Reimbursement for Nurse Practitioners
Reimbursement for Nurse Practitioners
The Issue
Medicare Part B Advanced Practice Nurse (APN) Reimbursement Revision
Triggering Mechanism
According to the American Association of Colleges of Nursing (AACN), its members voted on October 25, 2004 to “move the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate level by the year 2015” (American Association of Colleges of Nursing, 2009). This shift will place the educational level of new advanced practice nurses (APN) on par with Medical Doctors (MD). The legislation in question was enacted in 1998, well before this new policy to increase the educational standard for APNs; therefore, doctorate prepared nurses were not a consideration in this policy’s development (The United States Federal Government, 1998). The drafters of this legislation wrote it with the understanding that the standard of education for APNs was a Master’s Degree (The United Stated Federal Government, 2002). Since there is no statistical difference between the patient outcomes of APNs and MDs, one may infer that the drafters placed these restrictions on APN reimbursement due to a lower educational level when compared with MDs (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
Current Medicare Part B Policy
§ 414.56 Payment for nurse practitioners' and clinical nurse specialists' services.
a) Rural areas. For services furnished beginning January 1, 1992 and ending December 31, 1997, allowed amounts for the services of a nurse practitioner or a clinical nurse specialist in a rural area (as described in section 1861(s)(2)(K)(iii) of the Act) may not exceed the following limits:
(1) For services furnished in a hospital (including assistant-at-surgery services), 75 percent of the physician fee schedule amount for the service.
(2) For all other services, 85 percent of the physician fee schedule amount for the service.
(b) Non-rural areas. For services furnished beginning January 1, 1992 and ending December 31, 1997, allowed amounts
for the services of a nurse practitioner or a clinical nurse specialist in a nursing facility may not exceed 85 percent of the physician fee schedule amount for the service.
(c) Beginning January 1, 1998. For services (other than assistant-at-surgery services) furnished beginning January 1, 1998, allowed amounts for the services of a nurse practitioner or clinical nurse specialist may not exceed 85 percent of the physician fee schedule amount for the service. For assistant-at-surgery services, allowed amounts for the services of a nurse practitioner or clinical nurse specialist may not exceed 85 percent of the physician fee schedule amount that would be allowed under the physician fee schedule if the assistant-at-surgery service were furnished by a physician.
[63 FR 58911, Nov. 2, 1998] (The United States Federal Government, 1998).
Policy Recommendations
Currently, Medicare Part B is reimbursing APNs at a lesser rate than their MD colleagues. Since APNs produce patient outcomes with no statistical difference from MDs’, the only item that separates APNs from MDs is educational level (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009). However, in 2015, the American Association of Colleges of Nursing will eliminate this disparity by requiring new APNs to receive doctorate level education (American Association of Colleges of Nursing, 2009). With APNs producing statistically similar patient outcomes to MDs, and receiving an equivalent education to MDs, there is reason that APNs cannot receive the same reimbursement as MDs; therefore, recommendation for policy change include reimbursing APNs at the same rate for services as MDs, starting January 1, 2015.
Person’s Responsible for Taking on the Cause
The United States Senate
The United States House of Representatives
The President of the United States
Associations of Nursing (American Nurses Association, American Association of Colleges of Nursing, National Student Nurses’ Association, and the various state nurses’ associations).
Individual APNs
Obvious Stakeholders
APNs
o Effects of this Policy (Impact) - APNs receive less reimbursement, when compared with MDs for, providing the same services with no statistically significant difference in patient outcomes (Phillips, 2007, p. 26) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Efficiency (Cost vs. Benefit) - APNs receive less reimbursement, even though they are providing similar services to that of MDs. In addition, APNs provide similar quality of care and yield similar patient outcomes to that of MDs; however, they are still reimbursed at a lesser rate, and now they will have to incur the increased cost of graduate level education (Phillips, 2007, pp. 26-27) (Schuttelaar, M.L.A., Vermeulen, K.M., Drukker, N., & Coenraads, P.J., 2010, pp. 167-168).
o Equity (Fairness) - APNs produce patient outcomes that yield no statistically significant differences from those of MDs, and yet, they are still reimbursed at a lesser rate than MDs (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398) (The United States Federal Government, 1998). In addition, in 2015, most new APNs will be required to receive doctorate level education, which will eliminate the educational disparity.
