The effect of nurse practitioner scope of practice laws on primary care delivery

Work characteristics, job satisfaction and intention to leave: a cross-sectional survey of advanced nurse practitioners

BACKGROUND

Advanced Nurse Practitioners (ANPs) are highly skilled health care professionals with the potential to play a major role in improving the quality and accessibility of health care services. However, there is emerging evidence of disquiet among nurse practitioners who often work in suboptimal work environments. Therefore, it is important to understand the elements that contribute to ANPs' job satisfaction and retention in healthcare services.

AIM

To examine the effects of commitment to the workplace, work engagement, and influence at work on job satisfaction and intention to leave of ANPs.

METHODS

A total of 153 ANP's on the advanced practice section of the Nursing and Midwifery Board of Ireland register completed a web survey between July and August 2020. Independent variables (commitment to the workplace, work engagement, and influence at work) were measured using the Copenhagen Psychosocial Questionnaire (COPSOQ). Multivariable logistic regression models were used to investigate the association between dependent and independent variables.

RESULTS

Participants who reported higher levels of influence at work and higher levels of commitment to the workplace were also satisfied in their job (OR 1.05, 95% CI 1.01-1.09, p = 0.025), (OR 1.10, 95% CI 1.06-1.14, p < 0.001) respectively. Additionally, ANPs with higher levels of commitment to work were significantly less likely to leave their role (OR 0.94, 95% CI .92-.96, p < 0.001).

CONCLUSION

Healthcare organisations can improve job satisfaction and decrease intention to leave by creating environments in which ANPs are supported by their colleagues and supervisors, and facilitate their practice to the full extent of their capabilities.

Continued restrictions on nurse practitioners: A qualitative study of the early implementation of full practice authority in Massachusetts

BACKGROUND

In January 2021, the Commonwealth of Massachusetts granted nurse practitioners (NPs) full practice authority (FPA). Little is known about how care delivery changed after FPA legislation.

PURPOSE

To understand the NP perception of early implementation of FPA in Massachusetts.

METHODS

Qualitative descriptive design using inductive thematic analysis of open-ended responses to a web-based survey of NPs in Massachusetts from October to December 2021.

FINDINGS

Survey response rate was 50.3% (N = 144). Inductive thematic analysis of open-ended responses identified four themes, including: (a) internal and external barriers obstructed FPA implementation, (b) employer communication about scope-of-practice changes was minimal, (c) NPs led initiatives to implement FPA, and (d) some efforts effectively implemented FPA.

DISCUSSION

Almost 1 year after FPA was passed, external policies persisted that financially incentivized employers to not change NP scope-of-practice. Concerted efforts are needed to ensure that federal and payer policies, such as incident-to billing, are aligned with state law to encourage the implementation of FPA.

Practice pathways, education, and regulation influencing nurse practitioners' decision to provide primary care: a rapid scoping review

BACKGROUND/OBJECTIVE

Initially established to improve access to healthcare, particularly for primary care, the full potential of the nurse practitioner role is yet to be realised in most countries. Despite this, most countries are working to meet an ageing population's increasing healthcare needs and reduce healthcare costs and access disparities. Achieving these outcomes requires reform at multiple levels, including nurse practitioner practice pathways, education and regulation, and identifying the barriers and facilitators to optimising their primary care role.

METHODS

A rapid scoping review of nurse practitioner practice pathways, education and regulation inclusive of: (1) a systematic search of Medline and CINAHL for peer-reviewed English language articles, including opinion pieces published between January 2015 and February 2022; and (2) a web-based search of nurse practitioner program entry requirements of International Nurse Regulator Collaborative country members with a protected nurse practitioner title and prescribing rights, plus the Netherlands. The individually summarised search data was integrated and synthesised using Popay's narrative approach.

RESULTS

Emerging evidence from the included nurse practitioner courses (n = 86) and articles (n = 79) suggests nurse practitioners working in primary care provide safe, effective care and improve healthcare efficiencies. However, different regulatory and educational models are required if the primary care nurse practitioner is to meet growing demand.

