The commission also discussed a new path to turn mid-level providers into full-fledged physicians.
This article first appeared December 06, 2018 on Medpage Today.
By Shannon Firth
WASHINGTON -- What's known as "incident to" billing for nurse practitioners and physician assistants in Medicare could vanish if the government adopts a recommendation currently before the the Medicare Payment Advisory Commission (MedPAC).
At a meeting Thursday, the panel explored the pluses and minuses of scrapping this type of billing, under which mid-level providers bill services as "incident to" physician services using the physician's national provider identifier (NPI). If the recommendation is adopted, NPs and PAs would bill directly to Medicare for their services.
Currently, when NPs and PAs bill directly under their own NPIs, they're paid 85% of the fee schedule amount, whereas services billed "incident to" are paid at 100%. NPs and PAs may not bill "incident to" when working in a hospital with a new patient, or for a new problem with an existing patient, MedPAC technical staff explained.
Currently, Medicare claims don't require documentation of whether a service is billed "incident to" even though a "substantial share" of services are being billed that way, MedPAC's technical staff said.
In a draft recommendation for the Secretary of Health and Human Services, the commission would suggest that Congress require all advanced practice nurses and PAs to bill Medicare directly.
Staff told commission members that the "incident to" pathway has a number of flaws including clouding policymakers' understanding of who's providing care, preventing "an accurate valuation" of fee schedule services, and increasing Medicare and beneficiary spending.
They also noted a trend towards more PAs and NPs moving away from primary care towards specialties such as dermatology and orthopedics. Estimates suggest about half of NPs practice in primary care, as do about 27% of PAs. However, data in this area are limited, staff said.
The lack of solid information limits Medicare's ability to channel resources towards those areas that need it most, such as primary care.
Eliminating "incident to" billing would incur "modest savings" for the Medicare program, and beneficiaries costs would also be reduced, while staff did not expect any changes in access to care. Some NPs and PAs would see a slight decline in payment, staff added.
Allowed charges for NPs grew 17% annually from 2010 to 2017, from $1.2 billion to $3.8 billion, according to staff. Similarly PAs allowed charges grew an average 14% per year, from $0.9 billion to $2.2. billion. Numbers of NPs and PAs billing Medicare also grew, by 14% and 10%, respectively, per year from 2010 to 2017.
However, these figures may be underestimates because they don't include "incident to" billing charges, the staff explained.
Eliminating "incident to" billing is "long overdue" and "excellent policy," said commission member Brian DeBusk, PhD, of DeRoyal Industries in Powell, Tennessee, not only for clinical reasons but also to maintain data integrity.
Commissioner Susan Thompson, RN, of Unity Point Health, in Des Moines, Iowa, also supported the move to direct billing as a way of making the "front-line primary care" NPs and PAs provide more transparent.
Jaewon Ryu, MD, JD, noted it would be important, particularly in hospital systems and multi-specialty groups, to explore where NPs and PAs might choose to migrate as a result of the recommendation, or in what settings advanced practitioners could be allocated.
The recommendation "may have unintended consequences on primary care areas of those systems," Ryu said.
In addition to support for moving to direct billing, the group also saw near-unanimous agreement on two other recommendations: to refine Medicare's specialty designation of APRNs and PAs; and to maintain the physician payment update in current law for 2020, which is for no increase.
The commission will vote on all three recommendations in January.
'Degree Completion' for NPs, PAs?
DeBusk also floated a novel suggestion that prompted extensive discussion: creation of a streamlined "degree completion" path, as he called it, for NPs and PAs to become licensed physicians.
Not everyone was on board with that.
"[T]here's a lot in medical care that people that are trained less extensively than physicians can productively do," countered fellow commission member Paul Ginsburg, PhD, of the Brookings Institution.
"To take this and say, 'Well, we just want it to be a path to becoming a physician, by a way other than going to medical school,' seems to defeat the entire purpose of these physician extender categories," Ginsburg continued.
Commissioner Dana Gelb Safran, ScD agreed, noting that not all care requires a physician.
Given the emerging understanding of the importance of social determinants of health and the literature that shows physician training is "poorly adapted" to making use of this new evidence, Gelb Safran said she questioned the need to funnel more clinicians onto the physician track.
"I just think we need to give thought to how we are actually going to produce more health in the population and what's the workforce we need for that, as opposed to how are we going to produce more healthcare services," she said.
DeBusk said he wouldn't recommend that all NPs or PAs complete such programs but expressed frustration that mid-level providers who've demonstrated their skill and want to become physicians must "start over from scratch."
While she supported the concept of "degree completion," Marjorie Ginsburg, BSN, said she was surprised that there isn't already such a pathway and also took issue with the terminology.
"To make this in any way appear that they are physicians that somehow haven't yet happened is really a mistake."
DeBusk later apologized for using the term "degree completion," calling it "tone deaf."