Medicare
o Effects of this Policy (Impact) - Medicare benefits when its patients see APNs, because they can pay APNs less for providing the same services as MDs with no statistical difference in patient outcomes (The United States Federal Government, 1998) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Efficiency (Cost vs. Benefit) - Medicare saves money when patients see APNs, because they do not pay them as much for providing the same services (Phillips, 2007, p. 27). This benefits Medicare tremendously, because it pays out less for services that yield no statistical difference in patient outcomes (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Equity (Fairness) - Once new APNs are required to receive doctorate level education, Medicare will no longer be able to justify paying APNs less for the same services, because they produce patient outcomes that have no statistically significant difference from those of MDs, and because APNs will have an equivalent education to that of MDs (American Association of Colleges of Nursing, 2009) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
Taxpayers
o Effects of this Policy (Impact) - When Medicare patients see APNs, taxpayers save money, because APNs do not receive the same reimbursement for services that MDs do (Phillips, 2007, p. 26).
o Efficiency (Cost vs. Benefit) - Taxpayers save money when Medicare patients see APNs, because not as many tax dollars are spent for health care services when compared with the cost of MDs (Phillips, 2007, p. 26). In addition, this policy allows tax payers to pay less for the same quality of care provided by MDs (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Equity (Fairness) - Taxpayers no can no longer justify paying APNs less for the same services as MDs, because APNs produce patient outcomes with no statistical difference from the patient outcomes of MDs, and because as of 2015, APNs will require preparation at the doctorate level (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398) (American Association of Colleges of Nursing, 2009).
Health Care Organizations
o Effects of this Policy (Impact) - If APNs receive less reimbursement for services than MDs, health care organizations are obligated to pay APNs less for the same services. For instance, in the United States, the average Nurse Practitioner makes $89,345 per year (Salary.com, 2011). On the other hand, the average MD in the United states makes $172,627 per year for providing the same services with no statistical difference in patient outcomes (Salary.com, 2011) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Efficiency (Cost vs. Benefit) - Currently, APNs are a cost effective alternative to MDs, because healthcare organizations can pay them much less for providing the same services and patient outcomes as an MD (Salary.com, 2011) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Equity (Fairness) - Since APNs are reimbursed at a lesser rate than MDs by Medicare, Medicaid, and other insurance providers, health care organizations are justified in paying them a lesser salary than MDs; however, if this policy changes, then APNs would be entitled to equal compensation to that of MDs (Chapman, S.A., Wides, C.D., & Spetz, J., 2010).
Barriers to Implementation
Medicare Funding – In the downturn of the economy and the proportional increase of the age 65 and older population, Medicare’s resources have been stretched thin. In fact congress has been making attempts at cutting Medicare expenditures through reducing reimbursement for care provided (Reiser, W.S. & Brunicard, B.O., 2002, p. 68).
Taxes – Generally, taxpayers are unwilling to approve of tax increases, as most Americans resent parole taxes (income tax, social security, Medicare, Medicaid) to begin with (Cole, R.L. & Cincaid, J., 2001, p. 14). This being the case, many in congress would not approve raising taxes to provide more funding to Medicare Part B, because their constituents would disapprove. Voting to increase taxes could jeopardize their chances for reelection.
Medicare Part B Premiums – Medicare Part B expenditures have been increasing by approximately 11% per year. This has resulted in higher premiums for older adults who are likely on fixed incomes (Healthcare Financial Management, 2005). Higher premiums could result in some older adults being unable to afford Part B coverage.
References
American Association of Colleges of Nursing. (2009, October 5). Position Statement on the Practice Doctorate in Nursing. Retrieved April 1, 2011, from American Association ofColleges of Nursing:
http://www.aacn.nche.edu/DNP/dnpfaq.htm.
Chapman, S.A., Wides, C.D.,& Spetz, J. (2010). Payment regulations for advanced practice nurses: Implications for primary care. Policy, Politics and Nursing Practice, 11(2), 89-98.
