Bryan Caplan  

School Nurses and Econ 101

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Most people flip out when economists suggest relaxing government regulation of medical quality.  How dare we point out the trade-offs between price, quality, and access?  But Robin notes an amazing example we've all known about since kindergarten: the school nurse.
Most states have special laws allowing school nurses to directly manage students as patients. True, school nurses can't do everything docs can, but nurses who offered these same services to passersby at a shopping mall, without direct doc supervision, would violate medical licensing laws. Apparently, we like the comfort of knowing that medical help is onsite at school, but know that an onsite doctor would be very expensive, and so compromise with school nurses.
Pedagogical gold this pure goes straight into my labor econ lectures.  Textbook authors and principles teachers, take note.


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COMMENTS (4 to date)
Jeremy, Alabama writes:

Brilliant. Thanks for the link.

Shangwen writes:

The information as teaching material may be new to you, Bryan, but the practice is not. Most jurisdictions in North America allow the licensing of Nurse Practitioners who are effectively family doctors, but at far lower cost. In one clinic I manage, I am replacing a specialist physician with a specialist NP, and even after paying her tuition I will gain through reduced expenditures of over $100,000 per year and--since NPs can provide more service for less money--an economic value to patients of $90,000 per year in improved health care access (all patients combined, not per patient).

The more interesting lecture item, I propose, is to compare Nurse Practitioners with Physician Assistants (aka Physician Associates). There you have two groups that are functionally identical but differently licensed. Although I was pushed to go with a PA, I chose to use an NP as a physician substitute instead. NPs operate independently under their licences and so their salaries and billings are a fair measure of service volumes (setting aside the thornier problem of the real value of health care). PAs in most jurisdictions operate under a physician's supervision, and so a supervision fee is included. Looking at parallel situations in other health care professions, my assumption is that there will be increased rent-seeking by physicians for the cost of supervising PAs, while there is no such opportunity with NPs.

Although occupational licensing in health care (and elsewhere) is unquestionably value-destroying, supervision-based licensing is even more so.

Jenny writes:

My personal experiences with school nurses is not pleasant and I am certain one or more of them violated my personal rights but I guess having someone with some medical experience who is not a doctor is better than nothing.

ZD writes:

"Nurse Practitioners who are effectively family doctors, but at far lower cost"

As this is an econ site, it'd be a shame not to point out that what the above poster meant is at a lower 'direct cost'. Just because they make less, doesn't mean they don't cost the system less.

All it takes is the NP ordering one unnecessary high-end imaging study or complex lab test every few days (at costs ranging from several hundred to a thousand dollars or more) relative to what the more thoroughly trained physician would order, and any salary cost savings are quickly out the window.

Medicine is all at the margin. Sure, a well-trained, experience NP can provide quality care. Say they function at 97% of the level of an FP doc with regards to accurately diagnosing and treating patients. While they may have marginally lower direct costs, what is the societal cost of their decreased diagnostic performance/confidence relative to that of a physician? If they have to order one more test that may cost $500 to make the same diagnosis, they just cost more money than a physician seeing the patient. What if they delay a diagnosis for a few months, by mistaking vague abdominal pain for an enteritis instead of the early pancreatic cancer that it really is? How do you account for those costs?

While you'll never find reliably accurate numbers to prove or disprove the above (health-care outcomes are subject to too many variables to truly objectively measure and compare outcomes and costs with regards to most conditions) just ask any physician if they were having surgery, would they rather have their anesthesia managed by a physician anesthesiologist or a nurse anesthetist, you'll find them unanimous in their choice.

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