Randomized Trials in Epidemiology Essay Assignment

The Medicare reimbursement policy for nurse practitioners (NPs) mandates NPs to bill for their services at 85% of the physician rate. This implies that Medicare would only pay 85% when the services are provided and billed by an NP under the physician fee schedule but would pay a 100% rate if the same services are provided by an NP but billed by a supervising physician (Patel et al., 2022).

The Medicare reimbursement policy is under the Balanced Budget Act of 1997, which grants NPs the ability to bill Medicare for the services they perform directly but caveat that the reimbursement would only be provided at 85% of the physician rate. Before this policy, NPs could not be directly reimbursed for services provided to Medicare patients (Kidd & Hammonds, 2023).  Randomized Trials in Epidemiology Essay Assignment

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It is important to note that NPs are recognized as independently licensed acute and primary care providers who can provide high-quality care and incur the same overhead costs as their physician counterparts. As such, there is a need to reimburse NPs at the same rate as physicians for their services. Although the Balanced Budget Act of 1997 authorizes Medicare to reimburse NPs, the payment rates are less than those for physicians at 85%. This has influenced other payers to follow the same trend by reimbursing NPs less than physicians when providing the same services (Stanhope & Lancaster, 2019).

The Medicare reimbursement policy originates in the Omnibus Budget Reconciliation Act of 1990, which limited direct payments to NPs in rural areas at 75% of physician rates for services furnished in hospitals and 85% of physician rates for other services. The Balanced Budget Act of 1997 expanded NPs benefits by removing the limitation on setting and making the payment at the standard rate of 85% in all circumstances (Stanhope & Lancaster, 2019). Randomized Trials in Epidemiology Essay Assignment

The key terms identified for the policy are NP, physician, and Medicare reimbursement. An NP is an advanced practice registered nurse with graduate-level education who can perform many duties as physicians, including physical exams, diagnosing and treating diseases, and prescribing medication. An NP has completed either a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP) program and serves as a primary care or specialty care provider with similar responsibilities to physicians and more authority than registered nurses (DeNisco, 2022).

A physician is the general term for a health care provider with a medical degree, and takes on the role of maintaining, promoting and restoring health by studying, diagnosing and treating diseases and injuries. A physician provides patient care, which is effective, appropriate and compassionate to promote health. In addition, a physician is an expert in established and new cognate, clinical and biomedical sciences, and how to apply the knowledge in patient care. Besides that, a physician always looks for ways to improve practice by adopting a practice-based learning approach that investigates and evaluates their own care for improvement opportunities. Furthermore, a physician communicates effectively with patients and other health professionals, demonstrating professionalism and observing established ethical principles (DeNisco, 2022). Randomized Trials in Epidemiology Essay Assignment

Medicare reimbursement refers to the payments made to healthcare providers who accept Medicare assignments and perform healthcare services. It is the process by which the healthcare provider or facility receives funds for providing medical services to a Medicare beneficiary. The payments are made for services delivered to Medicare enrollees (Stanhope & Lancaster, 2019).

Policy Environment

There is a need to acknowledge the role of NPs as having evolved as more states grant nurses full practice authority, including prescriptive privileges. NPs are taking on more independent roles, leading nurse-managed retail clinics and health centers. In these evolved roles, NPs continue to demonstrate the ability to provide healthcare in different settings, including underserved communities and rural areas, and serve vulnerable populations, including low-income persons and older adults. The emergence of the Covid-19 pandemic further supports the independent role of NPs even as more states continue to grant full practice authority to NPs while others removed some of the practice restrictions (Kleinpell et al., 2021). Randomized Trials in Epidemiology Essay Assignment

This then raises the question of why do NPs get reimbursed less than physicians for providing the same care. The argument advanced for the 85% reimbursement policy is that physicians bear a higher cost, from higher student loans to caring for more complex patients, having higher malpractice premiums, and paying higher practice overhead costs. This may have been the case when the policy was first introduced as part of the Balanced Budget Act of 1997, but it is no longer the case. NPs have similarly borne higher costs from higher student loans, having attended advanced training programs to care for more complex patients, having higher malpractice premiums that vary based on specialty areas, and paying higher practice overhead costs from managing their own practices (Stanhope & Lancaster, 2019).

