The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care

How do dental practices respond to changes in scope of practice regulations?

Regulations that restrict the tasks that credentialed workers are allowed to perform may affect a firm's input choices, output, and which part of the market the firm serves. Using dental practice survey data from 1989 to 2014 and a stacked difference-in-differences design, this paper examines the effects of state-level scope of practice regulations on the behavior of dental practices. Results suggest that scope of practice deregulation in regards to dental hygienists' ability to administer nitrous oxide or local anesthesia is associated with fewer dentist visits per week in the short-term, lower patient wait times, and an increased likelihood of treating lower revenue generating publicly insured patients. There is weak evidence that scope of practice deregulation alters a practice's labor inputs.

The effects of dental hygienist autonomy on dental care utilization

We investigate the effects of regulations governing the practice autonomy of dental hygienists on dental care use with the 2001-2014 Medical Expenditure Panel Survey. We measure the strength of autonomy regulations by extending the Dental Hygiene Professional Practice Index to the years 2001-2014, allowing us to capture changes in regulations within states over time. Using a difference-in-differences framework applied to selected states, we find that relaxing supervision requirements to provide dental hygienists moderate autonomy results in an increase in total dental visits due to greater use of preventive dental care. However, the use of dental treatment decreases when states adopt the highest level of autonomy. Both sets of estimates increase in magnitude when we subset the sample to dental care provider shortage areas. In support of these findings, we show that dental visits shift to dental hygienists in shortage areas when states expand the scope of practice of hygienists, and that there is an increase in tasks performed by hygienists, such as cleanings and dental exams.

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.

Professionalism in Physician Assistant Education as a Predictor of Future Licensing Board Disciplinary Actions

PURPOSE

The purpose of this study was to evaluate associations between postgraduate disciplinary actions (PGDA) by state licensing boards and physician assistant (PA) school documented professionalism violations (DPV) and academic probation.

METHODS

This was a retrospective cohort study comprising PA graduates from 2001 to 2011 at 3 institutions (n = 1364) who were evaluated for the main outcome of PGDA and independent variable of DPV and academic probation. Random-effects multiple logistic regression and accelerated failure time parametric survival analysis were used to investigate the association of PGDA with DPV and academic probation.

RESULTS

Postgraduate disciplinary action was statistically significant and positively associated with DPV when unadjusted (odds ratio [OR] = 5.15; 95% CI: 1.62-16.31; P = .01) and when adjusting for age, sex, overall PA program GPA (GPA), and Physician Assistant National Certifying Exam Score (OR = 5.39; 95% CI: 1.54-18.85; P = .01) (fully adjusted). Academic probation increased odds to 8.43 times (95% CI: 2.85-24.92; P < .001) and 9.52 times (95% CI: 2.38-38.01; P < .001) when fully adjusted.

CONCLUSION

Students with professionalism violation or academic probation while in the PA school had significant higher odds of receiving licensing board disciplinary action compared with those who did not. Academic probation had a greater magnitude of effect and could represent an intersection of professionalism and academic performance.

The Relationship Between Scope of Practice Laws for Task Delegation and Nurse Turnover in Home Health

OBJECTIVE

Nurse turnover can compromise the quality and continuity of home health care. Scope of practice laws, which determine the tasks nurses are allowed to perform and delegate, are an important element of autonomy and vary across states. In this study, we used human resource records from a multistate home health organization to examine the relationship between nurse turnover and whether nurses can delegate tasks to unlicensed aides.

DESIGN

A retrospective, cross-sectional analysis.

SETTING AND PARTICIPANTS

The study sample included 1820 licensed practical nurses and 3309 registered nurses, who spanned 30 states. The study period was 2016 through 2018.

METHODS

We used weighted least squares to study the relationship between nurse turnover for registered and licensed practical nurses and task delegation across state-years. We measured task delegation continuously (0-16 tasks) and as a binary variable (14 or more tasks, which indicated the state was in the top half of the distribution).

RESULTS

Across state-years, the turnover rate was 30.8% for licensed practical nurses and 36.8% for registered nurses. Although there was no significant relationship between task delegation and turnover among registered nurses, we found that states in which nurses could delegate the most tasks had lower turnover rates among licensed practical nurses.

CONCLUSION AND IMPLICATIONS

The ability to delegate tasks to unlicensed aides was correlated with lower turnover rates among licensed practical nurses, but not among registered nurses. This suggests that the ability to delegate tasks is more likely to affect the workload of licensed practical nurses. This also points to a potential and unexplored element of expanding the scope of practice for nurses: reduced turnover. Given the added work-related hazards associated with home health care, including working in isolation, a lack of social recognition, and inadequate reimbursement, states should consider whether changes in their policy environment could benefit nurses working in home health.

