Nurse Who Reviews Drgs and Determines Payment Levels in Medicare

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Med Care Res Rev. Author manuscript; available in PMC 2018 Aug 1.

Published in terminal edited form as:

PMCID: PMC5114168

NIHMSID: NIHMS828514

Effects of Regulation and Payment Policies on Nurse Practitioners' Clinical Practices

Hilary Barnes

^aneAcademy of Pennsylvania, Philadelphia, PA, USA

Claudia B. Maier

¹University of Pennsylvania, Philadelphia, PA, USA

Danielle Altares Sarik

^oneUniversity of Pennsylvania, Philadelphia, PA, U.s.a.

Hayley Drew Germack

^aneUniversity of Pennsylvania, Philadelphia, PA, U.s.a.

Linda H. Aiken

¹University of Pennsylvania, Philadelphia, PA, United states of america

Matthew D. McHugh

¹Academy of Pennsylvania, Philadelphia, PA, USA

Abstract

Increasing patient demand following health intendance reform has led to concerns about provider shortages, particularly in primary intendance and for Medicaid patients. Nurse practitioners (NPs) represent a potential solution to coming together demand. However, varying land telescopic of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs. Using a national sample of 252,657 convalescent practices, we examined the upshot of land policies on NP employment in primary intendance and do Medicaid acceptance. NPs had 13% higher odds of working in principal care in states with full scope of do; those odds increased to twenty% if the state likewise reimbursed NPs at 100% of the physician Medicaid fee-for-service charge per unit. Furthermore, in states with 100% Medicaid reimbursement, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs. Removing telescopic of practice restrictions and increasing Medicaid reimbursement may increase NP participation in primary care and do Medicaid acceptance.

Keywords: nurse practitioners, scope of do, Medicaid, master care, access to care

Introduction

Under the Patient Protection and Affordable Care Human activity, over 22 million Americans have gained health care coverage through private wellness insurance and Medicaid (Medicaid. gov, 2015; U.Due south. Department of Health and Human Services, 2015). This number is expected to rise, leading to an increase in demand and provider shortages (Association of American Medical Colleges [AAMC], 2012; Wellness Resources and Services Assistants [HRSA], 2013). Nonetheless, these shortages are not expected to be compatible within or across states and are expected to be greatest in primary care and for Medicaid patients (Hofer, Abraham, & Moscovice, 2011; HRSA, 2013; Ku, Jones, Shin, Bruen, & Hayes, 2011).

Nurse practitioners (NPs) take the potential to contribute to alleviating primary care shortages and increasing admission to intendance (American Clan of Nurse Practitioners, 2015c; HRSA, 2013). In 2015, in that location were approximately 136,060 clinically active NPs in the United States, and it is projected that the supply of NPs will increase essentially in the coming years (Auerbach, 2012; Agency of Labor Statistics, 2016). Almost 50% of NPs practice in primary intendance, and the growth of the NPs in main care is expected to outpace growth in primary intendance physician supply (Biggs, Crosley, & Kozakowski, 2013; HRSA, 2014; Pohl, Barksdale, & Werner, 2015). Additionally, NPs intendance for Medicaid patients more frequently than physicians (Benitez, Coplan, Dehn, & Hooker, 2015; Buerhaus, DesRoches, Dittus, & Donelan, 2014).

One modifiable gene that has the potential to influence NP exercise is state scope of practice (SOP) regulations. NP SOP varies beyond states, and a major difference betwixt the least restrictive states and the most restrictive states is the requirement that an NP maintains a "collaborative understanding" with at to the lowest degree one physician to do, prescribe medication, or both (Fairman, Rowe, Hassmiller, & Shalala, 2011). Research has found that requiring collaborative agreements has a negative bear on on the number of NPs available to provide care (Reagan & Salsberry, 2013). Laws that limit specific elements of NP exercise, for example, the ability to prescribe certain categories of scheduled drugs, certify disability forms, or order physical therapy (Phillips, 2016), become less constructive every bit an NP is not able to provide any services in the absenteeism of an collaborative agreement. For an NP practicing in a land with collaborative agreement requirements, if the md collaborator moves or decides to cease the understanding, no services are able to be rendered by that NP. In 2015, 22 states plus the District of Columbia (D.C.) allowed for full NP SOP requiring no collaborative agreements with a doc; and 28 states required some sort of agreement, often supervisory, for do and prescribing (Phillips, 2016).

Favorable NP SOP environments too have the potential to do good Medicaid beneficiaries. Overall, Medicaid beneficiaries feel greater difficulty in securing main care appointments than individuals with other types of insurance (Rhodes et al., 2014). Richards and Polsky (2016) constitute improved access to treat Medicaid beneficiaries in practices that both employed more providers, including NPs and physician administration (PAs), and were located in states with the to the lowest degree restrictive SOP. In one study, a sample of Medicare beneficiaries reported shorter wait times for appointments and less difficulty accessing care in states with more than restrictive NP SOP regulations (Cross & Kelly, 2015).

