«Comparing the Cost of Care Provided to Medicare Beneﬁciaries Assigned to Primary Care Nurse Practitioners and Physicians Jennifer Perloff, ...»
14 HSR: Health Services Research To our knowledge, this is the ﬁrst national-level analysis of the cost of NPs providing primary care to Medicare beneﬁciaries. Because Medicare enrollments will expand rapidly as the baby boom generation ages, total spending on the program is likely to increase substantially. Further, as policy makers attempt to increase the capacity of the primary care workforce, in part by increasing the numbers of NPs, our results suggest that having more NPs providing primary care services to Medicare beneﬁciaries is unlikely to cost Medicare more than if the program relied solely on primary care physicians, and it may actually reduce costs. The $207 per beneﬁciary annual difference between primary care physicians and NPs on E&M services suggests that the Medicare program could obtain signiﬁcant cost savings if more NPs were providing primary care services to beneﬁciaries. Indeed, our results are consistent with a recent estimate from the CMS Ofﬁce of the Actuary that Medicare could save $60 million over 10 years by allowing CMS to assign beneﬁciaries to accountable care organizations based on services provided by NPs, physician assistants, and clinical nurse specialists (HHS FY2016). While the Ofﬁce of the Actuary’s study is not directly comparable to ours due to differences in methods, both studies suggest that expanding the role of NPs as primary care clinicians could result in savings to the Medicare program.
ACKNOWLEDGMENTSJoint Acknowledgment/Disclosure Statement: This work was generously supported by a grant jointly provided by the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, and Johnson and Johnson’s Campaign for Nursing’s Future. We also acknowledge the tremendous statistical and programming contributions of Galina Zolotusky. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. Dr. Perloff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Bodenheimer, T. S., and M. D. Smith. 2013. “Primary Care: Proposed Solutions to the
Physician Shortage without Training More Physicians.” Health Affairs 32 (11):
Brooten, D., M. D. Naylor, R. York, L. P. Brown, B. H. Munro, A. O. Hollingsworth, S.
M. Cohen, S. Finkler, J. Deatrick, and J. M. Youngblut. 2002. “Lessons Learned from Testing the Quality Cost Model of Advanced Practice Nursing (APN) Transitional Care.” Journal of Nursing Scholarship 34 (4): 369–75.
Caliendo, M., and S. Kopeining. 2008. “Some Practical Guidance for the Implementation of Propensity Score Matching.” Journal of Economic Surveys 22 (1):
Chien, A. T., and M. B. Rosenthal. 2013. “Medicare’s Physician Value-Based Payment Modiﬁer — Will the Tectonic Shift Create Waves?” New England Journal of Medicine 369 (22): 2076–8.
Elixhauser, A., C. Steiner, D. R. Harris, and R. M. Coffey. 1998. “Comorbidity Measures for Use with Administrative Data.” Medical Care 36 (1): 8–27.
Garrido, M. M., A. S. Kelley, J. Paris, K. Roza, D. E. Meier, R. S. Morrison, and M. D.
Aldridge. 2014. “Methods for Constructing and Assessing Propensity Scores.” Health Services Research 49 (5): 1701–20.
Health Care Cost Institute. 2012. Health Care Cost and Utilization Report. Washington, DC: HCCI.
Health and Human Services. 2015. “Fiscal Year 2016 Budget in Brief Strengthening Health and Opportunity for All Americans,” pp. 65–6. United States Department of Health [accessed on August 15, 2015]. Available at http://www.hhs.gov/ sites/default/ﬁles/budget/fy2016/fy-2016-budget-in-brief.pdf Hirano, K., and G. Imbens. 2001. “Estimation of Causal Effects Using Propensity Score Weighting: An Application to Data on Right Heart Catheterization.” Health Services and Outcomes Research Methodology 2 (3–4): 259–78.
Hofer, A. N., J. M. Abraham, and I. R. A. Moscovice. 2011. “Expansion of Coverage under the Patient Protection and Affordable Care Act and Primary Care Utilization.” Milbank Quarterly 89 (1): 69–89.
Institute of Medicine. 2010. The Future of Nursing. Washington, DC: The National Academies Press [accessed on August 15, 2015]. Available at http://www.thefutureofnursing.org/IOM-Report Laurant, M., M. Harmsen, H. Wollersheim, R. Grol, M. Faber, and B. Sibbald. 2009.
“The Impact of Nonphysician Clinicians: Do They Improve the Quality and Cost-Effectiveness of Health Care Services?” Medical Care Research and Review 66 (6 suppl): 36S–89S.
