Medicare Payment to Advanced Practice Nurses and Physician Assistants

Non physician practitioners in the health care workforce

NPPs represent a growing share of the health care provider workforce. The number of providers who are certified and practicing more than doubled over the past decade, from about 60,000 in 1992 to 124,000 in 2000 (AAPA2001, Spratley et al 2000, Sekscenski et al 1994, Moses 1992). In contrast, the number of active physicians grew 27 percent, to 772,000, over the same period (Cooper et al 2002). Currently, about 55,000 of these NPPs have Medicare provider numbers, which allow them to bill directly for Medicare services (Non-Physician Practitioner News 2002). In 2000, they provided about 8.5 million separately billed services to Medicare patients.

Because physicians also may bill (under their own provider number) for services provided by NPPs in their offices, information on the total number of services provided by NPPs is limited. According to one analysis, about 25 percent of primary-care office-based physicians used NPs or PAs during the 1995-1999 period. When NPs or PAs were used, they saw patients for an average of 11 percent of visits and in almost half of these visits the patient was not seen by a physician (Hooker and McCaig 2001). The use of NPs and PAs is much higher in rural areas. One study, for example, showed that NPs and PAs were present at 37 percent of rural outpatient hospital visits compared with only 5 percent of urban visits (Anderson and Hampton 1999).

PAs must be supervised by a physician, but CNMs, NPs, and CNSs may practice independently if state law allows. State regulation of CNMs, NPs, and PAs varies widely. Favorable practice environments are strongly associated with a larger supply of these practitioners (McCaig et al 1998, Sekscenski et al 1994).

Training programs for NPPs typically last two years and require prior health care experience. Training for CNMs, NPs, and CNSs is generally at the master’s level and requires a license as a registered nurse and b a c h e l o r’s degree (generally a bachelor’s of science degree in nursing). PAtraining can be at the certificate, a s s o c i a t e ’s, bachelor’s, or master’s level—although the majority of PAs have a bachelor’s degree before entering a training program—and most programs require prior experience in health care or a related field.

About 90 percent of NPs and 50 percent of PAs provide primary care (Hooker and McCaig 2001). CNMs focus on childbearing, family planning, and gynecological care for well women, although they also may assess and manage common acute episodic illnesses and care for newborns and infants up to one year of age. The majority of CNSs specialize in clinical psychiatry-mental health nursing or medical-surgical nursing, but others specialize in pediatrics, gerontology, community health, and home-health nursing.

Most services provided by NPPs are in the office setting, although NPs and CNSs provide substantial shares of their services in nursing homes. PAs perform a substantial share of their services in hospitals.