The stated mission of the American Medical Association (AMA) is to “promote the art and science of medicine and the betterment of public health.” But the AMA is also a lobbying organization that promotes the self-interest of its members: physicians and medical students. And sometimes the AMA put self-interest before the common good. Case in point: the AMA’s relentless campaign against allowing nurse practitioners (NPs) full authority to practice without physician supervision. As documented in the last post, the AMA gives “three big reasons” for opposing independent nurse practitioners:
It won’t solve the rural access problem.
It will raise health care costs, not cut them.
It threatens patient safety.
I tackled the rural access issue in the last post. This time I will address the second reason the AMA gives for opposing independent NPs.
It will raise health care costs, not cut them. “That’s because NPs in states that allow independent prescribing tend to prescribe 20 times more opioids than NPs in states that do not. NPs in states that allow independent prescribing tend to prescribe 20 times more opioids than NPs in states that do not. NPs also order more diagnostic imaging than physicians. Studies looking at Medicare claims data from 2003 to 2015 found skeletal x-ray ordering increased over 400% among non-physicians, primarily NPs and physician assistants. NPs also order more diagnostic imaging than physicians.” - American Medical Association. 2020
Note that the referenced research did not find that NPs ordered more diagnostic imaging than physicians, only that skeletal x-ray ordering increased more among non-physicians than physicians. That’s unsurprising, given that there are far fewer non-physicians ordering x-rays than physicians and increases from a small base will be larger than the same increase from a large base - if represented as a percentage. Also, although the AMA refers to “studies”, it appears just one study found the 400% increase in NP x-ray ordering between 2003-2015. See Mizrahi et al below, especially all the caveats.
What the referenced research re NP x-ray ordering actually says: “Among nonradiologist specialties in all health care settings over the study period, orthopedic surgeons increased 10.6%, chiropractors and podiatrists together increased 14.4%, nonphysician providers (primarily nurse practitioners and physician assistants) increased 441%, and primary care physicians' rate decreased 33.5%.” - Mizrahi et al
What other researchers say: “NPP-billed diagnostic imaging represented only 0.01% and 1.27% of all such services in 1994 and 2015, respectively.” – Makeeva et al, 2019 [NPP: Non-Physician Providers, mostly NPs]
What the referenced research re NP opioid prescribing actually says: “Most NPs/PAs [nurse practitioners/physician assistants] prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs… In states that granted independent prescription authority, 7.5% of NPs and 10.0% of PAs were high-frequency opioid prescribers…Limitations [of this study] include analysis of only 2015 Medicare claims data, a time near the peak of opioid prescribing in the USA. The dataset does not include the indication [reason] for prescriptions, which limits our ability to assess overprescribing appropriateness. Opioid prescribing for palliative care could confound results if, for example, NPs or PAs had more or less of these patients than MDs.” - Lozada, M.J., Raji, M.A., Goodwin, J.S. et al. (2020)
What other researchers say: “An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states.” McMichael, BJ (2020)
Again: It should be clear here that the AMA simply ignores evidence that doesn’t support their case against NP independence. And that case is about self-interest, not the public good.
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Links:
https://pmc.ncbi.nlm.nih.gov/articles/PMC6080248/ https://www.oregoncenterfornursing.org/wp-content/uploads/2024/07/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf
https://digitalcollections.ohsu.edu/record/685?v=pdf
https://pmc.ncbi.nlm.nih.gov/articles/PMC6583766/
https://healthforce.ucsf.edu/news/policy-perspective-how-nps-expand-healthcare-access-rural-areas
https://www.dailynurse.com/oregon-study-state-needs-primary-care-nps/
https://www.aanp.org/advocacy/state/state-practice-environment
https://www.beckershospitalreview.com/quality/nursing/states-by-nps-per-capita-2024/
References:
Lozada, M.J., Raji, M.A., Goodwin, J.S. et al. Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. J GEN INTERN MED 35, 2584–2592 (2020). https://doi.org/10.1007/s11606-020-05823-0
McMichael, B.J. (2021), Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing. The Milbank Quarterly, 99: 721-745. https://doi.org/10.1111/1468-0009.12524
Makeeva, Valeria, C. Matthew Hawkins, Andrew B. Rosenkrantz, Danny R. Hughes, Laura Chaves, and Richard Duszak Jr. "Diagnostic imaging examinations interpreted by nurse practitioners and physician assistants: a national and state-level Medicare claims analysis." American Journal of Roentgenology 213, no. 5 (2019): 992-997. https://doi.org/10.2214/AJR.19.21306
Mizrahi DJ, Parker L, Zoga AM, Levin DC. National Trends in the Utilization of Skeletal Radiography From 2003 to 2015. J Am Coll Radiol. 2018 Oct;15(10):1408-1414. DOI: 10.1016/j.jacr.2017.10.007 Epub 2018 Mar 23. PMID: 29580717.
Yang BK, Johantgen ME, Trinkoff AM, Idzik SR, Wince J, Tomlinson C. State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical Care Research and Review. 2020;78(3):183-196. doi:10.1177/1077558719901216
Xue, Ying, Viji Kannan, Elizabeth Greener, Joyce A. Smith, Judith Brasch, Brent A. Johnson, and Joanne Spetz. "Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties." Journal of Nursing Regulation 8, no. 4 (2018): 5-13.https://doi.org/10.1016/S2155-8256(17)30176-X