WEBVTT 00:00:05.500 --> 00:00:11.480 position:50% align:middle - [Monica] Really, in research, I think what makes our research more powerful, 00:00:11.480 --> 00:00:15.600 position:50% align:middle more impactful, more rigorous is when we engage in team science. 00:00:15.600 --> 00:00:20.740 position:50% align:middle So I'm really delighted to have my colleague with me here today, Dr. Alex Hoyt. 00:00:20.740 --> 00:00:25.020 position:50% align:middle He can perhaps introduce himself when it is his turn to go. 00:00:25.020 --> 00:00:31.170 position:50% align:middle But we received this funding from NCSBN in the middle of the pandemic. 00:00:31.170 --> 00:00:33.890 position:50% align:middle So grateful for their funding. 00:00:33.890 --> 00:00:40.020 position:50% align:middle I was a co-PI with Dr. Jennifer Perloff, who is at Brandeis University. 00:00:40.020 --> 00:00:43.030 position:50% align:middle And we also worked with a student at Boston College. 00:00:43.030 --> 00:00:47.530 position:50% align:middle And Dr. Perloff also has an appointment at the Institute for Accountable Care. 00:00:47.530 --> 00:00:57.170 position:50% align:middle So we're able to really take advantage of their rich, rich data source, which you'll hear about in a minute. 00:00:57.170 --> 00:01:04.150 position:50% align:middle So I'm hesitant to say that home-based primary care is an emerging innovation, 00:01:04.150 --> 00:01:10.830 position:50% align:middle because we all know that house calls and being seen in the home really has been around for centuries. 00:01:10.830 --> 00:01:16.730 position:50% align:middle But sometime in the 1800s, the American Hospital Association became powerful, 00:01:16.730 --> 00:01:22.240 position:50% align:middle and suddenly care shifted more conventionally into offices and into hospitals. 00:01:22.240 --> 00:01:30.590 position:50% align:middle But now it seems like receiving care in the home and not in an office space setting is making a resurgence. 00:01:30.590 --> 00:01:38.210 position:50% align:middle So home-based primary care visits billed to Medicare between 2012 to 2019, so pre-pandemic, 00:01:38.210 --> 00:01:39.220 position:50% align:middle increased by 42%. 00:01:39.220 --> 00:01:43.100 position:50% align:middle Some of this is really driven by the aging population. 00:01:43.100 --> 00:01:54.060 position:50% align:middle There's just a growing population that is really home-bound, where it's cumbersome for them to seek care 00:01:54.060 --> 00:01:55.730 position:50% align:middle in the office. 00:01:55.730 --> 00:02:01.990 position:50% align:middle And we also know that they've been receiving more primary care in skilled nursing facilities, 00:02:01.990 --> 00:02:06.950 position:50% align:middle and in assisted living facilities where primary care providers have been going to those facilities, 00:02:06.950 --> 00:02:10.190 position:50% align:middle which is really driving a lot of this growth. 00:02:10.190 --> 00:02:13.840 position:50% align:middle But there's also this expansion of this dedicated workforce. 00:02:13.840 --> 00:02:22.140 position:50% align:middle And nurse practitioners seem to be really driving a lot of this increase in volume. 00:02:22.140 --> 00:02:29.020 position:50% align:middle You can see here the comparison between physician decline in visits, that top line, the dark gray, 00:02:29.020 --> 00:02:34.940 position:50% align:middle and that slight increase or a stable line is nurse practitioners, the blue line on the bottom. 00:02:34.940 --> 00:02:38.780 position:50% align:middle And this is COVID, right, where care really dipped pretty low. 00:02:38.780 --> 00:02:43.940 position:50% align:middle So it's not surprising that that blue line is plateauing, it's pretty stable. 00:02:43.940 --> 00:02:50.845 position:50% align:middle But physician visits really decreased at about 35% between 2017 and 2021. 00:02:50.845 --> 00:03:00.060 position:50% align:middle And NPs increased by 10%. 00:03:00.060 --> 00:03:00.550 position:50% align:middle - [Dr. Hoyt] Thank you. 00:03:00.550 --> 00:03:01.770 position:50% align:middle I'm Alex Hoyt. 00:03:01.770 --> 00:03:03.210 position:50% align:middle Monica's colleague. 00:03:03.210 --> 00:03:07.960 position:50% align:middle Like Monica, I have my Ph.D. in social policy from Brandeis University. 00:03:07.960 --> 00:03:12.800 position:50% align:middle I'm now at the School of Nursing at the MGH Institute of Health Professions. 00:03:12.800 --> 00:03:18.320 position:50% align:middle And I do work for a research focused on APRNs. 00:03:18.320 --> 00:03:21.300 position:50% align:middle Thanks for having me here today. 00:03:21.300 --> 00:03:33.330 position:50% align:middle So if you are a nursing regulator whose mission is to protect the public from substandard nursing practice, 00:03:33.330 --> 00:03:41.820 position:50% align:middle you can be heartened by a large and growing literature showing the safety and quality 00:03:41.820 --> 00:03:45.490 position:50% align:middle of nurse practitioner care. 00:03:45.490 --> 00:03:59.210 position:50% align:middle However, the population of folks receiving home-based primary care is older, and frailer, 00:03:59.210 --> 00:04:06.850 position:50% align:middle and sicker than the general population of older adults. 