SCOPE OF PRACTICE
( continued from page 9 ) for those people with chronic conditions .
Physicians in clinical practice understand and value the unique relationship of physician and patient . The American health care system is often financed by large private , union and government payers . At the bottom-line level , many large payers seem to think of health care in terms of purchasing expenditures . In many of the large self-funded employer groups , it is the Procurement Department that makes the decisions on level of benefits and the insurer to administer them . So from a business mindset , paying for the lowest cost providers of health care services makes perfect sense . Purchasers do recognize the balance of cost and mitigation of complaints among their “ covered lives ” ( the euphemism for real people ). These purchasers – be it government , self-funded employers , unions or insurers – want “ value ” in terms of access to care , appropriate level of care ( i . e ., cost for outcomes ) and minimization of “ waste .” The latter encompasses redundant services such as repeat lab testing . But it also includes avoidable complications of medical or surgical treatment . Medicare and most insurers do not pay for conditions on the Hospital Adverse Events (“ Never Events ”) list 6 ( for example , operating on the wrong side , patient death or injury due to medication errors , transfusing the wrong blood type , etc .).
This “ value ” equation , as used among payers , takes access to care into consideration . As a nation , we do not have a sufficient number of physicians to provide for the entire population . The Association of American Medical Colleges ( AAMC ) estimates that by the year 2034 , the country will need between 37,800 and 124,000 more physicians . 1 A generation ago , the social engineering efforts of government and the private sector recognized this growing disparity between demand and the supply of physicians . Further , there was the understanding that the country needed health care professionals to be turned out much faster than the training time of doctors . The time from the decision to go to nursing school until completion of the requirements to be a nurse practitioner is six to seven years . Nurse practitioners can receive training to practice in half the time ( or less ) in comparison to a medical doctor . The social engineers in this process recognized that often what is billed by physicians , especially those in primary care , were low-risk encounters . Leaders in medical fields joined the social engineers in articulating a strategy to increase patient access to care by turning out nurse practitioners , nurse anesthetists and others with a nursing degree who may function independently within the bounds of licensing .
The argument was that this new influx of health professionals would be able to either 1 ) assist the specialists who employed them so that the specialist could see more patients , or 2 ) be able to see patients at a primary care level , thus creating more access . Additionally , the social engineers argued that nurse practitioners
HOW DOES “ INCIDENT TO ” WORK ?
“ Incident to ” is not applicable to some services . It applies only to services that do not have their own “ benefit category ” under Medicare . Benefit categories are defined by the Social Security Act ( section 1861 ( s )). Under Medicare Part B , the following services have their own benefit categories and specific required levels of supervision :
• Diagnostic tests , including x-rays and clinical laboratory tests X-ray , radium , and radiation therapy , including isotopes
• Surgical dressings , splints , casts , and other materials used to treat fractures and dislocations
• Durable Medical Equipment ( DME ), prosthetics , and orthotics
• Ambulance services
• Pneumococcal vaccines
• Services provided by Certified Registered Nurse Anesthetists ( CRNAs )
• Screening mammography and screening Pap smears
• Bone mass measurement
Source : The “ Incident To ” Provision of Medicare , Fact Sheet https :// www . cgsmedicare . com / partb / mr / pdf / incident _ to _ provision _ factsheet . pdf
would cost less , as their median income is less than physicians in similarly named fields . For example , Nurse . org indicates the median income of a family nurse practitioner is $ 103,803 in 2024 , and that of a certified registered nurse anesthetist ( CRNA ) is $ 212,650 in 2024 . 3 At the macro level , this seems to be a win for the patient and a win for the payer who now pays less for patient visits with a nurse practitioner rather than a more expensive physician .
Currently , nurse practitioners receive a lower reimbursement than medical doctors on most health plan fee schedules . Nurse practitioners working for a physician may have their services billed under the supervising physician ’ s NPI number according to the Centers for Medicare and Medicaid Services ( CMS ). This is considered “ incident to ” billing . There are restrictions on what services would qualify for such reimbursement .
Increasing numbers of nurse practitioners are becoming independent , not needing physicians to sign off on their activity . These independent nurse practitioners receive a percentage off of the usual fee schedule allowed for a medical doctor by that carrier . Those reimbursements for nurse practitioners may be at
10 LOUISVILLE MEDICINE