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Hall TL, Dickinson LM, Warman MK, Oser TK, Oser SM. Continuous glucose monitoring among nurse practitioners in primary care: Characteristics associated with prescribing and resources needed to support use. J Am Assoc Nurse Pract 2024:01741002-990000000-00237. [PMID: 39046421 DOI: 10.1097/jxx.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/03/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) can improve health for people with diabetes but is limited in primary care (PC). Nurse Practitioners (NPs) in PC can improve diabetes management through CGM, but NPs' interest in CGM and support needed are unclear. PURPOSE We describe behaviors and attitudes related to CGM for diabetes management among NPs in PC. METHODOLOGY This cross-sectional web-based survey of NPs practicing in PC settings used descriptive statistics to describe CGM experience and identify resources to support prescribing. We used multivariable regression to explore characteristics predicting prescribing and confidence using CGM for diabetes. RESULTS Nurse practitioners in hospital-owned settings were twice as likely to have prescribed CGM (odds ratio [OR] = 2.320, 95% CI [1.097, 4.903]; p = .002) than private practice; those in academic medical centers were less likely (OR = 0.098, 95% CI [0.012, 0.799]; p = .002). Past prescribing was associated with favorability toward future prescribing (coef. = 0.7284, SE = 0.1255, p < .001) and confidence using CGM to manage diabetes (type 1: coef. = 3.57, SE = 0.51, p < .001; type 2: coef. = 3.49, SE = 0.51, p < .001). Resources to prescribe CGM included consultation with an endocrinologist (62%), educational website (61%), and endocrinological e-consultations (59%). CONCLUSIONS Nurse practitioners are open to prescribing CGM and can improve diabetes management and health outcomes for PC patients. IMPLICATIONS Research should explore mechanisms behind associations with CGM experience and attitudes. Efforts to advance CGM should include educational websites and endocrinology consultations for NPs in PC.
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Affiliation(s)
- Tristen L Hall
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Patel SY, Auerbach D, Huskamp HA, Frakt A, Neprash H, Barnett ML, James HO, Smith LB, Mehrotra A. Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study. BMJ 2023; 382:e073933. [PMID: 37709347 PMCID: PMC10498453 DOI: 10.1136/bmj-2022-073933] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/16/2023]
Abstract
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.
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Affiliation(s)
- Sadiq Y Patel
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Austin Frakt
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Hannah Neprash
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hannah O James
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Campos-Castillo C. Impact of Beliefs About Local Physician Supply and Self-Rated Health on Willingness to See a Nurse Practitioner During the COVID-19 Pandemic: Web-Based Survey and Experiment. JMIR Form Res 2023; 7:e38965. [PMID: 37347928 PMCID: PMC10434700 DOI: 10.2196/38965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic overburdened primary care clinicians. For nurse practitioners (NPs) to alleviate the burden, the public must be willing to see an NP over a physician. Those with poor health tended to continue seeking care during the pandemic, suggesting that they may be willing to see an NP. OBJECTIVE The aim of this study is to evaluate the public's willingness to see an NP for primary care and how this may be associated with their beliefs about the local supply of physicians and self-rated health. Two studies were conducted: (1) a survey to identify correlations and (2) an experiment to assess how willingness is dependent on information about the local supply of physicians. METHODS The survey and experiment were conducted digitally in April and December 2020, respectively. Participants were US adults recruited from Amazon's Mechanical Turk platform. The key independent variables were self-rated health, which was a dichotomized 5-point scale (excellent, very good, good vs fair, and poor), and beliefs about local physician supply. The survey measured beliefs about local physician supply, while the experiment manipulated beliefs by altering information the participants read about the local supply of physicians. Willingness to see an NP was assessed in 2 ways. First as an overall preference over a physician and the second as a preference given 2 clinically significant scenarios in which participants imagined they were experiencing either coughing or a headache (presentation order randomized). Multiple regressions and ANOVAs were used to assess how beliefs about the local physician supply and self-rated health were associated with overall willingness to see an NP. Bivariate probits simultaneously estimated willingness to see an NP in the 2 clinically significant scenarios. RESULTS The survey showed that concerns about physician supply were associated with lower willingness to see an NP among respondents with comparatively better health but a greater willingness among respondents with comparatively worse health. The experiment suggests that only the latter is causal. For the 2 clinically significant scenarios, these patterns appeared for the coughing scenario in the survey and the headache scenario in the experiment. CONCLUSIONS US adults with comparatively worse self-rated health become more willing to see an NP for primary care when they hear information that raises their concerns about the local physician supply. The differences between the survey and experiment results may be useful for interpreting findings from future studies. Findings may aid in managing finite health care resources during public health crises and crafting successful messaging by NP advocacy groups. Efforts to address nursing shortages will also be needed.