Cole, R.L. & Cincaid, J. (2001). Public opinion and American federalism: Perspectives on taxes, spending, and trust. Spectrum: The Journal of State Government, 74(3), 14-18.
Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M. (2009). Nurse practitioners substituting for general practitioners: Randomized control trial. Journal of Advanced Nursing, 65(2), 391.401.
Healthcare Financial Management. (2005). Part B premiums to increase 12 percent. Healthcare Financial Management, 59(5), 16.
Phillips, S. (2007). NPs Face Challenges in the U.S. and the UK. The Nurse Practitioner, 32(7), 25-29.
Reiser, W.S. & Brunicard, B.O. (2002). Assessing the impact of Medicare payment changes. Healthcare Financial Managment, 56(6), 68-71.
Salary.com. (2011). Salary Wizard. Retrieved April 2, 2011, from Salary.com: http://www1.salary.com/Nurse-Practitioner-salary.html.
Salary.com. (2011). Salary Wizard. Retrieved April 2 2, 2011, from Salary.com: http://www1.salary.com/Physician-Family-Practice-salary.html.
Schuttelaar, M.L.A., Vermeulen, K.M., Drukker, N., & Coenraads, P.J. (2010). A randomized controlled trial in children with eczema: Nurse practitioner vs. dermatologist. British Journal of Dermatology, 62, 162-170.
The United Stated Federal Government. (2002, January 24). Advanced education nursing grants. Retrieved April 1, 2011, from Justia US Law: http://law.justia.com/codes/us/title42/42usc296j.html.
The United States Federal Government. (1998, November 2). Payment for nurse practitioners' and clinical nurse specialists' services. Retrieved April 1, 2011, from Justia US Law: http://law.justia.com/cfr/title42/42-2.0.1.2.14.2.51.20.html.
Casey FowlerPetition Starter
This petition had 71 supporters
The Issue
Medicare Part B Advanced Practice Nurse (APN) Reimbursement Revision
Triggering Mechanism
According to the American Association of Colleges of Nursing (AACN), its members voted on October 25, 2004 to “move the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate level by the year 2015” (American Association of Colleges of Nursing, 2009). This shift will place the educational level of new advanced practice nurses (APN) on par with Medical Doctors (MD). The legislation in question was enacted in 1998, well before this new policy to increase the educational standard for APNs; therefore, doctorate prepared nurses were not a consideration in this policy’s development (The United States Federal Government, 1998). The drafters of this legislation wrote it with the understanding that the standard of education for APNs was a Master’s Degree (The United Stated Federal Government, 2002). Since there is no statistical difference between the patient outcomes of APNs and MDs, one may infer that the drafters placed these restrictions on APN reimbursement due to a lower educational level when compared with MDs (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
Current Medicare Part B Policy
§ 414.56 Payment for nurse practitioners' and clinical nurse specialists' services.
a) Rural areas. For services furnished beginning January 1, 1992 and ending December 31, 1997, allowed amounts for the services of a nurse practitioner or a clinical nurse specialist in a rural area (as described in section 1861(s)(2)(K)(iii) of the Act) may not exceed the following limits:
(1) For services furnished in a hospital (including assistant-at-surgery services), 75 percent of the physician fee schedule amount for the service.
(2) For all other services, 85 percent of the physician fee schedule amount for the service.
(b) Non-rural areas. For services furnished beginning January 1, 1992 and ending December 31, 1997, allowed amounts
for the services of a nurse practitioner or a clinical nurse specialist in a nursing facility may not exceed 85 percent of the physician fee schedule amount for the service.
(c) Beginning January 1, 1998. For services (other than assistant-at-surgery services) furnished beginning January 1, 1998, allowed amounts for the services of a nurse practitioner or clinical nurse specialist may not exceed 85 percent of the physician fee schedule amount for the service. For assistant-at-surgery services, allowed amounts for the services of a nurse practitioner or clinical nurse specialist may not exceed 85 percent of the physician fee schedule amount that would be allowed under the physician fee schedule if the assistant-at-surgery service were furnished by a physician.
