Pandemic-related increases in provider vacancies did not significantly contribute to changes in claim costs, duration of disability, or types of care provided, according to a new study by the Workers’ Compensation Research Institute (WCRI), which examines recent trends in the health care market. Furthermore, there has been an increased reliance on nurse practitioners (NPs) and physician assistants (PAs), with NPs playing an increasing role in rural areas. Although shifts in the provider landscape affected who provided care, it has minor effects on most outcomes, the study finds.
“Concerns about adequate supply of medical providers are also important given increasing demand for health care services in the general population,” states the report. “Several factors drive the increasing demand for care, including the aging population, overall population growth, expanded insurance coverage under the Affordable Care Act, and the rising prevalence of chronic conditions.”
As a result of this demand, the medical community is concerned that the current supply of primary care physicians (PCPs) is insufficient to meet it. Many PCPs are approaching retirement age and leaving the profession, while the health care market is “characterized by significant rigidity of the physician supply, since the number of physicians cannot be increased in the short term.” Moreover, “the number of new physicians is limited by the restrictions on the number of federally funded graduate medical education positions, which limits the number of residency slots available for physician training, and the capacity of teaching hospitals.”
Impact of COVID-19 on Health Care Workforce
The COVID-19 pandemic further burdened the health care workforce, according to the report. “Medical provider shortages and their implications for access to care were of high concern for many policymakers and system stakeholders…. In the second year of the pandemic, many hospitals reported substantial challenges in filling open positions,” resulting from an “overwhelming burden on health care providers during the COVID-19 pandemic.”
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The longer hours and heavy increase in patients led many health care workers to experience burnout, influencing many to leave the field altogether. As a result, substantial shifts in the type of providers treating workers’ compensation patients have occurred. “Decreases in the number of PCPs, combined with increases in the number of [NPs] and [PAs], contributed to decreases in the likelihood that patients see a physician and increases in the likelihood that patients see a [NP] or [PA] for their office visits.”
At the same time, however, “changes in the aggregate supply of providers had relatively small impacts on the time to first service, the type of care provided, claim costs, and the duration of temporary disability benefits.”
Use of Advanced Practitioners in E&M Visits
The study compares changes in the percentage of first nonemergency evaluation and management (E&M) visits with physicians, NPs, and PAs across different groups of claims. “Claims with more than seven days of lost time versus medical-only claims and claims with the initial visit at an emergency department versus a physician office,” were examined, states the report. Researchers found “a more significant shift away from physicians when looking at less severe claims (those that were medical-only or had fewer than seven days of lost time). Among these claims, the percentage of first-office visits to physicians decreased by 22 percentage points, to 58% in 2022. In contrast, among claims with more than seven days of lost time, 65% of first nonemergency visits were with a physician in 2022.”
Likewise, claims that required an emergency department visit on the day of injury experienced smaller decreases in the percentage of first nonemergency E&M visits to physicians. Among claims that started with emergency department care, 69% went to see a physician for the first nonemergency E&M visit, compared with 58% among claims without emergency department visits. This may suggest traumatic cases may be more likely to receive a follow-up with a physician.
Restrictions for NPs and PAs
In more than half of the states in the U.S., NPs can practice autonomously under full practice authority, while in the rest, NPs may have restrictions on specific aspects of medical care or may need to provide care under a physician’s supervision. “Over the last decade, policy effort has focused on allowing more nurse practitioners to practice independently without physician supervision,” states the report. “Many stakeholders see this change as a way to expand access to care, especially in rural areas, and address shortages of PCPs. However, some express concerns about possible effects on patients’ safety…[as] many of the scope of practice regulations were temporarily relaxed during the COVID-19 pandemic.”
States also differ when it comes to practice authority for PAs, in terms of whether physician assistants have full prescriptive authority; ease of establishing a joint agreement outlining the scope of practice and supervision requirements; co-signing requirements; and limits on the number of physician assistants that a physician can supervise.
Workforce Changes and Comp Claim Outcomes
Changes in Providers Who Treat Workers
The study finds that more physicians in the market leads to a higher percentage of first nonemergency E&M visits with physicians, and a decrease in the number of physicians per capita leads to the opposite outcome. Likewise, an increase in NPs per capita leads to a decrease in first nonemergency E&M visits by physicians. However, the supply of PAs does not have a statistically strong relationship with nonemergency E&M visits performed by physicians.
Changes in the Time to First Service
“The typical (median) worker had the first E&M visit within two days after an injury,” states the report. “At the same time, the average time to the first E&M visit was 15 days, although this measure was driven by potential outlier cases.” The researchers found small changes in the time to the first nonemergency E&M visits in response to changes in the number of providers, with all estimates being small from a policy perspective, but some being statistically significant.
The results “raise a concern that a higher number of NPs in the market may lead to a slight increase in the time to the first E&M service. This may reflect the patients’ preference to see physicians instead of NPs for their first visits…patients waited longer for the first E&M visit when the visit was with a physician instead of an NP.” However, very little evidence was found supporting that changes in the supply of providers affect the types of care workers receive after their injuries.
Changes in the Costs of Care and Duration of Disability
“Changes in the supply of providers have relatively small effects on workers’ compensation costs and the duration of temporary disability benefits at 12 months of maturity,” states the report. “At the same time, we see some evidence that the average duration of temporary disability responds to changes in the supply of advanced practitioners. However, those responses are relatively small…the duration of temporary disability may increase if workers are still required to see a physician before they are released back to work. An increase in the number of PAs leads to a small decrease in the duration of temporary disability benefits.”