WEBVTT 00:00:03.380 --> 00:00:10.720 position:50% align:middle - [Dr. Bhai] I'd like to thank the National Council of State Boards of Nursing for funding this project. 00:00:10.720 --> 00:00:18.090 position:50% align:middle So, this was the start of my research in full practice authority and scope of practice. 00:00:18.090 --> 00:00:23.490 position:50% align:middle So, this is kind of my earlier work, and now I've started using claims data to kind of build 00:00:23.490 --> 00:00:24.160 position:50% align:middle upon this work. 00:00:24.160 --> 00:00:27.430 position:50% align:middle So, I'll start with this project first. 00:00:27.430 --> 00:00:28.080 position:50% align:middle All right. 00:00:28.080 --> 00:00:30.950 position:50% align:middle So, I came to study nurse... 00:00:30.950 --> 00:00:34.200 position:50% align:middle So, I'm a trained health economist. 00:00:34.200 --> 00:00:40.350 position:50% align:middle I came to see the value of nurse practitioners because disparities was...disparities in the United States were 00:00:40.350 --> 00:00:42.070 position:50% align:middle kind of alarming to me when I saw them. 00:00:42.070 --> 00:00:51.210 position:50% align:middle And I was thinking about what are tangible policy solutions to reducing disparities in the U.S. 00:00:51.210 --> 00:00:55.330 position:50% align:middle So, why should we care about scope of practice and nurse practitioners? 00:00:55.330 --> 00:00:59.490 position:50% align:middle So, nurse practitioners grow at 9.4% a year. 00:00:59.490 --> 00:01:03.720 position:50% align:middle So, NPs are growing substantially faster than physicians. 00:01:03.720 --> 00:01:08.600 position:50% align:middle So, we know physicians can only grow at 1% a year because CMS caps residencies. 00:01:08.600 --> 00:01:13.050 position:50% align:middle So, our population is getting older, has a lot of comorbidities, 00:01:13.050 --> 00:01:15.470 position:50% align:middle and needs requirement for care. 00:01:15.470 --> 00:01:21.010 position:50% align:middle NPs are part of the solution because they grow faster. 00:01:21.010 --> 00:01:29.260 position:50% align:middle Kaiser Permanente has a study that like 85% to 90% of the tasks that an MD physician in primary 00:01:29.260 --> 00:01:32.720 position:50% align:middle care performs, an NP can also perform. 00:01:32.720 --> 00:01:32.950 position:50% align:middle All right. 00:01:32.950 --> 00:01:40.510 position:50% align:middle So, we talk a lot about "let's improve insurance," and that is part of the solution of reducing disparities. 00:01:40.510 --> 00:01:46.250 position:50% align:middle But if you expand health insurance, if you give people Medicaid, 00:01:46.250 --> 00:01:50.370 position:50% align:middle just having an insurance card doesn't mean you can actually see a provider. 00:01:50.370 --> 00:01:54.300 position:50% align:middle So, insurance is part of the solution, but we also need to make sure that there are 00:01:54.300 --> 00:01:58.210 position:50% align:middle enough providers, especially in rural areas. 00:01:58.210 --> 00:01:59.490 position:50% align:middle Even in urban areas. 00:01:59.490 --> 00:02:00.850 position:50% align:middle So, even in, like... 00:02:00.850 --> 00:02:02.270 position:50% align:middle So, I come from Chicago. 00:02:02.270 --> 00:02:10.890 position:50% align:middle So, if you're in the lower SES neighborhoods, there are still shortages, even in urban areas. 00:02:10.890 --> 00:02:12.000 position:50% align:middle All right. 00:02:12.000 --> 00:02:14.620 position:50% align:middle And so many states still maintain these restrictions. 00:02:14.620 --> 00:02:17.880 position:50% align:middle These restrictions seem to be arbitrary and idiosyncratic. 00:02:17.880 --> 00:02:21.990 position:50% align:middle And so I explore what happens. 00:02:21.990 --> 00:02:23.390 position:50% align:middle I'm going to kind of skip this slide. 00:02:23.390 --> 00:02:28.160 position:50% align:middle So, we know nurse practitioners came out in the 1965 because we've had a history of shortages 00:02:28.160 --> 00:02:30.650 position:50% align:middle in this country. 00:02:30.650 --> 00:02:35.950 position:50% align:middle So, we know NPs are well trained, they have additional qualifications 00:02:35.950 --> 00:02:40.750 position:50% align:middle beyond the bachelor's, they have additional clinical hours. 00:02:40.750 --> 00:02:48.660 position:50% align:middle So, and they're increasing to be a sizable part of the primary care infrastructure in the United States. 00:02:48.660 --> 00:02:49.200 position:50% align:middle All right. 00:02:49.200 --> 00:02:56.160 position:50% align:middle So, this is the map that I find very compelling on why we need to look at NPs. 00:02:56.160 --> 00:02:56.450 position:50% align:middle All right? 00:02:56.450 --> 00:03:01.160 position:50% align:middle So, this is health professional shortage areas in the United States. 00:03:01.160 --> 00:03:01.470 position:50% align:middle All right? 00:03:01.470 --> 00:03:04.850 position:50% align:middle So, this is 2022, this is very recent. 00:03:04.850 --> 00:03:06.870 position:50% align:middle So, dark is bad. 00:03:06.870 --> 00:03:09.950 position:50% align:middle So, like if you see a darker shade of blue, that's pretty bad. 00:03:09.950 --> 00:03:14.330 position:50% align:middle But if you look at most of the country, most of the country is a healthcare 00:03:14.330 --> 00:03:15.890 position:50% align:middle provider shortage area. 00:03:15.890 --> 00:03:18.170 position:50% align:middle So, there's little pockets of light blue. 00:03:18.170 --> 00:03:22.910 position:50% align:middle So, most of the counties in the country contain a healthcare provider shortage area. 00:03:22.910 --> 00:03:24.360 position:50% align:middle So, even in Chicago. 00:03:24.360 --> 00:03:29.970 position:50% align:middle Like suburban Chicago is doing well, but Cook County has portions of healthcare 00:03:29.970 --> 00:03:31.870 position:50% align:middle provider shortage area. 00:03:31.870 --> 00:03:34.630 position:50% align:middle If you look at the South, if you look at the Mountain West, 00:03:34.630 --> 00:03:37.710 position:50% align:middle the whole county is a shortage area. 00:03:37.710 --> 00:03:37.960 position:50% align:middle All right? 