00:04:06.850 --> 00:04:14.000 position:50% align:middle And the home environment is not structured as a healthcare setting. 00:04:14.000 --> 00:04:25.030 position:50% align:middle And finally, most nurse practitioner students don't get a clinical experience doing home care, 00:04:25.030 --> 00:04:31.510 position:50% align:middle or advanced practice home care, which has a unique combination of primary care, 00:04:31.510 --> 00:04:39.540 position:50% align:middle and sometimes acute care, and sometimes morphing into palliative care. 00:04:39.540 --> 00:04:39.810 position:50% align:middle Right? 00:04:39.810 --> 00:04:50.610 position:50% align:middle So the conundrum for regulators is that regulation can have a protective effect for a vulnerable population. 00:04:50.610 --> 00:05:04.780 position:50% align:middle And it can have an unintended consequence of restricting access for a valuable service. 00:05:04.780 --> 00:05:11.670 position:50% align:middle So our research questions are organized around the regulators' concerns. 00:05:11.670 --> 00:05:18.980 position:50% align:middle So the impact of the scope of practice on access to home-based primary care, 00:05:18.980 --> 00:05:24.740 position:50% align:middle basically is that unintended consequence there? 00:05:24.740 --> 00:05:33.090 position:50% align:middle How does the home-based primary care of nurse practitioners compare to that of home-based primary 00:05:33.090 --> 00:05:38.430 position:50% align:middle care delivered by primary care physicians? 00:05:38.430 --> 00:05:48.900 position:50% align:middle And then finally, how is that influenced by scope of practice regulation? 00:05:48.900 --> 00:05:56.680 position:50% align:middle So to answer these questions, we're using all Medicare claims from 2018 and '19, 00:05:56.680 --> 00:06:08.040 position:50% align:middle and attributing Medicare beneficiary to a provider based upon the number and proportion of visits 00:06:08.040 --> 00:06:09.500 position:50% align:middle with that provider. 00:06:09.500 --> 00:06:14.310 position:50% align:middle We're measuring provider type in three categories. 00:06:14.310 --> 00:06:22.520 position:50% align:middle So some beneficiaries had all of their home-based primary care with a nurse practitioner, 00:06:22.520 --> 00:06:31.110 position:50% align:middle some had a mix of physician and NPs, and then some were entirely cared 00:06:31.110 --> 00:06:37.050 position:50% align:middle for by primary care physicians. 00:06:37.050 --> 00:06:52.930 position:50% align:middle And the access question is assessed, looking at the number of visits done by NPs 00:06:52.930 --> 00:07:01.360 position:50% align:middle in the state, as well as the proportion of NPs in the state who are doing home-based primary care. 00:07:01.360 --> 00:07:13.390 position:50% align:middle The care delivery question is addressed by looking at measures of acute care events, prevention, 00:07:13.390 --> 00:07:17.370 position:50% align:middle composite measures, as well as end of life care. 00:07:17.370 --> 00:07:27.580 position:50% align:middle And then finally, we use multi-level modeling to parse out the separate influences of beneficiaries 00:07:27.580 --> 00:07:35.750 position:50% align:middle at one level, providers at another level of data, and then state scope of practice at the highest 00:07:35.750 --> 00:07:42.090 position:50% align:middle level of data. 00:07:42.090 --> 00:07:50.220 position:50% align:middle - So we wanted to know if NPs are doing a little bit of this, or a lot of this, 00:07:50.220 --> 00:07:53.200 position:50% align:middle and how that compared to physicians. 00:07:53.200 --> 00:07:57.000 position:50% align:middle So here, you can see the dark gray is physicians. 00:07:57.000 --> 00:08:00.000 position:50% align:middle I imagine that's really hard to see in the back. 00:08:00.000 --> 00:08:03.070 position:50% align:middle And the blue is nurse practitioners. 00:08:03.070 --> 00:08:10.530 position:50% align:middle And across the bottom are 1 visit, 2 to 5 visits, 6 to 10 visits, all the way up to more than 500 visits. 00:08:10.530 --> 00:08:19.740 position:50% align:middle So you can see that physicians are really predominating in 1 to 2, up to 51 visits per year. 00:08:19.740 --> 00:08:22.020 position:50% align:middle So this is like a hybrid thing. 00:08:22.020 --> 00:08:23.880 position:50% align:middle This is an add-on to their office. 