Nurse practitioners (NPs) delivering emergency care without physician supervision or collaboration in the Veterans Health Administration (VHA) increase lengths of stay by 11% and raise 30-day preventable hospitalizations by 20% compared with emergency physicians. Those are findings included in a study published online ahead of print in the American Economic Review, which is widely regarded as one of the most prestigious—and influential—peer-reviewed journals in the profession of economics.
The study—“Productivity of Professions: Evidence from the Emergency Department”—was co-written by David C. Chan, MD, PhD, and Yiqun Chen, PhD, and uses a quasi-experimental design to compare emergency care provided by physicians with that of nurse practitioners who have full practice authority.
Dr. Chan is the Mark and Stephanie Robinson Chancellor's Chair, professor and faculty director of the Robinson Life Science, Business and Entrepreneurship Program at the University of California, Berkeley, Haas School of Business. He also is an investigator at the Department of Veterans Affairs, co-director of the VA Center for Policy Evaluation, and research associate at the National Bureau of Economic Research. Chen, meanwhile, is an assistant professor of economics at the University of Illinois Chicago and a faculty research fellow at the National Bureau of Economic Research.
“When comparing NPs and physicians as two professional classes, physicians, on average, exhibit higher productivity in the ED,” says the study co-written by Dr. Chan. “NPs, on average, use more inputs in the ED visit (longer lengths of stay and higher costs) but exhibit a higher 30-day preventable hospitalization rate.” Notably, the researchers found larger productivity differences within the professions studied than between them.
Overall, the study shows that nurse practitioners increase the cost of ED care by 7%, or about $66 per patient. The authors also estimated that allocating one-quarter of ED patients to nurse practitioners increases nonwage spending by $197 million per year to the VHA, with a net cost of $129 million per year, compared with staffing the ED with only physicians. This net cost occurs even after accounting for differences in nurse practitioner and physician salaries.
As part of its long-running efforts to fight scope creep, the AMA defends the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care. This year, the AMA has worked with more than 40 state medical associations and national specialty societies to defeat scope of practice legislation, and the AMA Scope of Practice Partnership has provided 14 grants to help state advocacy efforts on this issue in 2026.
The partnership has handed out $5.7 million in grants since its inception, and that effort has been stepped up, with AMA Board Chair David H. Aizuss, MD, announcing in January that the AMA will commit $1 million annually to the Scope of Practice Partnership.
What sets this study apart
Unlike other research comparing the performance of physicians and nonphysicians and the impact of scope-of-practice expansions on cost and quality of care, this economic study looks beyond correlation by using a high-quality causal analysis.
And while many other studies attempt to draw comparisons based on nurse practitioners or other nonphysicians who are actually practicing in collaborative arrangements with physicians, this study leverages data from a time—2017 to 2020, right before the pandemic—in which nurse practitioners within the VHA were truly practicing without physician supervision.
Physicians complete between 10,000 and 16,000 hours of clinical education and training—four years in medical school and another three to seven years of residency training. By comparison, nurse practitioners complete between 500–720 hours of clinical training during two or three years of graduate-level education.
A separate study by researchers from Johns Hopkins University, the University of New Mexico and other institutions, found that few nurse practitioners are certified to deliver emergency care and that nurse-practitioner qualifications to practice in emergency departments vary widely among states.
Visit AMA Advocacy in Action to find out what’s at stake in fighting scope creep and other advocacy priorities the AMA is actively working on.
Learn more with the AMA about what sets apart physicians and nurse practitioners.
