Cheaper Primary Care: Nurses May Be The Answer

When some surgeons at Mercy Hospital in Merced, Calif., prepare to operate, they no longer turn to a second physician to assist them. Instead, they call Karen A. Rezzelle, registered nurse. Depending on what the chief surgeon allows, Rezzelle does everything from prepping patients for surgery to sewing up incisions. Like physicians, she bills for her services and is reimbursed by insurers--except she's cheaper.

Nurses with advanced training such as Rezzelle are pushing the boundaries of their profession. They're delivering babies, administering anesthesia, and running clinics. Now, as the nation overhauls its health-care system, their role could expand even more. "There's going to be a concerted effort to get less expensive personnel to deliver care, especially primary care," says Dr. Stanley S. Bergen Jr., president of the University of Medicine & Dentistry of New Jersey. "And nurses are a natural."

BIG SAVINGS. There's plenty of evidence to back that idea up. Over the years, studies have repeatedly concluded that "advanced-practice nurses"--those with education and clinical training beyond the two to four years of basic nursing education--can provide 60% to 80% of all primary care. And they can do it as well as doctors, for less money.

How much less? First visits to a nurse practioner cost from 12% to 45% less than such visits to a physician, a 1989 survey found. Organized programs also can mean big savings. At the health maintenance organization at Carondelet St. Mary's Hospital & Health Center in Tucson, nurses monitor chronically ill patients after they leave the center. Through such care, the HMO has cut by one-third the number of inpatient days of 1,000 enrollees--at an average cost of $900 a day.

Health-care reform could also benefit nurses simply because of their numbers. The U.S. has 2.1 million registered nurses--including more than 100,000 with advanced training--compared with 615,000 physicians. Many nurses provide care in underserved areas or to the poor and elderly. By contrast, the increasing specialization of medicine has created a growing shortage of primary-care physicians--internists, pediatricians, and family doctors--who treat common ailments and practice preventive medicine.

The American Nurses Assn., the nation's largest nurses' organization, is using such data to push an ambitious reform plan. It urges restructuring the health-care system from a "medical model," based on expensive acute and high-tech treatment, to a cheaper "health model" that promotes wellness and prevention. The ANA--which actively supported Bill Clinton during his election campaign--has pitched the plan to Hillary Rodham Clinton and her health-reform task force. "I think Mrs. Clinton is going to be a great advocate for us," says ANA President Virginia Trotter Betts. "She understands what's wrong with health care from the point of view of the consumer."

Not everyone is convinced that nurses should fill the gap in primary care. Dr. James S. Todd, executive vice-president of the American Medical Assn., for one, questions whether nurses have the necessary training and whether they're really cheaper.

While nurses may ultimately benefit from the health-care overhaul, it may take some time. Legal barriers in many states keep nurses from qualifying for direct medicare and medicaid reimbursement, writing prescriptions, and admitting patients to hospitals. But given the growing need for affordable health care, an expanded role for nurses could be just what the doctor ordered.