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Affiliation(s)
- Celeste Campos-Castillo
- Department of Media and Information, Michigan State University, East Lansing, MI, United States
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Chung W. Changes in Barriers That Cause Unmet Healthcare Needs in the Life Cycle of Adulthood and Their Policy Implications: A Need-Selection Model Analysis of the Korea Health Panel Survey Data. Healthcare (Basel) 2022; 10:2243. [PMID: 36360584 PMCID: PMC9691171 DOI: 10.3390/healthcare10112243] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 01/31/2024] Open
Abstract
Using 68,930 observations selected from 16,535 adults in the Korea Health Panel Survey (2014-2018), this study explored healthcare barriers that prevent people from meeting their healthcare needs most severely during adulthood, and the characteristics that are highly associated with the barrier. This study derived two outcome variables: a dichotomous outcome variable on whether an individual has experienced healthcare needs, and a quadchotomous outcome variable on how an individual's healthcare needs ended. An analysis was conducted using a multivariable panel multinomial probit model with sample selection. The results showed that the main cause of unmet healthcare needs was not financial difficulties but non-financial barriers, which were time constraints up to a certain age and the lack of caring and support after that age. People with functional limitations were at a high risk of experiencing unmet healthcare needs due to a lack of caring and support. To reduce unmet healthcare needs in South Korea, the government should focus on lowering non-financial barriers to healthcare, including time constraints and lack of caring and support. It seems urgent to strengthen the foundation of "primary care", which is exceptionally scarce now, and to expand it to "community-based integrated care" and "people-centered care".
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Affiliation(s)
- Woojin Chung
- Department of Health Policy and Management, Graduate School of Public Health, Yonsei University, Seoul 03722, Korea
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Patel SY, Huskamp HA, Frakt AB, Auerbach DI, Neprash HT, Barnett ML, James HO, Mehrotra A. Frequency Of Indirect Billing To Medicare For Nurse Practitioner And Physician Assistant Office Visits. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:805-813. [PMID: 35666969 DOI: 10.1377/hlthaff.2021.01968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Sadiq Y Patel
- Sadiq Y. Patel, Harvard University, Boston, Massachusetts
| | | | - Austin B Frakt
- Austin B. Frakt, Veterans Affairs Boston Healthcare System, Harvard University, and Boston University, Boston, Massachusetts
| | - David I Auerbach
- David I. Auerbach, State of Massachusetts, Boston, Massachusetts
| | - Hannah T Neprash
- Hannah T. Neprash, University of Minnesota, Saint Paul, Minnesota
| | | | - Hannah O James
- Hannah O. James, Brown University, Providence, Rhode Island
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Chung W. Characteristics Associated With Financial or Non-financial Barriers to Healthcare in a Universal Health Insurance System: A Longitudinal Analysis of Korea Health Panel Survey Data. Front Public Health 2022; 10:828318. [PMID: 35372247 PMCID: PMC8971121 DOI: 10.3389/fpubh.2022.828318] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
While many studies have explored the financial barriers to healthcare, there is little evidence regarding the non-financial barriers to healthcare. This study identified characteristics associated with financial and non-financial barriers to healthcare and quantified the effects of these characteristics in South Korea, using a nationally representative longitudinal survey dataset. Overall, 68,930 observations of 16,535 individuals aged 19 years and above were sampled from Korea Health Panel survey data (2014-2018). From self-reported information about respondents' experiences of unmet healthcare needs, a trichotomous dependent variable-no barrier, non-financial barrier, and financial barrier-was derived. Sociodemographics, physical and health conditions were included as explanatory variables. The average adjusted probability (AAP) of experiencing each barrier was predicted using multivariable and panel multinomial logistic regression analyses. According to the results, the percentage of people experiencing non-financial barriers was much higher than that of people experiencing financial barriers in 2018 (9.6 vs. 2.5%). Women showed higher AAPs of experiencing both non-financial (9.9 vs. 8.3%) and financial barriers (3.6 vs. 2.5%) than men. Men living in the Seoul metropolitan area showed higher AAPs of experiencing non-financial (8.7 vs. 8.0%) and financial barriers (3.4 vs. 2.1%) than those living outside it. Household income showed no significant associations in the AAP of experiencing a non-financial barrier. People with a functional limitation exhibited a higher AAP of experiencing a non-financial barrier, for both men (17.8 vs. 7.8%) and women (17.4 vs. 9.0%), than those without it. In conclusion, people in South Korea, like those in most European countries, fail to meet their healthcare needs more often due to non-financial barriers than financial barriers. In addition, the characteristics associated with non-financial barriers to healthcare differed from those associated with financial barriers. This finding suggests that although financial barriers may be minimised through various policies, a considerable degree of unmet healthcare needs and disparity among individuals is very likely to persist due to non-financial barriers. Therefore, current universal health insurance systems need targeted policy instruments to minimise non-financial barriers to healthcare to ensure effective universal health coverage.