00:08:23.880 --> 00:08:26.480 position:50% align:middle They go out and they see a patient at the end of the day. 00:08:26.480 --> 00:08:29.170 position:50% align:middle Maybe they have a day a week that they dedicate to it. 00:08:29.170 --> 00:08:34.060 position:50% align:middle But the nurse practitioners on the right-hand side of the screen are really predominating in this, 00:08:34.060 --> 00:08:40.650 position:50% align:middle over 100 visits per year area, where they are sort of working out of their car most 00:08:40.650 --> 00:08:41.880 position:50% align:middle of the week. 00:08:41.880 --> 00:08:49.340 position:50% align:middle And they are the dedicated home-based primary care provider. 00:08:49.340 --> 00:08:53.430 position:50% align:middle And this I know you can't see in the back, but this is all 50 states. 00:08:53.430 --> 00:08:58.520 position:50% align:middle And you can get a sense of the gray is the amount of home-based primary care that's happening 00:08:58.520 --> 00:08:59.670 position:50% align:middle in that particular state. 00:08:59.670 --> 00:09:04.290 position:50% align:middle And the blue is the proportion that is provided by nurse practitioners. 00:09:04.290 --> 00:09:07.990 position:50% align:middle The first thing I want you to notice is the wide variation, right? 00:09:07.990 --> 00:09:13.420 position:50% align:middle So there are some states, like on the left, South Dakota, North Dakota, Vermont, Mississippi, 00:09:13.420 --> 00:09:15.590 position:50% align:middle where not a lot is happening. 00:09:15.590 --> 00:09:19.660 position:50% align:middle On the right, we have North Carolina, Michigan, and Florida. 00:09:19.660 --> 00:09:26.740 position:50% align:middle Florida, not surprisingly, God's waiting room, as my parents, who are residents there, call it. 00:09:26.740 --> 00:09:32.820 position:50% align:middle That's where there's a lot of home-based primary care happening. 00:09:32.820 --> 00:09:38.510 position:50% align:middle So the variation is also how much is happening at the state level, but also how much is provided 00:09:38.510 --> 00:09:40.180 position:50% align:middle by nurse practitioners. 00:09:40.180 --> 00:09:41.800 position:50% align:middle You can see Kentucky. 00:09:41.800 --> 00:09:44.040 position:50% align:middle Let's see if maybe... 00:09:44.040 --> 00:09:45.590 position:50% align:middle Where is Kentucky? 00:09:45.590 --> 00:09:46.080 position:50% align:middle Right here. 00:09:46.080 --> 00:09:47.880 position:50% align:middle See how much of that is blue? 00:09:47.880 --> 00:09:54.340 position:50% align:middle Almost all of the home-based primary care happening in Kentucky is done by nurse practitioners. 00:09:54.340 --> 00:09:58.680 position:50% align:middle But other states, like right here in New York, much less so, and definitely in California, 00:09:58.680 --> 00:10:03.950 position:50% align:middle a much lower share of the total volume of care is provided by NPs. 00:10:03.950 --> 00:10:08.550 position:50% align:middle So I think this is really important, as those of you who are here to represent your states. 00:10:08.550 --> 00:10:10.590 position:50% align:middle This isn't a one-size-fits-all situation. 00:10:10.590 --> 00:10:15.020 position:50% align:middle You really have to understand what the utilization is like at the state level. 00:10:15.020 --> 00:10:23.880 position:50% align:middle And fortunately, we have a paper that's published that has all 50 states with their measures in an appendix 00:10:23.880 --> 00:10:26.210 position:50% align:middle in the "Journal of Gerontological Nursing." 00:10:26.210 --> 00:10:28.060 position:50% align:middle Come see us afterwards. 00:10:28.060 --> 00:10:30.540 position:50% align:middle We can give you access to that paper. 00:10:30.540 --> 00:10:36.860 position:50% align:middle My apologies that...we thought about the QR code this morning. 00:10:36.860 --> 00:10:42.950 position:50% align:middle So we took all of those states and we grouped them according to AANP's category. 00:10:42.950 --> 00:10:48.760 position:50% align:middle You all know their famous map, the red, yellow, green map, right? 00:10:48.760 --> 00:10:52.160 position:50% align:middle So we have full reduced and restricted. 00:10:52.160 --> 00:10:59.460 position:50% align:middle And this is looking again at how state scope or practice impacts the volume of care using 00:10:59.460 --> 00:11:00.320 position:50% align:middle two different measures. 00:11:00.320 --> 00:11:05.260 position:50% align:middle One is the visit rate, and the other is the share of home-based primary care 00:11:05.260 --> 00:11:07.450 position:50% align:middle visits done by NPs. 00:11:07.450 --> 00:11:12.930 position:50% align:middle And you can see that there's really no discernible pattern using either of these measures. 00:11:12.930 --> 00:11:25.950 position:50% align:middle In fact, there's less volume happening in full practice states than there is in reduced states here. 00:11:25.950 --> 00:11:28.570 position:50% align:middle And here, this is almost the same, right? 00:11:28.570 --> 00:11:35.620 position:50% align:middle So scope of practice doesn't seem to be impacting the volume of NP-provided home-based primary care. 00:11:35.620 --> 00:11:39.710 position:50% align:middle However, none of our results were statistically significant. 