Another problem arising from the current policy is that it masks the true care NPs provide. NPs provide cost-effective and high-quality care with a favorable patient experience that is comparable to that of physicians. Under the ‘incident to’ billing effect, NPs would get 100% reimbursement, and this only occurs if the care is attributed to the physician. This masks the accuracy of the care provided regarding the number of patients the NP provided care to and the type of care delivered (DeNisco, 2022). Randomized Trials in Epidemiology Essay Assignment

The 85% reimbursement rule is detrimental to NPs, especially those who own their practices. That is because the decrease in reimbursement limits their employment opportunities, causing financial instability, not to mention decreasing recognition of the value of care NPs provide (DeNisco, 2022).

The healthcare environment vastly differs from when the reimbursement policy was presented in 1997. Many of these changes have been brought into sharp focus as many states sought to decrease barriers to care by lifting practice restrictions, allowing NPs to practice to the full extent of their licenses. States that are yet to grant NPs full practice authority are contemplating doing so or in the process of doing so. With this increase in practice independence for NPs, it becomes even more crucial that they receive full reimbursement for their services at 100% rate of the physicians. The increased role of NPs and their ability to provide care comparable to that of physicians creates a need to increase the Medicare reimbursement rate to 100% of the physician rate (Nies & McEwen, 2022). Randomized Trials in Epidemiology Essay Assignment

Current Policy

The Medicare reimbursement policy pays 85% rates for services billed by NPs, but pays a 100% rate for the same services when billed by physicians even if NPs provide the services.  To counter this difference in pay rates, NPs have been resorting to indirect billing, in which case the NPs provide services, but the physician does billing to ensure a 100% reimbursement rate (Kleinpell et al., 2023).

Criticism of the 85% reimbursement rate focuses on the 15% difference, noting that if the quality of care provided by an NP is equivalent to that of a physician, then the pay rates should similarly be matched. However, there is a counterargument that physicians bear an additional administrative burden as the legal perspective considers them responsible for the visit (Stanhope & Lancaster, 2019). Another criticism of the 85% reimbursement rate is that it is part of the fee-for-service payment model. There has been a shift away from a fee-for-service model towards a value-driven payment model. Retaining the 85% reimbursement rate would maintain the fee-for-service model while reimbursing NPs for transactional healthcare (Stanhope & Lancaster, 2019). Randomized Trials in Epidemiology Essay Assignment

Medicare beneficiaries increasingly rely on NPs for their care in the current healthcare environment. As graduate-level trained clinicians, NPs work independently, in collaboration with, or under the supervision of physicians to deliver patient care. However, NPs independence in clinical practice is increasing as state governments expand the scope of practice laws, enabling the NPs to practice with more autonomy and authority. In addition, NPs are shifting from the traditional primary care areas towards practicing in specialty care areas (Kleinpell et al., 2021). Despite the growing practice independence of NPs, they are not fully compensated for their services. Randomized Trials in Epidemiology Essay Assignment

Policy Alternatives

There is a need for policy changes to ensure that NPs are fully compensated for their services. The first policy alternative is eliminating limitations and increasing reimbursement for NPs from 85% to 100%. The payments to NPs should be at the same rate as physicians. There is precedence for this as the rates were increased from 75%, as indicated by the Omnibus Budget Reconciliation Act of 1990, to the current rate of 85%, as indicated by the Balanced Budget Act of 1997. It is important to note that neither the Omnibus Budget Reconciliation Act of 1990 nor the Balanced Budget Act of 1997 provided any guidance as to why the reimbursement for NPs was limited to 85% of physician rates. In the absence of any explanation to act as basis for the limitation, then the rationale is left to speculation. It does not appear logical to pay NPs differently for the same service that a physician would receive more pay. The most likely reason for the limitation in pay for NPs is budgetary as this is a less costly alternative. Conversely, eliminating the payment limits may have cost limitations that Medicare cannot bear (Stanhope & Lancaster, 2019). Randomized Trials in Epidemiology Essay Assignment

There is a precedence for removing the limitations. Between Omnibus Budget Reconciliation Act of 1087 and 1993, the established payment limits for new physicians increased from 80% to no limits. In making this change, Congress stipulated that it would be budget-neutral. This implied that all pay rates would be adjusted downward, with the difference used to cover the additional costs. This precedent illustrates that the pay limitation can be eliminated for NPs at no extra cost to Medicare (Green, 2022).