A second factor that may influence NP practise and access to care is Medicaid fee-for-service reimbursement rates for NP services. Medicaid is now the largest insurer in the United States (Rosenbaum, 2014), and increasing coverage for Medicaid beneficiaries has been associated with improved patient outcomes (Sommers, Baicker, & Epstein, 2012). In a 2014 study, Buerhaus et al. establish that primary care physicians who work with NPs were more likely to accept new Medicaid patients than those physicians working in practices without an NP. Even so, Decker (2012) plant that physicians were less probable to take new Medicaid patients in states with lower Medicaid physician fees. In states where NPs are reimbursed less than the md rate, varying from 75% to 100% of physician rates (Kaiser Family Foundation [KFF], 2012), practices may be discouraged from both employing NPs and accepting Medicaid.

There is limited evidence about the effect of existing SOP and reimbursement policies on NP practise patterns and their potential to undermine the goal of improving access to care. The purpose of this study was to examine how state SOP and Medicaid reimbursement policies affect NP participation in principal care and practice Medicaid acceptance. To better understand how these policies influence the outcomes, we analyzed the relationships at two levels. At the individual level, nosotros examined the odds that an NP works in a chief intendance practice in states with total SOP and 100% NP Medicaid reimbursement compared with states with less favorable regulatory environments. At the do level, we examined the odds of practice Medicaid acceptance based on the presence of an NP in the practice and whether the practice is also located in a land that allows for 100% NP Medicaid reimbursement.

Conceptual Basis for the Study

This report was based on the conceptual understanding that, examined together, both NP SOP and NP Medicaid reimbursement policies take the potential to influence NP participation in primary intendance and practice Medicaid acceptance. First, patients are more probable to receive main intendance from NPs in states that require no collaborative agreements for practice or prescribing (Kuo, Loresto, Rounds, & Goodwin, 2013). Notwithstanding, we do not know if SOP regulations encourage increased participation of NPs in main care. At the individual level, we hypothesized that states with full NP SOP (i.e., no collaborative understanding requirements for practice or prescribing) would see greater odds that individual NPs piece of work primary care practices. This is based on the premise that states with no restrictions on exercise would let NPs greater flexibility to work in practices where their services are most needed.

Additionally, depression fee-for-service reimbursement rates for NP services human activity as a bulwark to the financial sustainability of NP practice fifty-fifty in states that do non require collaborative agreements (Yee, Boukus, Cross, & Samuel, 2013). Polsky et al. (2015) found an well-nigh 8% increase in acceptance of new Medicaid patients for master intendance appointments afterwards an increment in Medicaid reimbursement rates. At the exercise level, nosotros hypothesized that reimbursing NPs at the full physician Medicaid fee-for-service rate would be associated with greater Medicaid acceptance within private practices. Nosotros posit that more generous reimbursement rates would incentivize practices to both use NPs and have Medicaid. Higher reimbursement would consequence in less financial brunt to practices employing NPs and enable these practices to see a higher proportion of patients covered under Medicaid.

New Contributions

Prior research on the NP workforce has primarily relied on administrative data, such as National Provider Identifier numbers (Kaplan, Skillman, Fordyce, McMenamin, & Doescher, 2012), Medicare billing data (DesRoches et al., 2013), or NP licensure and certification information (Freed, Dunham, Loveland-Cherry, Martyn, & Research Informational Commission of the American Board of Pediatrics, 2010; Kuo et al., 2013; Reagan & Salsberry, 2013). These data sources tend to underestimate the number of practicing NPs (Spetz, Fraher, Li, & Bates, 2015) considering NPs may not ever bill directly (Kaplan et al., 2012), and there are nurses who are licensed or certified equally NPs but may non exist working as an NP (e.m., they may piece of work in a registered nurse role; HRSA, 2014).

We used a national database linking individual NPs with their employing practices in main and specialty convalescent care. This database does not rely on licensure or certification data, only instead provides information on clinically active NPs within ambulatory practices. This approach makes this study the first to examine NP workforce distribution with detailed information nearly the practices in which those NPs piece of work. The granularity offered by these information provides a new context in which to examine the participation of NPs in principal care and practice Medicaid credence.

In that location are differing views on the extent to which provider shortages be and whether the supply of primary care providers is adequate to meet increasing demand (AAMC, 2012; Altman & Blumenthal, 2015; Salsberg, 2015). The growing use of NPs and PAs may be reducing, to some extent, shortages in principal care created by health care reform (Salsberg, 2015). However, improvements in accented numbers of primary care providers do not necessarily obviate the maldistribution of providers to the settings and populations of greatest need (Salsberg, 2015). The concept of NP participation in primary care is a focus of this study. The results from this study have of import implications for how regulations and payment policies might be altered to improve access to chief care.

