Advertisement

Using Medicare data to assess nurse practitioner–provided care

      Abstract

      Background

      To mitigate shortages of primary care physicians and ensure access to health care services for a growing number of Medicare beneficiaries, some policy makers have recommended expanding the supply and roles of nurse practitioners (NPs). Little is known about the number of NPs billing Medicare or their practice patterns.

      Purpose

      This study examines the geographic distribution and county characteristics of NPs billing Medicare, compares the types and quantities of primary care services provided to Medicare beneficiaries by NPs and primary care physicians, and analyzes the characteristics of beneficiaries receiving primary care from each type of clinician.

      Methods

      We performed a cross-sectional analysis of 2008 Medicare administrative data from 959,848 aged and/or disabled beneficiaries continuously enrolled in fee-for-service Medicare during the study period. Outcome measures included geographic distribution of NPs measured by the rate of NPs per 1,000 Medicare beneficiaries by state, average utilization, and patient characteristics.

      Discussion

      States with the highest rate of NPs billing were rural. Over 80% of the payments received by both NPs and primary care physicians were for evaluation and management services. Beneficiaries assigned to an NP were more likely to be female, to be dually eligible for Medicare and Medicaid, and to have qualified for Medicare because of a disability. NPs with assigned beneficiaries were significantly more likely than similar primary care physicians to practice in federally designated primary care shortage areas.

      Conclusions

      Approximately 45,000 NPs were providing services to beneficiaries and billing under their own provider numbers in 2008. Aspects of NP practice patterns were different from primary care physicians, and NPs appeared more likely to provide services to disadvantaged Medicare beneficiaries.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Nursing Outlook
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Aiken L.
        Nurses for the future.
        N Engl J Med. 2011; 364: 196-198https://doi.org/10.1056/NEJMp1011639
        • Andrews M.
        With doctors in short supply, responsibilities for nurses may expand.
        The New York Times, 2009, November 6 (p. 1)
        • Association of American Medical Colleges Center for Workforce Studies
        Recent Studies and Reports on Physician Shortages in the U.S.
        AAMC, Washington, DC2008
        • Bach P.
        • Guadagnoli E.
        • Schrang D.
        • Schussler N.
        • Warren J.
        Patient demographic and socioeconomic characteristics in the SEER-Medicare database applications and limitations.
        Med Care. 2002; 40: 19-25
      1. Balanced Budget Act of 1997, 105-33, 105th Cong. (1997).

        • Brooten D.
        • Naylor M.D.
        • York R.
        • Brown L.P.
        • Munro B.H.
        • Hollingsworth A.O.
        • Youngblut J.M.
        Lessons learned from testing the quality cost model of advanced practice nursing (APN) transitional care.
        Journal of Nursing Scholarship. 2002; 20: 158-163
      2. Bureau of Health Professions, HRSA, HHS. Data as of september 9/10/2011. Retrieved from http://bhpr.hrsa.gov/shortage/.

        • Chang C.
        • Stukel T.A.
        • Flood A.B.
        • Goodman D.C.
        Primary care physician workforce and Medicare beneficiaries' health outcomes.
        J Am Med Assoc. 2011; 305: 2096-2105https://doi.org/10.1001/jama.2011.665
        • Cooper R.
        New directions for nurse practitioners and physician assistants in the era of physician shortages.
        Acad Med. 2007; 82: 827-828
        • Deshefy-Longhi T.
        • Swartz M.K.
        • Grey M.
        Characterizing nurse practitioner practice by sampling patient encounters: an APRNet study.
        J Am Acad Nurse Pract. 2008; 20: 281-287https://doi.org/10.1111/j.1745-7599.2008.00318.x
        • Dierick-van Daele A.
        • Metsemakers J.
        • Derckx E.
        • Spreeuwenberg C.
        • Vrijhoef H.
        Nurse practitioners substituting for general practitioners: Randomized controlled trial.
        J Adv Nurs. 2009; 65: 391-401https://doi.org/10.1111/j.1365-2648.2008.04888.x
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Elsom S.
        • Happell B.
        • Manias E.
        Nurse practitioners and medical practice: Opposing forces or complementary contributions?.
        Perspect Psychiatr Care. 2009; 45: 9-16https://doi.org/10.1111/j.1744-6163.2009.00195.x
        • Fairman J.A.
        • Rowe J.W.
        • Hassmiller S.
        • Shalala D.E.
        Broadening the scope of nursing practice.
        N Engl J Med. 2011; 364: 193-196https://doi.org/10.1056/NEJMp1012121
        • Fisher E.
        • Wennberg D.
        • Stukel T.
        • Gottlieb D.
        • Lucas F.
        • Pinder E.
        The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care.
        Ann Intern Med. 2003; 138: 273-287
        • PwC
        Health Insurance Exchanges: Long on Options, Short on Time.
        PwC Health Research Institute, New York2012
      3. Health Resources and Services Administration. Primary medical care HPSA designation overview. Retrieved from http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsaoverview.html.

        • Health Resources and Services Administration
        The registered nurse population: Findings from the national sample survey of registered nurses.
        U.S Department of Health and Human Services, Washington, DC2010
      4. Henry J. Kaiser Family Foundation. (2012). Total number of Medicare beneficiaries, 2012. Retrieved from http://www.statehealthfacts.org/comparemaptable.jsp?yr=63&typ=1&ind=290&cat=6&sub=74.

