Transcript Will Expanding Role of NPs Increase Costs for Medicare?

Will Expanding Role of NPs
Increase Costs for Medicare?
The National Forum of State Nursing Workforce Centers
Denver, CO
June 10, 2015
Catherine DesRoches • Jennifer Perloff • Peter Buerhaus
Project team
 Peter Buerhaus, Vanderbilt University Medical Ctr
 Jennifer Perloff, Brandeis University
 Catherine DesRoches, Mathematica Policy Research
2
Acknowledgements
 Funders
– Gordon and Betty Moore Foundation
– Johnson & Johnson Campaign for Nursing’s Future
– Robert Wood Johnson Foundation
 Technical Advisory Panel
– Sean Clarke (U Toronto); Kevin Strange (U Michigan); John
Graves, Robert Dittus (Vanderbilt); Lisa Iezzoni (MGH/HMS)
3
Numbers and Scope of Practice
 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 Medicare
– In 2010 ≈ 152,000 NPs billing Medicare
 Over 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
4
Scope of Practice and Projections

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*
*Auerbach, D. 2012. Will the NP workforce grow in the future? New forecasts and implications for
healthcare delivery. Medical Care
5
Why the interest in expanding NPs providing primary care?

Access to care*
– 58 million Americans live in primary care shortage areas

Primary care physician shortages
– HRSA 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***
*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.
6
Why the Interest (Continued)

Preponderance of evidence shows quality of
NP care similar or better than physicians

Substantial government investments in NP
workforce
– Multiple care delivery programs relying on NPs (and
other APRNs), even Medicare
7
Research questions

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?
8
Sample of Medicare Beneficiaries

Sample: 1,000,000 Medicare beneficiaries with
a claim in 2008.
– 800,000 beneficiaries with at least one NP claim
– 200,000 beneficiaries with one or more PCP claims

Analytic 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.
9
Research question 1

What is the geographic distribution of NPs billing
Medicare under their own NPIs and how does this
compare to PCPs?
10
Rate of Number NPs Billing Medicare by State per 1,000
Medicare Beneficiaries
VT
WA
MT
NH
MN
ND
ME
NY
OR
ID
WI
SD
MI
PA
WY
IA
NB
OH
IL
NV
UT
CA
CO
KS
IN
WV
VA
KY
MO
NC
TN
OK
AZ
NM
MS
TX
AK
SC
TN
AK
AL
GA
LA
FL
Greater than 2
1.5 – fewer than 2
HI
Source: Authors preliminary calculations using 2008 Medicare claims data
11
1.3 - fewer than 1.5
.7 – fewer than 1.3
Less than .7
RI
CT
NJ
DC
MD
MA
Research question 2

Are there differences in the overall provision of
primary care services between NPs and PCPs?
12
Are NPs and PCPs billing for different services?
Percent of NP
billed payments
Percent of PCP
billed paymentsb
Evaluation and managementa
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%
aE&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.
Source: Authors preliminary calculations using 2008 Medicare claims data
13
Research question 3

What are the characteristics of NP panels and
how do they differ from PCP panels?
14
Episode Attribution
CAD
Primary
Care
Provider
PCI
Asthma
Specialist 1
Diabetes
Detached
Retina
Specialist 2
15
Episode Attribution with Co-produced Primary Care
Physician
CAD
NP
PCI
Asthma
Specialist 1
Diabetes
Detached
Retina
Specialist 2
16
Evaluation and Management Attribution
Primary Care
(or) E & M
Physician
or NP
•
•
•
•
•
CAD
PCI
Asthma
Diabetes
Detached
Retina
• All Other
Care
Specialist 1
Specialist 2
17
Plurality of Evaluation and Management Assignment
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 NPs
– 51.7% assigned to primary care physicians
– 30.1% assigned to specialists – these
beneficiaries were dropped from the
analysis.
18
Are NPs seeing different types of patients than PCPs?
Mean beneficiary age
All Sample
Beneficiaries
Total NP Assigned
Beneficiaries
Total PCP Assigned
Beneficiaries
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%
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 Indian
0.7%
1.1%
0.7%
Race/Ethnicity*
*NPs assigned beneficiaries are significantly different from PCP assigned beneficiaries at p < .05
Source: Authors preliminary calculations using 2008 Medicare claims data
19
Are NPs seeing different types of patients than PCPs?
Percent
Mean number of comorbidities
100%
Total
75%
73%
69%
NP
MD
NP assigned beneficiaries: .283
75%
PCP assigned beneficiaries: .297
50%
40%
26%
25%
30%
28%
24%
27%
0%
Age
Disability
Dually eligible*
Reason for original qualification for Medicare*
*NPs assigned beneficiaries are significantly different from PCP assigned beneficiaries at p < .05
Source: Authors preliminary calculations using 2008 Medicare claims data
20
Are NPs practicing in different places than PCPs?
NP
PCP
100%
75%
74%
78%
50%
40%* 36%
24%
25%
21%
2%
0%
Urban
Suburban
1%
Rural
Population Density*
*NPs assigned beneficiaries are significantly different from PCP assigned beneficiaries at p < .05
Source: Authors preliminary calculations using 2008 Medicare claims data
21
Primary care
shortage area
Research question 4

Will the increased use of NPs increase costs
for Medicare?
22
Sample of Medicare Beneficiaries
 Random sample of NPs and PCPs with NPIs
 Gathered 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
23
Attribution

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.
24
Analysis


Dependent variables
– The Medicare paid amount on paid claims 2010.
• Part A - inpatient
• Part B – outpatient
• Evaluation and management
– Work relative value unit
Analyses: estimates are adjusted for
– Medicare region
– Urban/rural
– Beneficiary characteristics: age, race, sex, dual status,
clinical severity
– Propensity to see an NP
25
Beneficiary characteristics



Confirms earlier findings
– NP assigned patients are:
• Younger
• Less likely to be white
• More likely to be dual eligible
• More likely to have qualified for Medicare
Clinical severity
– NP assigned patients are less likely to have each of the comorbid 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.
26
Medicare paid amounts
Inpatient
paid
amount
Part B
paid
amount
Evaluation
and
management
paid amount
Total
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 Rsquared
.22
.32
.44
.45
.46
Average
percent
difference NP
to MD
11%
18%
29%
15%
18%
27
Limitations
 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.
28
Discussion

NPs appear to be more likely to provide care to
vulnerable populations of Medicare beneficiaries.
– Rural
– Poor
– Disabled

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.
29
Discussion

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.
30
For More Information
• Catherine M. DesRoches
– [email protected]
• Jennifer Perloff
– [email protected]
• Peter Buerhaus
– [email protected]
31