(
Received October 5: revision accepted for publication November 19, 1971.)The BHHC-MGH program was partiall supported by grants from the Commonwealth Fund and the
Medical Care and Education Foundation. The data reported were collected pursuant to Contract No.
USM-llO-7l-6 with HSMHA. Department of Health, Education and Welfare.
ADDRESS FOR REPRINTS:
(
A.Y.)
Harvard School of Public Health, 55 Shattuck Street, Boston,Mas-vhusetts 02115.
PEDIATRICS, Vol. 49, No. 6, June 1972
878
THE
COSTS
OF
TRAINING
AND
THE
INCOME
GENERATION
POTENTIAL
OF
PEDIATRIC
NURSE
PRACTITIONERS
Alfred Yankauer, M.D., Sally Trlpp, B.S. (R.N.), Priscilla Andrews, M.S. (R.N.)
and John P. Connelly, M.D.
Ironi. 11w Children.s Service and Department of Nursing, Massachusetts General Hospital, The
Depart-ment of Health Services Administration, Harvard School of Public Health, arid the Department of
Pediatrics, Harvard Medical School, Boston, Massachusetts
ABSTRACT. The costs of training and the dollar income generation yields have been calculated for
26 graduates of the Pediatric Nurse Practitioner
Program of the Bunker Hill Health Center of the
Massachusetts General Hospital employed in
private practice settings. Training costs were esti-mated from the program experience. Income
gener-ated by the nurse was estimated from data
re-ported by nurse and employer 6 months or more after graduation from the program.
Direct educational costs were estimated at $1,410
per nurse, institutional overhead at $346 per nurse,
production losses ( associated with the training
time of 17 weeks ) at $1,442 per nurse. Total cost
of training was $3,197 per nurse.
The average annual salary paid 26 pediatric
nurse practitioners in private practice settings was
$9, 100 per year and the average number of
“nurse-only” face-to-face patient encounters of all types,
projected for full-lime employment, was 65 per
week. Net income generation potential over and
above salary averaged $2,500 per nurse per year
with 14 of the 26 nurses capable of generating
more than $3,000 per year over and above their
current net salaries. These estimates must be
inter-preted with caution, but they suggest that the
pri-vate sector of medicine can defray training costs in
full in cases where the paying demand for its
ser-vices is greater than physicians can supply
them-selves.
Pediatrics, 49:878, 1972., NURSE PRACTITIONER,
NURSE ASSOCIATE, TRAINING, COSTS.
T
HE purpose of this communication is toexamine the dollar costs and dollar
yields of a program which prepares one
type of “mid-level” primary caretaker, the
Pediatric Nurse Practitioner or Pediatric
Nurse Associate. The data address
them-selves to the following proposition : given
the current market value of ambulatory
pe-diatric services as reflected in private
prac-tice, to what extent can the fees charged for
pediatric nurse practitioner patient
encoun-ters cover the costs of their training from
the point of view of their employer.
The model used to examine this
proposi-lion was developed to fit available data
col-lected from graduates of the Pediatric
Nurse Practitioner Program of the Bunker
Hill Health Center of the Massachusetts
General Hospital. In estimating both
ser-vice production losses associated with
train-ing time and the income generation
poten-hal of the nurse, data obtained from
gradu-ates at work in private practice settings and
from their employers have been used.
These amount to statements of market
value in private practice rather than a
state-ment about the costs of producing a service.
More than half the program’s graduates are
employed in agency settings from which
nurse salaries are the only meaningful piece
of economic data available.
The data to be reported are based on the
empiric experience of the BHHC-MGH
program. The program itself, the
character-istics and work-survivorship of its
gradu-ates, and the patient-service outcomes of
their activities after graduation have been
be-TABLE I
PERCENTAGE DISTRIBUTION OF PROGRAM STAFF TIME
IN TRAINING-RELATED ACTIVITIES DURING ACADEMIC
AND NONACADEMIC PORTIONS OF TIlE YEAR
Adivity Sept-June* (N:V’18) J?dy-AUgU8I* (N:4O) Total (N:37.98)
Recruitment-screening 10 O I’
Supervision-follow-up 10 W 10
Planning-administration 49 70 .51
Group teaching Si
-
‘27Total 100 WI) 100
* All time spent in nontraining-related activities
ex-eluded from base figures. The Sept-June data are based
upon daily time-logs. The July-August data are
esti-mated and do not include vacation time.