Method

Data Sources

The chief data for this cross-sectional study were extracted from the 2012 SK&A doctor and NP/PA files. SK&A is a market enquiry firm that maintains and often updates information on ambulatory practices in all l states and D.C. (SK&A, 2016). Data are collected during the previous calendar twelvemonth. The NP/PA file contains data on NPs and PAs that are colocated with physicians in practices. The physician files have been used in prior research to answer questions of access to care in convalescent settings (Polsky et al., 2015; Rhodes et al., 2014; Richards, Saloner, Kenney, Rhodes, & Polsky, 2014), merely our study is the kickoff to incorporate the NP/PA file. Using Federal Data Processing Standard codes, we merged the SK&A information with the Surface area Health Resources Files (AHRF; HRSA, n.d.) to obtain additional county-level characteristics for each practice. NP SOP was based on 2011 state collaborative understanding requirements (Kuo et al., 2013; Phillips, 2012), and NP Medicaid fee-for-service reimbursement rates were obtained for each state (KFF, 2012; Phillips, 2012).

Telescopic of Do and Medicaid Reimbursement

NP SOP was categorized based on the requirement of a collaborative agreement with a physician for NP exercise or prescriptive say-so (Kuo et al., 2013). This method categorized states as assuasive for "independent practice and prescriptions" (least restrictive); "contained practise, but requiring supervision for prescriptions" (restrictive); or "requiring physician supervision for exercise and prescriptions" (nigh restrictive). Using these categories, we derived a binary variable reflecting either full SOP (least restrictive states) or without full SOP (restrictive and most restrictive states combined). Appendix Table A1 displays how our binary variable compares with the original three categories. Side by side, nosotros created a binary variable indicating whether a exercise was located in a state that reimbursed NP services at 100% of the physician rate or less than 100%. Medicaid reimbursement was measured equally a binary variable rather than continuous or categorical to examine the affect of an ideal reimbursement policy surroundings.

To examine the combined event of NP SOP and Medicaid reimbursement, nosotros categorized states into 4 groups (Effigy 1). States were categorized as having a "fully enabled" policy surroundings if both full SOP and 100% Medicaid reimbursement were present. Vii states plus D.C. were in this category. The remaining states were categorized equally full SOP only (6 states), 100% Medicaid reimbursement merely (twenty states), or neither (17 states). Finally, we created a binary variable to compare the "fully enabled" states with all other states.

NP scope of practice and NP medical reimbursement across states.

Note. NP = nurse practitioner; SOP = scope of practise; D.C. = District of Columbia. Based on 2011 NP telescopic of practice collaborative agreement requirements (Kuo et al., 2013) and NP Medical reimbursement (KFF, 2012).

Practices

Our last sample consisted of 252,657 ambulatory practices. Nosotros included practices that had at least ane physician present in the exercise whether or not the practise employed NPs. NPs were employed by fourteen.eight% (northward = 37,393) of the practices in the written report. We created a binary variable that designated a practice every bit principal care or specialty based on the doc specialty provided by SK&A. Physician specialty was chosen to designate do type because we anticipated that physician specialty would likely bulldoze the type of intendance provided at each site. Primary intendance specialties included adolescent medicine, family practitioner, general practitioner, geriatrician, internal medicine, and pediatrician. For practices with a mix of both primary care and specialty physicians, we designated a practice as primary intendance if at least ii thirds of physicians within the practise were chief intendance physicians.

Additional practice characteristics were derived from SK&A and the AHRF databases. Variables from SK&A included exercise size, NP presence in a practice, and practice Medicaid acceptance. Practice size was a continuous variable calculated as the number of NPs, physicians, and PAs in each practice. NP presence and do Medicaid acceptance were binary variables. From the AHRF, a binary variable indicating rural location was established using core-based statistical area (Office of Management and Upkeep), and poverty was a continuous variable that measured the percentage of the county living in poverty. High-poverty areas were defined as at to the lowest degree 20% of the canton population living in poverty (Bishaw, 2014).

Providers

The providers studied were employed in the 252,657 practices for which data were available. Our provider sample consisted of 57,148 NPs with 47% working in chief care based on our primary care do designation, which is consequent with the 2012 National Sample Survey of Nurse Practitioners finding of 48% of NPs working in primary care (HRSA, 2014). Additionally, 30% of the 561,799 physicians in our sample were in primary intendance, which compares roughly with the AAMC (2013) report that 36% of physicians are in primary intendance. Of note, 42,705 PAs were included in the SK&A NP/PA file and were counted in the analyses to make up one's mind the total number of providers within practices. However, our analyses did non examine PAs in human relationship to our outcomes of interest because PAs work under the supervision of their employing physicians, dissimilar NPs whose legal SOP is defined past state regulation. Besides, the national debate surrounding access to intendance and barriers to practice have focused on the NP and physician workforces (Gilman & Koslov, 2014; Found of Medicine, 2010; National Governors Association, 2012). Additional provider characteristics are available in Appendix Table A2.