[63 FR 58911, Nov. 2, 1998] (The United States Federal Government, 1998).
Policy Recommendations
Currently, Medicare Part B is reimbursing APNs at a lesser rate than their MD colleagues. Since APNs produce patient outcomes with no statistical difference from MDs’, the only item that separates APNs from MDs is educational level (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009). However, in 2015, the American Association of Colleges of Nursing will eliminate this disparity by requiring new APNs to receive doctorate level education (American Association of Colleges of Nursing, 2009). With APNs producing statistically similar patient outcomes to MDs, and receiving an equivalent education to MDs, there is reason that APNs cannot receive the same reimbursement as MDs; therefore, recommendation for policy change include reimbursing APNs at the same rate for services as MDs, starting January 1, 2015.
Person’s Responsible for Taking on the Cause
The United States Senate
The United States House of Representatives
The President of the United States
Associations of Nursing (American Nurses Association, American Association of Colleges of Nursing, National Student Nurses’ Association, and the various state nurses’ associations).
Individual APNs
Obvious Stakeholders
APNs
o Effects of this Policy (Impact) - APNs receive less reimbursement, when compared with MDs for, providing the same services with no statistically significant difference in patient outcomes (Phillips, 2007, p. 26) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Efficiency (Cost vs. Benefit) - APNs receive less reimbursement, even though they are providing similar services to that of MDs. In addition, APNs provide similar quality of care and yield similar patient outcomes to that of MDs; however, they are still reimbursed at a lesser rate, and now they will have to incur the increased cost of graduate level education (Phillips, 2007, pp. 26-27) (Schuttelaar, M.L.A., Vermeulen, K.M., Drukker, N., & Coenraads, P.J., 2010, pp. 167-168).
o Equity (Fairness) - APNs produce patient outcomes that yield no statistically significant differences from those of MDs, and yet, they are still reimbursed at a lesser rate than MDs (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398) (The United States Federal Government, 1998). In addition, in 2015, most new APNs will be required to receive doctorate level education, which will eliminate the educational disparity.
Medicare
o Effects of this Policy (Impact) - Medicare benefits when its patients see APNs, because they can pay APNs less for providing the same services as MDs with no statistical difference in patient outcomes (The United States Federal Government, 1998) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Efficiency (Cost vs. Benefit) - Medicare saves money when patients see APNs, because they do not pay them as much for providing the same services (Phillips, 2007, p. 27). This benefits Medicare tremendously, because it pays out less for services that yield no statistical difference in patient outcomes (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Equity (Fairness) - Once new APNs are required to receive doctorate level education, Medicare will no longer be able to justify paying APNs less for the same services, because they produce patient outcomes that have no statistically significant difference from those of MDs, and because APNs will have an equivalent education to that of MDs (American Association of Colleges of Nursing, 2009) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
Taxpayers
o Effects of this Policy (Impact) - When Medicare patients see APNs, taxpayers save money, because APNs do not receive the same reimbursement for services that MDs do (Phillips, 2007, p. 26).
o Efficiency (Cost vs. Benefit) - Taxpayers save money when Medicare patients see APNs, because not as many tax dollars are spent for health care services when compared with the cost of MDs (Phillips, 2007, p. 26). In addition, this policy allows tax payers to pay less for the same quality of care provided by MDs (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Equity (Fairness) - Taxpayers no can no longer justify paying APNs less for the same services as MDs, because APNs produce patient outcomes with no statistical difference from the patient outcomes of MDs, and because as of 2015, APNs will require preparation at the doctorate level (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398) (American Association of Colleges of Nursing, 2009).
Health Care Organizations
o Effects of this Policy (Impact) - If APNs receive less reimbursement for services than MDs, health care organizations are obligated to pay APNs less for the same services. For instance, in the United States, the average Nurse Practitioner makes $89,345 per year (Salary.com, 2011). On the other hand, the average MD in the United states makes $172,627 per year for providing the same services with no statistical difference in patient outcomes (Salary.com, 2011) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Efficiency (Cost vs. Benefit) - Currently, APNs are a cost effective alternative to MDs, because healthcare organizations can pay them much less for providing the same services and patient outcomes as an MD (Salary.com, 2011) (Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M., 2009, p. 398).
o Equity (Fairness) - Since APNs are reimbursed at a lesser rate than MDs by Medicare, Medicaid, and other insurance providers, health care organizations are justified in paying them a lesser salary than MDs; however, if this policy changes, then APNs would be entitled to equal compensation to that of MDs (Chapman, S.A., Wides, C.D., & Spetz, J., 2010).