TABLE II
DERIVATION OF PEDIATRIC NURSE PRACTITIONER
TRAINING COST ESTIMATES
.Innual Per Cour.cet
Per
Nurs4
I.Education
5/4Nurse
©
*57.000/yr. S/4Nurse©$15,000/yr.I/ Pediatrician @
$Qg.000/yr.
1Secretary
@
$6,500/yr.FICA
@
1O%salarieslI,75O II,5O
I I,000
6,500 4,850
6,373 5,63
5, 500 3Q50 Q,175 SO 8I 75 163 109 Guetfacu1tyfees Teachingaids
Telephone, postage, auppIie
Travel*
1,000
,ooo
Q ,000
1,000
500 1,000
1,000
500 5 50 50 5 Residential week-ends
(Qpercoure
#{174}
$50/individual)4,500 ,S0 115
Subtotal-direct costs .56,550 28,175 1410
Indirect costa
#{174}
53.5% oFsalaries less FICA 15,853 6,917 346
Total Educational Costs 70, 183 S5,09Q 1,7.55
II. 17-Week Production Loss to Practice Setting
60%RNsalary @$108/wk4I 44,080 2,040 I.I0
Directioss of earnings:
Equivalent to 4 visits/wk.
@$5/vsitjl 13,600 6,800 340
Subtotal 57,680 8,840 1,4W
Ill.GrandTotal l7,86S 6S,9S 5,197
SColumn ia baaed upon the experience of the Pediatric Nurse
Practitioner Program of the Bunker Hill Health Center of the
Massachuetta General Hospital. The program offers a 17-week
course requiring weekly 1 1/Q days release time and 1/ day field
practice time in nurse’s employment setting. The course is given twice a year to 50 nurses per course. (a total of 40 nurses per year).
t Repreenta half of first column.
Repreeents 1/Q0 of second col:zmn.
I Includea travel to and from practice setting.
IIFigures given have 40% of gross deducted for overhead.
ARTICLES 879
lieved that the BHHC-MGH program has
produced the largest number of active
“mid-level” primary caretakers in the
coun-try to date.
Courses are given twice a year to a
maxi-mum of 20 nurses per course. The
curricu-lum adheres to the guidelines established
by a joint committee of the American
Nurses’ Association and the American
Acad-emy of Pediatrics.3’4 Each course lasts 17
weeks and requires 1 days per week of
“re-lease time” for group classes and day per
week of field practice time in addition to
two residential teaching weekends.
Train-ees must be registered nurses and hold jobs
in a pediatric setting delivering
comprehen-sive pediatric care which is committed to
utilize the trainee in an expanded role.1’5
Applicants and their practice settings are
screened individually, but there are no other
formal admission requirements.
Course graduates and their employers
have been followed through structural mail
questionnaires at periodic intervals after
graduation. Seventy-four of the first 75
graduates have been so followed for 6
months to 2#{189}years after completing
train-ing.2 Thirty members of this group were
employed in private pediatric settings and
the remainder in voluntary public agency
settings at the time they took the course.
Data are available for analysis on 26 of the
30 nurses employed in private practice
set-tings.
The first four courses were offered
with-out charge to trainees. In September 1970 a
tuition fee of $800 per nurse was charged.
This was raised to $1,000 in September
1971.
The data to be presented are derived in
part from the empiric training cost
experi-ence of this program and in part from data
solicited from the trainees and their
em-ployers at the time of registration and
through the follow-up questionnaires, 6
months or more after graduation.2
COSTS OF THE TRAINING PROGRAM
The Bunker Hill program has never been
Total
880
‘FABLE III
Nt i n:lt . NI) ;l KIIAG I .\ NNtAL A I.AIIIES5 OF PEDIATRIC Nt1R.E PRACTITIONERS HY
EI)IJCATIONAI. IIA(KGROITNI)f AND TYPE OF PRAc’rIcE SETTING
lhirealaureale I)egree Thploiiia
Practice Selling
-
--
- -
_______
.v Salary N Salary N Salary
Private Practice 9
$
9,400 17 $ 9,000 26$
9,100(Solo) (1) 10,100 (6) 8,300 (7) 8,600
(Specialty group) (5) 9,00 (8) 9,500 (13) 9,400
(Multispecialty group) (3) 9,100 (3) 8,700 (6) 9,100
Voluntary Agency 8 9 ,500 1 9 ,00 9 9,500
Public Agency 6 9,600 6 10,100 12 10,100
Total 23 9 ,500 2li 9 ,00 47 9,800
* All salaries adjusted for a 38.75-hour work week on basis of hours/wk worked.