00:11:39.710 --> 00:11:44.970 position:50% align:middle So important to know. 00:11:44.970 --> 00:11:46.490 position:50% align:middle This is still me. 00:11:46.490 --> 00:11:52.830 position:50% align:middle So this takes a look at those different types of providers that I talked about before. 00:11:52.830 --> 00:11:57.420 position:50% align:middle This is all nurse practitioners that ever did a home. 00:11:57.420 --> 00:12:00.000 position:50% align:middle And even if they did one visit in the entire year. 00:12:00.000 --> 00:12:01.520 position:50% align:middle And this is those that did 10. 00:12:01.520 --> 00:12:05.490 position:50% align:middle So these are more dedicated home-based primary care providers, albeit not much. 00:12:05.490 --> 00:12:08.600 position:50% align:middle It's still just 10 visits in the year. 00:12:08.600 --> 00:12:10.550 position:50% align:middle But again, you can see there's not much change. 00:12:10.550 --> 00:12:16.060 position:50% align:middle Scope of practice really isn't impacting the volume for either the people that do a little bit, 00:12:16.060 --> 00:12:18.920 position:50% align:middle or the people that do a little bit more than a little bit. 00:12:18.920 --> 00:12:20.740 position:50% align:middle It's the same. 00:12:20.740 --> 00:12:25.310 position:50% align:middle And again, these results are not significant. 00:12:25.310 --> 00:12:32.820 position:50% align:middle So moving on to our quality question, does the home-based primary care by NPs differ much 00:12:32.820 --> 00:12:35.440 position:50% align:middle from that provided by physicians? 00:12:35.440 --> 00:12:38.800 position:50% align:middle And we first wanted to look at our patient population. 00:12:38.800 --> 00:12:39.760 position:50% align:middle Are they sicker? 00:12:39.760 --> 00:12:40.490 position:50% align:middle How do they differ? 00:12:40.490 --> 00:12:45.240 position:50% align:middle How is that going to impact what their quality outcomes end up being? 00:12:45.240 --> 00:12:51.340 position:50% align:middle So here, the green is all Medicare beneficiaries, regardless if you're a home-based primary care 00:12:51.340 --> 00:12:52.040 position:50% align:middle patient or not. 00:12:52.040 --> 00:12:55.880 position:50% align:middle So think of it as a comparison to the general population. 00:12:55.880 --> 00:13:00.000 position:50% align:middle Dark gray is still physicians, blue is nurse practitioners, 00:13:00.000 --> 00:13:02.680 position:50% align:middle and the light gray is a team-based approach. 00:13:02.680 --> 00:13:06.010 position:50% align:middle So a little bit by NPs, a little bit by physicians. 00:13:06.010 --> 00:13:07.220 position:50% align:middle And this is age. 00:13:07.220 --> 00:13:13.470 position:50% align:middle So you can see that their age is about the same for NPs and physicians, but much higher 00:13:13.470 --> 00:13:16.710 position:50% align:middle than the general population. 00:13:16.710 --> 00:13:19.860 position:50% align:middle In terms of disability, there's not that much difference. 00:13:19.860 --> 00:13:26.100 position:50% align:middle They're definitely more disabled than the general population, and NPs maybe still a little bit fewer, 00:13:26.100 --> 00:13:27.950 position:50% align:middle but not much. 00:13:27.950 --> 00:13:32.030 position:50% align:middle In terms of frailty, I think this is really important to think about when 00:13:32.030 --> 00:13:35.750 position:50% align:middle you hear our later results. 00:13:35.750 --> 00:13:38.300 position:50% align:middle The NP patients are more frail. 00:13:38.300 --> 00:13:42.280 position:50% align:middle Definitely, all of them that are receiving home-based primary care are more frail than the 00:13:42.280 --> 00:13:46.300 position:50% align:middle general population, but the NP patients are a little bit more frail than the physician patient, 00:13:46.300 --> 00:13:52.810 position:50% align:middle which echoes Dr. Nick Porter's [SP] message that NPs actually, yes, in some settings, 00:13:52.810 --> 00:13:58.100 position:50% align:middle there seems to be consistent evidence that we're providing care for more complex patient populations. 00:13:58.100 --> 00:14:06.380 position:50% align:middle And that's consistent with other papers that have come out specific to the Medicare population. 00:14:06.380 --> 00:14:17.290 position:50% align:middle - So these are forest plots showing the relationship between provider type and care delivery, 00:14:17.290 --> 00:14:20.210 position:50% align:middle specifically acute care events. 00:14:20.210 --> 00:14:25.030 position:50% align:middle We're going to spend just a moment talking through some interpretation here. 00:14:25.030 --> 00:14:39.980 position:50% align:middle The physician-only group is the reference category, and they're represented as the dot at the line 00:14:39.980 --> 00:14:42.690 position:50% align:middle representing basically no relationship. 