00:03:37.960 --> 00:03:39.390 position:50% align:middle So, I think this is kind of problematic. 00:03:39.390 --> 00:03:43.140 position:50% align:middle So, when we think about disparities, reducing disparities, 00:03:43.140 --> 00:03:47.850 position:50% align:middle it's hard to do that when we have these broad healthcare shortage areas. 00:03:47.850 --> 00:03:52.090 position:50% align:middle So, not enough providers for patients. 00:03:52.090 --> 00:03:57.310 position:50% align:middle So, I think this is part of the reason why we need to think about full practice authority. 00:03:57.310 --> 00:03:58.000 position:50% align:middle All right? 00:03:58.000 --> 00:04:04.770 position:50% align:middle So, these scope of practice restrictions limit tasks that nurse practitioners can perform. 00:04:04.770 --> 00:04:08.540 position:50% align:middle Oftentimes, they have to engage in collaborative practice agreements. 00:04:08.540 --> 00:04:14.570 position:50% align:middle In one of the states that I'm working to do policy change in, Pennsylvania, 00:04:14.570 --> 00:04:19.440 position:50% align:middle a nurse practitioner not only needs one physician, but they need two physicians to sign off on a 00:04:19.440 --> 00:04:21.830 position:50% align:middle collaborative practice agreement. 00:04:21.830 --> 00:04:23.930 position:50% align:middle And it's completely arbitrary. 00:04:23.930 --> 00:04:24.870 position:50% align:middle All right? 00:04:24.870 --> 00:04:28.610 position:50% align:middle So, if you look at the geography of the U.S., if you look at full practice authority, 00:04:28.610 --> 00:04:32.840 position:50% align:middle it's done in an arbitrary and idiosyncratic manner. 00:04:32.840 --> 00:04:37.620 position:50% align:middle So, the nice thing about the fact that we actually have certain states that have full practice authority and 00:04:37.620 --> 00:04:40.930 position:50% align:middle others that don't, that actually lets us have a counterfactual. 00:04:40.930 --> 00:04:41.130 position:50% align:middle Right? 00:04:41.130 --> 00:04:44.670 position:50% align:middle So, when people say, "When we get rid of...when we implement full 00:04:44.670 --> 00:04:49.530 position:50% align:middle practice authority, quality is going to go down," we've actually seen states pass full practice authority and 00:04:49.530 --> 00:04:51.590 position:50% align:middle we didn't see quality going down. 00:04:51.590 --> 00:04:56.650 position:50% align:middle And in fact, we see access to care improving, and we see certain improvements on patient outcomes. 00:04:56.650 --> 00:05:02.560 position:50% align:middle So, we actually know what happens when you get rid of scope of practice restrictions, 00:05:02.560 --> 00:05:05.230 position:50% align:middle and patients seem to benefit. 00:05:05.230 --> 00:05:05.730 position:50% align:middle All right? 00:05:05.730 --> 00:05:09.370 position:50% align:middle So, it's not a hypothetical scenario, what happens when we get rid of scope of practice and 00:05:09.370 --> 00:05:10.080 position:50% align:middle implement full practice. 00:05:10.080 --> 00:05:11.600 position:50% align:middle We've seen it happen. 00:05:11.600 --> 00:05:18.240 position:50% align:middle And historical evidence kind of provides us a guidance for states that still maintain these restrictions. 00:05:18.240 --> 00:05:18.950 position:50% align:middle All right? 00:05:18.950 --> 00:05:24.570 position:50% align:middle So, a lot of components are, you know, physician supervision, chart review. 00:05:24.570 --> 00:05:28.520 position:50% align:middle There's multiple articles in the Journal of Nursing Regulation that talks about how chart review is not 00:05:28.520 --> 00:05:30.030 position:50% align:middle really systematic, it's arbitrary. 00:05:30.030 --> 00:05:33.820 position:50% align:middle Physicians, when they have time, they'll kind of review charts. 00:05:33.820 --> 00:05:46.240 position:50% align:middle So, in many ways, a lot of the restricted scope of practice is not tied to patient outcomes. 00:05:46.240 --> 00:05:46.630 position:50% align:middle All right. 00:05:46.630 --> 00:05:52.120 position:50% align:middle So, before I motivate the study, so there's RCT evidence. 00:05:52.120 --> 00:05:55.710 position:50% align:middle So, I'm going to kind of steal some of Dr. Carthon's presentation. 00:05:55.710 --> 00:06:01.740 position:50% align:middle It's like we have plenty of evidence from previous studies that show that NPs are as effective 00:06:01.740 --> 00:06:03.490 position:50% align:middle as primary care providers. 00:06:03.490 --> 00:06:05.370 position:50% align:middle So, there's a randomized control trial. 00:06:05.370 --> 00:06:09.680 position:50% align:middle We also have surveys on how much time is spent with patients. 00:06:09.680 --> 00:06:12.730 position:50% align:middle We generally know NPs spend more time with patients. 00:06:12.730 --> 00:06:14.800 position:50% align:middle And there's a lot of population evidence. 00:06:14.800 --> 00:06:20.430 position:50% align:middle Ed Timmons finds that Medicaid costs actually go down. 00:06:20.430 --> 00:06:23.630 position:50% align:middle When we have full practice authority, Medicaid costs go down. 00:06:23.630 --> 00:06:29.290 position:50% align:middle Morris Kleiner shows that well-cared child visit prices go down. 00:06:29.290 --> 00:06:34.250 position:50% align:middle And Danny Hughes and the Journal of Rural Health, they find that debridements go down. 00:06:34.250 --> 00:06:39.370 position:50% align:middle So, I actually have a working paper that's going to come out in Contemporary Economic Policy that shows 00:06:39.370 --> 00:06:40.530 position:50% align:middle that when you... 00:06:40.530 --> 00:06:44.700 position:50% align:middle So, this is using commercial claims data from one of the large insurers in the U.S. 00:06:44.700 --> 00:06:50.160 position:50% align:middle When you have full practice authority, costs for diabetics go down and their non-primary care 00:06:50.160 --> 00:06:50.970 position:50% align:middle visits go down. 00:06:50.970 --> 00:06:57.170 position:50% align:middle So, NPs are likely, you know, to do more primary care because they're not... 00:06:57.170 --> 00:06:59.090 position:50% align:middle Physicians are constrained by the RVU model. 00:06:59.090 --> 00:06:59.370 position:50% align:middle Right? 