t Seven nurses with Master’s Degrees are excluded from this Table. Five of the seven were employed in public
agencies at an average annual salary of $11,600. One was employed in a voluntary agency at $9,600 per year and
one in a specialty group at $10,400 per year.
and overhead expenses have been donated
by the Massachusetts General Hospital and
the Harvard School of Public Health.
Fur-thermore a significant portion of program
staff time has been given to non-course
re-lated activities consisting of promoting the
pediatric nurse practitioner concept and
providing consultant servicis to agencies
and individuals interestcd in developing
comparable programs.
The full-time staff of the program
con-sists of two nurses and a secretary. The
nurses kept a time-activity log spanning the
‘FABLE IV
AVERAGE NUMBER OF ADJUSTED* NURSE PRA(TITIOS ;It
PATIENT ENCOUNTER.S I’ER WEEK PER NUItSE BY
TYPE OF ENCOUNTER AND Typ: OF PRIVATE
PRACTICE SETTING
Data Solo
. .
(roup
if
i,1Li-.pecialty Group
Total
NumberofNurses 7 13 6 6
Ave. hrs. worked/wk. 30. 1 36.0 34. 7 34l
Ave.OfliceVisits/wk.’ 46.6 49i 38.9 46.0
(Well Child) (3.7) (3..5) (34.7) (33.0)
(Sick Child) (13.9) (16.7) ( 4l) (13.0)
Ave.OtherVisits/wk.’ 10.4 S.9 16.3 18.7
(Iiospital)t ( 9.3) (rs.4) (15.3) (17.7)
(Home) ( 1.1) ( 0.5) ( 1.0) ( 1.0)
.Adjusted to a 38.75-hour week based upon actual number of
en-counters and actual hours per week worked as reported by nurse.
tPrimarily visits to maternity ,e-rvice and newborn nursery.
37-week period of the two courses offered
in 1970-1971. From these data, it is
esti-mated that 25% of staff time was allocated
to non-course related activities and cannot
legitimately be considered as a training
cost.
The time breakdown of the nurse
faculty’s course-related activities are shown
in Table I. About one-quarter of the time
was spent in individual screening and
follow-up supervision of applicants and
practice settings
(
including travel to andfrom setting
)
. Another quarter was spent indirect group teaching and the remainder in
planning and administration. Some portion
of the straight administrative activities
could have been carried out by a non-nurse
administrator.
Table II displays the derivation and
to-tals of the training cost estimates. The
edu-cational costs for 40 nurses reflect the
expe-rience of the Bunker Hill program. A figure
equivalent to 1 #{189}nurse-faculty
(
75% of thetwo-nurse faculty
)
has been used. All otheritems reflect actual expenditures except that
“donated” faculty services have been priced
at equivalent dollar-time values. The cost of
two residential teaching weekends is based
upon expenditures incident to renting an
appropriate facility in the Boston area and
3
2
1
0#{149} 20 40 60 80 100 120 140 160
Total Patient Encounters Per Week
ARTICLES 881
which include overhead and naintenance
\vere calculated l)y Ilsing the \lassachtlsctts
(eneral 1-lospitals federally approved
1r-(entage for research grants. This figure,
al-though crude, is more realistic than the 8%
figure generally allowed for training grants.
The direct educational costs COfliC to
$1,410 per nurse. The total costs, with
over-head figured as in a research grant, are
$1,755 per nurse. The absolute values of
these figures are probably less useful to
oth-ers than their derivation, since other
institu-tions can substitute dollar values derived
from their own costing systems. The figures
do not include costs of evaluation, or the
“start-up” costs of a program. The latter
would add to the costs of the first year or
two of O1)eration.
