The Effects of Expanded Nurse Practitioner and Physician Assistant Scope of Practice on the Cost and Intensity of Medicaid Patient Care Edward Timmons Director, Knee Center for the Study of Occupational Regulation (CSOR) Professor of Economics Saint Francis University Loretto, PA August 20 ; Alexandria, VA JCPP Summer 2019 Meeting

Motivation of Research Does liberalizing the scope of practice have measurable impact? Preview: Broader PA scope of practice (allowing prescription of controlled substances) associated with lower outpatient Medicaid claims Additional research: Broadening NP scope of practice increases care intensity without increasing cost.

Evolving Role of PAs and NPs Most states have expanded the role of each professional, but some laggards remain.

PA prescriptive authority in 2012 Note: Florida added in 2016.

NP prescriptive authority in 2012 Note: Alabama added in 2013 and Florida added in 2016

NP prescriptive authority changes: 1999-2012

Evolving Role of PAs and NPs Almost all states now allow PAs to prescribe controlled substances (KY only exception) All NPs are the same More states are allowing NPs authority to prescribe w/o physician supervision or obtaining a collaborative practice agreement.

Strategy Use what is called a difference-in-difference (DID) methodology, relying on states changing status Centers for Medicare and Medicaid Services Medicaid Statistical Information System (1999-2012)

Results Evidence that expanded PA scope of practice is associated with lower outpatient Medicaid claims (11.8-14.4% reduction) Why? Medicaid reimbursement rates for PAs in many states are lower. Market fees also are generally lower. Little evidence that expanded NP scope of practice is having measurable effect

Additional research Poghosyan, Timmons, Abraham, and Martsolf 2019 Journal of Nursing Regulation Use AANP definitions of scope of practice and focus on NPs Expanded NP SOP increases total care days by 8%, but does not increase cost. Grant funded: National Council of State Boards of Nursing

Conclusion Expanded PA and NP scope of practice seems to reduce healthcare cost without sacrificing access or quality States should consider expanding scope of practice for each professional.