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

OBJECTIVE: To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics. DESIGN: Cross-sectional time series study. SETTING: National data from the traditional Medicare insurance program in the USA. PARTICIPANTS: Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken. MAIN OUTCOME MEASURES: The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis. RESULTS: From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%). CONCLUSION: The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019.

OBJECTIVE: To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING: Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN: Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS: We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS: Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS: States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

Assessment of a Price Index for Hospital Outpatient Department Services Using Commercial Claims Data in Massachusetts.

This cross-sectional study assesses a market basket price index to evaluate hospital outpatient department price levels and growth.

An overview and policy implications of national nurse identifier systems: A call for unity and integration.

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

Characteristics of rural registered nurses and the implications for workforce policy.

PURPOSE: Rural registered nurses (RNs) play an integral role in providing care for an underserved population with worse health outcomes than urban counterparts. However, little information is available on the profile of this workforce, which is necessary to understand the capacity of these nurses to provide quality and demanded care presently and in the future. METHODS: We utilize data from the American Community Survey to provide a contemporary analysis on the supply of rural RNs in the United States. FINDINGS: While the number of physicians serving rural populations has decreased in recent years, and rural nurse practitioners (NPs) remain in short supply, rural RNs have steadily grown in numbers at a rate comparable to urban RNs. Rural RNs are markedly less diverse than the populations they serve and only half of rural RNs had a bachelor's degree or higher compared to over 70% for urban RNs. In their supply, young rural nurses appear on pace with urban nurses to adequately replace older nurses and continue to grow the workforce, based on data through 2019. CONCLUSIONS: The rural RN workforce is projected to steadily grow amidst declining rural physicians and limited rural NPs. The burgeoning investments in the rural health workforce present opportunities to help diversify, increase educational access, and further rural readiness for rural RNs moving forward.

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

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

Investigating consumer hospital choice: Demand and supply-side levers could address health care costs.

OBJECTIVE: Policies that aim to steer patients from higher to lower cost providers of comparable quality have potential to impact health care cost growth - but their effectiveness depends, in part, on consumer perceptions of value and willingness to make tradeoffs. We sought to understand what was required to shift substantial numbers of consumers to higher-value care settings for several "shoppable" conditions. METHODS: A discrete choice experiment (DCE) was conducted to elicit patient preferences for hospital type. We used an Internet panel of 1005 Massachusetts residents to conduct this experiment in 2016. The DCE data were analyzed using alternative-specific conditional logit regression. RESULTS: Consumers reported large influences of out of pocket costs, physician referrals and quality ratings on their choice of hospital. For example, up to a third of consumers would shift from Academic Medical Centers to community hospitals if the latter had higher quality ratings, lower copays or a physician referral. Choice of site for maternity care was most influenced by physician referral; cancer treatment and orthopedic procedures by quality ratings; and MRI by cost, suggesting that patients prioritize quality over cost as perceived risk increases. CONCLUSIONS AND IMPLICATIONS: Our findings provide guidance for identifying promising policy levers that most influence consumer choice of provider. However, the extent to which potential levers can influence choice is likely to be dependent upon the kind of care being sought.

How fast will the registered nurse workforce grow through 2030? Projections in nine regions of the country.

BACKGROUND: After an unprecedented increase in nursing school enrollment and graduates in the past 10 years, projected shortages of nurses have been erased at a national level. However, nursing markets are local, and an uneven distribution of health care providers of all types is a longstanding feature of health care in the United States. PURPOSE: The purpose of this study was to understand how the outlook for future registered nurse (RN) supply varies regionally across the United States. METHODS: We apply our nursing supply model to the nine U.S. Census Divisions to produce separate supply forecasts for each region. DISCUSSION: We find dramatic differences in expected future growth of the nursing workforce across U.S. regions. These range from zero expected growth in the number of RNs per capita in New England and in the Pacific regions between 2015 and 2030 to 40% growth in the East South Central region (Mississippi, Alabama, Tennessee, Kentucky) and in the West South Central region (Texas, Oklahoma, Arkansas, Louisiana). CONCLUSION: Assuming growth in the demand for RNs per population, some regions of the United States are expected to face shortfalls in their nursing workforce if recent trends do not change.

Will the RN Workforce Weather the Retirement of the Baby Boomers?