The changing employment of physicians, nurse practitioners, and physician associates/assistants

ABSTRACT

Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 nurse practitioners (NPs), and 139,100 physician associates/assistants (PAs). These three health care professionals accounted for approximately 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

The changing employment of physicians, NPs, and PAs

ABSTRACT

Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics (BLS) employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 NPs, and 139,100 physician associates/assistants (PAs). These three healthcare professionals accounted for about 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than that of physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

Current Programs and Incentives to Overcome Rural Physician Shortages in the United States: A Narrative Review

Access to healthcare continues to be a top priority and prominent challenge in rural communities, with 20% of the total U.S. population living in rural areas while only 10% of physicians practice in rural areas. In response to physician shortages, a variety of programs and incentives have been implemented to recruit and retain physicians in rural areas; however, less is known about the types and structures of incentives that are offered in rural areas and how that compares to physician shortages. The purpose of our study is to conduct a narrative review of the literature to identify and compare current incentives that are offered by rural physician shortage areas to better understand how resources are being allocated to vulnerable areas. We reviewed published peer-reviewed articles from 2015-2022 to identify incentives and programs designed to address physician shortages in rural areas. We augment that review by examining the gray literature, including reports and white papers on the topic. Identified incentive programs were aggregated for comparison and translated into a map that depicts high, medium, and low levels of geographically designated Health Professional Shortage Areas (HPSAs) and the number of incentives offered by state. Surveying current literature regarding different types of incentivization strategies while comparing to primary care HPSAs provides general insights on the potential influence of incentive programs on shortages, allows easy visual review, and may provide greater awareness of available support for potential recruits. Providing a broad overview of the incentives offered in rural areas will help illuminate whether diverse and appealing incentives are offered in the most vulnerable areas and guide future efforts to address these issues.

Determining and regulating scope of practice for health care professionals: A participatory, multiple stakeholder approach

BACKGROUND

Scope of practice varies between health professions and states.

OBJECTIVE

To explore stakeholders' preferences for determining and regulating health care professionals' scopes of practice.

METHODS

Stakeholders in medicine, nursing, and pharmacy, including practitioners, leaders of professional associations, regulatory board members, and healthcare executives, were recruited via professional organizations, social media, and snowball sampling. Stakeholder preferences were collected using concept mapping, an integrated mixed methods approach which includes 1) brainstorming of statements and 2) sorting and rating of statements. Multidimensional scaling, hierarchical cluster analysis, and Mann Whitney-U tests were used for analysis.

RESULTS

Thirty participants generated and sorted statements regarding preferences for scope of practice, creating eight clusters: 1) accountability to prioritize patient safety, 2) standardization, 3) collaborative regulation, 4) intra-professional regulation, 5) federal versus state, 6) role of non-health care professionals, 7) prioritization of patient outcomes, and 8) health care professional training and education. Fifty-seven participants rated statements in terms of importance and feasibility. Physicians and non-physicians held similar views on 68.5% (n = 37) and 81.5% (n = 44) of statements, respectively for importance and feasibility. The statements in the standardization and health care professional training and education clusters were perceived as the most important and feasible across stakeholder types.

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

Nurse practitioners (NPs) are an increasingly integral part of the primary care workforce. NPs' authority to practice without physician oversight is regulated by state-level scope of practice (SOP) restrictions. To the extent that SOP restrictions prevent NPs from practicing to their full abilities and capacity, they could create inefficiencies and restrict access to health care. In this paper, I study what happens at primary care practices when states relax their SOP laws. Using a novel dataset of claims and electronic health records paired with a difference-in-differences research design, I quantify the effects of relaxing SOP laws on: (1) NPs' autonomy in their day-to-day jobs; (2) total workload and patient allocation between NPs and physicians; and (3) the provision of low-value services at primary care practices. I find some evidence that NPs practice more autonomously following SOP changes, but I find no evidence that relaxing SOP laws changes the volume nor allocation of patients to NPs, nor the provision of low-value services. Given the lower reimbursement that NPs typically receive, these findings suggest that allowing NPs to practice without physician oversight could reduce health care spending, without harming patients.

Midlevel Injectable Practice Patterns in Dermatology and Plastic Surgery Offices

BACKGROUND

There is limited knowledge on the extent physicians delegate cosmetic procedures to midlevel providers.