Information Analysis

Descriptive statistics were used to examine provider distribution and practise characteristics. Nosotros and so used logistic regression models to gauge the effects of total SOP and 100% NP Medicaid reimbursement on the odds that an individual NP works in a primary care practice versus specialty practice. Nosotros considered both a main (or direct) effects model and a model that immune these two variables to interact in their effects. Both models included controls for practise size, percent of county population living in poverty, rural versus nonrural setting, and Medicaid acceptance. Nosotros estimated robust standard errors and significance levels that accounted for the clustering of private NPs within practices (White, 1980; Williams, 2000).

At the do level, we used logistic regression models to examine the main and interaction effects of NP presence in a practice and 100% NP Medicaid reimbursement on whether the practice accepts Medicaid. These models controlled for SOP, practice type, practice size, percentage of county population living in poverty, and rural versus nonrural setting. All analyses were conducted using STATA 13 (StataCorp, 2013).

Results

Scope of Practice and Medicaid Reimbursement

Merely over 6% (6.3%) of practices were located in "fully enabled" states (i.east., full SOP and 100% NP Medicaid reimbursement), and 35.5% of practices were in states that had neither "fully enabled" policy in identify (Appendix Table A3). The remaining 58.3% of practices were in states categorized as either full SOP or 100% Medicaid reimbursement. Within each category, we compared practices with and without NPs. In "fully enabled" states, 19.4% of practices had NPs followed closely by 18.4% in full SOP states. In states with 100% NP Medicaid reimbursement, 13.ix% of practices had NPs, and fifteen.1% of practices in states with neither policy enabled had NPs.

As tin be seen in Figure 2, in "fully enabled" states, at that place was a significantly higher per centum of individual NPs in primary care practices compared with specialty practices. These states besides saw the highest percentage of NPs in primary care practices compared with the other 3 state policy categories. Additionally, beyond all state policy categories, a significantly college pct of practices with NPs accepted Medicaid compared with practices without NPs (Figure three).

Per centum of NPs working in primary care compared with specialty practices.

Note. NP = nurse practitioner; SOP = telescopic of practice. Differences between NPs in primary care and specialty practices across land policy categories were significant at *p < .001, **p < .05. The difference in Full SOP Simply was nonsignificant. p Values generated from chi-square analyses.

Percentage of practices that accept Medicaid by practices with and without nurse practitioners.

Note. NP = nurse practitioner; SOP = scope of practice. Differences betwixt practices with and without NPs inside each country policy category were significant (p < .001).

Master Intendance and Specialty Practices

Approximately 1 3rd (33.8%) of practices in our sample were designated primary intendance (Table 1). Greater proportions of main care practices were in rural areas (vi.6%) compared with specialty practices (two.3%), equally well as areas designated as high poverty (17.9%) compared with specialty practices (15.5%). Amidst all practices, 21.1% of primary care practices had NPs compared with xi.6% of specialty practices. In chief care practices with NPs, significantly more than practices (12.i%) were located in rural settings compared with primary intendance practices without NPs (five.1%), but there was not a significant difference betwixt the specialty practices with NPs and those without NPs in rural areas. Hing and Hsiao (2015) found a like increase in the availability of NPs/PAs in master care practices as the practice setting became more rural. Chief intendance and specialty practices with NPs were located in areas of high poverty at a higher rate than both types of practices without NPs. Among both main intendance and specialty practices, significantly more than practices with NPs accustomed Medicaid than practices without NPs.

Tabular array 1

Characteristics of Principal Care and Specialty Practices With and Without NPs (N = 252,657).

	Main care, n = 85,446 (33.8%)					Specialty, north = 167,211 (66.2%)
	NP nowadays, n = xviii,033 (21.1%)		No NP nowadays, north = 67,413 (78.ix%)			NP nowadays, n = 19,360 (11.6%)		No NP present, northward = 147,851 (88.4%)
	n	%	n	%	p	n	%	n	%	p
Practice size					<.001					<.001
1-iii	8,764	48.6	57,511	85.3		vii,426	38.4	118,907	80.iv
4-9	7,503	41.6	8,807	xiii.1		8,025	41.five	22,552	15.3
≥10	1,766	9.8	1,095	1.6		three,909	20.ii	vi,392	4.3
Rural location	ii,182	12.one	3,432	v.1	<.001	452	2.3	3,341	two.three	.51
High poverty	3,788	21.0	eleven,543	17.1	<.001	3,153	16.3	22,732	15.4	<.001
Medicaid  acceptance	12,551	69.vi	forty,304	59.8	<.001	14,633	75.6	97,007	65.half-dozen	<.001

Note. NP = nurse practitioner. Primary care was established based on the presence of at to the lowest degree two-third chief care physicians in a practice. Primary care physicians included the following: adolescent medicine, family practice, general practitioner, geriatrician, internist, and pediatrician. Exercise size was calculated every bit the number of physicians, nurse practitioners, and doc assistants in each practice. Rural location was established using core-based statistical surface area (Office of Management and Upkeep), and high poverty was defined as at least 20% of the county population living in poverty. Percentages may not add to 100 considering of rounding. p Values generated from chi-foursquare analyses.

