1. Methodological challenges of investigating inter-professional workforce capacity to improve vulnerable population health outcomes
Andréa Sonenberg, PhD, WHNP, CNM-BC, Hillary Knepper, MPA, PhD, Paul Savage, MBA
Introduction Discussion and Health Policy Implications
In medically underserved communities, Federally Qualified Health Centers remain dependent upon NPs
and PAs for service delivery and to improve the patient-practitioner ratio (Shin & Rosenbaum, 2012).
Federal and state laws that reduce NP SOP barriers have the potential to expand the number of primary
care providers over a shorter period of time. With the continuing expansion of ACA and in particular access
to care for low-income populations, policy makers must address regulatory barriers that reform the primary
care delivery system. Further, it is necessary to focus reforms that improve efficiency and primary health
outcomes. Standardizing and modernizing NP regulatory policies can optimize access to care and support
successful implementation of the ACA.
Medicaid is one of the largest datasets tracking low-income services and providers. Consequently, the
quality of its data collection and reporting needs to be addressed. This study identified significant data
quality concerns related to tracking services rendered by nurse practitioners and physician assistants. Both
practitioners were under-represented in the datasets, therefore reducing our understanding of their true
impact on primary health care and costs associated with it. Improvements are imperative to achieve
optimization of workforce capacity through regulatory change and for better policy analysis.
This study offers three (3) main contributions:
1) Recognition of significant Medicaid data quality concerns
2) Under-representation in the data of two of the largest health practitioners types serving vulnerable
populations
3) An inability to accurately measure Medicaid cost efficiencies in primary care
The authors offer three (3) recommendations for improving the utilization and reporting of critical evidence
on which to base future health policy:
1) Improve and standardize Medicaid reporting requirements across states
2) Improve data quality and clarity by identifying actual service provider vs. billing provider
3) Disseminate data in a de-identified, open source format to allow researchers greater and more timely
access
The United States of America is a recognized global health leader. Despite its leading economic
and technological advances, health inequities persist among its citizens. Indeed, significant health
disparities continue to challenge policy-makers and exert a financial burden on communities. One
challenge to mitigating disparities and improving access, especially for vulnerable populations, is
developing adequate work force capacity. To address these challenges, the importance of inter-
sectorial and inter-professional efforts is essential. The expanded utilization of primary care nurse
practitioners and physician assistants is one approach to meeting workforce needs and ultimately
addressing disparities. Although evidence exists to support this recommendation, regulatory
challenges impede its implementation. Further, answering the complex policy problems
surrounding population health frequently involves the aggregation of datasets across disparate
platforms and years. Sophisticated statistical techniques are required to drive evidence based
health policy. The aim of this pilot study was to investigate the associations of regulatory policy,
workforce capacity, and primary care health outcomes of vulnerable populations.
Background
NP & PA primary care focuses on health promotion and disease prevention, often to underserved,
at-risk, resource-intensive populations 1, 2, 3, 4, 5. In the U.S., at least 65% of NPs and 24.8% of PAs
work in primary care practices 6 7. Under the Affordable Care Act, proposed reforms call for
maximizing the utilization of NP services to address primary care needs with improved quality and
access. Indeed, 2014 federal legislation improved access to NP services under the Public Health
Service Act, which enables Medicaid billing by appropriately licensed health care providers.
Meanwhile, regulation of NP scope-of-practice (SOP) occurs at the state level. States delegate
this oversight to Boards of Nursing, Education, or Medicine. Scope-of-practice laws regulate legal
authority, prescriptive authority, and reimbursement (authority and rate). The selected states
represent those with the greatest disparity across three chronic disease health outcomes and the
greatest difference in modernization of their NP SOP laws. Using 2010 data, the states with the
worst health outcomes related to diabetes and hypertension, as well as the most restrictive NP
SOP laws, were Alabama and Mississippi, while those with the best health outcomes and the least
restrictive NP scope-of-practice laws were Colorado and Utah.
Selected References
Methodology
1 Oliver, G. M., Pennington, L., Revelle, S., & Rantz, M. (2014). Impact of nurse practitioners on health outcomes of Medicare and
Medicaid patients. Nursing Outlook. 62 (6), 440-447.
2 Newhouse, R.P., Stanik-Hutt, J., White, K.M., Johantgen, M., Bass, E.B., Zangaro, G., … Weiner, J.P. (2011). Advanced practice
nurse outcomes 1990-2008: A systematic review. Nursing Economics, 29(5), 1-21.
3 Vonderheid, S., Pohl, J., Barkauskas, V., Gift, D., & Hughes-Cromwick, P. (2003). Financial performance of academic nurse
managed primary care centers. Nursing Economics, 21 (4), 167-175.
4 Cawley, J.F. & Hooker, R.S. (2013). Physician Assistants in American Medicine: The Half-Century Mark. Am J Manag Care. 19(10):e333-e341
5 National Commission on Certification of Physician Assistants. (2012) Competencies for the Physician Assistant Program. Retrieved from
www.nccpa.net/Uploads/docs/PACompetencies.pdf
6 U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health
Workforce Analysis. (2014a). Highlights from the 2012 National Sample Survey of Nurse Practitioners. Rockville, Maryland: U.S.
Department of Health and Human Services.
7 American Academy of Physician Assistants (2013). 2013 AAPA Annual Survey Report. Retrieved from
https://www.aapa.org/WorkArea/DownloadAsset.aspx?id=2902
8 Virani, S.S. et al. (2015). Comparative Effectiveness of Outpatient Cardiovascular Disease Care Delivery Between Physician and Non-Physician Primary
Care Providers: Implications for Care Under the Affordable Care Act. Circulation: Cardiovascular Quality and Outcomes,8(Suppl 2), A311-
A311.