00:06:59.370 --> 00:07:01.500 position:50% align:middle So, it is kind of... 00:07:01.500 --> 00:07:04.960 position:50% align:middle Sometimes, you know, it's part of the fact that they're part of a practice 00:07:04.960 --> 00:07:06.800 position:50% align:middle that wants them to have enough RVUs. 00:07:06.800 --> 00:07:10.230 position:50% align:middle It's not the physician, they're constrained by their work environment. 00:07:10.230 --> 00:07:12.730 position:50% align:middle And so NPs don't have similar constraints. 00:07:12.730 --> 00:07:18.430 position:50% align:middle So, we have a national study that shows that diabetics are much better off when you do 00:07:18.430 --> 00:07:19.430 position:50% align:middle full practice authority. 00:07:19.430 --> 00:07:22.530 position:50% align:middle And this is using very expensive commercial claims data. 00:07:22.530 --> 00:07:23.270 position:50% align:middle All right? 00:07:23.270 --> 00:07:31.130 position:50% align:middle So, there's a whole emerging body of evidence that's showing that full practice authority generally either 00:07:31.130 --> 00:07:34.640 position:50% align:middle improves patient outcomes or has no effect on patient outcomes. 00:07:34.640 --> 00:07:39.030 position:50% align:middle Either of those scenarios makes the case that we should have full practice authority. 00:07:39.030 --> 00:07:39.510 position:50% align:middle Right? 00:07:39.510 --> 00:07:45.660 position:50% align:middle So, even if you don't see any harm to patients, then why do we have scope of practice restrictions if 00:07:45.660 --> 00:07:47.400 position:50% align:middle you don't see any harm? 00:07:47.400 --> 00:07:47.810 position:50% align:middle All right? 00:07:47.810 --> 00:07:49.890 position:50% align:middle So, there's a considerable body of research. 00:07:49.890 --> 00:07:55.950 position:50% align:middle If you do a lit review, 80% to 90%...I would say more like 95% of the studies 00:07:55.950 --> 00:07:58.600 position:50% align:middle generally show full practice authority is very good. 00:07:58.600 --> 00:08:04.550 position:50% align:middle And those other 5% of the studies are kind of...make a lot of assumptions. 00:08:04.550 --> 00:08:04.820 position:50% align:middle All right? 00:08:04.820 --> 00:08:06.860 position:50% align:middle So, tons of studies on mental health. 00:08:06.860 --> 00:08:16.170 position:50% align:middle So, Diane Alexander talks about when states pass full practice authority, we see a reduction in suicides. 00:08:16.170 --> 00:08:21.990 position:50% align:middle So, and survey data from the Behavioral Risk Factor Surveillance System shows improvements 00:08:21.990 --> 00:08:22.720 position:50% align:middle in mental health. 00:08:22.720 --> 00:08:23.260 position:50% align:middle All right? 00:08:23.260 --> 00:08:28.871 position:50% align:middle So, this is a big population-level study using CDC data which samples about, like, 00:08:28.871 --> 00:08:36.020 position:50% align:middle 400,000 Americans a year that shows prescriptive authorities associated with improvements 00:08:36.020 --> 00:08:37.330 position:50% align:middle in mental health. 00:08:37.330 --> 00:08:42.480 position:50% align:middle We see reductions in emergency care and so forth. 00:08:42.480 --> 00:08:49.450 position:50% align:middle So, there's tons of high-quality studies using population data that generally shows that full practice 00:08:49.450 --> 00:08:51.540 position:50% align:middle authority is associated with improvements in health. 00:08:51.540 --> 00:08:52.700 position:50% align:middle All right. 00:08:52.700 --> 00:08:55.370 position:50% align:middle So, this study has...it's a two-part study. 00:08:55.370 --> 00:09:00.200 position:50% align:middle So, I'm going to look at how full practice authority affects children's health using survey data. 00:09:00.200 --> 00:09:05.720 position:50% align:middle So, children are a very interesting group because children are generally fully insured because of CHIP. 00:09:05.720 --> 00:09:09.030 position:50% align:middle For the most part, nearly all children have full insurance. 00:09:09.030 --> 00:09:14.640 position:50% align:middle And children are an interesting group because unhealthy children go up to become unhealthy adults. 00:09:14.640 --> 00:09:20.640 position:50% align:middle So, if we can invest in kids, that's a good way of potentially reducing disparities. 00:09:20.640 --> 00:09:26.270 position:50% align:middle The other thing about kids is that if you improve their health, you probably can improve their schooling, 00:09:26.270 --> 00:09:27.570 position:50% align:middle also, human capital. 00:09:27.570 --> 00:09:31.660 position:50% align:middle So, the biggest reasons kids miss school is, like, you know, uncontrolled asthma. 00:09:31.660 --> 00:09:35.810 position:50% align:middle So, just getting them an inhaler, having them see a provider. 00:09:35.810 --> 00:09:40.250 position:50% align:middle So, when we engage in full practice authority, it might not just be a health policy, 00:09:40.250 --> 00:09:44.090 position:50% align:middle but it might also be a human capital policy...or educational policy. 00:09:44.090 --> 00:09:44.830 position:50% align:middle All right? 00:09:44.830 --> 00:09:48.480 position:50% align:middle So, the study with kids is very limited. 00:09:48.480 --> 00:09:55.080 position:50% align:middle Again, any positive or zero effects suggest that scope of practice should be expanded. 00:09:55.080 --> 00:09:59.540 position:50% align:middle Negative effects suggest we should rethink scope of practice. 00:09:59.540 --> 00:10:00.430 position:50% align:middle All right. 00:10:00.430 --> 00:10:03.400 position:50% align:middle So, this is the second part of my paper here. 00:10:03.400 --> 00:10:09.600 position:50% align:middle So, if you look at children's health over time, as children get older, 00:10:09.600 --> 00:10:14.630 position:50% align:middle their self-reported health...or parentally-reported health worsens over time. 00:10:14.630 --> 00:10:14.970 position:50% align:middle All right? 00:10:14.970 --> 00:10:20.790 position:50% align:middle So, you could also do this by racial status and you'll see similar patterns, 00:10:20.790 --> 00:10:22.710 position:50% align:middle or a similar gradient if we did it by race. 00:10:22.710 --> 00:10:33.960 position:50% align:middle You know, African-American children have worse reported health, and those gaps increase over time. 00:10:33.960 --> 00:10:34.200 position:50% align:middle All right? 