Will Expanding Role of NPs Increase Costs for Medicare? - PowerPoint Presentation

Slide1

Will Expanding Role of NPs Increase Costs for Medicare?

The National Forum of State Nursing Workforce CentersDenver, CO

Catherine DesRoches • Jennifer Perloff • Peter Buerhaus

June 10, 2015Slide2

Peter

Buerhaus, Vanderbilt University Medical CtrJennifer Perloff, Brandeis UniversityCatherine DesRoches,

Mathematica Policy ResearchProject team

2Slide3

Funders

Gordon and Betty Moore FoundationJohnson & Johnson Campaign for Nursing’s FutureRobert Wood Johnson FoundationTechnical

Advisory PanelSean Clarke (U Toronto); Kevin Strange (U Michigan); John Graves, Robert Dittus (Vanderbilt); Lisa Iezzoni (MGH/HMS)

Acknowledgements

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The

Balanced Budget Act of 1997 included an amendment allowing NPs to bill Medicare at 85% of physician fees.*

In 1996 ≈ 64,000 NPs billing MedicareIn 2010 ≈ 152,000 NPs billing MedicareOver

this period, many states changed their regulations to expand NP roles, including permitting NPs to practice independently of

physicians

.

*

Pub.L

. 105–33

, 111 

Stat. 251, enacted August 5, 1997

Numbers and Scope of Practice

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Currently,

22 states and DC permit NPs to practice and prescribe medications without physician oversight; 17 require some physician oversight; 7 require full supervision

NP workforce projections* Adding 6,000 to 7,000 NPs per year ≈ 244,000 NPs by 2025*

Scope of Practice and Projections

5

*Auerbach, D. 2012. Will the NP workforce grow in the future? New forecasts and implications

for

healthcare delivery

.

Medical CareSlide6

Access to

care*58 million Americans live in primary care shortage areas

Primary care physician shortagesHRSA projects shortage of 45,000 by 2020**

Growing

demand for primary

care

32 million Americans obtaining health insurance

Adding between 15 M and 24 M primary care visits by 2019***

Why the interest in expanding NPs providing primary care?

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*Designated Health Professional Shortage Areas (

HPSA

) Statistics, Health Resources and Services Administration (

HRSA

), February 2012. 

**Estimates from the American Academy of Family Physicians.

***Hofer, A., Abraham, J.

Moscovice

, I. (2011). Expansion of Coverage under the Patient Protection and Affordable Care Act and Primary Care Utilization.  The Milbank Quarterly. 89(1):69-89. Slide7

Preponderance of evidence shows quality of NP care similar or better than physicians

Substantial government investments in NP workforceMultiple care delivery programs relying on NPs (and other

APRNs), even MedicareWhy the Interest (Continued)

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What

is the geographic distribution of NPs billing Medicare under their own NPIs and how does this compare to PCPs?Are there differences in the overall provision of primary care services between NPs and PCPs

?What are the characteristics of NP panels and how do they differ from PCP panels? Will the increased use of NPs increase costs for Medicare?

Research

questions

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Sample: 1,000,000 Medicare beneficiaries with a claim in 2008.

800,000 beneficiaries with at least one NP claim200,000 beneficiaries with one or more PCP claimsAnalytic file includes 959,848 Medicare beneficiaries continuously enrolled in Medicare

FFS during the study period.Analytic file was linked with the Area Resource File to describe characteristics of the population where each clinician practiced.

Sample of Medicare Beneficiaries

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What is the geographic distribution of NPs billing Medicare under their own

NPIs and how does this compare to PCPs?

Research question 110Slide11

Source: Authors preliminary calculations using 2008 Medicare claims data

Rate of Number NPs Billing Medicare by State per 1,000 Medicare Beneficiaries

11

WA

MT

WY

KS

NB

SD

ND

MN

WI

TN

VT

MS

KY

KY

KS

MA

ME

NH

AK

HI

FL

TX

LA

VA

IA

MO

AK

OK

AZ

NM

NV

CA

CO

UT

OR

PA

CT

NY

RI

MD

Greater than 2

1.5 – fewer than 2

1.3 - fewer than 1.5

Less than .7

.7 – fewer than 1.3

MI

IL

IN

OH

WV

TN

NC

S

C

GA

AL

NJ

DC

IDSlide12

Are there differences in the overall provision of primary care services between NPs and PCPs?

Research question 2

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a

E&M categories include: 1) Office visits (new and established patients) 2) Hospital visit (initial, subsequent, critical care), 3) Emergency department visit, 4) Home visit, 8) Nursing home visit, 8) Specialist visit (pathology, psychiatry, opthmology, other, consultations)bDistribution of BETOS Categories differ significantly between the two groups of clinicians at the p .05 level.

Are NPs and PCPs billing for different services?

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Source: Authors preliminary calculations using 2008 Medicare claims data

Percent of NP billed payments

Percent of PCP billed

payments

b

Evaluation

and

management

a

80.1%

82.5%

Procedures

9.1%

4.6%

Imaging

studies

1.3%

3.9%

Tests

4.8%

5.8%

Durable medical

equipment

.02%

0.0%

Other

4.6%

2.2%

Unclassified

0.2%

0.9%Slide14

What are the characteristics of NP panels and how do they differ from PCP panels?