9 Knepper, H., Sonenberg, A., & Levine, H. (2015). Cost-savings of nurse practitioner managed diabetes primary care: A preliminary Study.
International Journal of Services and Standards: Special Issue "Healthcare Management Quality and Standards in a Global World." 10:1/2, p. 17-31.
10 Buerhaus, P. I., DesRoches, C. M., Dittus, R., & Donelan, K. (2015). Practice characteristics of primary care nurse practitioners and physicians. Nursing
Outlook, 63(2), 144-153.
11 Chin, W. Y., Lam, C. K., & Lo, S. V. (2011). Quality of care of nurse-led and allied health personnel-led primary care clinics. Hong Kong Medical Journal ,
Xianggang Yi Xue Za Zhi, 17(3), 217-230.
12 Grumbach, K., Hart, G.L., Mertz, E., Coffman, J., & Palazzo, L. (2003). Who is caring for the underserved? A comparison of primary care physicians and non-
physician clinicians in California and Washington. Annals of Family Medicine, 1 (2), 97-104.;
13 Hansen-Turton,T., Ware, J., & McClellan, F. (2010). Nurse practitioners in primary care, Temple Law Review, 82, 1235-1263.
14 Jacobson, P.D. & Jazowski, S.A. (2011). Physicians, the affordable care act, and primary care: Disruptive change or business as usual? Journal of General
Internal Medicine, 26(8), 934–7.
15 Keleher, H. Parker, R., Abdulwadud, O., & Francis, K. (2009). Systematic review of the effectiveness of primary care nursing. International Journal of Nursing
Practice, 15, 16–24.
Quality & Capacity
 Cardiac care delivered by teams including NPs and PAs results in patients having better
compliance and outcomes for cholesterol and HTN than physician only care 8
 Cost-savings related to improved diabetes outcomes under NP managed care vs.
traditional medical model 9
 NPs & PAs deliver more care to underserved populations than physicians 2, 8, 9, 10, 11, 12
 Effectiveness of NPs & PAs in primary health care provision:
 NP & PA care results in most quality of chronic care indicators being similar to those
of physicians 2, 13
 NP care results in Improved patient knowledge and compliance14
 Patient satisfaction and trust higher for NP & PA care 2, 4, 12, 15
The investigators sought access to federal Medicaid data sources to compare population
health outcomes of the four target states. First, the investigators had to strengthen university
security and privacy infrastructure, write data security policies, and purchase adequate
technology. Next, an application was made to CMS for a Data Use Agreement for Medicaid
claims data of four states (Alabama, Colorado, Mississippi, & Utah). After de-identifying the
data (per CMS and HIPPAA policy), descriptive and analytic associations were made for
obesity, diabetes, & hypertension, to draw attention to the proportions of services delivered
by each primary care specialty provider. Analyses were made of cost and payment,
calculating mean and deviation by provider specialty type (NP, PA, & MD), for both billing
provider and actual service provider. However, the quality and reliability of the datasets varied
significantly. Coding was inconsistent across states and service provider specialty codes
were missing altogether from two states. Ultimately, there was insufficient statistical evidence
to draw valid conclusions regarding proportion of services provided by NP or PA specialty
types.
The primary finding was that key variables were missing critical data,
including ‘service provider specialty code’. Of the four states, Colorado and
Utah had had ostensibly no reporting of NP or PA services provided for the
three chronic conditions of focus, despite the fact that NPs made up >50%
and PAs up to 36% relative to MD capacity. Alabama had 85% reporting on
service provider specialty with MDs providing a significantly higher
proportion of services for obesity, DM, & HTN. NPs provided less than 5%
of services for three chronic conditions, and PAs even less, in spite of
significant higher employment capacity.
There are substantive methodological challenges in accessing and using
Medicaid data for investigating workforce capacity and outcome of
services. As one of the largest datasets tracking low-income services and
providers, the quality of this data collection has been found to be
inadequate or misleading for the purposes of researching access to care
and health outcomes of this population. The methodological barriers
encountered while utilizing the Medicaid databases for Alabama, Colorado,
Mississippi, and Utah precluded the research team from drawing any
associations among regulatory policy, workforce capacity, and primary care
health outcomes of the most vulnerable populations.
State Number of
claims
Data
Dictionary:
Variable
“Service
Provider
Specialty
Code”
Data
Dictionary:
Number of
Characters
For Variable
MAX-OT File:
Number of
Characters for
Specified
Variable
MAX-OT File:
Number of
Missing Values
for Variable
Alabama 30,853,391 48 4 5-9 Most
Colorado 25,976,840 48 4 7-8 Most
Mississippi 19,247,646 49 4 N/A All
Utah 1,285,888 50 4 1 Most
CMS Medicaid Claims Data-MAX Other Therapy File-2010
Source: CMS Medicaid Claims Data-MAX Other Therapy Files-2010-for Alabama, Colorado, Mississippi, & Utah
Findings
State
Primary Care
Medical
Doctors
Nurse
Practitioners
NP
proportion
relative to
MDs
Physician
Assistants
PA
proportion
relative to
MDs
Alabama 5,345 2,789 52% 560 10%
Colorado 6,646 3,294 48% 2,416 36%
Mississippi 2,728 1,226 45% 826 30%
Utah 2,922 2,233 76% 104 4%