00:14:42.690 --> 00:14:44.520 position:50% align:middle They're at one here. 00:14:44.520 --> 00:14:45.480 position:50% align:middle Okay? 00:14:45.480 --> 00:14:55.290 position:50% align:middle And the nurse practitioner-only, and the mixed groups are represented by the dot, 00:14:55.290 --> 00:14:57.920 position:50% align:middle and then the error bars. 00:14:57.920 --> 00:15:05.640 position:50% align:middle The error bars showing the confidence interval of the point estimate. 00:15:05.640 --> 00:15:10.670 position:50% align:middle So the dot and... 00:15:10.670 --> 00:15:12.380 position:50% align:middle Oops, sorry. 00:15:12.380 --> 00:15:20.580 position:50% align:middle The dot and the error bars sort of make those look like the TIE fighters from "Star Wars." 00:15:20.580 --> 00:15:23.350 position:50% align:middle Right? 00:15:23.350 --> 00:15:34.840 position:50% align:middle So you can distinguish a significant result by seeing if the wings of the TIE fighter cross the line of one 00:15:34.840 --> 00:15:38.620 position:50% align:middle where the reference category is. 00:15:38.620 --> 00:15:43.960 position:50% align:middle If they do cross that, that's not a statistically significant result. 00:15:43.960 --> 00:15:56.670 position:50% align:middle So the models here also demonstrate an interaction term with the beneficiaries whose home was 00:15:56.670 --> 00:15:59.280 position:50% align:middle in skilled nursing facility. 00:15:59.280 --> 00:16:04.300 position:50% align:middle And we sort of showed their estimates separately. 00:16:04.300 --> 00:16:15.100 position:50% align:middle And the models control for age, and sex, and race frailty, and 30 different co-morbidities. 00:16:15.100 --> 00:16:20.380 position:50% align:middle And these models hold state constant. 00:16:20.380 --> 00:16:33.480 position:50% align:middle So what this is showing is that the beneficiaries who had NP-only home-based primary care had about 26% 00:16:33.480 --> 00:16:47.470 position:50% align:middle higher odds of acute care admission, and about 13% higher odds of an avoidable ED visit. 00:16:47.470 --> 00:16:55.670 position:50% align:middle Here you see that this slide shows the preventive care composites by provider type. 00:16:55.670 --> 00:17:04.660 position:50% align:middle Beneficiaries with NP-only care had 22% lower scores in the prevention composite, 00:17:04.660 --> 00:17:16.160 position:50% align:middle 24% lower in the chronic care composite, and 4% higher odds of influenza immunization compared 00:17:16.160 --> 00:17:24.460 position:50% align:middle to the reference group, again, which is physician only. 00:17:24.460 --> 00:17:38.320 position:50% align:middle So in a population who are older, and frailer, and sicker than the general population of older adults, 00:17:38.320 --> 00:17:42.820 position:50% align:middle it appears that NPs prioritize end-of-life care. 00:17:42.820 --> 00:17:54.370 position:50% align:middle Beneficiaries with NP-only care had more than twofold higher odds of having their advanced care 00:17:54.370 --> 00:17:57.650 position:50% align:middle directive counseling done. 00:17:57.650 --> 00:18:05.305 position:50% align:middle They had 45% higher odds of being in hospice at the time of their death, 00:18:05.305 --> 00:18:13.472 position:50% align:middle and 33% more hospice visits in the last 3 days of life. 00:18:19.920 --> 00:18:31.250 position:50% align:middle So to assess the influence of scope of practice, it's helpful to first recognize that the data sort 00:18:31.250 --> 00:18:35.070 position:50% align:middle of exists in a nested structure. 00:18:35.070 --> 00:18:37.160 position:50% align:middle So you have these visits. 00:18:37.160 --> 00:18:43.590 position:50% align:middle The visits are done by providers who have...that's a level of nesting. 00:18:43.590 --> 00:18:47.130 position:50% align:middle And the providers, of course, are working in states. 00:18:47.130 --> 00:18:53.370 position:50% align:middle And so that's another nested level of the data. 00:18:53.370 --> 00:18:59.970 position:50% align:middle And as a first step, it's helpful to know if there's variation in the 00:18:59.970 --> 00:19:07.400 position:50% align:middle care delivery, which of those levels is that variation happening at? 00:19:07.400 --> 00:19:14.050 position:50% align:middle With the beneficiary being the sort of bottom level, and provider type, and then state, okay? 00:19:14.050 --> 00:19:18.550 position:50% align:middle So how much variation is happening at the state level? 00:19:18.550 --> 00:19:20.530 position:50% align:middle Not much. 00:19:20.530 --> 00:19:33.080 position:50% align:middle Ninety percent or more is happening at the beneficiary level, 5% or less happening at the provider level, 00:19:33.080 --> 00:19:40.860 position:50% align:middle and 5% or less happening at the state level. 00:19:40.860 --> 00:19:54.490 position:50% align:middle So when we model full practice authority amongst the home-dwelling recipients of home-based primary care, 00:19:54.490 --> 00:20:02.660 position:50% align:middle so not the facility folks, just the folks residing at home, 00:20:02.660 --> 00:20:07.810 position:50% align:middle we see that full practice authority had a minimal effect. 