A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals' use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016-2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26-5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13-1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11-1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.