The debate about the increasing role of nurse practitioners was taken up by the Medicare Payment Advisory Commission (MedPAC) early in April, when the commission addressed issues of reimbursement for NPs and other non-physician practitioners.
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NPs, other advanced practice nurses and physician assistants are expected to take a greater role in healthcare as changes fueled by reform and a shortage of primary care providers convince the industry and regulators to recognize more patient-care professionals.
Medicare has accepted nurse practitioners as licensed independent providers. Their practice is overseen through state licensing and scope of practice requirements that vary by state.
"Medicare generally does not impose additional restrictions on APN/PA practice but generally follows state law," said Kate Bloniarz, a MedPAC analyst, during the meeting. Provider and payer policies can also vary in how APNs and PAs can practice, such as if the hospital allows APNs to admit patients and if insurers pay APNs directly or through a physician.
Medicare can pay for APN services directly if permitted under state law or as part of payment for a physician's services. "But we don't know how much is going to APNs and PAs," Bloniarz said.
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If paid directly, Medicare pays APNs 85 percent of what a physician receives, she said. If the APN must practice under a physician's supervision, the physician receives 100 percent of the fee and reimburses the APN an amount. In a MedPAC analysis of claims data, direct payments to APNs and PAs accounted for 4 percent of fee schedule spending in 2011.
NPs and other APNs will be critical to handle the influx of millions of newly insured individuals and the establishment of more coordinated care, said Angela Golden, president of the American Association of Nurse Practitioners (AANP), in an interview following the MedPAC meeting. While many physicians are currently expressing concerns about increased non-physician patient care management, she believes more physicians will accept inter-professional patient-centered models.
"We're seeing good evidence, good outcomes, and we're at the tipping point of recognizing that we're going to have to embrace these new models," she said.
Increased autonomy for NPs and other non-physician practitioners "… doesn't mean that there won't be collaboration and consultation," she said. "I consult as a family practitioner with cardiology, with orthopedics, with physical therapy for any of my patients that might need that just as my family practice physician colleagues do."
As a result of changes in policy around fee-for-service, there may be more of a role for these healthcare professionals said Kevin Hayes, MedPAC principal policy analyst, during the MedPAC meeting.
Before MedPAC makes any specific recommendations regarding reimbursement of NPs and other APNs, he suggested that MedPAC drill down more deeply into the functions that APNs, PAs and other clinicians could have in delivery system reform, Medicare's role relative to others, including the states, and budget implications of policy changes.
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