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Gronbeck C, Jain NP, Zhou AE, Sloan B, Feng H. Changing Dermatologic Procedural Patterns in the Medicare Population: A National Trend Analysis. Dermatol Surg 2024:00042728-990000000-00832. [PMID: 38837756 DOI: 10.1097/dss.0000000000004263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Dermatologists are trained in diagnostic and therapeutic procedures for cutaneous lesions, yet comparative trends for basic dermatologic procedures across dermatology providers are lacking at the national level. OBJECTIVE To trend common dermatologic procedures among general dermatologists, Mohs surgeons, primary care providers or primary care physicians (PCPs), and nonphysician clinicians (NPCs). METHODS Longitudinal analysis of 2016 to 2021 Medicare Public Use Files. RESULTS Aggregate dermatologic procedural volume decreased 3.0%. Procedural volume declined among general dermatologists (-11.7%), Mohs surgeons (-16.7%), and PCPs (-41.7%) but increased among NPCs (+57.5%). The proportion of procedures by general dermatologists decreased substantially for premalignant destructions (-6.2%), skin biopsies and shave removals (-4.7%), and malignant excisions (-4.1%) and more notably in counties that were nonmetro (-7.1%), low in income (-6.1%), and with <4.0 dermatologists per 100,000 population (-7.0%). CONCLUSION Aggregate procedural volume decreased across the study period with general dermatologists, Mohs surgeons, and PCPs performing a progressively smaller proportion. The increase in procedures by NPCs may help to address demand but underscores the value of formalized procedural training. The procedural decline by general dermatologists in rural and low-income counties and those with baseline dermatologist shortages may exacerbate existing unmet need. Primary limitation included lack of commercial data.
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Affiliation(s)
- Christian Gronbeck
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Neelesh P Jain
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Albert E Zhou
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Brett Sloan
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
- Department of Dermatology, Department of Veterans Affairs, Newington, Connecticut
| | - Hao Feng
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
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Elvidge N, Hobbs M, Fox A, Currie J, Williams S, Theobald K, Rolfe M, Marshall C, Phillips JL. Practice pathways, education, and regulation influencing nurse practitioners' decision to provide primary care: a rapid scoping review. BMC PRIMARY CARE 2024; 25:182. [PMID: 38783189 PMCID: PMC11112961 DOI: 10.1186/s12875-024-02350-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/25/2024] [Indexed: 05/25/2024]
Abstract
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.
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Affiliation(s)
- Norah Elvidge
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Megan Hobbs
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Amanda Fox
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Metro North Health, Redcliffe Hospital, Redcliffe, Australia
| | - Jane Currie
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Suzanne Williams
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Karen Theobald
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Melanie Rolfe
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Claire Marshall
- Improving Palliative Care Through Clinical Trials (ImPaCCT), Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jane L Phillips
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia.
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
- Improving Palliative Care Through Clinical Trials (ImPaCCT), Faculty of Health, University of Technology Sydney, Sydney, Australia.
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Valentin VL, Najmabadi S, Honda TJ. Associations between state scope of practice laws and US physician assistant wages from 1997 to 2017: a longitudinal analysis. BMJ Open 2021; 11:e052849. [PMID: 34408059 PMCID: PMC8375714 DOI: 10.1136/bmjopen-2021-052849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The purpose of this study is to determine whether, and to what degree, variations in physician assistant (PA) state scope of practice (SOP) laws across states are associated with (1) PA median wage over time and (2) if a specific SOP key element has greater impact on PA median wage than others. We hypothesise that expanded SOP laws will be associated with higher PA wage. DESIGN Longitudinal analysis from 1997 to 2017. SETTING Fifty states and the District of Columbia (US capital region). PARTICIPANTS Employed PAs from 1997 to 2017. METHODS Four national data sets were combined to allow for longitudinal analysis of state-level annual PA wage and state SOP laws. We used linear regression models to explore the associations of SOP elements with PA wage in 5-year intervals and individual growth models to assess the change in PA annual wage over the study period. RESULTS There was a 220% increase in weighted PA annual wage over two decades. There was a positive linear correlation between annual wage and age in 2012 and 2017 (r=0.52, p<0.01; r=0.29, p=0.04, respectively). The adjusted R2 for individual SOP elements in the selected years were all small (range: 0.0-0.29), with no appreciable pattern across time for any SOP element. In 1997, several SOP laws show association with median wage but this impact disappears over time. CONCLUSIONS PA median wage has risen over twofold in the past two decades, with the rise in PA wage mainly explained by time and provider age. In 1997 some SOP elements were associated with increased average wage; however, the impact of this increase diminished over time in all such instances. As the PA profession moves towards Optimal Team Practice, future research should examine if this move towards greater autonomy impacts wage.