Nurse Practitioners in Primary Care

At the private level (n = 57,148), we examined the main effects (left panel of Tabular array 2) and interaction furnishings (right panel of Tabular array 2) of full SOP and 100% NP Medicaid reimbursement on the distribution of individual NPs to primary care. These models controlled for practice size, percentage of county population living in poverty, rural versus nonrural setting, and Medicaid credence. The main effects model indicated that NPs had xiii% higher odds (odds ratio [OR] = 1.thirteen, 95% confidence interval [CI: 1.04, 1.23]) of practicing in primary intendance settings (vs. specialty intendance) in states with full SOP compared with states without full SOP. Likewise, NPs had vi% higher odds (OR = i.06, 95% CI [i.003, 1.12]) of working in a principal care practice when the state allowed for 100% NP Medicaid reimbursement compared with states that reimburse for NP services at less than 100% of the physician charge per unit. The interaction outcome introduced in the model is nonsignificant, which indicates that the effect of total SOP on whether an NP works in master care is the aforementioned regardless of whether the state allows for 100% NP Medicaid reimbursement. Moreover, the main effects model implies that in states which have both total SOP and 100% NP Medicaid reimbursement, NPs have twenty% higher odds of practicing in master care settings (i.e., odds are higher past a cistron of 1.xiii × i.06 = one.twenty).

Tabular array 2

Logistic Regression Models Examining the Odds That an NP Works in a Main Intendance Exercise Given Total SOP and 100% NP Medicaid Reimbursement.

	Full SOP and 100% NP Medicaid reimbursement master furnishings		Interaction model with primary effects
	Odds ratio	95% CI	Odds ratio	95% CI
Full SOP	one.13**	[1.04, 1.23]	1.04	[0.ninety, 1.20]
100% NP Medicaid  reimbursement	1.06*	[one.003, 1.12]	i.04	[0.99, one.10]
Full SOP × 100% NP  Medicaid reimbursement	—	—	i.14	[0.95, i.35]
Exercise size
1-iii	ii.31***	[2.thirteen, ii.50]	2 31***	[2.13, two.50]
4-9	2.x***	[1.94, ii.28]	2.ten***	[1.94, 2.28]
≥10 (ref.)	1	—	1	—
% Population in poverty	1.00	[0.999, 1.01]	1.00	[0.999, ane.01]
Rural location	6.23***	[five.51, 7.05]	6.22***	[5.50, 7.03]
Medicaid acceptance	0.68***	[0.64, 0.72]	0.68***	[0.64, 0.72]
Northward	57,148		57,148

Medicaid Acceptance

At the practise level (N = 252,657), we examined the main and interaction effects of NP presence in a practice and 100% NP Medicaid reimbursement on the likelihood of the practice accepting Medicaid (Tabular array 3). These models adapted for SOP, exercise type, practice size, pct of county population living in poverty, and rural versus nonrural setting. The main effects model suggests that practices had 17% college odds (OR = i.17, 95% CI [i.14, ane.xx]) of accepting Medicaid if an NP was employed in the exercise compared with practices without NPs. Too, a practice had 13% college odds (OR = 1.13, 95% CI [1.11, 1.15]) of accepting Medicaid if the land immune for 100% NP Medicaid reimbursement.

Table 3

Logistic Regression Models Examining the Odds That a Do Accepts Medicaid Given NP Presence in a Practice and 100% NP Medicaid Reimbursement.

	NP presence in a practice and 100% NP Medicaid reimbursement main effects		Interaction model with main effects
	Odds ratio	95% CI	Odds ratio	95% CI
NP nowadays in practice	one.17***	[1.xiv, 1.xx]	ane.10***	[1.06, 1.14]
100% NP Medicaid  reimbursement	1.13***	[1.xi, 1.xv]	1.11***	[1.09, 1.13]
NP present in practice  × 100% NP Medicaid  reimbursement	—	—	ane.12***	[ane.06, 1.eighteen]
Full SOP	ane.24***	[one.xx, ane.28]	one.24***	[1.twenty, ane.28]
Principal care	0.77***	[0.76, 0.78]	0.77***	[0.76, 0.78]
Practice size
1-3	0.28***	[0.27, 0.29]	0.28***	[0.27, 0.29]
iv-9	0.45***	[0.43, 0.48]	0.45***	[0.43, 0.48]
≥x (ref.)	1	—	1	—
% Population in poverty	1.05***	[one.04, one.05]	1.05***	[1.04, 1.05]
Rural location	3.63***	[3.42, iii.87]	3.64***	[3.42, 3.87]
N	252,657		252,657