00:10:34.200 --> 00:10:35.260 position:50% align:middle So, I'm going to... 00:10:35.260 --> 00:10:37.580 position:50% align:middle So, for one part of my paper, I'm going to use the National Survey 00:10:37.580 --> 00:10:38.600 position:50% align:middle of Children's Health. 00:10:38.600 --> 00:10:44.230 position:50% align:middle So, this is a large, repeated cross-section of kids in America, age 0 to 17. 00:10:44.230 --> 00:10:45.760 position:50% align:middle So, I'm going to... 00:10:45.760 --> 00:10:47.510 position:50% align:middle So, there's two parts to this survey. 00:10:47.510 --> 00:10:53.150 position:50% align:middle I'm going to use the most recent one because that incorporates sampling with cell phones. 00:10:53.150 --> 00:10:53.810 position:50% align:middle All right? 00:10:53.810 --> 00:10:58.720 position:50% align:middle So, the survey asks a parent like, you know, "Could you please report about your child's access 00:10:58.720 --> 00:11:01.610 position:50% align:middle to healthcare, how they're doing, and so forth?" 00:11:01.610 --> 00:11:06.700 position:50% align:middle The nice thing about this is that this survey actually samples small states very well. 00:11:06.700 --> 00:11:13.720 position:50% align:middle So, in Wyoming, Arkansas, the Dakotas, you actually have enough observations in those states. 00:11:13.720 --> 00:11:18.190 position:50% align:middle Because a lot of times, if there's a survey, a lot of the observations are going to be based 00:11:18.190 --> 00:11:19.640 position:50% align:middle on like California or New York. 00:11:19.640 --> 00:11:24.550 position:50% align:middle So, the nice thing about this is that it's making sure that we have enough observations 00:11:24.550 --> 00:11:26.430 position:50% align:middle in our low-population states. 00:11:26.430 --> 00:11:27.290 position:50% align:middle All right? 00:11:27.290 --> 00:11:28.680 position:50% align:middle So, it's a very nice survey. 00:11:28.680 --> 00:11:30.090 position:50% align:middle So, keep in mind, this is a survey. 00:11:30.090 --> 00:11:33.590 position:50% align:middle So, it's not claims, but it's survey. 00:11:33.590 --> 00:11:37.900 position:50% align:middle But it can kind of still enlighten us. 00:11:37.900 --> 00:11:38.730 position:50% align:middle All right? 00:11:38.730 --> 00:11:41.100 position:50% align:middle So, this was the start of the agenda, we started with this survey. 00:11:41.100 --> 00:11:47.430 position:50% align:middle So, there's actually not very many good surveys for children that contain lots of observations. 00:11:47.430 --> 00:11:52.540 position:50% align:middle So, we chose the National Survey of Children's Health because it has enough statistical power for us to kind 00:11:52.540 --> 00:11:56.330 position:50% align:middle of do our analysis. 00:11:56.330 --> 00:11:58.450 position:50% align:middle Since then, I've actually also have a claims project. 00:11:58.450 --> 00:12:01.250 position:50% align:middle So, but this was a start. 00:12:01.250 --> 00:12:01.780 position:50% align:middle All right? 00:12:01.780 --> 00:12:06.930 position:50% align:middle So, we're going to use Ben McMichael and Sara Markowitz's database on full practice laws. 00:12:06.930 --> 00:12:11.970 position:50% align:middle So, this is probably the most comprehensive. 00:12:11.970 --> 00:12:15.300 position:50% align:middle And they've gone through the statutes. 00:12:15.300 --> 00:12:19.720 position:50% align:middle And so we're going to use McMichael and Markowitz for full practice authority. 00:12:19.720 --> 00:12:24.440 position:50% align:middle We're going to also pull in some state-level covariates to kind of condition 00:12:24.440 --> 00:12:28.240 position:50% align:middle on economic...potentially economic confounders. 00:12:28.240 --> 00:12:32.260 position:50% align:middle And what I'm doing is I'm going to use a quasi-experimental method, 00:12:32.260 --> 00:12:34.300 position:50% align:middle I'm going to use differences in differences. 00:12:34.300 --> 00:12:37.690 position:50% align:middle So, the idea there is, since we can't really do a randomized controlled 00:12:37.690 --> 00:12:44.160 position:50% align:middle trial here, we're going to assume that when a state passes full practice authority, 00:12:44.160 --> 00:12:47.970 position:50% align:middle like when Arkansas...which recently passed full practice authority, we're going to consider that 00:12:47.970 --> 00:12:49.270 position:50% align:middle the treatment group. 00:12:49.270 --> 00:12:55.940 position:50% align:middle And we would consider, like, a neighboring state, such as Tennessee or Oklahoma, as our control group. 00:12:55.940 --> 00:12:59.220 position:50% align:middle So, this is a way of trying to emulate RCT. 00:12:59.220 --> 00:13:01.730 position:50% align:middle So, it's a way to kind of try to reduce confounders. 00:13:01.730 --> 00:13:05.690 position:50% align:middle It's not perfect, but it might be an improvement. 00:13:05.690 --> 00:13:06.230 position:50% align:middle All right? 00:13:06.230 --> 00:13:08.530 position:50% align:middle So, I'll ignore the equation. 00:13:08.530 --> 00:13:08.970 position:50% align:middle All right? 00:13:08.970 --> 00:13:13.350 position:50% align:middle So, there are certain assumptions that go with these models. 00:13:13.350 --> 00:13:14.530 position:50% align:middle All right. 00:13:14.530 --> 00:13:19.490 position:50% align:middle So, before I look at children, my other part of the project was to look at the 00:13:19.490 --> 00:13:21.190 position:50% align:middle American Community Survey. 00:13:21.190 --> 00:13:25.980 position:50% align:middle So, how are the ways that full practice authority could improve health? 00:13:25.980 --> 00:13:33.290 position:50% align:middle So, one way is that full practice authority could make the existing nurse practitioners more efficient. 00:13:33.290 --> 00:13:33.450 position:50% align:middle Right? 00:13:33.450 --> 00:13:37.950 position:50% align:middle So, they don't have to spend time on preparing notes for physicians, they don't have to engage 00:13:37.950 --> 00:13:40.290 position:50% align:middle in chart review, they don't have to do a lot of administration. 