Prescriber influence

The role of nurse practitioners and physician assistants in workers' compensation

The increasing demand for medical care due to the implementation of the Affordable Care Act is changing the healthcare landscape. Shortage of physicians, access to care, changes in reimbursement rules and rates, and a number of underserved patient populations have led to an expansion in the role of Nurse Practitioners (NPs) and Physician Assistants (PAs) in healthcare.

In fact, The Milwaukee Journal Sentinel and MedPage Today reported earlier this year that “non-doctors,” a group which includes NPs and PAs, wrote thirty million prescriptions for narcotic painkillers nationwide in 2013. This is about one third of the 92 million prescriptions written by primary care doctors, according to data provided by IMS Health.


Nurse practitioners
Nurse practitioners are registered nurses who have completed graduate-level education and have trained to provide a broad range of primary care services. According to the American Association of Nurse Practitioners (AANP), there are more than 189,000 NPs practicing in the U.S., the majority of whom work in a primary care setting; however, practice authority differs among the states. Some states allow NPs to evaluate patients, diagnose, order and interpret diagnostic tests, and initiate and manage treatments, including prescribe medications. Others limit these functions by requiring a “collaborative agreement” with, or supervision by, a physician or outside health discipline in order for the NP to provide patient care.

Physician assistants
According to the American Academy of Physician Assistants (AAPA), physician assistants on the other hand, practice medicine under the supervision of a physician, and more than two-thirds work with specialists. Unlike their NP counterparts, in most states, the supervising physician delegates the scope of practice for PAs, and all states including DC permit delegated prescribing by PAs. This means that a PA may prescribe medications – including controlled substances.

Because prescriber demographics and behavior can influence the outcome of a workers’ compensation claim, particularly as relates to potential future costs, the expanding role and prescribing patterns of nurse practitioners and physician assistants warrants a closer look. What we’ve found is that the practice not only appears to be more pronounced in workers’ compensation, but is influencing outcomes.

Workers’ compensation impact
Looking at our data, in 2013, 15.8% of prescriptions for opioid analgesics were written by NPs and PAs, compared to just 14.2% in 2012. This increase is seemingly insignificant until you consider that in 2007, the number was just shy of 7%; which means in six years, the percentage has more than doubled. Not to mention, all else equal, we’ve found that claims with prescriptions written by NPs have an 8% higher long-term pharmacy cost than those written by other prescribers. They also tend to have higher morphine equivalent dose (MED) per prescription. The average MED per prescription is 83 for a NP, while PAs and other prescribers average about 70.

Older claims incur higher costs and involve more prescription medications. Therefore, the influence on cost and MED could simply stem from the fact that NPs are treating older claims. Review of our data reveals that for claims age bands three years and less, NPs are involved with 3 – 4% of injured workers. This number increases to 7% for claims older than three years. Conversely, PA involvement declines as a claim matures.

Another possible cause is the difference in legislation and oversight in each state.For example, some states, like Florida, Alabama, and Louisiana, seem to be dodging the trend entirely, with less than 2% of workers’ compensation prescriptions written by non-doctors. Other states, such as Tennessee and North Carolina are driving the trend more strongly, with 21 – 23% of prescriptions written by non-doctors today, compared with about 10% in 2007. Meanwhile, New Hampshire has long had the highest rate of non-doctors prescribing in workers’ compensation, at more than 30% today. Looking more deeply into these and other states may offer additional insight.

Regardless of the reason, our data shows that a collaborative approach in conjunction with the ability to proactively predict potential high risk, high cost claims sooner positions payers to make better decisions, ultimately leading to earlier claim closure, return to work and greater cost savings.

As the role of NPs and PAs continues to expand, having insight into how these (and other) prescriber demographics and practices influence outcomes along with the clinical expertise, tools and resources to effectively control pharmacy cost and utilization will become increasingly important to a payer’s overall cost containment strategy.