        • Hofer A.
        • Abraham J.
        • Moscovice I.
        Expansion of coverage under the Patient Protection and Affordable Care Act.
        Millbank Q. 2011; 89https://doi.org/10.1111/j.1468-0009.2011.00620.x
        • Horrocks S.
        • Anderson E.
        • Salisbury C.
        Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.
        British Medical Journal. 2002; 324: 819-823https://doi.org/10.1136/bmj.324.7341.819
        • Iglehart J.
        Medicare, graduate medical education, and new policy directions.
        N Engl J Med. 2008; 359: 643-650https://doi.org/10.1056/NEJMhpr0803754
        • Institute of Medicine
        The Future of Nursing: Leading Change, Advancing Health.
        The National Academies Press, Washington, DC2011
        • Jencks S.
        • Huff E.
        • Cuerdon T.
        Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001.
        J Am Med Assoc. 2003; 289: 1670-1676
        • Kaplan L.
        • Skillman S.M.
        • Fordyce M.A.
        • McMenamin P.D.
        • Doescher M.P.
        Understanding APRN Distribution in the United States using NPI Data.
        J Nurse Pract. 2012; 8: 626-635https://doi.org/10.1016/jnurpra.2012.05.022
        • Ku L.
        • Jones K.
        • Shin P.
        • Bruen B.
        • Hayes K.
        The states' next challenge–securing primary care for expanded medicaid populations.
        N Engl J Med. 2011; 364: 493-495https://doi.org/10.1056/NEJMp1011623
        • Laurant M.
        • Hermens R.
        • Braspenning J.
        • Akkermans R.P.
        • Sibbald B.
        • Grol R.P.
        An overview of patients' preferences for, and satisfaction with, care provided by general practitioners and nurse practitioners.
        J Clin Nurs. 2008; 17: 2690-2698https://doi.org/10.1111/j.1365-2702.2008.02288.x
        • McGlynn E.
        • Asch S.
        • Adams J.
        • Keesey J.
        • Hicks J.
        • DeCristofaro A.
        • Kerr E.
        The quality of health care delivered to adults in the United States.
        N Engl J Med. 2003; 348: 2635-2645https://doi.org/10.1056/NEJMsa022615
        • Medpac
        Report to Congress: Reforming the Delivery System.
        Medpac, Washington, D.C.2008
        • Mundinger M.
        • Kane R.
        • Lenz E.
        • Trotten A.
        • Tsai W.
        • Cleary P.
        • Shelanski M.
        Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial.
        J Am Med Assoc. 2000; 283: 59-68https://doi.org/10.1001/jama.283.1.59
        • Naylor M.D.
        • Kurtzman E.T.
        The role of nurse practitioners in reinventing primary care.
        Health Aff (Millwood). 2010; 29: 893-899https://doi.org/10.1377/hlthaff.2010.0440
      5. Pear, R. Shortage of Doctors an Obstacle to Obama Goals. (2009, April 26). The New York Times, p. 1.

      6. Pearson, L. The 2012 Pearson Report: A National Overview of Nurse Practitioner Legislation and Health Care Issues, NP Communications, LLC, Monroe Township, N.J.

        • Pham H.
        • Schrag D.
        • O'Malley A.
        • Wu B.
        • Bach P.
        Care patterns in Medicare and their implications for pay for performance.
        N Engl J Med. 2007; 356: 1130-1139https://doi.org/10.1056/NEJMsa063979
        • Public Broadcast System
        Are nurse practitioners the solution to shortage of primary care doctors.
        Public Broadcast System (Director), 2011, May 26 ([Video/DVD])
        • Roblin D.
        • Becker E.
        • Adams E.
        • Howard D.
        • Roberts M.
        Patient satisfaction with primary care: Does type of practitioner matter?.
        Med Care. 2004; 42: 579-590
        • SAS Institute Inc.
        SAS Base 9.2, Procedures Guide.
        The SAS Institute, Cary, NC2011
        • Southern D.A.
        • Quan H.
        • Ghali W.A.
        Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data.
        Med Care. 2004; 42: 355-360
        • Spratley E.
        • Johnson A.
        • Sochalski J.
        • Fritz M.
        • Spencer W.
        The registered nurse population: findings from the national sample survey of registered nurses.
        Division Nursing, Bur Health Professions, Health Resour Serv Administration, U.S Department of Health and Human Services, Washington, D.C.2002
        • Staiger D.O.
        • Auerbach D.I.
        • Buerhaus P.I.
        Comparison of physician workforce estimates and supply projections.
        J Am Med Assoc. 2009; 302: 1674-1680https://doi.org/10.1001/jama.2009.1461
        • U.S. Congress, Office of Technology Assessement
        Nurse practitioners, physician assistants, and certified nurse midwives: a policy analysis (No. OTA-hcs-37:5).
        U.S. Government Printing Office, Washington, D.C.1986
        • United States Government Accountability Office
        Primary care professionals: Recent supply trends, projections, and valuation of services. (No. GAO-08–472T).
        U. S. Government Accountability Office, Washington, D.C.2008
        • West C.P.
        • Dupras D.M.
        General medicine vs. subspecialty career plans among internal medicine residents.
        J Am Med Assoc. 2012; 308: 2241-2247https://doi.org/10.1001/jama.2012.47535
      7. World Health Organization. Life tables. Retrieved from http://apps.who.int/whosis/database/life_tables.cfm.