Advanced Practice Providers: Claims Data and Risk Reduction

A nationwide study of malpractice claims filed between 2012 and 2021 confirmed what most malpractice insurance carriers already know: nurse practitioners and physician assistants (collectively, advanced practice providers or “APPs”) are rarely named as defendants. Nurse practitioners (NPs) and physician assistants (PAs) were named in less than 4% and 5%, respectively, of the more than 65,000 cases studied. Even when APPs are involved in care that results in a lawsuit, they are infrequently named as defendants. It is far more likely that a physician or a health care organization will be named as a defendant. Fewer claims mean lower insurance premiums, and APPs continue to pay far less in yearly premiums than physicians. 

APP claims frequency has remained low even though the total number of APPs nationwide grew by 94% between 2012 and 2021. As we approach 2030, however, APPs’ roles in health care are evolving. In both inpatient and outpatient settings nationwide, APPs are practicing with fewer regulatory requirements for supervision and rendering more and different care to an aging population with increasingly complex health needs. Common sense suggests that under these circumstances, APPs’ claims frequency rates should rise because they have greater claims exposure.  

This article will: 

• • touch on the factors contributing to increased exposure, 
     
  • examine APP claims trends between 2012 and 2021, and
     
  • recommend strategies to mitigate APP liability risk.  

Changing Landscape of Health Care Delivery 

Between 2012 and 2021 the number of new APPs joining the health care workforce grew by 94%, while the number of new physicians edged up by only 19%. As of 2021, one quarter of all U.S. clinicians were APPs. These growth trends are expected to continue.  

By 2029, researchers project that APPs will represent nearly one-third of all U.S. clinicians. By contrast, physician shortages are expected to intensify in coming years. The Association of American Medical Colleges predicts that by 2036 the U.S. will have a shortage of over 20,000 primary care physicians, 10,000 surgeons, and nearly 25,000 specialists. 

At the same time, patient volume is steadily expanding. Patient care needs of an aging population are increasingly complex, but physician reimbursement rates are shrinking. As a result, APPs currently deliver 25% of care in the U.S. and likely will provide even more as we enter the 2030s.  

APPs are utilized in a wide range of settings and medical specialties. Primary care has relied on APPs for years, and their numbers continue to steadily increase in that setting as well as in emergency departments and urgent care facilities. Between 2008 and 2016, data indicates that NPs were joining specialty practices at nearly the same rate as primary care practices.  

In addition, APP practice scope is expanding as state licensing regulations change. NPs are now able to practice independently in more than half of the 50 states. Regulatory restrictions on PAs are also loosening. Recently, Arizona, Colorado, Montana, and Utah (all states where MICA provides coverage) passed legislation giving PAs more autonomy. These laws generally allow PAs with more experience to practice collaboratively, without the need for a supervising physician who remains legally responsible for their care. 

This changing landscape will result in increased liability exposure for APPs that are providing more and increasingly complex care with less physician supervision. Only time will tell whether increased exposure will produce more claims against APPs.  

General Trends in Cases Involving APPs – 2012-2021 

Though it’s impossible to say definitively that APPs will see more claims as they provide more care, there is no downside to planning for that possibility by focusing on risk reduction. One way that all health care professionals can reduce liability risks is to analyze malpractice claims. Claims analysis can reveal where care and process improvements are needed, allowing clinicians and practices to implement changes to reduce risk and improve patient outcomes. 

In the study mentioned above, analyzing 65,000 claims filed between 2012 and 2021, researchers found that the following issues increased the likelihood a case involving an APP will close with payment: 

• • Improper use of equipment;
     
  • Policy or protocol (i.e., failure to adhere to a policy or lack of a policy);
     
  • Insufficient or missing documentation;
     
  • Communication breakdowns among providers;
     
  • Gaps in patient assessment; and
     
  • Improper selection or management of therapy. 

In addition, the study results revealed the following APP-specific trends: 

• • Most cases involving APPs arise out of ambulatory care. 
     
  • PAs are more frequently named in emergency department cases than either NPs or physicians.
     