CONCLUSIONS

International variations in entry criteria, curriculum, and regulation shape the global profile of the nurse practitioner primary care workforce and their practice setting. For countries to grow their primary care nurse practitioner workforce to meet unmet needs, different entry requirements, program content and accredited post-registration transitional programs must be urgently considered.

Health outcomes and provider choice under full practice authority for certified nurse-midwives

Full practice authority grants non-physician providers the ability to manage patient care without physician oversight or direct collaboration. In this study, we consider whether full practice authority for certified nurse-midwives (CNMs/CMs) leads to changes in health outcomes or CNM/CM use. Using U.S. birth certificate and death certificate records over 2008-2019, we show that CNM/CM full practice authority led to little change in obstetric outcomes, maternal mortality, or neonatal mortality. Instead, full practice authority increases (reported) CNM/CM-attended deliveries by one percentage point while decreasing (reported) physician-attended births. We then explore the mechanisms behind the increase in CNM/CM-attended deliveries, demonstrating that the rise in CNM/CM-attended deliveries represents higher use of existing CNM/CMs and is not fully explainable by improved reporting of CNM/CM deliveries or changes in CNM/CM labor supply.

Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study

OBJECTIVE

To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics.

DESIGN

Cross-sectional time series study.

SETTING

National data from the traditional Medicare insurance program in the USA.

PARTICIPANTS

Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken.

MAIN OUTCOME MEASURES

The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis.

RESULTS

From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%).

CONCLUSION

The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

The role of restrictive scope-of-practice regulations on the delivery of nurse practitioner-delivered home-based primary care

BACKGROUND

Nurse practitioners (NPs) are the largest group of providers delivering home-based primary care (HBPC) in the U.S. We examined the association of scope-of-practice regulations and NP-HBPC rates.

METHODS

Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state-level analysis to examine the impact of scope-of-practice regulations on the utilization of NP-HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341-99,345, 99,347-99,350) and domiciliary settings (99324-99,328, 99,334-99,337). We used linear regression to compare NP-HBPC utilization rates between states of either restricted or reduced scope-of-practice laws to states with full scope-of-practice, adjusting for a number of NP-HBPC providers, state ranking of total assisted living, the proportion of fee-for-service (FFS) Medicare beneficiaries and neighborhood-level socio-economic status and race and ethnicity.

RESULTS

Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope-of-practice, states with restricted or reduced scope-of-practice had higher adjusted rates of NP-HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP-HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full- scope-of-practice laws, respectively. The rate of NP-HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13-1.72; p = 0.023) and reduced scope-of-practice laws (Beta coefficient = 0.91; 95%CI 0.03-1.79; p = 0.043) compared to states with full scope-of-practice laws.

CONCLUSION

Restricted state NP scope-of-practice regulations were associated with higher rates of FFS Medicare NP-HBPC care delivery compared with full or reduced scope-of-practice. Understanding underlying mechanisms of how scope-of-practice affects NP-HBPC delivery could help to develop scope-of-practice regulations that improve access to HBPC for the underserved homebound population.

State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].

Emergency Removal of Supervision Requirements for Psychiatric Mental Health Nurse Practitioners: A Mixed-Methods Survey

OBJECTIVE

Physician supervision of nurse practitioners (NPs) was temporarily waived in Massachusetts in response to a state of emergency due to the COVID-19 pandemic. The authors examined the impact of the scope-of-practice changes and pandemic-related demands on psychiatric mental health NPs (PMHNPs) during the state's first COVID-19 surge.

METHODS

A mixed-methods Web-based survey was conducted in May and June of 2020. Fisher's exact test was used to compare associations across certification types, and inductive content analysis was applied to open-ended responses.

RESULTS

The survey response rate was 41% (N=389 of 958), consisting of 26 PMHNPs and 363 other NPs. Compared with other NPs, PMHNPs were significantly more likely to work in a telehealth setting (42% vs. 11%, p<0.001), to spend more time working during the initial surge (50% vs. 26%, p<0.05), and to believe that the waiver improved clinical work (52% vs. 25%, p<0.01). Content analysis of PMHNPs' open-ended responses identified four themes: the supervision waiver reduced burden on PMHNPs, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet the high demand for such care.

