Developing Safe Harbors to Address Malpractice Liability and Wasteful Health Care Spending.

This Viewpoint discusses the feasibility of developing safe harbors that account for the role of medical malpractice liability and go beyond generic guidelines discouraging the overuse of health care resources.

Toward a Uniform Classification of Nurse Practitioner Scope of Practice Laws.

Many states' scope of practice laws limits the ability of nurse practitioners to deliver care by requiring physician supervision of their practices and prescribing activities. A robust literature has evolved around examining the role of these scope of practice laws in various contexts, including labor market outcomes, health care access, health care prices, and the delivery of care for specific diseases. Unfortunately, these studies use different, and sometimes conflicting, measures of scope of practice laws, limiting their comparability and overall usefulness to policymakers and future researchers. We address this salient problem by providing a recommended coding of nurse practitioner scope of practice laws over a 24-year period based on actual statutory and regulatory language. Our classification of scope of practice laws solves an important problem within this growing literature and provides a solid legal foundation for researchers as they continue to investigate the effects of these laws.

Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing.

Policy Points The increased use of nurse practitioners represents a viable policy option to address continuing access-to-care deficiencies across the United States, but state scope-of-practice laws limit the ability of nurse practitioners to deliver health care. Groups in favor of restrictive scope-of-practice laws have argued that relaxing these laws will lead to increases in opioid prescriptions during an already severe opioid crisis, implicating patient safety concerns. An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states. CONTEXT: As many parts of the United States continue to face physician shortages, the increased use of nurse practitioners (NPs) can improve access to care. However, state scope-of-practice (SOP) laws limit the ability of NPs to provide care by restricting the services they can provide and often requiring physician supervision of their practices. One important justification for the continuation of these restrictive SOP laws is preventing the overprescription of certain medications, particularly opioids. METHODS: This study examined a data set of approximately 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level. A series of difference-in-differences regression models was estimated to examine the association between laws allowing NPs to practice independently and opioid prescribing patterns among physicians and NPs. Opioid prescriptions were measured in total annual morphine milligram equivalents (MMEs) prescribed by individual providers. FINDINGS: Across all NPs and physicians, independent NP practice was associated with a statistically significant decline of 6%, 2%, 3%, 7%, and 5% in total annual MMEs prescribed to commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively. Medicaid patients saw no statistically significant change in annual MMEs. Across all payers, NPs generally increase and physicians generally decrease the number of opioids they prescribe following a grant of NP independence. These counterbalancing changes result in an overall net decline in MMEs. CONCLUSIONS: No evidence supports the contention that allowing NPs to practice independently increases opioid prescriptions. The results support policy changes that allow NPs to practice independently.

Open Payments Reporting of Industry Compensation for Orthopedic Residents.

OBJECTIVES: Residents receiving industry payments are not legally required to be reported on the Centers for Medicare & Medicaid Services (CMS) Open Payments Database. The purpose of this study is to review reporting of orthopedic surgery residents and identify the trends for which payments or transfers in value were received. DESIGN: The CMS Open Payments Database was used to search for all available orthopedic residents from 2014 to 2016. All data available on the CMS Open Payments Database was recorded. SETTING/PARTICIPANTS: This is a database study. Participants are residents reported in the CMS Open Payments Database. RESULTS: Over the 3-year period, 6832 resident "entities" were identified from 151 programs. A total of 3217 entities (47%) were reported as receiving payments from industry during this time period. This totaled $3,786,754 over the 3 year study period. The largest itemized categories for payment were education (32.5%) and grants (30.9%) totaling more than $2.4 million. Other areas of payment included travel (17.0%), food (16.0%), consultation fee (1.7%), research (0.8%), speaker fee (0.7%), gift (0.1%), honoraria (0.1%), and other (0.02%). CONCLUSION: Overall, 47% of orthopedic resident entities were reported on the CMS Open Payments Database. The vast majority of payments were related to education and grants. Residents should become familiar with how to navigate the Open Payments Database and be educated on maintaining appropriate relationships with industry.

Association of State Legislation and Industry Compensation to Orthopaedic Residents: A 3-Year Review of the Centers for Medicare and Medicaid Services Open Payments Database.

BACKGROUND: The Sunshine Act aims to increase the transparency of physicians receiving compensation from pharmaceutical and medical device companies. Nine states have supplementary legislation in addition to the Federal Sunshine Act. The purpose of this study is to assess the characteristics of financial compensation to orthopaedic residents on the Centers for Medicare and Medicaid Services (CMS) Open Payments Database in states with more restrictive regulations compared with those without additional restrictions. METHODS: A complete list of accredited orthopaedic residency programs in the United States was compiled using the Accreditation Council for Graduate Medical Education and American Osteopathic Academy of Orthopedics websites. The website of each orthopaedic residency program was searched to compile a list of residents who attended their program from 2014 to 2016. The CMS Open Payments Database was used to search the residents identified for the corresponding years. All data available on the CMS Open Payments Database were recorded. RESULTS: Over the 3-year period, 3,622 residents were identified from 151 programs. A total of 41% of the residents were reported as receiving compensation from the industry. The percent of residents reported from programs in less restrictive states was 45% versus 28% in more restrictive states (P < 0.001). Residents had a mean of 5.3 transactions per year in less restrictive states and 2.4 transactions per year in more restrictive states (P < 0.001). The mean compensation per resident reported was $2,730 for less restrictive sates versus $1,937 for more restrictive states (P < 0.001). DISCUSSION: Overall, 41% of orthopaedic residents were reported on the CMS Open Payments Database with fewer transactions and less compensation going to residents in states with more restrictive legislature. Potential implications on resident education remain unknown.