00:20:07.810 --> 00:20:16.230 position:50% align:middle Among the significant relationships, there was a 1.9% higher odds of an acute 00:20:16.230 --> 00:20:31.195 position:50% align:middle care admission, lower odds of access to preventive care, but also lower odds of an avoidable ED visit. 00:20:35.845 --> 00:20:42.060 position:50% align:middle - So you've heard a couple of times today the limitations of using Medicare claims 00:20:42.060 --> 00:20:45.140 position:50% align:middle to study provider practice. 00:20:45.140 --> 00:20:47.810 position:50% align:middle And even you heard about incident-to billing. 00:20:47.810 --> 00:20:54.010 position:50% align:middle So nurse practitioners receive 85% of the physician rate if they bill under their own NPI. 00:20:54.010 --> 00:20:59.170 position:50% align:middle If they bill under their physician NPI, they receive 100% of the physician rate, 00:20:59.170 --> 00:21:04.430 position:50% align:middle but that renders their care, if billed incident-to invisible in the claims data. 00:21:04.430 --> 00:21:10.020 position:50% align:middle Recent studies have shown about 30% to 40%, we believe of NP care is billed incident-to, 00:21:10.020 --> 00:21:12.510 position:50% align:middle and therefore invisible in the claims. 00:21:12.510 --> 00:21:14.530 position:50% align:middle So that is a major limitation. 00:21:14.530 --> 00:21:21.330 position:50% align:middle We have some tricks that hopefully will be advancing research in the future, but we're not quite there yet. 00:21:21.330 --> 00:21:23.170 position:50% align:middle We couldn't account for... 00:21:23.170 --> 00:21:27.030 position:50% align:middle So there's many different home-based primary care practice models out there. 00:21:27.030 --> 00:21:32.080 position:50% align:middle If those of you in the room are on the ground doing this, you know this really well. 00:21:32.080 --> 00:21:33.650 position:50% align:middle And some work better than others. 00:21:33.650 --> 00:21:37.570 position:50% align:middle And in billing data, we couldn't really capture the processes, 00:21:37.570 --> 00:21:43.960 position:50% align:middle or the team composition, or how the schedule works to then see how that really 00:21:43.960 --> 00:21:45.710 position:50% align:middle affected our outcomes. 00:21:45.710 --> 00:21:49.750 position:50% align:middle And then we're using 2018 data, which is pre-COVID. 00:21:49.750 --> 00:21:54.040 position:50% align:middle We're not quite out of the slump. 00:21:54.040 --> 00:21:59.030 position:50% align:middle Home-based primary care hasn't rebounded yet, but care in general seems to be shifting 00:21:59.030 --> 00:22:03.890 position:50% align:middle to the community, whether that be in the home via telehealth. 00:22:03.890 --> 00:22:11.180 position:50% align:middle And this seems to be an area that we anticipate will continue to grow. 00:22:11.180 --> 00:22:13.520 position:50% align:middle So let's just recap quickly. 00:22:13.520 --> 00:22:19.800 position:50% align:middle NPs may be caring for sicker home-based primary care patients and physicians. 00:22:19.800 --> 00:22:25.140 position:50% align:middle We see this because the frailty was higher, they had higher mortality. 00:22:25.140 --> 00:22:28.360 position:50% align:middle So the complexity seems to be higher. 00:22:28.360 --> 00:22:30.470 position:50% align:middle There is comparable quality. 00:22:30.470 --> 00:22:37.430 position:50% align:middle However, they didn't do so well on their traditional primary care measures, prevention, access, 00:22:37.430 --> 00:22:41.860 position:50% align:middle immunizations, and those quality of care...well, they did do well on immunizations, but the other ones, 00:22:41.860 --> 00:22:43.170 position:50% align:middle they didn't do so well on. 00:22:43.170 --> 00:22:46.620 position:50% align:middle But they did really well on palliative care outcomes. 00:22:46.620 --> 00:22:51.460 position:50% align:middle And so this really raises the question of what kinds of patients are nurse practitioners working 00:22:51.460 --> 00:22:53.570 position:50% align:middle with in home-based primary care setting. 00:22:53.570 --> 00:22:57.660 position:50% align:middle So it's different from the kinds of patients that are physicians working with. 00:22:57.660 --> 00:23:04.620 position:50% align:middle And where is that line between what begins as primary care, and then slowly turns into end-of-life 00:23:04.620 --> 00:23:08.370 position:50% align:middle palliative care, where you have measures, you just use different quality of care 00:23:08.370 --> 00:23:10.220 position:50% align:middle measures differently, right? 00:23:10.220 --> 00:23:13.650 position:50% align:middle In end of life, you're not so worried about an immunization or [inaudible 00:23:13]. 00:23:13.650 --> 00:23:17.200 position:50% align:middle You're definitely worried about that advanced directive. 