OBJECTIVE

To assess dermatology and plastic surgery practice patterns for the injections of neurotoxins and dermal fillers.

MATERIALS AND METHODS

Four hundred ninety-two dermatology and plastic surgery practices were identified from 10 major US metropolitan areas. These practices were contacted, and staff were asked a series of questions to best characterize the practice patterns in regard to who performs the injectables in the office.

RESULTS

Although most dermatology and plastic surgery practices had physicians as the only provider who gives injectables, 18.35% of dermatology and 25.4% of plastic surgery practices had nurse practioners and physician assistants giving injectables both with and without oversight of the supervising physician onsite.

CONCLUSION

In a large majority of both plastic surgery and dermatology practices, physicians exclusively perform injections of neurotoxins and fillers. For practices that allow midlevel providers to perform injectables, the level of physician supervision is variable. In a small percentage of plastic surgery practices, surveyed midlevel providers exclusively performed injectables.

Retention and change in PAs' first years of employment

OBJECTIVE

Employment analyses demonstrate that physician assistants (PAs) exhibit role flexibility in US medicine. The next step in understanding this labor-shifting observation is to know at what career stage it first occurs.

METHODS

Using matriculate data linked to the American Academy of PAs (AAPA) census survey data, a longitudinal analysis of seven graduate cohorts revealed that one-third of PAs changed specialty roles at least once during their first decade of employment.

RESULTS

From this series, it appears that new PAs spend about 3.4 years in their first job, on average, before they decide to move to another medical or surgical field. In examining PAs who changed their clinical role during this time period, 28% shifted from primary care to another medical or specialty role. Overall, the PA career movement to nonprimary care specialties increased substantially.

CONCLUSIONS

These findings support observations that PAs provide an adaptive role in a dynamic and changing medical workforce.

Advance Practice Provider Transformational Leadership Structure: A Model for Change

BACKGROUND

The role of the advanced practice provider (APP) is rapidly expanding in healthcare, whereas infrastructure to support it is not keeping pace. A large academic healthcare organization implemented the role of a director of APPs; supported by the C-suite, one who understands scope of practice, revenue models, and compliance and addresses engagement and retention to meet this challenge. This article chronicles the implementation of innovative success strategies, supporting APPs across a large academic health system, employing more than 1000 APPs, which has led to improvements in APP-generated revenue, patient access, engagement, and alignment.

METHODS

Emory Healthcare rapidly expanded the number of APPs (nurse practitioners and physician assistants) over the past 10 years. APPs reported to administration or nursing leadership leading to APP dissatisfaction, questions on return on investment (ROI) and productivity, and poor utilization due to lack of role clarity. An APP leadership structure was created so that every APP reported to an APP leader. In alignment with the goals and plan for Emory Healthcare, standardized service line productivity and accountability expectations were developed and implemented, as well as a vision and strategic plan to support APPs.

RESULTS

Improvement in productivity was seen across service lines, supported by the increase in full-time equivalent numbers, while improving the ROI for the organization. A roadmap to aligning an APP and organizational strategic plan has been created and implemented. Improvement in APP engagement was realized.

CONCLUSIONS

An APP director and leadership structure are vital to the creation of infrastructure to support APPs in this healthcare. Optimization and standardization of APP practice resulted in role clarity and allowed for support of practice development.

Health care costs associated with primary care physicians versus nurse practitioners and physician assistants

BACKGROUND

Significant primary care provider (PCP) shortage exists in the United States. Expanding the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) can help alleviate this shortage. The Department of Veterans' Affairs (VA) has been a pioneer in expanding the role of NPs and PAs in primary caregiving.

PURPOSE

This study evaluated the health care costs associated with VA patients cared for by NPs and PAs versus primary care physicians (physicians).

METHODS

A retrospective data analysis using two separate cohorts of VA patients, one with diabetes and the other with cardiovascular disease (CVD), was performed. The associations between PCP type and health care costs were analyzed using ordinary least square regressions with logarithmically transformed costs.

RESULTS

The analyses estimated 12% to 13% (US dollars [USD] 2,626) and 4% to 5% (USD 924) higher costs for patients assigned to physicians as compared with those assigned to NPs and PAs, after adjusting for baseline patient sociodemographics and disease burden, in the diabetes and CVD cohort, respectively. Given the average patient population size of a VA medical center, these cost differences amount to a total difference of USD 14 million/year per center and USD 5 million/year per center for diabetic and CVD patients, respectively.

