Does It Matter Where Primary Care NPs Practice?

Abstract

urse practitioners (NPs) and physician assistants (PAs) have been touted as a solution to the shortage of primary care providers (PCPs). The Nmost comprehensive, systematic review of the quality of NP care ever published appeared in the September 2013 issue of JNP. That study concluded that, for all 11 outcomes examined, care provided by NPs was comparable or better to care by physicians (or teams without NPs), providing more evidence of our ability to fill the primary care gap that is expected to grow even larger as the Affordable Care Act rolls out. But are NPs really practicing in primary care? The American Academy of Family Medicine, in a commissioned study conducted by The Robert Graham Center that examined insurance claims submitted by NPs and PAs, argues we may not be. The study identified the practice locations of the NPs and PAs who submitted claims by their National Provider Identifier (NPI) number, which was then compared to the specialty of co-located physicians. An NP was assumed to be practicing primary care if more than half of any physicians working in the same location as the NP listed primary care specialties on their NPI application. An NP with no co-located physicians was also deemed to be practicing primary care. Using this inferential assignment, the researchers concluded that slightly more than half, 52.4%, of NPs were practicing in primary care. However, in a recent blog posted on their Web site, the American Nurses Association applauded the 35,000 NPs—over two-thirds of the more than 50,000 NPs that provided services to Medicare fee-for-service beneficiaries in 2012—who were recognized by the Centers for Medicare and Medicaid Services (CMS) for Primary Care Excellence under the Primary Care Incentive Program. NPs were eligible for the incentive payment if their primary care services accounted for at least 60% of their allowed charges in a year. The CMS findings are based on auditable claims submitted to Medicare carriers and likely underestimate the volume of primary care provided by NPs, since CMS does not track these services if provided “incident to” a physician’s service. This finding that two-thirds of NPs were providing predominantly primary care services—and doing it in an excellent manner—is in sharp contrast to the assertion of the Graham Center. So which estimate is accurate? Is either figure accurate? The truth is, we as a profession don’t know. The Graham Center calculation, based on an unreported number of NP insurance claims, rests on 1 very large, unproven assumption: that primary care services provided by NPs are provided only in primary care settings. The CMS data would argue otherwise. The blog author notes that an analysis of NPI applications, which require applicants to identify their primary provider taxonomy code to specifically describe their specialty, found that only 15% of participating NPs listed a non-primary care specialty, supporting an argument that the vast majority of NPs perceive themselves as providing primary care. NPs have already been down the rabbit hole of responding to an ever-changing array of false claims and distorted arguments about quality of the care we provide. The argument about quality is over. Case closed. Time to move on.