Thread by @Laura2smith

💫New research💫 I'm excited to share my paper on the effects of nurse practitioner scope of practice laws in primary care, newly published in Health Economics. Check it out here: doi.org/10.1002/hec.44…

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Nurse practitioners (NPs) are an integral, rapidly-growing part of the primary care workforce and are shown to provide safe, high-quality, & cost-effective primary care.

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However, in many states, scope of practice (SOP) laws & regs restrict NPs from practicing to the full extent of their training & ability, requiring them to practice with physician oversight.

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I examine the effects of relaxing SOP laws (i.e., removing requirements for physician oversight) on NPs’ day-to-day autonomy, workload & allocation of patients to NPs vs. physicians, & the provision of low-value services at primary care practices.

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Historically, these things have been hard to study b/c NP-provided services are often billed under physician ID’s (i.e., “incident-to billing”), meaning they are attributed to physicians rather than NPs in traditional claims datasets (e.g., Medicare claims).

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I use claims & EHR data from @athenahealth that circumvent this issue by recording both the rendering & billing clinicians for all services, enabling a novel, granular look at NP-provided services at a national sample of primary care practices from 2011-2017.

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I find evidence that NPs have more autonomy after SOP restrictions are removed – specifically, NPs bill independently, rather than incident-to a supervising physician, more often.

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I also find no evidence that removing SOP restrictions changes patient volume, the complexity of patients that NPs see, nor how often low-value services are provided.

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Independent billing by NPs is cost-saving, since NP services are billed at ~85% of the physician rate (vs. 100% when services are billed incident-to a supervision physician), & it increases transparency of claims data by reflecting who actually provided the care.

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What does this mean? Many others have found no evidence that removing SOP restrictions adversely affects patient health outcomes…

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…My findings further suggest that removing SOP restrictions enables NPs to practice with more autonomy, without otherwise affecting the actual delivery of care at primary care practices.

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A key priority for future research will be to examine the longer-term effects of SOP laws on primary care access, quality, & costs, as I was limited to a relatively short “post” period in most states.

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MANY thanks to my dissertation advisors @EGolberstein & @HNeprash & committee members @Ateevm & @abrah042; to @athenahealth for their amazing data; to @AHRQNews & @urbaninstitute for their instrumental support; & to many others for their helpful feedback & suggestions!💫

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