IMPLICATIONS FOR PRACTICE

This study highlights the potential cost savings associated with primary caregiving by NPs and PAs. In light of the PCP shortage, the study supports increased involvement of NPs and PAs in primary caregiving. Future studies examining the reasons for these cost differences by provider type are required to provide more scientific evidence for regulatory decision making in this area.

Cross-sectional analysis of US scope of practice laws and employed physician assistants

OBJECTIVE

This study examined if the variation in physician assistant (PA) state scope of practice (SOP) laws across states are associated with number of employed PAs, PA demographics and PA/population ratio per state. The hypothesis was that less restrictive SOP laws will increase the demand for PAs and the number of PAs in a state.

DESIGN

Retrospective cross-sectional analysis at three time points: 1998, 2008, 2017.

SETTING

Fifty states and the District of Columbia.

PARTICIPANTS

Employed PAs in 1998, 2008, 2017.

METHODS

SOP laws were categorised as permissive, average and restrictive. Three national datasets were combined to allow for descriptive analysis of employed PAs by year and SOP categories. We used linear predictive models to generate and compare PA/population ratio least square means by SOP categories for each year. Models were adjusted for percent female PA and PAs mean age.

RESULTS

There was a median PA/population ratio of 23 per 100 000 population in 1998 and 33 in 2017. A heterogeneous expansion of SOP laws was seen with 17 states defined as super expanders while 15 were never adopters. In 2017, comparing restrictive to permissive states showed that in adjusted models permissive SOP laws were associated with 11.7 (p .03) increase in ratio of employed PAs per 100 000 population, demonstrating that states with permissive SOP laws have an increased PA density.

CONCLUSIONS

There has been steady growth in the mean PA/population ratio since the turn of the century. At the same time, PA SOP laws in the USA have expanded, with just 10 states remaining in the restrictive category. Permissive SOP laws are associated with an increase in the ratio of employed PAs per state population. As states work to meet the projected physician need, SOP expansion may be an important policy consideration to increase the PA workforce.

Availability of Adult Vaccination Services by Provider Type and Setting

INTRODUCTION

Knowledge regarding the benefits for adult vaccination services under Medicaid's fee-for-service arrangement is dated; little is known regarding the availability of vaccination services for adult Medicaid beneficiaries in MCO arrangements. This study evaluates the availability of provider reimbursement benefits for adult vaccination services under fee-for-service and MCO arrangements for different types of healthcare providers and settings.

METHODS

A total of 43 Medicaid directors across the 50 U.S. states and the District of Columbia participated in a semistructured survey conducted from June 2018 to June 2019 (43/51). The frequency of Medicaid fee-for-service and MCO arrangements reporting reimbursement for adult vaccination services by various provider types and settings were assessed in 2019. Elements of vaccination services examined in this study were vaccine purchase, vaccine administration, and vaccination-related counseling.

RESULTS

Under fee-for-service, 41 Medicaid programs reimburse primary care providers for adult vaccine purchase (41/43); fewer programs reimburse vaccine administration and vaccination-related counseling (33/43 and 30/43, respectively). Similar results were observed for obstetricians-gynecologists, nurse practitioners, and pharmacies. Although 24 fee-for-service (24/43) and 23 MCO (23/34) arrangements cover adult vaccination services in most settings, long-term care facilities have the lowest reported reimbursement eligibility.

CONCLUSIONS

In most jurisdictions, vaccination services for adult Medicaid beneficiaries are available for a variety of healthcare provider types and settings under both fee-for-service and MCO arrangements. However, because provider reimbursement benefits remain inconsistent for adult vaccination counseling services and within long-term care facilities, access to adult vaccination services may be reduced for Medicaid beneficiaries who depend on these resources.

Driving high-functioning clinical teams: An advanced practice registered nurse and PA optimization initiative

BACKGROUND

Rapid changes in the healthcare marketplace are driving healthcare systems to modify operations by which advanced practice registered nurses (APRNs) and physician assistants (PAs) serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands, resulting in high-functioning clinical teams.

LOCAL PROBLEM

With the growing number of APRNs and PAs in a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these healthcare providers.

METHODS

Directors of the APP Best Practice Center developed an internal NP/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service which conducted evaluations to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists.

INTERVENTIONS

Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and more than 200 individual NP/CNM/CNS/PA interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members.

RESULTS

Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support.

CONCLUSIONS

Several recommendations were presented to department leaders about NP/CNM/CNS/PA practice. Departments that implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.

Nurse practitioners' workforce outcomes under implementation of full practice authority

BACKGROUND

Full practice authority laws that permit nurse practitioners (NPs) to practice independently and prescribe medications may influence NPs' workforce outcomes.