CONCLUSIONS

PMHNPs may be more sensitive to the scope-of-practice changes and telehealth expansion than other NPs because of the constraints of the psychiatrist shortage and high relative uptake of telehealth in psychiatric care. The interactions of workforce supply, telehealth expansion, and scope-of-practice laws are important to consider in the development of policies to improve access to mental health care.

A Mixed-Methods Sequential Explanatory Study of the Factors That Impact Nurses' Perspectives toward Nurse Practitioners' Roles in Saudi Arabia

Nurse practitioners' roles need to be clearly defined in Saudi Arabia. Therefore, we aimed to explore potential factors that impact nurses' perspectives toward nurse practitioners' roles and whether they are interested in becoming nurse practitioners. A mixed-methods study design was employed using a questionnaire and focus groups. The survey was sent to nurses working at a public hospital in the Riyadh region. Participants (N = 77) reported that having more nurse practitioners would improve quality of care and patient safety. Additionally, most participants stated that an increased supply of nurse practitioners would have a positive impact on effectiveness, equity of care, and healthcare costs. In regression analysis, participants with favorable perspectives towards nurse practitioners were significantly more likely to have interest in becoming nurse practitioners (odds ratio [95% confidence interval]:1.04 [1.01-1.07]). In the qualitative domain, three positive factors were identified: effective collaboration with other staff, better contribution to quality care and patient safety, and better contribution to evidence-based practice. Two barriers were also determined: lack of motivation to become a nurse practitioner and unclear scope of practice. Results showed that nurse practitioners can provide quality healthcare services that meet patients' different needs. The growing role of this speciality warrants further research to show its value in daily practice.

The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity

Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.

Frequency Of Indirect Billing To Medicare For Nurse Practitioner And Physician Assistant Office Visits

Nurse practitioners (NPs) and physician assistants (PAs) represent a growing share of the health care workforce, but much of the care they provide cannot be observed in claims data because of indirect (or "incident to") billing, a practice in which visits provided by an NP or PA are billed by a supervising physician. If NPs and PAs bill directly for a visit, Medicare and many private payers pay 85 percent of what is paid to a physician for the same service. Some policy makers have proposed eliminating indirect billing, but the possible impact of such a change is unknown. Using a novel approach that relies on prescriptions to identify indirectly billed visits, we estimated that the number of all NP or PA visits in fee-for-service Medicare data billed indirectly was 10.9 million in 2010 and 30.6 million in 2018. Indirect billing was more common in states with laws restricting NPs' scope of practice. Eliminating indirect billing would have saved Medicare roughly $194 million in 2018, with the greatest decrease in revenue seen among smaller primary care practices, which are more likely to use this form of billing.

The effect of Medicaid expansion on Medicaid participation, payer mix, and labor supply in primary care

Evidence of increased health care utilization associated with the Medicaid expansion suggests that clinicians increased capacity to meet demand. However, little is known about the mechanism underlying this response. Using a novel source of all-payer data, we quantified clinicians' response to the Medicaid expansion - examining whether and how they changed their Medicaid participation decisions, payer mix, and overall labor supply. Primary care clinicians in expansion states provided an average of 49 additional appointments per year (a 21% relative increase) for patients insured by Medicaid, compared to clinicians in non-expansion states - with new-patient visits representing half (25 appointments) of this overall increase. Clinicians did not increase their labor supply to accommodate these additional appointments. They instead offset the 1.7 percentage point average increase in Medicaid payer mix with an equivalent reduction in commercial payer mix. However, this reduction in commercial patient share represented only a 2.8% relative decrease, with commercially insured patients still comprising the majority of the average clinician's patient panel. Subsample analyses revealed a larger increase in care for Medicaid patients among clinicians with high Medicaid participation preceding the eligibility expansion.