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The second policy alternative is changing the definition of NPs to match that of physicians. The policy defines physicians as medical doctors, podiatrists, optometrists, dentists, doctors of osteopathy, and chiropractors. This expansive definition of physicians can be revised to include NPs so that they similarly enjoy a 100% reimbursement rate. NPs are licensed, independent practitioners with a distinct scope of practice different from other health disciplines. They are not dependent on or an extension of the care provided by physicians or other health care providers. As such, defining NPs as physicians does not create conflicts, allowing them to continue their current practice while enjoying 100% reimbursement rates (Buppert, 2019). Randomized Trials in Epidemiology Essay Assignment

The third policy alternative is changing the reimbursement rule and allowing NPs to supervise care and be paid for services furnished to Medicare patients. The Centers for Medicare & Medicaid Services (CMS) allows NPs, as non-physicians, to supervise healthcare services. Although the CMS indicates that the supervision requirement emanates from ‘incident to’ physician services language that does not apply to non-physicians, it points out that NPs are recognized in statute and regulation as providing services analogous to physician services. Although NPs can supervise ‘incident to’ services, they are precluded from supervising diagnostic tests, and cardiac and intensive cardiac rehabilitation services. The same rationale that was applied in allowing NPs to supervise ‘incident to’ services, could also be applied to the supervision of other services beyond the 1861(r) definition because NPs are recognized in statute and regulation as providing services analogous to physician services. Allowing NPs to supervise care places them places them in the same category as physicians, thereby enabling them to receive 100% reimbursement rate (Elsevier Health Sciences, 2023). Randomized Trials in Epidemiology Essay Assignment

References

Buppert, C. (2020). Nurse Practitioner’s Business Practice and Legal Guide. Jones & Bartlett Learning.

DeNisco, S. M. (2022). Role Development for the Nurse Practitioner (3rd ed.). Jones & Bartlett Learning, LLC.

Elsevier Health Sciences (2023). Legal and Ethical Issues for Health Professions (5th ed). Elsevier Health Sciences.

Green, M. (2022). Understanding Health Insurance: A Guide to Billing and Reimbursement, 2022 Edition. Cengage Learning.

Kidd, V. D., & Hammonds, J. (2023). The Perceived Impact of the New Medicare Rules for Split/Shared Visits: A Survey of Advanced Practice Administrators. Cureus, 15(6), e40815. https://doi.org/10.7759/cureus.40815

Kleinpell, R., Myers, C. R., & Schorn, M. N. (2023). Addressing Barriers to APRN Practice: Policy and Regulatory Implications During COVID-19. Journal of nursing regulation, 14(1), 13–20. https://doi.org/10.1016/S2155-8256(23)00064-9

Kleinpell, R., Myers, C. R., Schorn, M. N., & Likes, W. (2021). Impact of COVID-19 pandemic on APRN practice: Results from a national survey. Nursing outlook, 69(5), 783–792. https://doi.org/10.1016/j.outlook.2021.05.002

Nies, M. A., & McEwen, M. (2022). Community/Public Health Nursing (8th ed.). Elsevier Health Sciences.

Patel, S. Y., Huskamp, H. A., Frakt, A. B., Auerbach, D. I., Neprash, H. T., Barnett, M. L., James, H. O., & Mehrotra, A. (2022). Frequency Of Indirect Billing To Medicare For Nurse Practitioner And Physician Assistant Office Visits. Health affairs (Project Hope), 41(6), 805– Randomized Trials in Epidemiology Essay Assignment