Advanced practitioners: Expanded role, bigger impact

Despite the potential benefits PAs offer, significant challenges to fully integrating them remain.

Recent studies suggest that the savings resulting from increased use of physician assistants (PAs) and nurse practitioners (NPs) could be significant. Still, legislative barriers at the state level related to scope of practice guidelines may be keeping their full cost-savings benefits at bay.

A recent study by Roderick S. Hooker, PhD, MBA, PA, a health policy consultant, and Ashley N. Muchow, a RAND Corporation assistant policy analyst, evaluated how revising state scope of practice laws would impact healthcare costs.

The analysis focused on Alabama, which researchers identified as one of the states with the most restrictive PA and NP legislation. In fact, the American Association of Nurse Practitioners (AANP) places the state in its "reduced practice category," meaning "state practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice."

Related:Ten ways certified PAs improve quality, reduce costs

The Hooker-Muchow analysis found that if Alabama's laws were aligned with less-restrictive laws in other states, such as Washington and Arizona, more PAs and NPs would practice there, which would lead to higher NP and PA utilization. This would lead to a net savings of $729 million over a 10-year period, according to the study findings.

Cost and quality

Much of the potential cost benefit associated with PA/NP utilization can be attributed to the reimbursement environment. Medicare and Medicaid tend to pay PAs and NPs approximately 85% of what they pay physicians for the same services.

Increased PA/NP utilization may also increase patient access to care. This could lead to higher patient use of primary-care services, which could lead to cost-savings in the long term.

While quality of care remains a common question surrounding increased use of PAs and NPs, many studies, including a 2009 study by the RAND Corporation, find that NPs and PAs provide the same quality of care at lower costs when compared to primary-care physicians. 


NEXT: Legislative issues


Legislative issues

The American Academy of Physician Assistants (AAPA) has identified six key elements of PA practice it says should be included in state legislation. They are:

  • Using "licensure" as the regulatory term to describe the process by which states authorize PAs to practice;

  • Determining PA scope of practice at the practice level;

  • Enabling supervising physicians to delegate prescriptive authority to PAs;

  • Enabling practices and physicians to determine PA on-site requirements;

  • Enabling practices and physicians to determine chart co-signature requirements; and

  • Eliminating restrictions on the number of PAs with whom physicians can practice.

States vary widely when it comes to adopting these elements. At press time, four states, (Massachusetts, North Dakota, Rhode Island, and Vermont), had adopted all six.

Related:Nurse practitioner representation in health plans is a "win-win"

On the nurse practitioner side, the AANP advocates for "full scope of practice" for NPs, which it defines as the ability to evaluate patients, diagnose conditions, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing.

At press time, 21 states-Alaska, Arizona, Colorado, Connecticut, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, Vermont, Washington, and Wyoming-had adopted full scope of practice for NPs, according to the AANP.


NEXT: Recent changes


Recent changes

The Medicare Access and CHIP Reauthorization Act (MACRA) signed into law this past summer and which repealed the sustainable growth rate, may also pave the way toward higher PA/NP utilization.

The law includes an increase in Medicare payment rates for physicians, PAs, and NPs, for each of the next five years. MACRA also authorizes PAs and NPs to document face-to-face encounters to obtain durable medical equipment. The new provision eliminates the need for any direct physician involvement, which may lead to increased PA/NP use.

The law also reiterates that PAs and NPs can provide care to patients with under the new chronic care management code, 9940. The code is for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.