  • Cases that include an APP defendant are more likely to close with payment, and the average payment is higher than physician-only cases. This may be because cases with multiple defendants often involve more complex care and allegations of higher severity injuries. 

Nurse Practitioner Claims Trends – 2012-2021 

The study also offers insights specific to cases involving NPs. 

The most frequent allegations in cases with a NP defendant are: 

• • Missed/delayed diagnosis (34%)
     
  • Errors in medical treatment (24%)
     
  • Errors in surgical treatment (12%)  

The top contributing factors in cases involving a NP defendant include: 

• • Failure to appreciate or reconcile relevant signs, symptoms, or test results (35%)
     
  • Failure to order a diagnostic test (25%)
     
  • Provider-provider miscommunication about patient’s condition (22%)
     
  • Failure to obtain a consult or referral (18%) 

In cases involving a NP defendant, top services involved in the care at issue include: 

• • General medicine (27%)
     
  • Medicine subspecialities (16%)
     
  • Nursing (11%)
     
  • Emergency medicine (9%)
     
  • Ob/gyn (8%) 

Physician Assistant Claim Trends – 2012-2021 

Physician assistant claims data was also reported in the study. 

The most frequent allegations in cases involving PAs include: 

• • Missed or delayed diagnosis (34%)
     
  • Errors in surgical treatment (28%)
     
  • Errors in medical treatment (21%) 

Nearly half of all cases with a PA defendant involved orthopedic or emergency care. Other top specialty areas where PAs were named include: 

• • General medicine (16%)
     
  • Medicine subspecialties (15%)
     
  • Surgery (9%) 

For cases involving PAs, the top contributing factors include: 

• • Failure to appreciate or reconcile relevant signs, symptoms, or test results (33%)
     
  • Failure to order a diagnostic test (25%)
     
  • Technical performance issues resulting in a known complication (21%)
     
  • Provider-provider miscommunication about a patient’s condition (19%) 

Strategies to Reduce APP Risk 

The contributing factors and top allegations in APP cases, described above, are consistent with historical trends seen in all malpractice cases, regardless of provider type or specialty. For example, two of the most common contributing factors present in malpractice claims generally are provider-provider communication failures and missing or insufficient documentation. In addition, for many years, the leading cause of malpractice claims has been diagnostic error, including missed or delayed diagnoses.  Common breakdowns in the diagnostic process include diagnostic assessment errors, testing and results processing failures, and lapses in follow-up communication and coordination. To reduce risk, APPs and practices should implement standardized processes and systems to address breakdowns in these areas. 

Onboarding and Opportunities for Growth 

The rapid growth of APP numbers means many new graduates, with limited experience, are joining medical practices. To reduce liability risk, promote patient safety, and enhance APP job satisfaction, practices should: 

• • Design a comprehensive orientation program.
     
  • Communicate documentation expectations. 
     
  • Consider standardized documentation protocols, and regularly review medical records to identify documentation issues that may contribute to breakdowns in care.
     
  • Provide education on policies and procedures. 

• • Establish performance expectations and benchmarks and provide regular performance evaluations.
     
  • Provide educational opportunities for growth and to stay current on best practices. 

Communication 

To reduce the risk of credible allegations that physician-APP supervision or collaboration was lacking:  

• • Promote a culture of communication and mentoring between physicians and APPs. 
     
  • APPs that have any doubt or question about clinical decisions, differential diagnoses, scope of practice limitations, and other issues should timely collaborate with or refer to a physician.
     
  • Communicate an open-door policy that encourages APPs to raise questions and concerns with practice leadership.
     
  • Develop a system that provides regular opportunities for physician-APP collaboration, even for APPs with extensive clinical experience.
     
  • APPs and physicians should thoroughly document patient-specific collaborative or supervisory communication in the medical record. 

Strategies to Decrease Diagnostic Errors and Breakdowns in Treatment Decisions 

• • Address diagnostic error risk by implementing protocols to standardize the information gathering process.
     
  • Develop systems designed to “close the loop” on test results, consult reports, and imaging reports and ensure timely clinician action and communication with patients about results and follow up.
     
  • Implement processes to help APPs and other clinicians ensure they follow the latest testing recommendations.