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Do NP, PA Ordering Habits Lead to Higher Healthcare Costs?

A study found that primary care provider ordering habits may result in higher healthcare costs versus the habits of nurse practitioners and physician assistants.

Physician order habits, not those of nurse practitioners or physician assistants, may have upped healthcare costs, a study showed

Source: Thinkstock

By Jacqueline LaPointe

- Nurse practitioners and physician assistants did not contribute to higher healthcare costs by ordering more ancillary or expensive services compared to primary care providers, a recent American Journal of Managed Care study uncovered.

The analysis of 180,000 Kaiser Permanente Georgia patient cases treated for neck or back pain and acute respiratory infections between January 2006 and March 2008 revealed that primary care providers ordered significantly more low-value and expensive services.

“In our study, the pattern of ancillary services use suggests that NPs/PAs [nurse practitioners/physician assistants] might have been more judicious in use of ‘low-value’ ancillary services than PCPs [primary care providers],” the authors wrote.

Hospitals are increasingly turning to nurse practitioners and physician assistants to alleviate the national physician shortage. The Association of American Medical Colleges (AAMC) recently projected the provider shortfall to reach up to 104,900 physicians by 2030.

However, some stakeholders have questioned how increasing their advanced practice clinician workforce would affect healthcare costs and utilization.

Hospitals may save healthcare costs by increasing the staffing ratio because nurse practitioner and physician assistant compensation are significantly less than a physician’s. For example, physician assistants earned about $111,500 on average in 2016 versus $294,000 for average physician compensation in 2017.

But the salary differential may be offset by the ordering habits of nurse practitioners and physician assistants, which have produced mixed results. A 2015 JAMA Internal Medicine study found that the staff ordered significantly more CTs and MRIs for primary care visits for Medicare patients than physicians.

In contrast, a 2016 Annals of Internal Medicine study uncovered no significant differences in office-based care between advanced practice clinicians and physicians.

The Kaiser Permanente Georgia data, however, uncovered that primary care providers ordered more diagnostic and therapeutic services for neck or back pain and acute respiratory infections compared to nurse practitioners and physician assistants.

Primary care providers ordered more expensive tests among alternatives, such as CTs and MRIs versus x-rays for adults with neck or back pain and broad spectrum antibiotics versus first-line general antibiotics for adults with acute respiratory infections.

Specifically, researchers found the following ordering habits for primary care providers and advanced practice clinicians for neck or back pain patients after propensity score matching:

• Primary care providers were more likely to order a CT or MRI (3.3 percent of cases) compared to physician assistants and nurse practitioners (2.1 percent of cases)

• Physician assistants and nurse practitioners tended to order more nonnarcotic analgesics with a prescription in 13.5 percent of cases compared to just 8.5 percent for primary care providers

• Advanced practice clinicians also prescribed musculoskeletal relaxants in slightly more cases with an order 45.8 percent of the time versus 42.5 percent for primary care providers

• X-ray ordering habits were not statistically different across providers with 21.6 percent of cases treated by a physician assistant and nurse practitioner compared to 22.1 percent of patients treated by primary care providers

For acute respiratory infection visits, the data showed significant ordering habit differences between the provider types with primary care providers prescribing more tests.

Primary care providers ordered more x-rays (8.6 percent of cases compared to 6.3 percent for the other provider types), CTs and MRIs (0.5 percent of cases versus 0.3 percent), broad-spectrum antibiotics (42.5 percent of cases compared to 41.5 percent), and rapid strep tests (9.7 percent of cases versus 6.3 percent).

While primary care providers tended to order more tests and services overall, physician assistants and nurse practitioners tended to prescribe more antibiotics for acute respiratory infections. The clinicians ordered any antibiotic for 73.7 percent of patients, whereas primary care providers only prescribed them for 65.8 percent of patients.

Overall, primary care providers tended to order more low-value tests and medications compared to physician assistants and nurse practitioners.

Researchers attributed less low-value ordering habits of physician assistants and nurse practitioners to their education.

“Training of NPs/PAs typically emphasizes patient education and self-management over other interventional strategies,” the study stated. “Thus, NPs/PAs may be more comfortable in initially managing N/B [neck and back] pain or ARI [acute respiratory infections] with fewer ancillary services.”

Physician assistant and nurse practitioner training also emphasize clinical practice guideline compliance in primary care, particularly for the two conditions studied.

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