Barriers to Implementation
Medicare Funding – In the downturn of the economy and the proportional increase of the age 65 and older population, Medicare’s resources have been stretched thin. In fact congress has been making attempts at cutting Medicare expenditures through reducing reimbursement for care provided (Reiser, W.S. & Brunicard, B.O., 2002, p. 68).
Taxes – Generally, taxpayers are unwilling to approve of tax increases, as most Americans resent parole taxes (income tax, social security, Medicare, Medicaid) to begin with (Cole, R.L. & Cincaid, J., 2001, p. 14). This being the case, many in congress would not approve raising taxes to provide more funding to Medicare Part B, because their constituents would disapprove. Voting to increase taxes could jeopardize their chances for reelection.
Medicare Part B Premiums – Medicare Part B expenditures have been increasing by approximately 11% per year. This has resulted in higher premiums for older adults who are likely on fixed incomes (Healthcare Financial Management, 2005). Higher premiums could result in some older adults being unable to afford Part B coverage.
References
American Association of Colleges of Nursing. (2009, October 5). Position Statement on the Practice Doctorate in Nursing. Retrieved April 1, 2011, from American Association ofColleges of Nursing:
http://www.aacn.nche.edu/DNP/dnpfaq.htm.
Chapman, S.A., Wides, C.D.,& Spetz, J. (2010). Payment regulations for advanced practice nurses: Implications for primary care. Policy, Politics and Nursing Practice, 11(2), 89-98.
Cole, R.L. & Cincaid, J. (2001). Public opinion and American federalism: Perspectives on taxes, spending, and trust. Spectrum: The Journal of State Government, 74(3), 14-18.
Dierick-van Daele, A.T.M., Metsemakers, J.F.M., Derckx. E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M. (2009). Nurse practitioners substituting for general practitioners: Randomized control trial. Journal of Advanced Nursing, 65(2), 391.401.
Healthcare Financial Management. (2005). Part B premiums to increase 12 percent. Healthcare Financial Management, 59(5), 16.
Phillips, S. (2007). NPs Face Challenges in the U.S. and the UK. The Nurse Practitioner, 32(7), 25-29.
Reiser, W.S. & Brunicard, B.O. (2002). Assessing the impact of Medicare payment changes. Healthcare Financial Managment, 56(6), 68-71.
Salary.com. (2011). Salary Wizard. Retrieved April 2, 2011, from Salary.com: http://www1.salary.com/Nurse-Practitioner-salary.html.
Salary.com. (2011). Salary Wizard. Retrieved April 2 2, 2011, from Salary.com: http://www1.salary.com/Physician-Family-Practice-salary.html.
Schuttelaar, M.L.A., Vermeulen, K.M., Drukker, N., & Coenraads, P.J. (2010). A randomized controlled trial in children with eczema: Nurse practitioner vs. dermatologist. British Journal of Dermatology, 62, 162-170.
The United Stated Federal Government. (2002, January 24). Advanced education nursing grants. Retrieved April 1, 2011, from Justia US Law: http://law.justia.com/codes/us/title42/42usc296j.html.
The United States Federal Government. (1998, November 2). Payment for nurse practitioners' and clinical nurse specialists' services. Retrieved April 1, 2011, from Justia US Law: http://law.justia.com/cfr/title42/42-2.0.1.2.14.2.51.20.html.
Casey FowlerPetition Starter
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The Decision Makers
U.S. Senate
2 MembersWashington
U.S. Senate - Washington
U.S. Senate - Washington
U.S. Senate - Washington
U.S. Senate - Washington
Former U.S. House of Representatives - Washington 5th Congressional District
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Petition created on April 8, 2011