APRNs Are Aces Again at Primary Care

By Peter McMenamin posted 08-16-2013 16:26


Two-thirds of NPs Recognized by CMS for Primary Care Excellence

For Calendar Year 2012 there were 35,080 NPs and 637 CNSs awardees under the Primary Care Incentive Program (PCIP) instituted through the Affordable Care Act, §5501(a).  That section of the Affordable Care Act authorized a quarterly incentive payment program to augment the Medicare payment for primary care services when furnished by primary care practitioners beginning in 2011 and ending in 2015.  NP winners of PCIP awards received $49,693,372 and CNS winners received $1,146,898.  The 2012 incentive payments represented a 27% increase for NPs and a 34% increase for CNSs relative to 2011, the first year of the program.  The number of NPs who won awards increased 46% with CNSs increasing by 55%.  The number of award winners practicing in rural areas also increased substantially.  With respect to winning clinicians across all specialties there were 62% more practicing in rural areas than there were in the prior year.  Rural NPs who won PCIP payments more than doubled, from 3181 to 7226.

Those selected APRNs, certain primary care physician specialties, and PAs were eligible for the incentive payment if their primary care services (CPT codes 99201 through 99215 and 99304 through 99350) accounted for at least 60 percent of their total allowed charges under the physician fee schedule in the qualifying calendar year.  Emergency, hospital in-patient, drug and laboratory charges were not included when making the 60% calculation.  To identify the clinicians that qualified CMS used Medicare claims data from the calendar year 2010 (two years prior to the PCIP incentive payment year).  During that year 52,062 NPs and 2519 CNSs provided services to Medicare fee-for-service beneficiaries.  That means that one quarter of the CNSs and over two thirds of the NPs excelled at providing primary care to their Medicare patients.  With respect to the NPs, this finding is in sharp contrast to the assertion through “inferential assignment” from The Robert Graham Center that only 52% of NPs are “practicing primary care.”  The Graham Center methodology deemed an NP to be practicing primary care if more than half of any physicians working in the same location as the NP exhibited primary care specialties on their NPI application.  An NP with no co-located physicians was deemed to be practicing primary care. 

In fact, many NPs who work with non-primary care physicians provide primary care services for those practices’ patients.  The CMS findings are based on auditable claims submitted to Medicare carriers.  This performance based assessment (backed up by nearly $50 million in incentive payments) should carry more weight than the inferential assignments based on the specialty mix of physicians who happen to also practice in the NPs’ neighborhoods.

CMS does tabulate data from individuals' applications for an NPI.  In particular, they ask applicants to identify their primary provider taxonomy code to specifically describe their specialty.  There are 18 separate codes available for nurse practitioners.  Based on CMS data from 2010 and 2011 regarding the NPs who directly bill Medicare Part B carriers, only 15% of participating NPs indicated a primary taxonomy that involved non-primary care: Acute Care, Critical Care, Neonatal, Neonatal Critical Care, Pediatrics Critical Care, Perinatal, and Psychiatric/Mental Health.  Thus based on their own appraisals of their practice orientation, 85% of NPs who bill for providing Part B services using their own NPI believe their focus is primary care.

This pattern observed among NPs who directly participate in Medicare Part B appears likely to be replicated among new NP grads.  Joanne Pohl, Debra Barksdale, and Kitty Werner analyzed 2012 data on new NP graduates collected by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties. Those data showed a continued increase in primary care.  Primary care NP graduates include those prepared as pediatric, family, adult, gerontological, adult/gerontological, and women’s health NPs.  Primary Care NP graduates accounted for 84 percent of all NP graduates in 2012 whereas U.S. medical school primary care matches accounted for about 14.6 percent of the U.S. matches including international medical graduates.  There were 11,764 new NPs graduating in primary care compared to 3,718 new physicians entering primary care residencies.

As it happens, CMS does not track primary care services provided by NPs or CNSs that are billed incident to physician services of those primary care practices that may (or may not) have won PCIP awards.  We can only guess about how many APRNs might have qualified “incident to” because at the national level there are virtually no data on how many APRNs have services billed in that fashion.  Therefore the count of 35,717 APRN PCIP winners is at best a minimum estimate of the total number of APRNs whose primary care service billings were at least 60% of their total.  Further, because of the discriminatory 15% discount applied to NP and CNS and PA approved charges to Medicare, those clinicians received 10.6% of the awards, but provided no less than 12.2% of the primary care services that were recognized.