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Affiliation(s)
- Woojin Chung
- Department of Health Policy and Management, Graduate School of Public Health, Yonsei University, Seoul, South Korea
- Institute of Health Services Research, Yonsei University, Seoul, South Korea
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Smith LB. The effect of nurse practitioner scope of practice laws on primary care delivery. HEALTH ECONOMICS 2022; 31:21-41. [PMID: 34626052 DOI: 10.1002/hec.4438] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/11/2021] [Accepted: 09/18/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Laura Barrie Smith
- Health Policy Center, Urban Institute, Washington, District of Columbia, USA
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Neprash HT, Zink A, Sheridan B, Hempstead K. The effect of Medicaid expansion on Medicaid participation, payer mix, and labor supply in primary care. JOURNAL OF HEALTH ECONOMICS 2021; 80:102541. [PMID: 34700139 DOI: 10.1016/j.jhealeco.2021.102541] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/13/2021] [Accepted: 10/03/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Hannah T Neprash
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455.
| | - Anna Zink
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455
| | - Bethany Sheridan
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455
| | - Katherine Hempstead
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455
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Li Y, Jones CB. Care received by patients from nurse practitioners and physicians in U.S. primary care settings. Nurs Outlook 2021; 69:826-835. [PMID: 33814158 DOI: 10.1016/j.outlook.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/24/2021] [Accepted: 02/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Nurse practitioners (NPs) and physicians serve in both usual source of care (USC) and supplement roles to each other in the provision of primary care to patients. Yet little is known about the care that patients receive from providers in these roles. This study examined the care individuals received when NPs and physicians served in USC and supplemental roles. DATA SOURCES Pooled data from the Household Component of the Medical Expenditure Panel Survey 2002-2013. STUDY DESIGN Cross-sectional, secondary data analysis using propensity score matching and multinomial logistic regression. DATA COLLECTION Data were collected from a national subsample of households. PRINCIPAL FINDINGS Regardless of provider role, patients reported receiving more therapeutic or preventive care from NPs but more diagnostic care and biomedical treatments from physicians. Patients reported having similar diagnoses when seen by NPs and physicians serving in USC roles, but different diagnoses when NPs and physicians served in supplemental roles. CONCLUSIONS NPs and physicians providing different care when serving in the same role. Findings can inform policy-makers as they develop policies for serving patients and utilizing the relevant expertise of NPs and physicians.
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Affiliation(s)
- Yin Li
- Assistant Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.
| | - Cheryl B Jones
- Professor, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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AANP Forum. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pany MJ, Chen L, Sheridan B, Huckman RS. Provider Teams Outperform Solo Providers In Managing Chronic Diseases And Could Improve The Value Of Care. Health Aff (Millwood) 2021; 40:435-444. [DOI: 10.1377/hlthaff.2020.01580] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Maximilian J. Pany
- Maximilian J. Pany is an MD-PhD candidate in health policy at Harvard Medical School, in Boston, Massachusetts. Pany and Lucy Chen are co–first authors
| | - Lucy Chen
- Lucy Chen is an MD-PhD candidate in health policy at Harvard Medical School. Chen and Maximilian Pany are co–first authors
| | - Bethany Sheridan
- Bethany Sheridan is a senior manager of the Research and Insights team at athenahealth, Inc., in Watertown, Massachusetts
| | - Robert S. Huckman
- Robert S. Huckman is the Albert J. Weatherhead III Professor of Business Administration and the Unit Head for Technology and Operations Management at Harvard Business School, in Boston, Massachusetts
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