Research question 3

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Episode Attribution

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CAD

Asthma

PCI

Diabetes

Detached Retina

Primary Care Provider

Specialist 1

Specialist 2Slide16

Episode Attribution with Co-produced Primary Care

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CAD

Asthma

PCI

Diabetes

Detached Retina

Physician

Specialist 1

Specialist 2

NPSlide17

Evaluation and Management Attribution

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Primary Care (or) E & M

CAD

PCI

Asthma

Diabetes

Detached

Retina

All Other

Care

Physician

or NP

Specialist 1

Specialist 2Slide18

Beneficiaries were assigned to clinicians based on

the clinician providing the plurality of their evaluation and management services.15.2% of beneficiaries were assigned to NPs51.7% assigned to primary care physicians30.1% assigned to specialists – these beneficiaries were dropped from the analysis.

Plurality of Evaluation and Management Assignment

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*NPs assigned beneficiaries are significantly different from PCP assigned beneficiaries at p

< .05

Are NPs seeing different types of patients than PCPs?19

Source: Authors preliminary calculations using 2008 Medicare claims data

All Sample Beneficiaries

Total

NP Assigned

Beneficiaries

Total

PCP Assigned Beneficiaries

Mean beneficiary

age

72.1

71.7

73.0*

Percent of assigned

beneficiaries

Beneficiary

gender*

Male

39.0%

35.3%

37.7%

Female

60.9%

64.7%

62.3%

Race/Ethnicity*

White

87.1%

85.5%

87.4%

Black

8.8%

10.2%

8.5%

Hispanic

.9%

.7%

1.0%

Asian

1.4%

1.4%

1.4%

American Indian0.7%1.1%

0.7%Slide20

*NPs assigned beneficiaries are significantly different from PCP assigned beneficiaries at p

< .05

Are NPs seeing different types of patients than PCPs?20

Source: Authors preliminary calculations using 2008 Medicare claims dataSlide21

Are NPs practicing in different places than PCPs?

21

Source: Authors preliminary calculations using 2008 Medicare claims data

*NPs assigned beneficiaries are significantly different from PCP assigned beneficiaries at p

<

.05Slide22

Will the increased use of NPs increase costs for Medicare?

Research question 4

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Random sample of NPs and PCPs with

NPIsGathered all claims for beneficiaries treated by these clinicians in 2009.128,000 beneficiaries with a claim submitted by an NP and 9,422 NPs.474,000 beneficiaries with a claims submitted by a family or internal medicine physician and 68,069 physicians

Sample of Medicare Beneficiaries

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Used 2009 evaluation and management claims for attribution.

Clinician had to be responsible for the plurality of a beneficiaries claims AND this proportion had to equal at least 30% of the beneficiaries total claims.

Attribution24Slide25

Dependent variables

The Medicare paid amount on paid claims 2010.Part A - inpatientPart B – outpatientEvaluation and managementWork relative value unit

Analyses: estimates are adjusted forMedicare regionUrban/ruralBeneficiary characteristics: age, race, sex, dual status, clinical severityPropensity to see an NP

Analysis

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Confirms earlier findings

NP assigned patients are:Younger Less likely to be whiteMore likely to be dual eligibleMore likely to have qualified for Medicare

Clinical severityNP assigned patients are less likely to have each of the co-morbid conditions except paralysis, neurological conditions, weight loss, alcohol abuse, drug abuse, and psychoses.Propensity score weighting balanced the two groups on all demographic and diagnostic characteristics.Beneficiary characteristics

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Inpatient

paid amount

Part B paid amountEvaluation and management paid amountTotal

dollar adjusted

RVU

Total

dollar adjusted evaluation and management

RVU

Intercept

22,898

2,955

705

1,911

713

NP

-2474

-522

-207

-282

-128

Adjusted R-squared

.22

.32

.44

.45

.46

Average percent difference

NP to MD

11%

18%

29%

15%

18%

Medicare paid amounts

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Propensity score weighting is not perfect.Incident to billing cannot be identified in claims data.

State scope of practice restrictions, organizational regulations, and employment arrangements likely affect NPs propensity to bill under their own NPI.Not generalizable to all NPs.

Limitations28Slide29

NPs appear to be more likel

y to provide care to vulnerable populations of Medicare beneficiaries.RuralPoorDisabled Paid amounts are consistently lower for NP assigned beneficiaries.

RVU modeling suggests differences in practice patterns.Incident to billing continues to limit what we can learn from Medicare claims data.

Discussion

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Increasing the number of NPs providing primary care to Medicare beneficiaries is unlikely to increase costs.

The $207 difference between primary care physicians and NPs on E&M services could result in an estimated savings of $1.03 trillion annually if 5 million beneficiaries had an NP as a primary care providers.

Discussion30Slide31

For More Information

Catherine M. DesRochescdesroches@mathematica-mpr.comJennifer Perloff

perloff@brandeis.eduPeter BuerhausPeter.buerhaus@Vanderbilt.edu