The impact of cannabis access laws on opioid prescribing.

While recent research has shown that cannabis access laws can reduce the use of prescription opioids, the effect of these laws on opioid use is not well understood for all dimensions of use and for the general United States population. Analyzing a dataset of over 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level, we find that recreational and medical cannabis access laws reduce the number of morphine milligram equivalents prescribed each year by 11.8 and 4.2 percent, respectively. These laws also reduce the total days' supply of opioids prescribed, the total number of patients receiving opioids, and the probability a provider prescribes any opioids net of any offsetting effects. Additionally, we find consistent evidence that cannabis access laws have different effects across types of providers, physician specialties, and payers.

The Association of Nurse Practitioner Scope-of-Practice Laws With Emergency Department Use: Evidence From Medicaid Expansion.

BACKGROUND: Overuse and inappropriate use of emergency departments (EDs) remains an important issue in health policy. After implementation of Medicaid expansion, many states experienced an increase in ED use, but the magnitude varied. Differential access to primary care might explain such variation. OBJECTIVE: To determine whether the increase in ED use among Medicaid enrollees following Medicaid expansion was smaller in states that allowed greater access to primary care providers by permitting nurse practitioners (NPs) to practice without physician oversight. RESEARCH DESIGN: Examining data on ED use by Medicaid beneficiaries, we estimated random effects models to examine changes in ED visits. Models for 8 different clinical conditions were estimated, with each model including a linear time trend, indicators for Medicaid expansion and for the absence of physician oversight requirements, and an interaction between these 2 indicators. RESULTS: States requiring physician oversight of NPs had a 28% increase in ED visits relative to the preexpansion period, while states allowing NP practice without physician oversight had only a 7% increase. The increase in the share of visits covered by Medicaid in no-oversight states was 40% of the size of the increase in oversight states. CONCLUSIONS: Allowing NPs to practice without physician oversight was associated with a reduction in the magnitude of increase in ED use following Medicaid expansion. States that restrict NP practice should weigh the costs of maintaining these restrictions against the potential benefits of lower ED use. States considering Medicaid expansion should also consider relaxing NP scope-of-practice laws.

"Sorry" Is Never Enough: How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk.

Based on case studies indicating that apologies from physicians to patients can promote healing, understanding, and dispute resolution, thirty-nine states (and the District of Columbia) have sought to reduce litigation and medical malpractice liability by enacting apology laws. Apology laws facilitate apologies by making them inadmissible as evidence in subsequent malpractice trials. The underlying assumption of these laws is that after receiving an apology, patients will be less likely to pursue malpractice claims and will be more likely to settle claims that are filed. However, once a patient has been made aware that the physician has committed a medical error, the patient's incentive to pursue a claim may increase even though the apology itself cannot be introduced as evidence. Thus, apology laws could lead to either increases or decreases in overall medical malpractice liability risk. Despite apology laws' status as one of the most widespread tort reforms in the country, there is little evidence that they achieve their goal of reducing litigation. This Article provides critical new evidence on the role of apology laws by examining a dataset of malpractice claims obtained directly from a large national malpractice insurer. This dataset includes substantially more information than is publicly available, and thus presents a unique opportunity to understand the effect of apology laws on the entire litigation landscape in ways that are not possible using only publicly available data. Decomposing medical malpractice liability risk into the frequency of claims and the magnitude of those claims, we examine the malpractice claims against 90% of physicians in the country who practice within a particular specialty over an eight-year period.

Public attitudes toward contemporary issues in liver allocation.

Allocation of scarce livers for transplantation seeks to balance competing ethical principles of autonomy, utility, and justice. Given the history and ongoing dependence of transplantation on public support for funding and organs, understanding and incorporating public attitudes into allocation decisions seems appropriate. In the context of the current controversy around liver allocation, we sought to determine public preferences about issues relevant to the debate. We performed multiple surveys of attitudes around donation and evaluated these using conjoint analysis and clarifying follow-up questions. We found little public support that allocation decisions should be based solely on risk of waiting-list mortality. Strong public sentiment supported maximizing outcomes after transplantation, prioritizing US citizens or residents, keeping organs local, and considering cost in allocation decisions. We then present a methodology for incorporating these preferences into the Model for End-Stage Liver Disease (or MELD) priority score. Taken together, these findings suggest that current allocation schemes do not accurately reflect public preferences and suggest a framework to better align allocation with the values of the public.

The Extraregulatory Effect of Nurse Practitioner Scope-of-Practice Laws on Physician Malpractice Rates.

Patients can hold physicians directly or vicariously liable for the malpractice of nurse practitioners under their supervision. Restrictive scope-of-practice laws governing nurse practitioners can ease patients' legal burdens in establishing physician liability. We analyze the effect of restrictive scope-of-practice laws on the number of malpractice payments made on behalf of physicians between 1999 and 2012. Enacting less restrictive scope-of-practice laws decreases the number of payments made by physicians by as much as 31%, suggesting that restrictive scope-of-practice laws have a salient extraregulatory effect on physician malpractice rates. The effect of enacting less restrictive laws varies depending on the medical malpractice reforms that are in place, with the largest decrease in physician malpractice rates occurring in states that have enacted fewer malpractice reforms. Relaxing scope-of-practice laws could mitigate the adverse extraregulatory effect on physicians identified in this study and could also lead to improvements in access to care.