Still, these ORs would non be the preferred estimates to utilize to describe those effects, since the interaction introduced in the 2d model is highly significant (right panel of Tabular array 3). The interaction model suggests that the direct effects of NP presence (OR = 1.x, 95% CI [1.06, ane.14]) and 100% Medicaid reimbursement (OR = one.11, 95% CI [one.09, 1.13]) are somewhat smaller than the main effects model indicated, or (given our 0 and 1 coding of the two variables) that the result of either is smaller when the other is absent. Considering of the significant interaction, the effect of both being present is bigger than the main effects model would indicate. Thus, in states without 100% NP Medicaid reimbursement, practices with NPs had 10% higher odds of accepting Medicaid than practices without NPs. In states with 100% Medicaid reimbursement, however, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs (i.e., odds are college by a gene of 1.10 × 1.12 = 1.23).

It is noteworthy that in an additional model which did non control for practice size (right cavalcade of Appendix Table A4), the main and interaction effects of NP presence and 100% NP Medicaid reimbursement on practise Medicaid credence remained significant and were decidedly larger. Practices with NPs had 39% higher odds (OR = ane.39) of accepting Medicaid compared with practices without NPs in states without 100% NP Medicaid reimbursement. In states with 100% NP Medicaid reimbursement, practices with NPs had 61% higher odds (i.due east., odds are higher past a factor of i.39 × 1.sixteen = ane.61) of accepting Medicaid compared with practices without NPs. Thus, part but not all of the consequence of NP presence on Medicaid acceptance, both in states with and without 100% NP Medicaid reimbursement, is attributable to differences in the size of the practices in which NPs are present.

Finally, at that place were findings from our analyses that warrant a brief discussion. In the regression models, practice Medicaid acceptance was negatively associated with NP participation in primary intendance (Tabular array two), and main care practice designation was negatively associated with practise Medicaid acceptance (Table 3). These results are interesting and unexpected, and they may be driven by practice characteristics not included in this written report. For example, one study constitute NP/PA presence was higher in primary care practices in which Medicaid revenue deemed for a higher percentage of their total acquirement (Hing & Hsiao, 2015). Actual or potential Medicaid revenue, in both primary intendance and specialty practices, could affect a practice's ability to have Medicaid, equally well as rent an NP. These relationships are indeed interesting, and more research is needed to explore the impact of the inclusion of NPs in chief care and specialty practices, as well as practice Medicaid credence on workforce and do outcomes.

Discussion

Our findings signal that NP participation in master care is greatest in states that allow for both total SOP and 100% NP Medicaid reimbursement. Additionally, the presence of an NP in a do is associated with higher odds that the practice accepts Medicaid, and the odds of Medicaid acceptance is even higher when the country likewise allows for 100% NP Medicaid reimbursement. These results are striking considering only half dozen% of the study's practices were in states with both total SOP and 100% NP Medicaid reimbursement, and one 3rd of practices were in states with restrictions on NP practice and depression NP Medicaid reimbursement. Thus, collaborative agreement requirements and low Medicaid reimbursement rates appear to exist barriers to states increasing the distribution of NPs into needed settings. In order to fully utilise the existing NP workforce to contribute to improving access to care, changes to state policies are required.

NP SOP has garnered more attention since the landmark 2010 Institute of Medicine report "The Future of Nursing: Leading Change, Advancing Health" and subsequent policy initiatives calling for the removal of NP practise restrictions (Gilman & Koslov, 2014; National Governors Association, 2012). There is growing support for revisiting regulations at the state level and advancing efforts to remove collaborative agreements. In 2015, Nebraska and Maryland have get the 20th and 21st states, respectively, to enact legislation for full NP SOP (American Association of Nurse Practitioners, 2015a, 2015b). Collaborative agreement requirements take been shown to reduce the number and slow the growth of available NPs in communities (Reagan & Salsberry, 2013), and they have been found to increase the cost of care. Independent analyses in iii states constitute that removing restrictions and allowing for total NP SOP could provide meaning economic benefits to states, as well as lower wellness care costs and improve access to care (Conover & Richards, 2015; Eibner, Hussey, Ridgely, & McGlynn, 2009; Weinberg & Kallerman, 2014).

At that place has been opposition in response to efforts to remove collaborative agreements requirement (Colombo, 2014; Pennsylvania Medical Society, n.d.). However, there is no empirical show that removing collaborative agreements diminishes quality of care (Fairman et al., 2011). A large trunk of enquiry has found patient safety, patient satisfaction, and quality of intendance are non negatively affected with NP-provided intendance (Horrocks, Anderson, & Salisbury, 2002; Newhouse et al., 2011; Stanik-Hutt et al., 2013). Moreover, regulatory changes removing requirements for collaborative agreements between NPs and physicians have no bearing on professional norms and expectations that all health intendance professionals have interprofessional networks for patient referrals and consultations consistent with loftier standards of health intendance delivery. Unrestricted NP practice has the potential to improve access to main intendance and to augment the health care workforce without detrimental furnishings to patients.