IMPORTANCE: After forecasts made more than a decade ago suggested dire nursing shortages, enrollment in nursing schools doubled. The implications of this unprecedented change for the nursing workforce have not yet been fully explored. OBJECTIVE: To forecast the size and age distribution of the nursing workforce to the year 2030 and to compare to demand recently projected by the Health Resources and Services Agency. DESIGN: A retrospective cohort analysis of employment trends by birth year and age were used to project age and employment of registered nurses (RNs) through 2030. SETTING: Data on employed RNs from the United States Bureau of the Census Current Population Survey (1979-2000, N=72,222) and American Community Survey (2001-2013, N=342,712). PARTICIPANTS: RNs between the ages of 23 and 69 years. MAIN OUTCOME MEASURE: Annual full-time equivalent (FTE) employment of RNs in total and by single year of age. RESULTS: Annual retirements from the nursing workforce will accelerate from 20,000 a decade ago to near 80,000 in the next decade as baby boomer RNs continue to age. We project that this outflow will be more than offset by continued strong entry of new RNs into the workforce. Overall, we project that the registered nursing workforce will increase from roughly 2.7 million FTE RNs in 2013 to 3.3 million in 2030. We also find that the workforce will reach its peak average age in 2015 at 44.4. This increase in workforce size, which was not expected in forecasts made a decade ago, is contingent on new entry into nursing continuing at its current rate. Even then, supply would still fall short of demand as recently projected by the Health Resources and Services Agency in the year 2025 by 128,000 RNs (4%). CONCLUSIONS: The unexpected surge of entry of new RNs into the workforce will lead to continued net growth of the nursing workforce, both in absolute FTE and FTE per capita. While this growth may not be sufficient to meet demand, such projections are uncertain in the face of a rapidly evolving health care delivery system.

How will provider-focused payment reform impact geographic variation in Medicare spending?

OBJECTIVES: The Institute of Medicine has recently argued against a value index as a mechanism to address geographic variation in spending and instead promoted payment reform targeted at individual providers. It is unknown whether such provider-focused payment reform reduces geographic variation in spending. STUDY DESIGN: We estimated the potential impact of 3 Medicare provider-focused payment policies-pay-for-performance, bundled payment, and accountable care organizations-on geographic variation in Medicare spending across Hospital Referral Regions (HRRs). We compared geographic variation in spending, measured using the coefficient of variation (CV) across HRRs, between the baseline case and a simulation of each of the 3 policies. METHODS: Policy simulation based on 2008 national Medicare data combined with other publicly available data. RESULTS: Compared with the baseline (CV, 0.171), neither pay-for-performance nor accountable care organizations would change geographic variation in spending (CV, 0.171), while bundled payment would modestly reduce geographic variation (CV, 0.165). CONCLUSIONS: In our models, the bundled payment for inpatient and post acute care services in Medicare would modestly reduce geographic variation in spending, but neither accountable care organizations nor pay-for-performance appear to have an impact.

Do Associate Degree Registered Nurses Fare Differently in the Nurse Labor Market Compared to Baccalaureate-Prepared RNs?

Roughly 40% of the nearly 3 million registered nurses (RNs) in the United States have an associate's degree (ADN) as their highest level of nursing education. Yet even before the recent Institute of Medicine report on The Future of Nursing, employers of RNs have increasingly preferred baccalaureate-prepared RNs (BSNs), at least anecdotally. Data from the American Community Survey (2003-2013) were analyzed with respect to employment setting, earnings, and employment outcomes of ADN and BSN-prepared RNs. The data reveal a divergence in employment setting: the percentage of ADN-prepared RNs employed in hospitals dropped from 65% to 60% while the percentage of BSN-prepared RNs employed in hospitals grew from 67% to 72% over this period. Many ADNs who would have otherwise been employed in hospitals seem to have shifted to long-term care settings.

Examining the value of inpatient nurse staffing: an assessment of quality and patient care costs.

