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APRNs serve 30% of Medicare FFS beneficiaries.

In previous postings on the ANA NurseSpace Blog One Strong Voice (, I have provided information on the participation of APRNs in directly billing Medicare Part B carriers for services provided to their Medicare patients. This included information on total approved charges; primary care incentive payments awarded to NPs and CNSs; bonuses for high-quality and electronic prescribing awarded to APRNs in each of the four roles; and also Medicaid incentive payments to NPs and CNMs for electronic health record installation and use. Recently, I received some new Medicare data not previously published with respect to counts of individual patients who received services from those APRNs.

These important data show the increasing involvement of APRNs in caring for patients. Not only are there increases in the numbers of APRNs directly billing Medicare Part B, those nurses are providing services to an increasing number of patients in the program, representing increasing percentages of patients. In 2011, 100,585 APRNs directly billed Part B carriers for $2.4 billion in approved charges for services provided to 10,385,355 Part B fee-for-service beneficiaries. To some observers--given Medicare Part B's $126 billion total budget--the APRN share may merely be Medicare dust, but it ain't peanuts. Thirty percent of patients in traditional (fee-for-service) Medicare received one or more services from an advanced practice registered nurse.

Thousands of Medicare patients in each of the 50 states are acquainted with an APRN as a source of Part B services. In most states it is hundreds of thousands. APRNs are a substantial and growing clinical presence in the Medicare program. Despite hurdles to APRNs being able to practice to the full extent of their education and experience there is an increasing patient acceptance and satisfaction with receiving Part B services from an advanced practice registered nurse. APRNs may only be nine percent of all Medicare Part B providers, but they treat more than three times that percentage of all fee-for-service patients.

The Data

The Medicare terms of art for these new data are "persons served" and "persons served per thousand." These concepts have actually been employed by Medicare since the beginning of the program, and they involve counting (a) the number of unique patients who have had one or more claims for service approved by Medicare carriers and/or intermediaries, and (b) total Medicare eligibles that could have used such services. To compute these data one used to have to wait until well after the end of a calendar to identify all of the unique beneficiaries ever enrolled in Part B and all of the unique beneficiaries with respect to a particular set of services. Thus, while counts of services and approved charges were computed within months following the end of a year, the reported persons served data often lagged by several years. Better computer services have vastly shortened those lags.

Persons served can be computed across all services or for particular services such as the services of a particular type of provider. For example, since early in the program approximately 20 percent of Medicare beneficiaries have been hospitalized in any one year. This percentage includes some eligibles who were hospitalized two or more times. In calendar year 2010, the official hospital statistic for "persons served per thousand" was 211, i.e., 21.1 percent of Medicare eligible were hospitalized at least once. Across all Part B services, persons served per thousand elderly in 2010 was 988. (At nearly 99 percent very few Part B eligibles did not have a claim for service that year. In 1975 the figure was 536; in 1966 it was approximately 360.)

The table below shows the 2009 to 2011 values for participating APRNs, persons served and persons served per fee-for-service eligible. (Approximately 25 percent of Medicare eligibles are enrolled in Medicare Advantage plans and thus are not considered eligible for treatment under fee-for-service Medicare.) Over that time frame the total number of APRNs directly billing Part B carriers increased from about 82,000 to 100,000; persons served increased from 9 million to 10.4 million; and the persons served percentage increased from 26 percent to 28 percent to 30 percent. Increases in participation, persons served, and the persons served percentage can be observed for all of the years for each of the APRN roles.

[The persons served percentage for CNMs should have an asterisk. The data only include total fee-for-service eligibles rather than the gender and age specific data one would want, particularly for the Medicare disabled population.]

The 10.4 million beneficiaries who did receive APRN services in the traditional Medicare program were spread across the country. The number in each State was a function of both the number of beneficiaries and the number of participating APRNs. Florida had the highest number of persons served, at 873,278, followed by Texas at 702,257. Thirty one states each had more than 100,000 Medicare persons served. Hawaii was the state with the smallest number at 7948. The persons served numbers for each state were relatively stable over these years with typical average annual growth rates between 5 to 11 percent.

Across the U.S., 30 percent of Medicare fee-for-service beneficiaries were persons served with respect to APRN services. In fact, one must acknowledge that this is a lower bound estimate of the percentage of Medicare patients who received APRN services. Some fee-for-service beneficiaries receive APRN services in physician practices or clinics where a physician practice identifier or only the practice specific National Provider Identifier (NPI) is used for billing. In such instances those services will not be counted as APRN services, so those encounters would not contribute to the APRN persons served statistics. In addition, it is well known that many Medicare Advantage plans make substantial use of APRNs. Those patient encounters are simply not recorded at all in the Part B database.

In terms of persons served per thousand, Tennessee was the state with the highest value, at 580. North Dakota was second at 554. Thus, we observe two states where more than half of the fee-for-service beneficiaries received services from an APRN. The states at the high end of the persons served spectrum are more likely to be perceived as relatively rural with more urban states at the low end of the spectrum. This is not a strict rule: relatively rural Delaware, Nevada, Oklahoma, Wyoming and Montana are among the 15 states at the bottom of the spectrum.

To reiterate, thousands of Medicare patients in every state are acquainted with an APRN as a source of Part B services. In most states, it is hundreds of thousands. In all but five states at least one (FFS) beneficiary in five received covered services from an APRN enrolled as an independent Medicare Part B provider. This is not a fad or passing fancy. Despite hurdles to APRNs being able to practice to the full extent of their education and experience there is an increasing patient acceptance and satisfaction with receiving Part B services from an advanced practice registered nurse. APRNs may only be nine percent of all Medicare Part B providers, but they treat more than three times that percentage of all fee-for-service patients--a share that recent statistics confirms is growing.

By Peter McMenamin, PhD Senior Policy Fellow, American Nurses Association
Variable YR NPs CRNAs CNSs CNMs

# APRNs 2011 59,196 36,600 2,564 2,225
 2010 52,062 34,946 2,519 1,931
 2009 46,386 33,151 2,421 1,746
Persons served 2011 5,780,000 4,356,743 226, 576 23,016
 2010 5,218,035 4,158,556 217,869 19,168
 2009 4,806,124 3,946,619 204,411 18,910
Persons served % 2011 16.5% 12.5% 0.6% 0.1%
 2010 15.1% 12.1% 0.6% 0.1%
 2009 14.1% 11.6% 0.6% 0.1%

GA persons served statistics:


# APRNs 2009 1,181 1,170 49 39 2,439
 2010 1,329 1,226 59 40 2,654
 2011 1,524 1,239 66 61 2,890
Persons served 2009 127,452 137,376 6,429 327 271,584
 2010 130,533 132,761 6,461 363 270,118
 2011 143,044 139,555 6,490 382 289,471
Persons served % 2009 12.57% 13.55% 0.63% 0.03% 26.79%
 2010 13.41% 13.64% 0.66% 0.04% 27.74%
 2011 14.45% 14.10% 0.66% 0.04% 29.24%
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Title Annotation:APRN Corner
Author:McMenamin, Peter
Publication:Georgia Nursing
Date:May 1, 2013
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