As the United states moves from a primarily fee-for-service to increasingly value-based payment model (Burwell, 2015), an opportunity arises to revisit reimbursement mechanisms for NPs in order to maximize patient access to intendance. This is specially relevant in the context of emerging models of multidisciplinary, team-based care, in which NPs will have a significant role in providing care for patients with chronic and acute conditions (Goodell, Dower, & O'Neil, 2011). The willingness of practices to hire NPs and in an effort to provide the best admission to care for their patients will depend on how SOP and Medicaid reimbursement policies are revised. Thus, our findings suggest that it is in the public's interest for states to grant total practice authority to NPs and reimburse NP services at 100% of the physician fee-for-service charge per unit.

Limitations

Nosotros used a cross-sectional design, which limits our ability to determine causality. Due to the nature of cross-sectional information and the inability to determine causality, endogeneity among some of the variables is a potential result, and in the absence of an instrumental variable and longitudinal data, endogeneity becomes a limitation of our study. Since the SK&A data are self-reported by practices, there may exist errors in reporting and data entry (King, Furukawa, & Buntin, 2013; Lynch et al., 2014). Individual practices that are solely associated with NPs and without physicians (east.g., nurse-managed wellness centers and retail clinics) are not represented. Finally, nosotros only had data on whether a practise accepted Medicaid; no information was bachelor whether a practice was accepting new Medicaid patients.

Conclusion

The United States is experiencing shortages of principal care providers and practices that accept Medicaid, which will only increment as wellness care reform extends insurance coverage and the population ages and grows. NPs offer the potential to moderate these shortages, but our findings suggest that their contributions are undermined by state regulations that unnecessarily restrict practice and reduce Medicaid reimbursement rates that are already depression for physicians. Removal of country regulations restricting NP SOP, too as providing full Medicaid reimbursement for NP services, are actionable policy changes that hold significant promise for increasing access to care.

Acknowledgments

The authors thank the Leonard Davis Plant of Wellness Economics workforce working group in facilitating access to the data, likewise as Dr. Doug Sloane and Dr. Daniel E. Polsky for their comments and suggestions during manuscript grooming.

Funding

The author(s) disclosed receipt of the following fiscal support for the research, authorship, and/or publication of this article: This research was supported past the Eastern Nursing Enquiry Society/American Nurse Foundation Scholar Award; National Constitute of Nursing Research (Grant No. T32NR007104, Aiken, PI & Grant No. R01NR014855, Aiken, PI); National Institute on Aging (Grant No. R01AG04109901, McHugh, PI); and the Robert Wood Johnson Foundation.

Appendix

Table A1

Categorization of 50 States and the District of Columbia past NP Scope of Practice.

Binary telescopic of practice variable a	Three-category telescopic of practice b	State
Full scope of  exercise	"Independent exercise and prescriptions"	Alaska Arizona Colorado District of Columbia Hawaii Idaho Iowa	Maine Montana New Hampshire New Mexico Oregon Washington Wyoming
Without full scope  of practice	"Contained practice  but requiring  supervision for  prescriptions"	Arkansas Indiana Kentucky Maryland Michigan New Bailiwick of jersey	North Dakota Oklahoma Rhode Isle Tennessee Utah West Virginia
	"Requiring physician  supervision for  practice and  prescriptions"	Alabama California Connecticut Delaware Florida Georgia Illinois Kansas Louisiana Massachusetts Minnesota Mississippi	Missouri Nebraska Nevada New York North Carolina Ohio Pennsylvania South Carolina Southward Dakota Texas Vermont Virginia Wisconsin

Table A2

Provider Characteristics.

	Nurse practitioners, north = 57,148 (8.6%)		Physicians, north = 561,799 (84.9%)		Doctor assistants, north = 42,705 (6.5%)
Practise characteristics	due north	%	northward	%	northward	%
Practice type
Principal intendance	26,877	47.0	169,479	thirty.2	xvi,771	39.3
Specialty	30,271	53.0	392,320	69.8	25,934	threescore.7
Practice size
1-3	17,715	31.0	222,506	39.vi	12,058	28.2
iv-ix	24,564	43.0	169,756	xxx.2	17,818	41.7
≥10	14,869	26.0	169,537	30.ii	12,829	xxx.0
Medicaid credence	42,732	74.8	408,150	72.7	30,608	71.7
Rural location	iii,585	six.iii	15,951	2.8	2,358	5.5
Loftier poverty	10,656	18.vii	89,875	16.0	half-dozen,353	xiv.9
Total scope of exercise simply	2,414	4.2	20,010	3.half-dozen	2,303	5.iv
100% Medicaid  reimbursement only	29,560	51.seven	311,444	55.four	23,211	54.4
Full scope of practice  and 100% Medicaid  reimbursement	4,868	8.five	43,877	vii.viii	iv,469	ten.v