00:23:17.200 --> 00:23:21.440 position:50% align:middle So this really presents a challenge for the home-based primary care research world. 00:23:21.440 --> 00:23:24.790 position:50% align:middle And what is quality in this setting? 00:23:24.790 --> 00:23:29.330 position:50% align:middle And do we need other measures that are really looking at the patient's experience, 00:23:29.330 --> 00:23:35.600 position:50% align:middle and patient-centered measures like quality of life, or something like that? 00:23:35.600 --> 00:23:41.470 position:50% align:middle In regards to that regulatory question, we found no obvious effect on the state of practice, 00:23:41.470 --> 00:23:46.270 position:50% align:middle on volume, or quality of nurse practitioner home-based primary care. 00:23:46.270 --> 00:23:48.990 position:50% align:middle I'll follow up with that in a second. 00:23:48.990 --> 00:23:56.470 position:50% align:middle But we also saw that really the variation in quality wasn't even mostly influenced by the provider. 00:23:56.470 --> 00:24:01.820 position:50% align:middle It was mostly influenced by the beneficiaries characteristic, and how high-risk they were, 00:24:01.820 --> 00:24:05.300 position:50% align:middle and how sick they were. 00:24:05.300 --> 00:24:10.460 position:50% align:middle So does this just mean that we give up on full practice authority, and we're just saying, "We're all fine." 00:24:10.460 --> 00:24:14.460 position:50% align:middle No, no, that's not what we want to say here. 00:24:14.460 --> 00:24:20.870 position:50% align:middle What we see in the state is that NPs are providing access to high-quality home-based primary care, 00:24:20.870 --> 00:24:23.820 position:50% align:middle where they need it, and when they need it, and how they need it. 00:24:23.820 --> 00:24:28.260 position:50% align:middle We can see that NPs are dynamic, and they're able to provide primary care and the 00:24:28.260 --> 00:24:31.680 position:50% align:middle palliative care, and they can shift with patient needs. 00:24:31.680 --> 00:24:36.020 position:50% align:middle We also see that the scope of practice restrictions that we have right now are not actually harming 00:24:36.020 --> 00:24:37.310 position:50% align:middle home-based primary care. 00:24:37.310 --> 00:24:38.610 position:50% align:middle They weren't any worse. 00:24:38.610 --> 00:24:41.710 position:50% align:middle There's just no discernible pattern. 00:24:41.710 --> 00:24:43.910 position:50% align:middle So what's going on here? 00:24:43.910 --> 00:24:49.930 position:50% align:middle And I think something that's really important for us to consider is we know we have the state level scope 00:24:49.930 --> 00:24:55.690 position:50% align:middle of practice laws, but we all know that there's lots of other barriers coming from lots of other places, 00:24:55.690 --> 00:25:01.500 position:50% align:middle whether it be from the organization, from the payer, from somewhere else, from Medicare. 00:25:01.500 --> 00:25:03.650 position:50% align:middle There's lots of other barriers. 00:25:03.650 --> 00:25:10.120 position:50% align:middle So it's really difficult to just rely on that state scope of practice variable to determine whether or not 00:25:10.120 --> 00:25:14.710 position:50% align:middle scope of practice policies are really changing the quality. 00:25:14.710 --> 00:25:19.380 position:50% align:middle So do we need to shift our focus then towards organizations, towards payers, 00:25:19.380 --> 00:25:25.320 position:50% align:middle towards insurance companies, towards Medicare to see if lifting those restrictions 00:25:25.320 --> 00:25:29.090 position:50% align:middle really helps to make a change to either the volume or the quality of care? 00:25:29.090 --> 00:25:35.400 position:50% align:middle And then lastly, what's the role of regulators in this particular situation. 00:25:35.400 --> 00:25:36.560 position:50% align:middle Quality looks different. 00:25:36.560 --> 00:25:38.790 position:50% align:middle Does safety look different in this setting? 00:25:38.790 --> 00:25:44.930 position:50% align:middle Are you more concerned about diversion in the home if you're working with palliative care patients 00:25:44.930 --> 00:25:50.040 position:50% align:middle versus adverse outcomes in a healthier primary care patient? 00:25:50.040 --> 00:25:52.040 position:50% align:middle We don't have all the answers. 00:25:52.040 --> 00:25:53.580 position:50% align:middle We're here to provide you with the data. 00:25:53.580 --> 00:25:58.970 position:50% align:middle But I hope that this has given you a really good overall sense of this resurgence 00:25:58.970 --> 00:26:01.500 position:50% align:middle of this unique setting. 00:26:01.500 --> 00:26:01.810 position:50% align:middle Thank you. 00:26:01.810 --> 00:26:03.347 position:50% align:middle Happy to take questions. 00:26:07.553 --> 00:26:09.620 position:50% align:middle - [Female] Thank you so much for your presentation. 