PURPOSE

To examine whether implementation of full practice authority laws affect NP self-employment, average earnings, and likelihood of residing in a primary care health professional shortage area (HPSA).

METHODS

A nationally representative U.S. sample of 9,782 NPs employed in health care during 2010 to 2018 was drawn from the American Community Survey. Difference-in-differences regression was used to estimate covariate-adjusted mean differences in NPs' workforce outcomes after full practice authority implementation.

FINDINGS

Among full-time employed NPs, full practice authority was associated with an increased probability of residing in a HPSA (adjusted odds ratio [aOR]:2.34, 95%CI 1.14, 4.83) and with a higher mean probability of self-employment (aOR:4.97, 95%CI 1.00, 24.86).

DISCUSSION

Full practice authority implementation improves access to primary care providers in health professional shortage areas and may increase practice ownership among NPs.

Driving high-functioning clinical teams: An advanced practice registered nurse and physician assistant optimization initiative

BACKGROUND

Rapid changes in the health care marketplace are driving health care systems to modify operations by which the advanced practice registered nurse (APRN) and physician assistant (PA) clinicians serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands resulting in high-functioning clinical teams.

LOCAL PROBLEM

With the growing number of APRNs and PAs within a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these health care providers.

METHODS

Directors of the Advanced Practice Provider Best Practice Center developed an internal nurse practitioner (NP)/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service in which evaluations were conducted to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists.

INTERVENTIONS

Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and over 200 individual NP/CNM/CNS and PA provider interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members.

RESULTS

Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support.

CONCLUSIONS

Several recommendations were presented to department leaders regarding NP/CNM/CNS/PA practice. Those departments who implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.

A survey of nurse practitioner controlled drugs and substances prescribing in three Canadian provinces

AIMS AND OBJECTIVES

In Canada, nurse practitioners (NP) were legally authorised to prescribe controlled drugs and substances (CDS) in 2012. The objective of this study was to understand current NP-CDS prescribing in Alberta, Manitoba and Saskatchewan, Canada. This study is a component of a larger three-phase survey of NP practice patterns in these same provinces.

BACKGROUND

Nurse practitioners are nurses with a graduate degree who have the legal authority to perform expanded functions in health systems, including prescribing CDS. Given the novelty of CDS prescribing for NPs in Canada, little is known about this component of their role.

DESIGN

A secondary analysis of survey data collected between March 2016 and May 2017 was used to examine NP-CDS-prescribing patterns and identify potential associated factors.

METHODS

Nurse practitioners in Alberta, Manitoba and Saskatchewan were invited to complete a professional practice pattern survey. The survey was administered through a secure electronic data collection software application (redcap). In the practice pattern survey, 42 variables from 15 distinct conceptual questions were analysed in this study as potential predictors of NP-CDS prescribing within a purposeful selection ordinal logistic regression model. This scientific submission has been assessed for accuracy and completeness using the Equator STROBE guideline criteria (see Appendix S1).

RESULTS/FINDINGS

Five variables were found to be associated with an increased odds of more frequent NP-CDS prescribing in addition to three confounders/clinically relevant variables. Factors commonly associated with an increased frequency of NP-CDS prescribing relate to location of practice, area of practice, previous nursing experience, team environments and common diagnoses.

CONCLUSION

Little is known about NP-CDS prescribing. Understanding this important component of the NPs emerging legal scope of professional practice can contribute to the continued refinement of this role as well as support ongoing enquiry into the causes of, and potential interventions to prevent, the present opioid overdose deaths occurring while under an active prescription.

RELEVANCE TO CLINICAL PRACTICE

Understanding factors that influence NP-CDS prescribing has relevance to the current drug-related prescription fatalities crisis in all countries.

Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm

BACKGROUND

Rapid changes in health care are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity.

LOCAL PROBLEM

The Directors of the APP-Best Practice Center conducted assessments of each clinical area at MUSC Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (nurse practitioners/physician assistants) but also in the utilization of APPs to practice to the fullest extent of their license, education, and experience.

METHODS

By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built while following updated practice laws, compliance/legal standards, and hospital bylaws/regulations.

INTERVENTIONS

A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation.

RESULTS

This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity.

CONCLUSIONS

With the APP work force growing, the implementation of electronic medical record systems, and today's health care financial constraints, it is imperative that health care systems standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.

Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm

BACKGROUND

Rapid changes in healthcare are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity.