00:13:40.290 --> 00:13:46.110 position:50% align:middle So, one way full practice authority could improve health is that it makes NPs more efficient because they 00:13:46.110 --> 00:13:48.130 position:50% align:middle don't have this administrative task. 00:13:48.130 --> 00:13:53.140 position:50% align:middle The other way is that it could mean that nurse practitioners maybe work more. 00:13:53.140 --> 00:13:56.290 position:50% align:middle Maybe they start becoming entrepreneurial, they start their own practice. 00:13:56.290 --> 00:13:58.410 position:50% align:middle There's limited evidence for that, but they are starting. 00:13:58.410 --> 00:14:01.320 position:50% align:middle So, once they get full practice... 00:14:01.320 --> 00:14:03.280 position:50% align:middle There's very few self-employed nurse practitioners. 00:14:03.280 --> 00:14:06.900 position:50% align:middle But there's evidence that once they have full practice, some of them are going to move out to rural areas and 00:14:06.900 --> 00:14:09.500 position:50% align:middle start their own practices. 00:14:09.500 --> 00:14:16.230 position:50% align:middle So, what I actually see is when full practice authority happens, we see earnings for nurse practitioners go up. 00:14:16.230 --> 00:14:19.330 position:50% align:middle Part of this could be that they don't have to pay a large sum to physicians 00:14:19.330 --> 00:14:21.090 position:50% align:middle for collaborative practice agreements. 00:14:21.090 --> 00:14:25.980 position:50% align:middle The other thing is that once you do become an independent nurse practitioner, 00:14:25.980 --> 00:14:29.530 position:50% align:middle you could start your own practice and you will also get billed under RVUs. 00:14:29.530 --> 00:14:30.260 position:50% align:middle Right? 00:14:30.260 --> 00:14:35.820 position:50% align:middle So, we see some evidence that, you know, nurse practitioner... 00:14:35.820 --> 00:14:38.090 position:50% align:middle We see robust evidence earnings go up. 00:14:38.090 --> 00:14:43.940 position:50% align:middle And this is very much an estimate of what an NP has to pay for a collaborative practice agreement. 00:14:43.940 --> 00:14:47.340 position:50% align:middle We also see, like, some evidence they start working more. 00:14:47.340 --> 00:14:51.930 position:50% align:middle So, you know, they might work more because they have more agency. 00:14:51.930 --> 00:14:57.480 position:50% align:middle So, there's some evidence that full practice authority would improve population health because NPs might shift 00:14:57.480 --> 00:15:04.930 position:50% align:middle from the salary model to becoming their own...or moving towards a more independent approach where they 00:15:04.930 --> 00:15:07.690 position:50% align:middle determine their own hours, they see their patients, and so forth. 00:15:07.690 --> 00:15:11.450 position:50% align:middle So, this is some evidence why full practice authority should improve health, 00:15:11.450 --> 00:15:16.080 position:50% align:middle because nurse practitioners can now, you know, start their own clinics, can see more patients. 00:15:16.080 --> 00:15:18.450 position:50% align:middle So, there's some evidence that they will work more. 00:15:18.450 --> 00:15:22.700 position:50% align:middle So, there's two ways then how full practice authority could improve health. 00:15:22.700 --> 00:15:28.530 position:50% align:middle Increased labor supply, more efficiency of the existing medical care system. 00:15:28.530 --> 00:15:33.460 position:50% align:middle And there's a third way which we don't test, is that when you have full practice authority, 00:15:33.460 --> 00:15:37.440 position:50% align:middle if you're an NP and you just graduated, do you want to live in a state that has full practice 00:15:37.440 --> 00:15:39.760 position:50% align:middle authority or restricted practice? 00:15:39.760 --> 00:15:44.950 position:50% align:middle So, the other way is, of course, nurse practitioners could migrate to full 00:15:44.950 --> 00:15:46.270 position:50% align:middle practice authority states. 00:15:46.270 --> 00:15:49.410 position:50% align:middle Or if you're a nurse and you're thinking whether you should... 00:15:49.410 --> 00:15:51.820 position:50% align:middle A lot of nurses think about becoming an NP. 00:15:51.820 --> 00:15:55.590 position:50% align:middle And so, like, full practice authority could kind of motivate you to take that step. 00:15:55.590 --> 00:15:57.270 position:50% align:middle So, that's the third way we don't test. 00:15:57.270 --> 00:16:00.910 position:50% align:middle But, so, there's at least three mechanisms that we can think of why full practice authority is going to be 00:16:00.910 --> 00:16:05.160 position:50% align:middle good for population health. 00:16:05.160 --> 00:16:05.420 position:50% align:middle All right? 00:16:05.420 --> 00:16:11.110 position:50% align:middle So, I wanted to show you the results of full practice authority on physicians. 00:16:11.110 --> 00:16:17.640 position:50% align:middle So, when states implement full practice authority, there's no change on physician earnings. 00:16:17.640 --> 00:16:21.890 position:50% align:middle There's no change on their labor supply. 00:16:21.890 --> 00:16:25.720 position:50% align:middle There's a small change, but it doesn't hurt their bottom line, 00:16:25.720 --> 00:16:27.340 position:50% align:middle it doesn't hurt physician earnings. 00:16:27.340 --> 00:16:31.750 position:50% align:middle We don't see any change on their work behavior or how they work. 00:16:31.750 --> 00:16:35.610 position:50% align:middle So, this is part of why... 00:16:35.610 --> 00:16:42.160 position:50% align:middle Like, the big roadblock to implementing full practice authority is the state AMAs. 00:16:42.160 --> 00:16:46.380 position:50% align:middle They're concerned that, you know, full practice authority is going to harm physicians. 00:16:46.380 --> 00:16:52.050 position:50% align:middle So, if you look at the American Community Survey, which is a 1% sample of all Americans, 00:16:52.050 --> 00:16:56.600 position:50% align:middle we don't see harm to physicians on...in their pocketbooks. 