Expanding Role of NPs in Medicare Costs

Will Expanding Role of NPs Will Expanding Role of NPs Increase Costs for Medicare? 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 ME VT WA NH MN MT ND MA NY OR RI WI MI ID SD CT NJ DC PA WY IA OH NB MD IN IL WV NV VA UT KY KY CO KS KS MO CA NC TN SC OK TN AK AZ NM GA AL MS TX LA AK FL Greater than 2 1.5 fewer than 2 1.3 - fewer than 1.5 .7 fewer than 1.3 HI Less than .7 Source: Authors preliminary calculations using 2008 Medicare claims data 11

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 80.1% 9.1% 1.3% 4.8% .02% 4.6% 0.2% Percent of PCP billed paymentsb 82.5% 4.6% 3.9% 5.8% 0.0% 2.2% 0.9% Evaluation and managementa Procedures Imaging studies Tests Durable medical equipment Other Unclassified 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? 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 Indian 0.7% 1.1% 0.7% *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 NP MD NP assigned beneficiaries: .283 75% 73% 75% 69% PCP assigned beneficiaries: .297 50% 40% 30% 28% 27% 26% 24% 25% 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% 78% 74% 75% * 50% 40% 36% 24% 21% 25% 2% 1% 0% Urban Suburban Rural Primary care shortage area 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

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 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. 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 713 Intercept 22,898 2,955 705 1,911 NP -2474 -522 -207 -282 -128 Adjusted R- squared Average percent difference NP to MD .22 .32 .44 .45 .46 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 cdesroches@mathematica-mpr.com Jennifer Perloff perloff@brandeis.edu Peter Buerhaus Peter.buerhaus@Vanderbilt.edu 31 31