No stipends or scholarships have been
available to trainees. Most trainees have
l)een eniployed and paid a salary during
the training period. Presumably while
ab-sent from the setting, the services of the
trainee must be replaced. The total of time
lost afl(l time replaced is equivalent to 3
Ce
41 Ce
I.,
3 z
0
4) .0
E 3 z
days per week. The dollar loss has been
fig-ured as equivalent to 60% of the average
net#{176}veekly salary of graduates, for a
pe-nod of 17 veeks.
The field practice experience of the
nurses is carried out in the setting where
they are employed. The pediatrician who
will collaborate with each trainee must take
the time to review and go over each case
she handles as a teaching exercise until he
is satisfied that she can function relatively
independently. The resultant dollar losses
have been calculated based upon fees
charged for health supervision visits
pro-cessed by pediatricians in private practice
settings
(
less 40% for overhead)
and timespent in field practice teaching by the
pedi-atrician employer. The total values of these
two calculations, $1,442 per nurse, is about
equal to the direct educational costs.
\Vhen both educational costs and
produc-tion losses are totalled, it can be estimated
that the total costs of the training program
0 Gross salary’ less 40% for overhead.
Fic. 1. Frequency distribution of Pediatric Nurse Practitioners employed III private practice settings according to the number of face-to-face Patient
882
TABLE V
I)IFFEuENcE BETWEEN ANNUAL SALARY AND INCOME
GENERATION POTENTIAL OF PEDIATRIC NURSE PILAcTITI0NEILs IN PItIvATE
PRACTICE SETTINGS5
Data Solo
.
Specialty cup
Multi-specialty Group
Total
AnnualincomeGenerated $18,500 $0,600 $17,800 $19,400 Generatedlncomeiess40% 11,100 P1,400 11,700 11,600
#{192}y.Annual Salary 8,600 9,400 9,100 9,100
Difference between Salary
andAdjustedlncome +,500 +3,000 +,60O +,500
SFigures rounded to nearest $100.
amount to $3,197 per nurse. Not included is
cost of trainee travel to and from the
train-ing program. In a few cases this has been a
significant figure.
NURSE-GENERATED INCOME
The average annual salaries of 47 nurse
practitioners employed in different types of
settings with 3 and 4 years of education
(degree versus diploma) are displayed in
Table III. Nurses reported differing weekly
hours of work and hourly pay rates so that
all figures have been adjusted to a
38.75-hour work week, the standard work week
used by the Massachusetts Nursing
Associa-tion. Differences in aggregate values are
not great and suggest there is no important
salary differential between the two types of
registered nurses, particularly since “years
of experience” is not included as an
addi-tional variable. Nurses holding Master’s
Degrees earned higher salaries, but most of
them were employed in public agencies
which tended to pay generally higher
sala-ries than other employers. The average
an-nual salary of nurses employed in private
practice settings was $9,100 per year.
In order to place a dollar value on the
nurse’s activities the number of weekly
face-to-face patient encounters reported as
“nurse only” visits by each nurse were first
adjusted to a 38.75-hour work week using
the actual hours per week worked reported
by the nurse. Table IV displays the
aggre-gate values obtained : 46 office visits and
18.7 other visits per week. The hospital
vis-its are primarily to newborn infants. Nurses
employed in specialty groups have the
larg-est number of patient encounters. It should
be emphasized that these are not actual
visit figures because they have been
pro-jected to a full work week for nurses who
worked less than 38.75 hours per week.
There was substantial range and a
rela-tively flat distribution of the number of
pa-tient encounters reported. The curve of
dis-tribution suggests slight skewing to the left.
These points are illustrated in Figure 1.
In order to convert these nursing
activi-ties to dollar values, the fee charged for
well child “nurse only” visits as reported by
the pediatrician employer was multiplied
by the adjusted number of weekly well
child visits reported by the nurse. A $3
fac-tor for immunization was added to the
value of 25% of the reported well child
vis-its. Sick child office visits, hospital visits,
and home visits were priced at $5, $3, and
$10 for each visit respectively. The total
weekly dollar value was multiplied by a
fac-tor of 47 to obtain an annual figure.
