July 11, 2019 – Advanced practitioners (APs) have been effective for helping healthcare organizations maintain adequate patient care access and appointment availability, even following the Affordable Care Act (ACA), according to a new study published in the Annals of Family Medicine.
Following the ACA’s passage, medical industry leaders were concerned that the law would lengthen patient wait times or restrict access to care. After all, the ACA was slated to make health insurance coverage more affordable, and tax penalties would expand the number of patients purchasing private insurance plans.
At the same time, states were given the option to expand Medicaid access, boosting the number of low-income individuals with access to health insurance.
All said, the ACA led to a drop in the uninsured rate from 13.3 percent of Americans to only 8.8 percent who did not have health insurance by 2017.
“Because the supply of primary care physicians remained relatively stable, concerns were raised about a potential erosion in access to primary care for Medicaid beneficiaries,” pointed out the researchers, who hail from the University of Pennsylvania.
But those concerns were quickly assuaged, as researchers found that primary care appointment availability not only did not falter, but in most areas increased.
One study cited by the UPenn researchers found that appointment availability for new patients covered by Medicaid actually increased from 58 percent to 63 percent in 2016, while access to care for patients with private insurance remained consistently high.
But what accounted for that consistent – even growing – patient care access? As more patients accessed care from the same number of physicians, how did organizations keep pace?
“Multiple theories have been proposed to explain these findings, including an increased reliance on advanced practitioners (APs), such as nurse practitioners and physician assistants, who may be more likely to treat Medicaid patients,” the researchers posited.
To test that theory, the UPenn researchers conducted a “secret shopper” investigation during which they called one of nearly 4,000 primary care clinics in 10 states included in the study. Investigators requested an appointment and asked whether the appointment would be led by a nurse practitioner (NP) or physician assistant (PA).
Overall, the proportion of appointments with APs increased from 7.7 percent in 2012 to 12.9 percent in 2016, suggesting that these providers filled in the primary care access gaps as they emerged.
Some clinics benefitted from the expertise of APs more than others, the researchers added. For example, federally qualified health centers (FQHCs), which faced increased requirements for improving care access per the ACA, saw a greater share of APs delivering care than other settings.
Consistent with that finding, the researchers found that clinics in low-income areas had more appointments with APs than clinics in more affluent regions, although the team did not investigate the forces behind this trend.
Perhaps the added reimbursement incentives FQHCs faced as a part of the ACA led to more clinics in low-income areas – which likely included a large share of FQHCs – to tapping APs to deliver primary care.
There was, however, little difference in AP appointment frequency in rural versus urban settings, the researchers reported. APs conducted primary care appointments in rural areas no more frequently than they did in urban settings.
Notably, the study provided some support for expanding scope of practice laws for APs. Across the country, nurse practitioners, physician assistants, and other medical professionals have made the case for expanding scope of practice in an effort to also expand patient access to care.
“While there was no variation in major scope of practice laws for nurse practitioners or physician assistants from 2012 through 2016 to exploit empirically in our selected states, the proportion of AP appointments scheduled in 3 states where nurse practitioners had prescribing authority (Oregon, Iowa, and Montana) was twice the rate in other states,” the researchers said.
Specifically, 18.8 percent of appointments in states that had granted nurse practitioners prescribing authority were led by APs. APs led only 9.1 percent of appointments in states that had no expanded scope of practice. This suggests that it’s easier to hand off some primary care appointments to APs when they have been allowed broader scope of practice.
While these findings do cement the feasibility of adequate patient care access following the ACA, it also has future implications. The physician shortage, which plagues the country and is expected to continue for years to come, has drawn calls for more employment of APs and expanded scope of practice.
As demand for primary care appointments rises, healthcare organizations may consider the role of advanced practitioners in their clinics.
“As the population ages and chronic conditions increase, demand for primary care may strain the supply of primary care physicians,” the researchers concluded. “Medicaid beneficiaries are at particular risk of poor access due to lower reimbursement rates and less physician participation in Medicaid. Our findings indicate that primary care practices are already accommodating these patients by increasing the proportion of appointments scheduled with APs.”