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Affiliation(s)
- Virginia L Valentin
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shahpar Najmabadi
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Trenton J Honda
- School of Clinical and Rehabilitation Sciences, Northeastern University, Boston, Massachusetts, USA
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Abstract
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.
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Affiliation(s)
- Virginia L Valentin
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shahpar Najmabadi
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - C Everett
- Community and Family Medicine, Duke University, Durham, North Carolina, USA
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Najmabadi S, Honda TJ, Hooker RS. Collaborative practice trends in US physician office visits: an analysis of the National Ambulatory Medical Care Survey (NAMCS), 2007-2016. BMJ Open 2020; 10:e035414. [PMID: 32565462 PMCID: PMC7311045 DOI: 10.1136/bmjopen-2019-035414] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Practice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing. DESIGN Temporal ecological study. SETTING Non-federal physician offices. PARTICIPANTS Patient visits to a physician, PA or NP, spanning years 2007-2016. METHODS A stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007-2011 and 2012-2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type. RESULTS Within years 2007-2011 and 2012-2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012-2016 compared with years 2007-2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012-2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers. CONCLUSIONS In non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery.
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Affiliation(s)
- Shahpar Najmabadi
- Department of Family and Preventive Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Trenton J Honda
- Department of Family and Preventive Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Cimiotti JP, Li Y, Sloane DM, Barnes H, Brom HM, Aiken LH. Regulation of the Nurse Practitioner Workforce: Implications for Care Across Settings. JOURNAL OF NURSING REGULATION 2019; 10:31-37. [PMID: 33833902 DOI: 10.1016/s2155-8256(19)30113-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction The current shortage of physicians in the United States has potential to dramatically limit access to healthcare. Nurse practitioners (NPs) can provide a cost-effective solution to the shortage, yet few states allow NPs to practice independently. Purpose The purpose of this study was to provide an up-to-date description of the NP workforce and to identify the professional and organizational factors associated with NP care quality. Methods Cross-sectional survey data from a sample of NPs actively employed in four states with reduced or restricted practice (California, Florida, New Jersey, and Pennsylvania) was used. NPs were categorized into acute and primary care. Regression models were fit to estimate the odds of three measures of care quality: overall quality of patient care, NP confidence that patients and their caregivers can manage their care at home, and whether NPs would recommend their practice facility to family and friends. Results Receiving support from administrative staff and physicians was associated with an increase in the three measures of quality. The greatest effects were seen in primary care settings. Conclusion It is imperative that legislators and healthcare administrators implement policies that provide NPs with an environment that supports clinical practice and enhances care delivery.