00:16:56.600 --> 00:16:57.220 position:50% align:middle You know? 00:16:57.220 --> 00:17:00.830 position:50% align:middle So, full practice authority doesn't hurt them. 00:17:00.830 --> 00:17:06.020 position:50% align:middle We have enough disparities and we have enough people in America who lack access to care. 00:17:06.020 --> 00:17:09.340 position:50% align:middle So, NPs aren't taking their business. 00:17:09.340 --> 00:17:15.100 position:50% align:middle So, this is 2005 to 2019 American Community Survey. 00:17:15.100 --> 00:17:15.390 position:50% align:middle All right. 00:17:15.390 --> 00:17:19.490 position:50% align:middle So, let me go to my child health visit piece. 00:17:19.490 --> 00:17:24.980 position:50% align:middle So, we show that once there's full practice authority, we see reductions in hospitalizations. 00:17:24.980 --> 00:17:32.410 position:50% align:middle We also see a potential change of, like, no ER visits, but the estimates are noisy. 00:17:32.410 --> 00:17:35.750 position:50% align:middle I also had another table on, like, time spent with the child. 00:17:35.750 --> 00:17:39.450 position:50% align:middle And that also goes up, but I did not include that here. 00:17:39.450 --> 00:17:43.930 position:50% align:middle So, there's strong evidence that once you have nurse practitioners, they are providing full 00:17:43.930 --> 00:17:48.470 position:50% align:middle practice authority, they are providing more primary care, and they are spending more time even with kids 00:17:48.470 --> 00:17:50.220 position:50% align:middle who already have insurance. 00:17:50.220 --> 00:17:56.510 position:50% align:middle And so on some of these effects, we don't see any changes. 00:17:56.510 --> 00:18:00.100 position:50% align:middle But the overall evidence suggests that NPs don't harm patients. 00:18:00.100 --> 00:18:04.990 position:50% align:middle So, when we think about policy change, full practice authority is a very 00:18:04.990 --> 00:18:07.870 position:50% align:middle cost-effective policy change. 00:18:07.870 --> 00:18:09.400 position:50% align:middle I will say this. 00:18:09.400 --> 00:18:15.420 position:50% align:middle When you talk to state legislators, they're very concerned about cost. 00:18:15.420 --> 00:18:19.220 position:50% align:middle Like when you privately talk to them, they're concerned about cost. 00:18:19.220 --> 00:18:24.710 position:50% align:middle And my story, I think, is that, look, this is actually good for state policy. 00:18:24.710 --> 00:18:30.000 position:50% align:middle Because, for example, with my diabetes patients, it's much easier to treat people and put them 00:18:30.000 --> 00:18:33.780 position:50% align:middle on metformin than it is to perform an amputation. 00:18:33.780 --> 00:18:36.080 position:50% align:middle It's bad for the government and it's bad for patients. 00:18:36.080 --> 00:18:36.300 position:50% align:middle Right? 00:18:36.300 --> 00:18:43.130 position:50% align:middle So, it's much easier for us to treat chronic conditions than to perform heavy operations. 00:18:43.130 --> 00:18:49.680 position:50% align:middle So, I think in due time, we will see evidence that, you know, having full practice authority leads to more 00:18:49.680 --> 00:18:53.490 position:50% align:middle primary care and we are reducing these heavy chronic procedures. 00:18:53.490 --> 00:18:58.050 position:50% align:middle Which are not good for patients and which are not good for taxpayers. 00:18:58.050 --> 00:18:58.720 position:50% align:middle All right? 00:18:58.720 --> 00:19:02.590 position:50% align:middle So, it just makes sense to do this. 00:19:02.590 --> 00:19:08.510 position:50% align:middle Because it doesn't cost anything, we already have well-trained professionals. 00:19:08.510 --> 00:19:13.160 position:50% align:middle If we have restricted scope of practice, we're not using our resource, 00:19:13.160 --> 00:19:16.770 position:50% align:middle which is NPs that are well trained, to fully practice to their training. 00:19:16.770 --> 00:19:19.540 position:50% align:middle So, lots of economic and policy significance. 00:19:19.540 --> 00:19:24.880 position:50% align:middle So, NPs are likely to improve...are likely to work more. 00:19:24.880 --> 00:19:27.830 position:50% align:middle They're also likely to improve children's access to healthcare. 00:19:27.830 --> 00:19:30.090 position:50% align:middle At the core, we don't see any harm. 00:19:30.090 --> 00:19:31.330 position:50% align:middle All right? 00:19:31.330 --> 00:19:36.100 position:50% align:middle So, we need to think about beyond physicians, because, you know, physicians just aren't going 00:19:36.100 --> 00:19:37.600 position:50% align:middle to grow very fast. 00:19:37.600 --> 00:19:42.570 position:50% align:middle When you look at even physicians, their burnout rates are increasing. 00:19:42.570 --> 00:19:48.190 position:50% align:middle There is a study in the Journal of General Medicine that talks about that the average physician would need 00:19:48.190 --> 00:19:53.680 position:50% align:middle 27 hours in a day to adequately take care of all the chronic conditions that the patients have. 00:19:53.680 --> 00:19:58.510 position:50% align:middle So, we're in a country where lots of people have chronic conditions and we need to think about how we 00:19:58.510 --> 00:20:00.000 position:50% align:middle could better manage that. 00:20:00.000 --> 00:20:02.510 position:50% align:middle All right? 00:20:02.510 --> 00:20:05.990 position:50% align:middle So, and I'll also talk about physician policy. 00:20:05.990 --> 00:20:11.880 position:50% align:middle So, there's a lot of policies that work to increase physicians in rural areas. 00:20:11.880 --> 00:20:15.050 position:50% align:middle My understanding of the literature is that these just don't work. 00:20:15.050 --> 00:20:18.780 position:50% align:middle So, a lot of incentives that say, "Sell, if you stick around for five years, 00:20:18.780 --> 00:20:20.910 position:50% align:middle we'll pay off a portion of your loan." 00:20:20.910 --> 00:20:22.890 position:50% align:middle First, the amount is trivial. 00:20:22.890 --> 00:20:27.220 position:50% align:middle And therefore, you don't see a lot of responsiveness. 