Lenz, M., R. Kane, S. Hopkins, and S. Lin. 2004. “Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: Two-year Follow-up.” Medical Care Research and Review 61: 332–51.
Mehrotra, A., J. L. Adams, J. W. Thomas, and E. A. McGlynn. 2010. “The Effect of Different Attribution Rules on Individual Physician Cost Proﬁles.” Annals of Internal Medicine 152 (10): 649–54.
Mundinger, M. O., R. L. Kane, E. R. Lenz, A. M. Totten, W. Y. Tsai, P. D. Cleary, W. T.
Friedewald, A. L. Siu, and M. L. Shelanski. 2000. “Primary Care Outcomes in 16 HSR: Health Services Research Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial.” The Journal of the American Medical Association 283 (1): 59–68.
National Governor’s Association. 2012. The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care. Washington, DC: National Governors Association Center for Best Practices.
Naylor, M. B., D. A. Brooten, R. L. Campbell, G. Maislin, K. M. McCauley, and J. S.
Schwartz. 2004. “Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial.” Journal of the American Geriatrics Society 52 (5): 675–84.
Newhouse, J. P., and R. P. Graham. 2013. Variation in Health Care Spending: Target Decision Making, Not Geography. Washington, DC: Institute of Medicine of the National Academies.
Ohman-Strickland, P. A., A. J. Orzano, S. V. Hudson, L. I. Solberg, B. DiCiccio-Bloom, D. O’Malley, A. F. Tallia, B. A. Balasubramanian, and B. F. Crabtree. 2008.
“Quality of Diabetes Care in Family Medicine Practices: Inﬂuence of NursePractitioners and Physician’s Assistants.” Annals of Family Medicine 6 (1): 14–22.
Research Data Assistance Center. 2012. “Identifying Dual Eligible Medicare Beneﬁciaries in the Medicare Beneﬁciary Enrollment Files” [accessed on October 4, 2014]. Available at http://www.resdac.org/resconnect/articles/149 Roblin, D. W., D. H. Howard, E. R. Becker, E. Adams, and M. H. Roberts. 2004. “Use of Midlevel Practitioners to Achieve Labor Cost Savings in the Primary Care Practice of an MCO.” Health Services Research 39 (3): 607–26.
Sakr, M. K., R. Kendall, J. Angus, A. Sanders, J. Nicholl, and J. Wardrope. 2003.
“Emergency Nurse Practitioners: A Three Part Study in Clinical and Cost Effectiveness.” Emergency Medicine Journal 20 (2): 158–63.
Sears, J. M., T. M. Wickizer, G. M. Franklin, A. D. Cheadle, and B. Berkowitz. 2007a.
“Nurse Practitioners as Attending Providers for Injured Workers: Evaluating the Effect or Role Expansion on Disability and Cost.” Medical Care 45 (12): 1154–61.
Sears, J. W., T. M. Wickizer, G. M. Franklin, A. D. Cheadle, and B. Berkowitz. 2007b.
“Nurse Practitioners as Attending Providers for Workers with Uncomplicated Back Injuries: Using Administrative Data to Evaluate Quality and Process of Care.” Journal of Occupational and Environmental Medicine 49 (8): 900–8.
Venning, P. D., A. Durie, M. Roland, C. Roberts, and B. Leese. 2000. “Randomized Controlled Trial Comparing Cost Effectiveness of General Practitioners and Nurse Practitioners in Primary Care.” British Medical Journal 320: 1048–53.
Weintraub, W. S., M. V. Grau-Sepulveda, J. M. Weiss, S. M. O’Brien, E. D. Peterson, P.
Kolm, Z. Zhang, L. W. Klein, R. E. Shaw, C. McKay, L. L. Ritzenthaler, J. J.
Popma, J. C. Messenger, D. M. Shahian, F. L. Grover, J. E. Mayer, C. M. Shewan, K. N. Garratt, I. D. Moussa, G. D. Dangas, and F. H. Edwards. 2012. “Comparative Effectiveness of Revascularization Strategies.” New England Journal of Medicine 366 (16): 1467–76.
Wilson, I. B., B. E. Landon, L. R. Hirschhorn, K. McInnes, L. Ding, P. V. Marsden, and P. D. Cleary. 2005. “Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians.” Annals of Internal Medicine 143 (10): 729– 36.
Comparing the Costs of NP and PCMD Care 17
SUPPORTING INFORMATIONAdditional supporting information may be found in the online version of this
Appendix SA1: Author Matrix.
Appendix SA2: Sensitivity of Results to Attribution Threshold.