Note. Primary care was established based on the presence of at least two-3rd primary care physicians in a exercise. Primary care physicians included the following: adolescent medicine, family practice, general practitioner, geriatrician, internist, and pediatrician. Practice size was calculated every bit the number of physicians, nurse practitioners, and physician assistants in each do. Rural location was established using cadre-based statistical area (Office of Management and Budget), and loftier poverty was divers as at to the lowest degree 20% of the canton population living in poverty. Percentages may not add to 100 considering of rounding.

Table A3

Characteristics of Practices With and Without NPs Based on SOP and Medicaid Reimbursement (Northward = 252,657).

	Full SOP and 100% NP Medicaid reimbursement, n = xv,803 (half-dozen.three%)					Full SOP only, n = viii,282 (3.three%)					100% NP Medicaid, reimbursement only, n= 139,011 (55.0%)					Neither full SOP nor 100% NP Medicaid reimbursement, n = 89,561 (35.v%)
	NP nowadays, n = three,069 (nineteen.4%)		No NP nowadays, north= 12,734 (80.vi%)			NP nowadays, due north = ane,522 (eighteen.4%)		No NP present, north = 6,760 (81.6%)			NP nowadays, n = 19,274 (13.9%)		No NP present, n= 119,737 (86.1%)			NP present, n= 13,528 (xv.i%)		No NP present, n = 76,033 (84.ix%)
	n	%	n	%	p	n	%	north	%	p	n	%	n	%	p	northward	%	n	%	p
Exercise size					<.001					<.001					<.001					<.001
i-3	one,139	37.one	9,749	76.6		623	40.9	v,447	80.6		7,985	41.4	98,027	81.9		half dozen,443	47.6	63,195	83.one
4-9	1,360	44.iii	2,309	18.1		702	46.one	1,049	15.5		8,067	41.ix	17,531	14.6		5,399	39.9	10,470	13.8
≥10	570	18.6	676	5.3		197	12.9	264	iii.ix		iii,222	xvi.seven	4,179	3.5		ane,686	12.v	2,368	3.1
Primary care practice	1,575	51.iii	3,679	28.9	<.001	729	47.ix	2,044	thirty.ii	<.001	ix,091	47.2	37,493	31.iii	<.001	half dozen,638	49.one	24,197	31.eight	<.001
Medicare acceptance	2,426	79.1	nine,877	77.half dozen	.08	ane,229	80.eight	5,469	80.9	.89	15,580	80.8	95,659	79.ix	<.01	x,754	79.5	60,893	80.1	.11
Medicaid credence	two,366	77.1	viii,615	67.7	<.001	ane,187	78.0	four,756	70.4	<.001	fourteen,186	73.6	76,533	63.9	<.001	ix,445	69.8	47,407	62.5	<.001
Rural location	293	9.half dozen	706	five.v	<.001	126	8.3	299	4.iv	<.001	1,097	5.7	3,235	2.7	<.001	1,118	8.three	2,533	three.three	<.001
High poverty	248	8.one	947	7.4	.05	348	22.9	1,496	22.ane	<.05	iii,060	fifteen.9	16,704	14.0	<.001	3,285	24.three	fifteen,128	19.nine	<.001

Note. NP = nurse practitioner; SOP = scope of practice. Primary care was established based on the presence of at least two-third primary care physicians in a do. Primary care physicians included the following: boyish medicine, family do, full general practitioner, geriatrician, internist, and pediatrician. Practise size was calculated every bit the number of physicians, nurse practitioners, and physician assistants in each practice. Rural location was established using core-based statistical expanse (Function of Management and Budget), and high poverty was defined as at least twenty% of the canton population living in poverty. Percentages may not add together to 100 considering of rounding.

Table A4

Logistic Regressions Comparison Odds That a Do Accepts Medicaid With and Without Controlling for Practice Size (Northward = 252,657).

	Odds ratios [95% CI] that a practice accepts Medicaid
	Original model with main and interaction furnishings	Model with practice size omitted
NP present in practice a	1.10 [1.06, 1.xiv]***	1.39 [1.34, 1.45]***
100% NP Medicaid  reimbursement a	ane.11 [1.09, ane.13]***	1.12 [1.ten, i.14]***
NP present in do × 100%  NP Medicaid reimbursement a	1.12 [one.06, 1.18]***	1.16 [ane.11, one.22]***

Footnotes

Declaration of Conflicting Interests

The author(due south) declared no potential conflicts of interest with respect to the inquiry, authorship, and/or publication of this commodity.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114168/

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