00:20:27.220 --> 00:20:31.200 position:50% align:middle So, there's lots of policies that try to get physicians to rural areas, but they don't seem 00:20:31.200 --> 00:20:32.480 position:50% align:middle to be very effective. 00:20:32.480 --> 00:20:34.650 position:50% align:middle So, we need to think out of the box. 00:20:34.650 --> 00:20:39.230 position:50% align:middle And my disclaimer is, you know, any research on NPs is not, like, anti-physician. 00:20:39.230 --> 00:20:44.300 position:50% align:middle The whole point is, like, you know, we have well-trained providers, such as NPs. 00:20:44.300 --> 00:20:49.290 position:50% align:middle And in a functioning medical care system, we'll have NPs do a lot of these tasks that they are 00:20:49.290 --> 00:20:50.370 position:50% align:middle trained to do. 00:20:50.370 --> 00:20:54.320 position:50% align:middle And then we'll have a system of referrals, you know. 00:20:54.320 --> 00:20:59.020 position:50% align:middle So, this is one of the things that people talk about for, like, patient safety, is like, "Well, 00:20:59.020 --> 00:21:00.100 position:50% align:middle NPs aren't trained to do everything." 00:21:00.100 --> 00:21:02.080 position:50% align:middle But neither are primary care providers. 00:21:02.080 --> 00:21:04.790 position:50% align:middle We have a system of referrals, we have a system of malpractice. 00:21:04.790 --> 00:21:10.260 position:50% align:middle So, we actually have ways for the system to work with full practice authority. 00:21:10.260 --> 00:21:11.630 position:50% align:middle All right? 00:21:11.630 --> 00:21:16.330 position:50% align:middle So, we should think about NPs more, and in their role of managing, like, 00:21:16.330 --> 00:21:18.310 position:50% align:middle you know, chronic conditions. 00:21:18.310 --> 00:21:18.670 position:50% align:middle All right? 00:21:18.670 --> 00:21:19.860 position:50% align:middle So, this is cost-effective. 00:21:19.860 --> 00:21:26.290 position:50% align:middle The FTC, the Hamilton Policy Project, and lots of scholars, the National Academy of Medicine, 00:21:26.290 --> 00:21:31.560 position:50% align:middle and there's various op-eds in even the New England Journal of Medicine that talk about how, look, 00:21:31.560 --> 00:21:35.500 position:50% align:middle we're going to have to go give NPs full practice authority. 00:21:35.500 --> 00:21:39.180 position:50% align:middle And I'll talk about Dr. Carthon's point, too. 00:21:39.180 --> 00:21:42.650 position:50% align:middle I mean, there's also proposals that we need to let nurses do more and just be more involved. 00:21:42.650 --> 00:21:49.150 position:50% align:middle Because, you know, they're at the forefront and they can kind of build relationships with patients. 00:21:49.150 --> 00:21:55.880 position:50% align:middle So, we need to think about reform to fully use our healthcare workforce, human capital. 00:21:55.880 --> 00:21:56.430 position:50% align:middle All right? 00:21:56.430 --> 00:21:57.410 position:50% align:middle So, I will stop here. 00:21:57.410 --> 00:21:58.796 position:50% align:middle Thank you. 00:22:12.000 --> 00:22:12.810 position:50% align:middle - [Monica] Hi. 00:22:12.810 --> 00:22:14.000 position:50% align:middle Thanks for a great presentation. 00:22:14.000 --> 00:22:18.340 position:50% align:middle I'm Monica Riley-Jacob at Columbia University, an NP researcher. 00:22:18.340 --> 00:22:29.240 position:50% align:middle And a theory that I just wanted to offer you that could be behind the physician salaries not changing once they 00:22:29.240 --> 00:22:34.580 position:50% align:middle get full practice authority and revenue of practices potentially staying the same, or getting better. 00:22:34.580 --> 00:22:42.140 position:50% align:middle The admin time that NPs and physicians spend together, it can be cumbersome. 00:22:42.140 --> 00:22:48.910 position:50% align:middle And when that expectation gets taken away, both physicians and NPs now have more time to see 00:22:48.910 --> 00:22:51.840 position:50% align:middle more patients, get reimbursed more. 00:22:51.840 --> 00:22:53.360 position:50% align:middle So, just one thought. 00:22:53.360 --> 00:23:00.080 position:50% align:middle And then I think we need to be really careful about assuming that more NPs means more primary care, 00:23:00.080 --> 00:23:04.670 position:50% align:middle because it's not a direct link. 00:23:04.670 --> 00:23:08.440 position:50% align:middle We have some evidence that only 40% of NPs that... 00:23:08.440 --> 00:23:12.730 position:50% align:middle In claims, everybody just kind of assumes that all NPs are primary care providers. 00:23:12.730 --> 00:23:16.750 position:50% align:middle And it's really hard to tease out who's doing what in Medicare claims. 00:23:16.750 --> 00:23:21.880 position:50% align:middle But only about 40% of NPs seem to be actually providing primary care. 00:23:21.880 --> 00:23:24.250 position:50% align:middle So, I think it's... 00:23:24.250 --> 00:23:29.220 position:50% align:middle You know, as a profession, we can sort of put ourselves into a tricky situation 00:23:29.220 --> 00:23:34.290 position:50% align:middle when we just always assume, "Churn out the NPs, we can improve the primary care workforce," when it's 00:23:34.290 --> 00:23:36.980 position:50% align:middle much more lucrative, as most of the people in the room can tell you if 00:23:36.980 --> 00:23:42.140 position:50% align:middle you're an NP, it's much more lucrative to go into a specialty and you can still be trained as a 00:23:42.140 --> 00:23:43.270 position:50% align:middle primary care provider. 00:23:43.270 --> 00:23:46.110 position:50% align:middle And you get trained on the job or orientation or things like that. 00:23:46.110 --> 00:23:50.800 position:50% align:middle Anyway, it's just this disconnect between what's going on in the research and what's going 00:23:50.800 --> 00:23:52.300 position:50% align:middle on in the real world. 00:23:52.300 --> 00:23:54.260 position:50% align:middle - Yeah, thank you so much. 00:23:54.260 --> 00:23:59.160 position:50% align:middle So, I agree with your first point, that it actually...full practice authority is also 00:23:59.160 --> 00:24:04.210 position:50% align:middle better for physicians in the sense that they are also no longer engaging in this 00:24:04.210 --> 00:24:05.730 position:50% align:middle administration or monitoring. 