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Affiliation(s)
| | - Yin Li
- Nell Hodgson Woodruff School of Nursing, Emory University
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Keller AO, Hooker RS, Jacobs EA. Visits for Depression to Physician Assistants and Nurse Practitioners in the USA. J Behav Health Serv Res 2019; 45:310-319. [PMID: 29230618 DOI: 10.1007/s11414-017-9579-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Abiola O Keller
- College of Nursing, Marquette University, Clark Hall 363, PO Box 1881, Milwaukee, WI, 53201, USA.
| | - Roderick S Hooker
- Physician Assistant Program, Northern Arizona University, Phoenix Biomedical Campus, Phoenix, AZ, USA
| | - Elizabeth A Jacobs
- Departments of Population Health and Internal Medicine, Dell Medical School, The University of Texas at Austin, 1701 Trinity St., Austin, TX, 78712, USA
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Leach B, Morgan P, Strand de Oliveira J, Hull S, Østbye T, Everett C. Primary care multidisciplinary teams in practice: a qualitative study. BMC FAMILY PRACTICE 2017; 18:115. [PMID: 29284409 PMCID: PMC5747144 DOI: 10.1186/s12875-017-0701-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care. METHODS Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis. RESULTS Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients. CONCLUSIONS Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.
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Affiliation(s)
- Brandi Leach
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Perri Morgan
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | | | - Sharon Hull
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Truls Østbye
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Christine Everett
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
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Barnes H, Maier CB, Sarik DA, Germack HD, Aiken LH, McHugh MD. Effects of Regulation and Payment Policies on Nurse Practitioners' Clinical Practices. Med Care Res Rev 2017; 74:431-451. [PMID: 27178092 PMCID: PMC5114168 DOI: 10.1177/1077558716649109] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Increasing patient demand following health care reform has led to concerns about provider shortages, particularly in primary care and for Medicaid patients. Nurse practitioners (NPs) represent a potential solution to meeting demand. However, varying state scope of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs. Using a national sample of 252,657 ambulatory practices, we examined the effect of state policies on NP employment in primary care and practice Medicaid acceptance. NPs had 13% higher odds of working in primary care in states with full scope of practice; those odds increased to 20% if the state also reimbursed NPs at 100% of the physician Medicaid fee-for-service rate. Furthermore, in states with 100% Medicaid reimbursement, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs. Removing scope of practice restrictions and increasing Medicaid reimbursement may increase NP participation in primary care and practice Medicaid acceptance.
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Morgan P, Everett CM, Smith VA, Woolson S, Edelman D, Hendrix CC, Berkowitz TSZ, White B, Jackson GL. Factors Associated With Having a Physician, Nurse Practitioner, or Physician Assistant as Primary Care Provider for Veterans With Diabetes Mellitus. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017712762. [PMID: 28617196 PMCID: PMC5558456 DOI: 10.1177/0046958017712762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Expanded use of nurse practitioners (NPs) and physician assistants (PAs) is a potential solution to workforce issues, but little is known about how NPs and PAs can best be used. Our study examines whether medical and social complexity of patients is associated with whether their primary care provider (PCP) type is a physician, NP, or PA. In this national retrospective cohort study, we use 2012-2013 national Veterans Administration (VA) electronic health record data from 374 223 veterans to examine whether PCP type is associated with patient, clinic, and state-level factors representing medical and social complexity, adjusting for all variables simultaneously using a generalized logit model. Results indicate that patients with physician PCPs are modestly more medically complex than those with NP or PA PCPs. For the group having a Diagnostic Cost Group (DCG) score >2.0 compared with the group having DCG <0.5, odds of having an NP or a PA were lower than for having a physician PCP (NP odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.79-0.88; PA OR = 0.85, CI: 0.80-0.89). Social complexity is not consistently associated with PCP type. Overall, we found minor differences in provider type assignment. This study improves on previous work by using a large national dataset that accurately ascribes the work of NPs and PAs, analyzing at the patient level, analyzing NPs and PAs separately, and addressing social as well as medical complexity. This is a requisite step toward studies that compare patient outcomes by provider type.
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Affiliation(s)
| | | | - Valerie A Smith
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Sandra Woolson
- 2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - David Edelman
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Cristina C Hendrix
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | | | | | - George L Jackson
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
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Timmons EJ. The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care. Health Policy 2017; 121:189-196. [DOI: 10.1016/j.healthpol.2016.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/04/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
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