The aggregate results of these
manipula-tions by practice setting are displayed in
Table V. The income generation potential
of the entire group of 26 nurses comes to
$19,400 per year, a figure slightly higher
than the $16,800 per year reported by
Schiff, Fraser and Walters from Denver in
196768.6 Since the nurse functions
inde-pendently during her patient encounter
time, net income generation potential was
calculated as 60% of the gross income,
de-ducting a flat 40% for overhead. For each
nurse the difference between net income
and salary was next calculated. For the
group as a whole net annual income
gener-ation potential exceeded annual salary by
$2,500. The aggregate data are shown in
Table V.
As in the case of patient encounters, there
was substantial nurse variation in the
differ-ence between salary and net income
gen-erated. The difference ranged from - $6,900
to + $15,500. The distribution of these
ARTICLES 88:3
5’ a
a
4’
3
z
3-S
E
3
z #{149}
1--e -s -4 -2
0
::i.i
+2 +4 +5 +1 +10 +12 +14 +1*
Thousands of Dollars
l1G. 2. Frequency’ distribution of Pediatric Nurse Practitioners employed in
private practice settings according to difference between annual salary
(
less overhead)
and annual income generation potential.It 5CCI115 1)rOhahle that in the case of the
three nurses whose net income generation
potential was $5,000 or less than their
sala-ries, overhead reduction was not justified
since a substantial portion of the nurse’s
own time (not spent in patient caretaking
on her own
)
must already he included inthe overhead. To a lesser extent this may
have been true of other nurses whose
gen-crated income was at the low end of the
scale. The effect of accounting for this
fac-tor would be to increase the positive
aggre-gate difference between nurse salaries and
nurse income generation potential.
It is also probable that the addition of a
nurse practitioner to the pediatric team is
not equivalent to the addition of a
physi-cian who can function completely
indepen-dently. If the pediatric hours per week
required for consultation with and
supervi-sion of the nurse were known, it would be
possible to place a dollar value upon them.t
The effect of accounting for this factor
would be to decrease the aggregate positive
difference between nurse salaries and nurse
net income generation potential.
The available data do not allow a
calcu-lation to be made of the income generated
1w an “office nurse” prior to taking the
course who will convert to a “nurse
practi-tioner” after completing the course. The
“office nurse does not see patients on her
own” but acts as support to the
pediatri-cian’s own face-to-face patient encounters.
The assumption is made that after
comple-tion of training, these supportive services
will be provided by a replacement for the
nurse and included in the allowance made
for overhead. By and large these services
can be rendered by a nonprofessional aidu
who can be paid a lower salary.
Neverthe-less the effect of this variable could be to
lower the income generation potential of
the nurse who is “converted” from “office
nurse” to nurse practitioner in the same
set-ting. Presumably this variable would not
operate if the nurse practitioner was newly
hired by the practice setting.
The data presented have not taken into
account the telephone calls handled by the
Data collected by the Center for Health
Ser-vices Research and Development, American
Medi-cal Association, show that the average net income
for pediatricians in Metropolitan Areas was
$30,267 C1968), the average number of hours
practiced per week, 52.8 ( 1969), and average
number of weeks practiced 48.0 (1968).’ In 1968,
net income for pediatricians in Metropolitan Areas was 61.6 of the sim of net income and “expenses.” Pediatricians had a lower net income than any other
type of physician including general practitioners.’
884
nurse, since normally no fee is charged for
this service in pediatric practice. The nurse
practitioner telephone load is substantial,
however, amounting to about 40 “clinical”
and advice giving calls per day in the
ag-gregate. This is equivalent to added
“re-lease time” for the pediatrician and would
act to raise the income generation potential
of the nurse accordingly.
Various ways of correlating
nurse-gener-ated income potential with nurse salaries
were explored. The figures are small and no
firm conclusions can be drawn from them,
but there appeared to be a slight positive
correlation if the three nurses whose
in-come generation potential was very low are
eliminated.
TUITION FEE PAYMENT
As of June 1971, the BHHC-MGH
pro-gram had graduated 33 nurses, for each of
whom a tuition fee of $800 was paid. In the
case of the voluntary or public agency
em-ployer, the fee was most apt to be paid by
the employer, but in 3 of 23 cases the nurse
paid the tuition fee herself. In contrast, one
of 10 nurses employed by practicing
physi-cians or groups of physicians paid full
tu-ition themselves; the employer paid in full
for two nurses, and the cost was shared in
the remaining case.