00:24:05.730 --> 00:24:08.540 position:50% align:middle And so it should add an efficiency component for them, too. 00:24:08.540 --> 00:24:12.190 position:50% align:middle And to your second point, yeah, thank you. 00:24:12.190 --> 00:24:13.930 position:50% align:middle So, I will look into that. 00:24:13.930 --> 00:24:18.810 position:50% align:middle So, that is one of the things that we're trying to work on with our commercial claims, just to see, like, 00:24:18.810 --> 00:24:24.400 position:50% align:middle what do NPs bill...or what claims are assigned to NPs and what claims are assigned to CNMs. 00:24:24.400 --> 00:24:32.558 position:50% align:middle And yeah, so, I will keep that in mind, about kind of, you know, looking at the roles and the NP involvement 00:24:32.558 --> 00:24:33.990 position:50% align:middle in non-primary care, as well. 00:24:33.990 --> 00:24:38.840 position:50% align:middle But, yeah, thank you. 00:24:38.840 --> 00:24:40.340 position:50% align:middle - [Dr. Lyon] Hi. 00:24:40.340 --> 00:24:44.180 position:50% align:middle Karen Lyon, I'm the CEO of the Louisiana State Board of Nursing. 00:24:44.180 --> 00:24:48.750 position:50% align:middle I really appreciated your presentation. 00:24:48.750 --> 00:24:53.760 position:50% align:middle My entire state, as your slide showed early on, is a health professional shortage area. 00:24:53.760 --> 00:24:58.360 position:50% align:middle I came from Texas, entire state is a health professional shortage area. 00:24:58.360 --> 00:25:02.720 position:50% align:middle And then Mississippi, our neighbor to the east, is the whole state. 00:25:02.720 --> 00:25:08.640 position:50% align:middle But, so, you have lots of really good information and I appreciate all that. 00:25:08.640 --> 00:25:16.940 position:50% align:middle An early slide of yours inferred that boards of nursing are responsible for scope of practice restrictions and 00:25:16.940 --> 00:25:19.350 position:50% align:middle full practice authority restrictions. 00:25:19.350 --> 00:25:21.440 position:50% align:middle That is absolutely not true. 00:25:21.440 --> 00:25:22.840 position:50% align:middle It's legislatures. 00:25:22.840 --> 00:25:27.340 position:50% align:middle We've been fighting for 10 years, introduced five different bills over the course of the 00:25:27.340 --> 00:25:28.920 position:50% align:middle 10 years I've been there. 00:25:28.920 --> 00:25:29.500 position:50% align:middle And it's... 00:25:29.500 --> 00:25:39.260 position:50% align:middle As you pointed out, it's the Louisiana Medical Society, in Texas it was the Texas Medical Association that 00:25:39.260 --> 00:25:43.620 position:50% align:middle fight so hard against full practice authority for nurses. 00:25:43.620 --> 00:25:49.330 position:50% align:middle So, I just caution you to be careful about statements that you make like that. 00:25:49.330 --> 00:25:55.190 position:50% align:middle Because I think boards of nursing in our jurisdictions across the United States for states that are striving 00:25:55.190 --> 00:26:03.240 position:50% align:middle very hard to get full practice authority for our APRNs, all APRNs, not just nurse practitioners, work hard, 00:26:03.240 --> 00:26:06.520 position:50% align:middle you know, with a lot of collaborating organizations. 00:26:06.520 --> 00:26:10.500 position:50% align:middle And we have been working that way for a long time. 00:26:10.500 --> 00:26:17.150 position:50% align:middle And it seems like the wind is always coming at us, rather than behind us. 00:26:17.150 --> 00:26:18.770 position:50% align:middle So, but thank you. 00:26:18.770 --> 00:26:20.170 position:50% align:middle Really excellent study. 00:26:20.170 --> 00:26:21.480 position:50% align:middle - Yeah, no, thank you so much. 00:26:21.480 --> 00:26:21.710 position:50% align:middle Yeah. 00:26:21.710 --> 00:26:27.350 position:50% align:middle So, that was one of the issues, like, in my involvement in Arkansas, is that, you know, 00:26:27.350 --> 00:26:28.760 position:50% align:middle legislators were a roadblock. 00:26:28.760 --> 00:26:34.900 position:50% align:middle And ultimately, one of the doctors who was fighting very hard in the legislature realized when he 00:26:34.900 --> 00:26:39.160 position:50% align:middle retired that, you know, he wouldn't have...his constituents wouldn't 00:26:39.160 --> 00:26:40.520 position:50% align:middle have any care and that kind of tipped him over. 00:26:40.520 --> 00:26:42.390 position:50% align:middle But yeah, you're right. 00:26:42.390 --> 00:26:45.310 position:50% align:middle So, that was a bad sentence on the slide. 00:26:45.310 --> 00:26:46.160 position:50% align:middle Yeah. 00:26:51.800 --> 00:26:55.400 position:50% align:middle - [Audience Member] When you're talking about pediatrics and child healthcare, 00:26:55.400 --> 00:27:00.870 position:50% align:middle if you look at the Pediatric Nursing Certification Board, they will be able to tell you which pediatric 00:27:00.870 --> 00:27:05.620 position:50% align:middle nurse practitioners are taking acute care versus primary care certification exams. 00:27:05.620 --> 00:27:07.400 position:50% align:middle And it is separate for us. 00:27:07.400 --> 00:27:09.940 position:50% align:middle If you get primary care, I can't work in acute care. 00:27:09.940 --> 00:27:13.690 position:50% align:middle If you get acute care, you can't work in primary care, unless you get dual certification. 00:27:13.690 --> 00:27:16.660 position:50% align:middle So, that's one way you'll be able to extract some of that information. 00:27:16.660 --> 00:27:17.330 position:50% align:middle - Yeah. 00:27:17.330 --> 00:27:17.910 position:50% align:middle Thank you so much. 00:27:17.910 --> 00:27:23.440 position:50% align:middle So, my next project is kind of looking at pregnancy episodes using commercial claims. 00:27:23.440 --> 00:27:28.320 position:50% align:middle So, we will be able to look at NPIs, and hopefully we'll be able to kind of unpack the 00:27:28.320 --> 00:27:32.300 position:50% align:middle mechanism and look at what kind of NPs are involved. 00:27:32.300 --> 00:27:36.960 position:50% align:middle But thank you, that will be very helpful for our next project. 00:27:36.960 --> 00:27:39.331 position:50% align:middle All right, thank you.