LOCAL PROBLEM

The directors of the APP-Best Practice Center conducted assessments of each clinical area at the Medical University of South Carolina (MUSC) Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (NPs and physician assistants) but also in the use of APPs to practice to the fullest extent of their license, education, and experience.

METHODS

By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built that follows updated practice laws, compliance/legal standards, and hospital bylaws and regulations.

INTERVENTIONS

A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation.

RESULTS

This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity.

CONCLUSIONS

With the APP workforce growing, the implementation of electronic medical record systems, and today's healthcare financial constraints, healthcare systems must standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.

American Association of Nurse Practitioners National Nurse Practitioner sample survey: Update on acute care nurse practitioner practice

BACKGROUND AND PURPOSE

Data from national surveys on the practice of nurse practitioners (NPs) provides valuable information on aspects of practice, demographic characteristics of providers and patients, plans for continued employment, and role satisfaction. The American Association of Nurse Practitioners (AANP) has been conducting the AANP Sample Survey since 1988.

METHODS

The most recent AANP Sample Survey was conducted in 2016 with a random stratified survey of 40,000 NPs. Data were collected bimodally, by internet and mail surveys. Responses were received from 3,970 respondents (9.9% response rate), with 335 respondents reporting NP certification in acute care as adult-gerontology acute care and/or pediatric acute care.

RESULTS

Almost all acute care nurse practitioners (ACNPs) reported that they were clinically practicing in 2016 (99.3%), with the top three areas encompassing cardiovascular (20.5%), critical care (12.1%), and hospitalist roles (6.3%). More than 1 in 4 ACNPs worked in a hospital inpatient setting, with 16.1% reporting work in a hospital outpatient clinic, 7.7% in a private group practice, 6.5% at a public university, and some in combined roles covering both inpatient and outpatient care, or on consultation service or specialty-based teams. On average, 34.1% of the patients ACNPs saw were between the ages of 66 and 85 years, and 11.2% were 85 years and older. The top 3 medication classes in which ACNPs regularly prescribe were diuretics (31.9%), analgesic narcotics (31.2%), and antibiotics (27.3%). Majority (88%) report satisfaction with the role, and approximately one third (31.1%) expect to continue to work in their current practice for more than 10 years.

IMPLICATIONS FOR PRACTICE

The findings of the 2016 AANP National NP Sample Survey data related to ACNP practice identify expansion of work settings, practice consistent with acute care scope of practice, role satisfaction, and intent to continue working. Continued monitoring of practice components and employment is indicated to track ACNP workforce trends.

North American naturopathic medicine in the 21st century: Time for a seventh guiding principle - Scientia Critica

The World Health Organization strategy for global health includes a culturally-sensitive blending of western biomedicine with traditional forms of healing; in practical terms this approach is often referred to as integrative medicine. One distinct element within the systems of North American integrative healthcare is naturopathic medicine; while the basic premise of its fundamental approach to care - supporting healthy lifestyle behaviors - is as old as medicine itself, the early history of organized naturopathy in North America was heavy in theory and light on critical analysis. Dozens of questionable modalities and protocols have been housed under the rubric of naturopathy. It is our contention that the progression of professional naturopathic medicine in the 21st century - with goals of personal, public and planetary health - requires the active pursuit of critical analysis. We examine the primary guiding principles which drive the training and practice of North American naturopathic medicine; while these principles are laudable in the age of patient-centered care, we argue that there are shortcomings by absentia. We propose a seventh principle - Scientia Critica; that is, the ability to critically analyze accumulated knowledge - including scientific facts, knowledge about the self (critical consciousness) and values of the patient.

Association of State-Level Restrictions in Nurse Practitioner Scope of Practice With the Quality of Primary Care Provided to Medicare Beneficiaries

Context: State scope of practice (SoP) laws impose significant restrictions on the services that a nurse practitioner (NP) may provide in some states, yet evidence about SoP limitations on the quality of primary care is very limited. Method: This study uses six different classifications of state regulations and bivariate and multivariate analyses to compare beneficiaries attributed to primary care nurse practitioners and primary care physicians in 2013 testing two hypotheses: (1) chronic disease management, cancer screening, preventable hospitalizations, and adverse outcomes of care provided by primary care nurse practitioners are better in reduced and restricted practice states compared to states without restrictions and (2) by decreasing access to care, SoP restrictions negatively affect the quality of primary care. Findings: Results show a lack of consistent association between quality of primary care provided by NPs and state SoP restrictions. Conclusion: State regulations restricting NP SoP do not improve the quality of care.