As of November 1971, the program had
admitted 21 nurses, for each of whom a
hi-ition fee of $1,000 was paid. Eleven of these
21 nurses were employed by practicing
physicians or groups of physicians. Only 2
of these 11 nurses paid full tuition
them-selves; the employer paid in full for eight
nurses, and the cost was shared in the
re-maining case. Our experience is too limited
to conclude that the different source of
hi-ition payment between this group and the
preceding group represents a trend.
As of November 1971, 23 candidates had
already applied for admission to the course
I Estimate(I 40 telepholle calls per (lay derive(l
from data discussed in reference 2, adjusted to
38.75-hour work week.
starting in February 1972. All applicants
met the qualifications for admission and all
had arranged for tuition fee payment of
$1,000. Nine of the 23 applicants were
em-ployed by private physicians or physician
groups.
When nurses have paid the tuition fee
themselves, they have sometimes been able
to obtain low cost loans. Salary
arrange-ments during the period of training have
been variable ranging from no salary for a
few nurses who were “brand-new” to an
employer to full or partial salary for nurses
who had been employed in a setting for
some time prior to training. Salary raises for
nurses in private settings after completion
of training were often granted when the
nurse had paid the tuition fee herself;
where the employer had paid the fee, the
nurse, formally or informally, agreed to
re-main in the setting for a given period of
time or to repay tuition costs should she
re-sign before then.
Both the tuition charge and the
produc-tion losses appear to have been viewed as
an investment with anticipated returns for
employer and employee. A variety of
ar-rangements were made to adjust the
pay-ment of training costs to these returns
whether the employer or the employee or
both acted as direct investor.
IMPLICATIONS AND SPECULATIONS
The data which have been used to
esti-mate the income generation potential of
nurse practitioners have a number of
limita-tions. They are based upon responses to a
mail questionnaire whose specific meanings
may not always have been interpreted in
the same way. Although the fee pricings
used were those reported by the
pediatri-cians, the patient encounters reported by
the nurse may not have been billed at the
same price or if billed may not all have
been collected. An unknown number of
hos-pital visits may have been made jointly
with the physician. The amount of extra
pe-diatric time required to review cases with
the nurse even after training is not known.
TABLE VI
SUMMARY OF COSTS AND BENEFITS ASSOCIATED WITH A
PEDIATRIC NURSE PRACTITIONER TRAINING PROGRAM
(FIGuRIm DERIVED FROM EMPIRIC DATA)
Assum4ions about Practice Setting
1. Overhead figure includes space, maintenance, equipment,
ad-ministration, salaries of supporting workers, RN FICA and
other benefits, billing losses, etc.
. Transportation to and from classes not included in training cost
estimates.
S. Nurse newly hired to be trained as a pediatric nurse practi-tioner.
4. Nurse work week 38.75 hours.
.5. Effective demand will absorb nurse income generation potential.
6. No change in quality of service or M .D. working hours.
Other possible outcomes which would change expressed dollar benefit.
I. Improved quality of service and/or more time per patient
en-counter.
- Reduction in M.D. work time (telephone calls, less time in
office and hospital. see fewer patients etc.).
3. Change in nurse salary or work hours.
4. Change in fees for service.
5. Improved M.D. scheduling.
6. M.D. time in “supervision” not accounted for.
7. Mounting numbers of “emergency calls” place limits on
accept-ing new patients.
ARTICLES 885
caretaking is applied in a given practice
setting so that the use of aggregate data can
be misleading.
Perhaps the most important limitation of
the data is lack of accurate figures to
mea-sure effective demand or to document any
changes in volume of service ascribable to
the nurse practitioner’s contribution to the
setting which employed her. This
informa-tion was solicited but not obtained in usable
form. In many cases other changes had
occurred in the setting, or demand was
af-fected by such factors as unemployment
and economic recession. More importantly,
most of the private practice settings
em-ploying nurse practitioners were already
overburdened. Rather than taking on a
greater volume of cases, the effect of the
nurse was to improve the care delivered to
families already dependent on the setting
for pediatric services, and to reduce
pediat-nc time.2 The nurse’s advent into a
pediat-nc setting under these circumstances may
have no effect on net income or may result
in income loss. Her impact can be
ex-pressed only in terms of better service
qual-ity, more time per patient visit, or less
phy-sician time worked.
