Bovine Fecal Matter: Here’s An Easy Way to Increase Access to High-Quality, Affordable Health Care

I’m all for being a team player and support all the different healthcare roles in today’s healthcare environment, but I don’t like lies or manipulation such as being put forth by the above referenced article (1):

“In study(2) after rigorous study (3), evidence demonstrates that NPs offer significant cost savings (4) with no sacrifice of quality of care (5). Indeed, they show that NPs often provide superior care (6), including spending more time with patients on prevention and counseling.”

            I’m ashamed of my former profession purporting such misinformation and constantly pitting NPs against physicians. This article has to do with expanding the role of nurse practitioners in providing primary care. As a former nurse practitioner (NP), I’m all for the proper utilization of NPs on physician lead healthcare teams. What irks me the most is the lies and manipulation about these studies and research. These are not as rigorous as professed. They are not as high quality as professed. Data and conclusions in the studies are often misinterpreted and misreported. This needs to stop!  

            The first study referenced in the article (2) Poghosyan, Lusine & Timmons, Edward & Abraham, Cilgy & Martsolf, Grant. (2019). The Economic Impact of the Expansion of Nurse Practitioner Scope of Practice for Medicaid. Journal of Nursing Regulation. 10. 15-20. 10.1016/S2155-8256(19)30078-X concluded: States that expand NP SOP may provide greater intensity of care (measured using total care days) to Medicaid patients without increasing total costs of care. This study had three outcome variables: (a) total outpatient costs per Medicaid beneficiary; (b) total prescription drug costs per Medicaid beneficiary; and (c) care intensity (measured by the total number of care days received by Medicaid patients in each state annually). The independent variable was NP SOP.  State NP SOP was categorized according to the AANP as (a) full practice if NPs have the authority to evaluate, diagnose, order tests, initiate and manage treatments, and prescribe drugs; (b) reduced practice if a collaborative or written practice agreement is required for NPs to perform one or more elements of practice; and (c) restricted practice if supervision, delegation, or team management is required. The purpose of this study was to estimate the impact of expanded NP SOP regulations on the cost of total outpatient visits and prescription drugs as well as total care days (defined as care intensity) received by Medicaid patients nationwide. The study hypothesized that “NP SOP expansion in the state would result in a reduction in outpatient and prescription drug costs and an increase in care intensity for Medicaid beneficiaries.”  I’m having trouble matching the statistics to the conclusion listed above. If my fledgling statistical knowledge is correct, based on the below statistical table, it would seem that a Type I error is committed with the conclusion. Referencing the values, the statistics seem to not support a statistical significance of the findings. A Type I error of course being that which rejects a true null hypothesis in favor of a statistically insignificant hypothesis (value greater than 0.05). I mean no disrespect to the authors of the study as they were kind enough to send me the full text, but this study shouldn’t be used as evidence as stated in the article referenced in this blog (1). 

            The second study referenced (3): Perloff J, DesRoches CM, Buerhaus P. Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians. Health Serv Res. 2016;51(4):1407–1423. doi:10.1111/1475-6773.12425 concluded: “This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.” The aim of this study was to determine the difference in paid claims for services provided to Medicare beneficiaries who were assigned to either an NP or to a primary care physician. While the hypothesis is not explicitly stated, it can be implied or inferred based on the introduction and particular statements: “no study has used national-level data to systematically examine the cost of primary care services provided by NPs and primary care physicians over an extended time frame.” Implying that NPs provide the same quality care at lower costs. It’s hard to discern about the sample from the data provided. As such, I’m going to claim sampling bias here (In statistics, sampling bias is a bias in which a sample is collected in such a way that some members of the intended population have a lower sampling probability than others). “we purposefully weighted our sample to include approximately two-thirds NP associated beneficiaries and one-third primary care physicians beneficiaries to help capture an adequate number of NPs.”

“our results should be interpreted with awareness that it is unclear whether incident to billing under- or overstates the differences between these two groups of clinicians.”

            The third study referenced in the blog article (4) Chattopadhyay, S., Zangro, G. (2019) The Economic Cost and Impacts of Scope of Practice Restrictions on Nurse Practitioners. Nursing Economics. Nov/Dec 2019., Vol 37 No 6 concluded: Empirical results show that eliminating restrictions significantly reduces Medicare costs statistically, suggesting the need for increased participation of NPs in primary care to ensure access, patient safety, and quality of care at reduced cost. At the national level, eliminating restrictions is shown to result in annual Medicare cost savings of $44.5 billion. I may be missing something here, but it seems to go from a correlation to a cause and effect. In this study, there is obvious author and publication bias with statements such as: NPs primarily practice in rural areas, and with increasing shortage of primary care physicians, access to care in rural areas is decreasing, thereby negatively impacting health outcomes. This has been proven not to be true:

            The fourth study referenced in the blog article (5) Newhouse RP, Stanik-Hutt J, White KM, Johantgen M, Bass EB, Zangaro G, Wilson RF, Fountain L, Steinwachs DM, Heindel L, Weiner JP. Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economic$ 2011; 29(5): 230-250 concluded: that advanced practice registered nurses provided safe, effective and quality care in a variety of settings and in partnership with physicians and other providers had a significant role in the promotion of health. An independent review of this study – Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: wrote: There were questions about data quality and some of the review methods, but the relatively conservative conclusions appear reasonable. There is also questionable author bias and publication bias. It was unclear whether unpublished studies were sought so publication bias may have affected the review.

This study was quite large and complicated.  The review methods appeared to be aimed at reducing possible reviewer error and bias. Study quality was assessed using an unpublished system and reported only as an overall rating of high or low quality; this made it difficult to comment independently on the reliability of evidence presented. I will leave it here. 

The fifth study referenced in the blog article (6) Kurtzman, E.T., & Barnow, B.S. (2017). A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers. Medical Care, 55, 615–622 concluded: Across the outcomes studied, results suggest that NP and PA care were largely comparable to PCMD care in HCs (community health centers -HC; primary care physicians -PCMDs). The blog article used this study to conclude NPs provide superior care when the study itself reported the following results: On 7 of the 9 outcomes studied, no statistically significant differences were detected in NP or PA care compared with PCMD care.The blog author might be well served to know that no statistical significance/difference does not equate to superiority. Another falsehood. 

            After a brief review of the evidence presented in the article, I conclude that the blog premise is based on data of questionable quality. While that might not have been the author’s intention, it seems consistent with many writings that pit NPs against MD/DOs.  The article is correct about one thing though “Unfortunately, the supply of primary care doctors isn’t keeping up with the demand.” However, this shortage of physicians is a problem that must be solved by physicians with increased production of physicians. You be the judge. 



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