BACKGROUND: Inpatient quality deficits have important implications for the health and well-being of patients. They also have important financial implications for payers and hospitals by leading to longer lengths of stay and higher intensity of treatment. Many of these costly quality deficits are particularly sensitive to nursing care. OBJECTIVE: To assess the effect of nurse staffing on quality of care and inpatient care costs. DESIGN: Longitudinal analysis using hospital nurse staffing data and the Healthcare Cost and Utilization Project State Inpatient Databases from 2008 through 2011. SUBJECTS: Hospital discharges from California, Nevada, and Maryland (n=18,474,860). METHODS: A longitudinal, hospital-fixed effect model was estimated to assess the effect of nurse staffing levels and skill mix on patient care costs, length of stay, and adverse events, adjusting for patient clinical and demographic characteristics. RESULTS: Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs. CONCLUSIONS: The study findings provide support for the value of inpatient nurse staffing as it contributes to improvements in inpatient care; increases in staff number and skill mix can lead to improved quality and reduced length of stay at no additional cost.

How Will the Patient Protection and Affordable Care Act Affect Liability Insurance Costs?

The Patient Protection and Affordable Care Act (ACA) will greatly expand private coverage and Medicaid while making major changes to payment rates and the health care delivery system. These changes will affect traditional health insurers, individuals, and government payers. In addition, a considerable amount of health care is paid for directly by or is indirectly paid for via legal settlements after the care occurs, by liability insurers. This study identifies potential mechanisms through which the ACA might affect claim costs for several major types of liability coverage, especially auto insurance, workers' compensation coverage, and medical malpractice. The authors discuss the conceptual basis for each mechanism, review existing scholarly evidence regarding its importance, and, where possible, develop rough estimates of the size and direction of expected impacts as of 2016. They examine how each mechanism might operate across different liability lines and discuss how variation across states in legal rules, demographics, and other factors might moderate each mechanism's operation. Overall, expected short-term effects of the ACA appear likely to be small relative to aggregate liability insurer payouts in the markets in question. However, under reasonable assumptions, some mechanisms can generate potential cost changes as high as 5 percent or more in particular states and insurance lines. The authors also discuss longer-run changes that could be fostered by the ACA that might exert more significant effects on insurance claim costs, including shifts in tort law, changes in physician supply, new pricing approaches under the accountable care organization model, and changes in population health.

Response: effectiveness in primary care is paramount, but need not come at the expense of efficiency.

Effective primary care is vital to sustainable provision of primary care for the US population. However, efficiency and effectiveness go hand-in-hand. Effective care is that which enables a health system to optimize the performance of all care providers while eliminating wasteful practices. If high-quality patient care and strengthened patient-provider relationships are to occur outside of isolated pockets of innovation and spread to the populace as a whole, each primary care physician must work within a system that affords the tools, opportunity, and support needed to optimally manage a growing number of patients with mounting health care needs. The expectation that primary care physicians must come into direct contact with each and every patient, no matter the acuity or chief complaint, no longer meets the expectations of patients or those whom we would attract to enter the field of primary care. We can no longer repair the faults in our primary care workforce by simply increasing the number of providers working in exactly the same way primary care physicians have always worked. A modern workforce will require efficient practices to produce the most effective health care for the population.

Do we really need more physicians? Responses to predicted primary care physician shortages.

Predicted primary care shortages have spurred action to increase the number of primary care physicians. However, simply increasing the number of primary care providers is not the only solution to resolving the imbalance between the supply of primary care physicians and the demand for primary care services. In this point-counterpoint, we highlight the limitations of existing primary care shortage predictions and discuss strategies to deliver primary care services without necessarily increasing the number of primary care physicians for a given population. Innovative solutions can be used to reduce or even eliminate projected primary care shortages while changing the prevailing paradigm of primary care.

Policy solutions to address the foreign-educated and foreign-born health care workforce in the United States.

Foreign-educated and foreign-born health workers constitute a sizable and important portion of the US health care workforce. We review the distribution of these workers and their countries of origin, and we summarize the literature concerning their contributions to US health care. We also report on these workers' experiences in the United States and the impact their migration has on their home countries. Finally, we present policy strategies to increase the benefits of health care worker migration to the United States while mitigating its negative effects on the workers' home countries. These strategies include attracting more people with legal permanent residency status into the health workforce, reimbursing home countries for the cost of educating health workers who subsequently migrate to the United States, improving policies to facilitate the entry of direct care workers into the country, advancing efforts to promote and monitor ethical migration and recruitment practices, and encouraging the implementation of programs by US employers to improve the experience of immigrating health workers.