Nurse utilization is the major factor
which influenced the proposition to which
this communication addressed itself. If the
assumptions used in calculating cost and
in-come generation potential are accepted, 14
of the 26 nurses could expect to generate
more than enough net income to cover the
total costs of the training program in 1 year
or less of work and 6 of the 17 to do so in 6
months or less. If the aggregate figure is
used, the time required is 15 months.
How-ever, it should be remembered that the
cal-culations used to derive these statements
are based upon a full work week whereas,
ill fact, many of the nurses worked less than
a full work week. Hence even these empiric
data represent potentiality rather than
actu-ality. Effective demand is the major
mediat-ing factor.
Clearly it is possible for any interested
employer to calculate the financial or
work-saving returns of a training program of this
Training Coth/Nurse Benefils/Nurse/ Year
Educational Cost
RNsalary
$1,755
351 Expenses
GrossSalary $ 9,100
Subtotal
Production foregone (RN)
Production foregone (M D)
Q‘806
S51
340
Revenue Generated
Gross
-40, Overhead
19,400
-7 ,760
Subtotal
Grand Total
891
$3,197
Subtotal
Net Profit
I I
,
6405 Q,540
Total Training Cos ts less on e year’s Net Profit: $653
nature by setting his own targets for the
nurse and himself and placing dollar values
on the features which contribute to them.
Table VI summarizes the costs and benefits
associated with the BHHC-MGH pediatric
nurse practitioner program and provides a
guide to such calculations. It does not
con-sider the problem of job turnover. In the
ex-perience of the BHHC-MGH program, this
is an issue to which employer and employee
seem to address themselves when coming to
an agreement concerning the payment of
tuition.
It may be difficult for an employee to
es-timate demand, i.e., to predict whether an
increase in paying service volume sufficient
to absorb the nurse’s income generation
886
is subject to great local variation. It is not
necessarily related to need or to fee
charges, and it is subject to variation based
on the health of the economy rather than on
the health of children. Nevertheless an
eco-nomic prediction of the effect of a pediatric
nurse practitioner in a practice setting is no
different in principle from predicting the
effect of a new pediatrician entering a
prac-flee setting. If a difference exists it is
re-lated to arrangements for out-of-hours
coy-erages for emergency calls. In a small
number of practice settings in rural areas,
arrangements for nurse practitioner
cover-age of such calls, with physician back-up
when necessary is known to exist.
It is dangerous to generalize on the
idio-syncratic experience of one established
pro-gram whose trainees and physician
employ-ers are self-selected and highly motivated.
Acceptance of the nurse practitioner role by
professional peers is just beginning to take
root. The BHHC-MGH program has made
no special recruitment efforts, yet has been
able to maintain full enrollment even after
establishing a tuition fee which covered
60% of its estimated training costs. It seems
probable, given the current methods of
financing health care in the private sector
of medicine, that the operations of this
see-tor are capable of supporting BHHC-MGH
current training costs in full. However, such
a probability remains to be demonstrated,
as does its generalizability to other training
programs. It should also be pointed out that
current methods of paying for health care
via a fee for service system are not
neces-sarily the methods of the future.
Certainly for any program which is less
well established or smaller, start-up costs
must be added to the calculations. Any new
program must “demonstrate itself” to
con-vince potential consumers of its
capabili-ties. During this start-up period it may be
unrealistic to charge tuition. Furthermore, prior to its inception and during its start-up
period. planning time is essential. The
dia-logue between physicians and nurses is an
active one, but there are plenty of
remain-ing communication problems.
Agencies are at a disadvantage in coping
with tuition fee payments especially if they
are dependent upon government funding.
Salaries are less easy to adjust than in the
private sector, and government regulations
tend to make it impossible to treat a capital
outlay for tuition as an investment to be
re-couped through more efficient operations.
This need not continue to be true but
change in regulations and perhaps in laws
may be required.
Other issues raised by these data relate to
the salary of the nurse and the fee charged
to patients. Although the average salary
paid the pediatric nurse practitioner
com-pares favorably with that paid the average
hospital-based nurse in Massachusetts, she
appears underpaid in many cases in relation
to the net income she generates.
