies to them applies also to their other advanced-practice colleagues.) The most relevant passages of this section of the report are quoted below.

Option: Encourage Greater Use of Nurse Practitioners26

Nature of the Problem

Even though they are educated to perform many routine aspects of primary and specialty are and even though studies have shown that they provide care similar to that provided by physicians, NPs generally cannot practice as independent medical providers and therefore are underutilized in the provision of primary care…. Given widespread agreement that there is a critical shortage of primary care physicians in the Commonwealth, expanding scope-of-practice laws could be a viable mechanism for increasing primary care capacity and reducing health care costs.

Proposed Policy Option

Under a changed [more independent] scope of practice, public and private insurers could choose to reimburse NPs directly for their services and could allow consumers to choose a non-physician provider as their primary care [provider]. Specifically,

  • Allow NPs to practice independently, without physician oversight.

  • Allow greater practice autonomy for NPs by eliminating the requirement that the Board of Registration in Nursing consult and reach consensus with the Board of Registration in Medicine to promulgate its APN regulations.


For a summary of results of further modeling of eight of the original policy options on a national scale, see Hussey et al. (2009).


A third option relevant to ANPs, Create Medical Homes, is not included here since the modeled analysis was limited specifically to “physician-led teams,” and some current reform proposals include a broader definition of primary care provider-led health homes which could be led by APNs.


This latter option is important because retail clinics are staffed principally by nurse practitioners.


Although the RAND report included PAs and NPs in this policy option, I have omitted references to PAs from this summary, both because my focus is on APNs, and because the regulatory scheme for PAs is fundamentally different than that for APNs, in that, though individually licensed, their scope of practice in all states is determined by delegation by a required supervising physician.

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