00:26:09.620 --> 00:26:15.040 position:50% align:middle I actually used to do home-based care, so your presentation really resonated. 00:26:15.040 --> 00:26:21.080 position:50% align:middle I was wondering about if you refer to this as home-based primary care? 00:26:21.080 --> 00:26:24.160 position:50% align:middle How does that overlay with the consensus model? 00:26:24.160 --> 00:26:30.720 position:50% align:middle Which looks at primary care and acute care separately for nurse practitioners. 00:26:30.720 --> 00:26:35.720 position:50% align:middle And that your certification is in one area, or the other, or both if you're dual certified. 00:26:35.720 --> 00:26:38.370 position:50% align:middle But I'd just be interested in your thoughts on that. 00:26:38.370 --> 00:26:40.080 position:50% align:middle - That's an excellent question. 00:26:40.080 --> 00:26:46.290 position:50% align:middle I'm going to turn to the expert on the consensus model for this. 00:26:46.290 --> 00:26:46.970 position:50% align:middle - Yeah. 00:26:46.970 --> 00:27:00.000 position:50% align:middle The consensus model has these sort of two tracks in an environment where both skill sets are called upon, 00:27:00.000 --> 00:27:01.260 position:50% align:middle and that becomes really difficult. 00:27:01.260 --> 00:27:07.420 position:50% align:middle It almost seems like the ideal nurse practitioner has both their acute care certification, 00:27:07.420 --> 00:27:12.610 position:50% align:middle as well as their primary care certification. 00:27:12.610 --> 00:27:16.630 position:50% align:middle - So they would do both educational programs? 00:27:16.630 --> 00:27:21.000 position:50% align:middle - So the definition of primary care, especially according to the consensus model, 00:27:21.000 --> 00:27:25.770 position:50% align:middle it's longitudinal care has a lot to do with it. 00:27:25.770 --> 00:27:34.030 position:50% align:middle And you can provide primary care in an acute care setting in the traditional definition 00:27:34.030 --> 00:27:35.560 position:50% align:middle of the consensus model. 00:27:35.560 --> 00:27:41.000 position:50% align:middle And in this particular situation, when care has been moved to the home, it's 00:27:41.000 --> 00:27:41.640 position:50% align:middle all gray, right? 00:27:41.640 --> 00:27:42.550 position:50% align:middle It's all subjective. 00:27:42.550 --> 00:27:44.130 position:50% align:middle And one can make a case one way or the other. 00:27:44.130 --> 00:27:48.970 position:50% align:middle But I could see how this could shift more towards primary care for a particularly 00:27:48.970 --> 00:27:51.760 position:50% align:middle complex acute population. 00:27:51.760 --> 00:27:54.950 position:50% align:middle - Yeah. 00:27:54.950 --> 00:28:02.280 position:50% align:middle And the definition of acute care is that patients are unstable. 00:28:02.280 --> 00:28:07.450 position:50% align:middle Well, yeah, that's often the case. 00:28:07.450 --> 00:28:09.500 position:50% align:middle Did you have a follow-up question? 00:28:09.500 --> 00:28:10.320 position:50% align:middle - No. 00:28:10.320 --> 00:28:11.160 position:50% align:middle That's fine. 00:28:11.160 --> 00:28:11.530 position:50% align:middle Thank you. 00:28:11.530 --> 00:28:12.630 position:50% align:middle - Murky waters. 00:28:12.630 --> 00:28:12.880 position:50% align:middle - Yeah. 00:28:12.880 --> 00:28:13.710 position:50% align:middle - It is. It is. 00:28:13.710 --> 00:28:16.850 position:50% align:middle I'm acute care nurse practitioner, so I was practicing in the home, 00:28:16.850 --> 00:28:21.840 position:50% align:middle but the care I was delivering was very acute, in my opinion. 00:28:21.840 --> 00:28:26.670 position:50% align:middle Because as your study shows, there's less of a focus on prevention when you're 00:28:26.670 --> 00:28:31.640 position:50% align:middle caring for this patient population, and more focus on how do we prevent [crosstalk] 00:28:31.640 --> 00:28:35.159 position:50% align:middle how do we address their end-of-life needs. 00:28:35.159 --> 00:28:39.660 position:50% align:middle - That's where NPs are shining in those particular quality of care measures, right? 00:28:39.660 --> 00:28:40.820 position:50% align:middle We don't know how much... 00:28:40.820 --> 00:28:46.860 position:50% align:middle And how would you define who's primary and who's end of life? 00:28:46.860 --> 00:28:48.020 position:50% align:middle It's such a continuum. 00:28:48.020 --> 00:28:51.610 position:50% align:middle - Yeah, it's very murky, as you said. 00:28:51.610 --> 00:28:53.150 position:50% align:middle - Great question, though. 00:28:53.150 --> 00:28:54.741 position:50% align:middle Thank you. 00:28:58.290 --> 00:28:59.100 position:50% align:middle Wonderful. 00:28:59.100 --> 00:29:00.670 position:50% align:middle Time for the boxed lunch. 00:29:00.670 --> 00:29:02.450 position:50% align:middle - Thank you. 00:29:02.450 --> 00:29:13.000 position:50% align:middle - Thank you, all.