Presum-ably this gap will lessen in the future.
Although one way of reducing a seeming
inequity is to raise the salary of the nurse.
another is to reduce the fee charged to
pa-tients. It has been argued that the costs of a
service should be less when performed by
“mid-level” personnel than when performed
by the more “highly trained” physician.
However, there is much illogic in such
rea-soning. Fee schedules in general follow no
rational rules related to the “training” or
“capabilities” of medical caretakers; they
derive from tradition, surgically-set
insur-ance company rates, and other imprecise
reflections of service values.
A strong argument can be made for the
fact that nurse practitioners are equally if
not more skilled than physicians in some
areas of health supervision and counselling.
There is no question but that they spend
more time per patient in allaying parental
concerns and counselling and that this is
what parents desire2 and appear willing to
pay for. In the case of 16 private practice
settings from which accurate data were
available, the fees for health supervision
visits were the same for nurse and
physi-cian in five cases. In the remainder of the
cases the nurse fees were 67 to 83% of the
physician fees.
The costs of American health care on the
one hand and the use of “mid-level”
tradi-ARTICLES 887
(EDITOR’S NOTE: See also pp. 871 and 92-4-928.)
tionally delivered by American physicians
on the other hand may be two quite
sepa-rate issues. They may share some common
ground, but only if the costs of professional
education are considered. The production
of a pediatrician is more expensive than the
production of a pediatric nurse practitioner.
An analysis which balanced educational
costs against service outputs and work
sur-vival rates for nurse practitioner and
pedia-trician would shed light on this question.
SUMMARY
The costs of training and the dollar
in-come generation yields have been
calcu-lated for 26 graduates of the Pediatric
Nurse Practitioner Program of the Bunker
Hill Health Center of the Massachusetts
General Hospital employed in private
prac-tice settings. Training costs were estimated
from the program experience. Income
gen-erated by the nurse was estimated from
data reported by nurse and employer 6
months or more after graduation from the
program.
Direct educational costs were estimated
at $1,410 per nurse, institutional overhead
at $346 per nurse, production losses
(associ-ated with the training time of 17 weeks) at
$1,442 per nurse. Total cost of training was
$3,197 per nurse.
The average annual salary paid 26
pedi-atric nurse practitioners in private practice
settings was $9,100 per year and the
aver-age number of “nurse-only” face-to-face
pa-tient encounters of all types, projected for
full-time employment, was 65 per week.
Net income generation potential over and
above salary averaged $2,500 per nurse per
year with 14 of the 26 nurses capable of
generating more than $3,000 per year over
and above their current net salaries. These
estimates must be interpreted with caution,
but they suggest that the private sector of
medicine can defray training costs in full in
cases where the paying demand for its
ser-vices is greater than physicians can supply
themselves.
REFERENCES
1. Andrews, P., Yankauer, A., and Connelly, J. P.:
Changing the patterns of ambulatory
pediat-nc caretaldng: An action oriented training
program for nurses. Amer. J. Public Health,
60:870,
1970.2. Yankauer, A., Tripp, S., Andrews, P., and
Con-nelly, J. P. : The outcomes and service impact of a pediatric nurse practitioner training
pro-gram. To be published, Amer. J. Public
Health.
3. Guidelines on short-term continuing education
programs for pediatric nurse associates. A
Joint Statement of the American Nurses’
As-sociation and The American Academy of
Pe-diatrics. Amer. J. Nurs., 71:509, 1971.
4. Guidelines on short-term continuing education
programs for pediatric nurse associates.
Psm-ATRICS, 47:1075, 1971.
5. Andrews, P., and Yankauer, A. : The pediatric
nurse practitioner. 2. Examining the role.
Amer. J.Nurs., 71:507, 1971.
6. Schiff, D. W., Fraser, C. H., and Walters, H. L.: The pediatric nurse practitioner in the office of pediatrics in private practice. PmlAnucs,
44:62, 1969.
7. Reference Data on the Profile of Medical Prac-tice. Center for Health Services Research and
Development. American Medical Association,
Chicago, 1971.
8. Yankauer, A., Connelly, J. P., Andrews, P. A.,
and Feldman, J. J.: The practice of nursing
