Health Practitioner Bonuses and Their Impact on the Availability and Utilization of Primary Care Services. A. Study Design Overview

12/22/2014

The Medicare primary care incentive is available to eligible primary care practitioners for services provided under selected categories of E&M. An eligible primary care practitioner is a physician, nurse practitioner, clinical nurse specialist or a physician assistant who satisfies the following criteria:

  1. Enrolled in Medicare with a primary specialty designation of family practice, internal medicine, pediatrics or geriatrics; and

  2. At least 60 percent of the practitioner’s allowed charges under the Medicare physician fee schedule (excluding hospital inpatient care and emergency department visits) are for primary care services.

This temporary payment is available for primary care services furnished by an eligible primary care practitioner on or after January 1, 2011 and before January 1, 2016. The payment is made on a quarterly basis and it amounts to 10 percent of the payment amount for the Part B-covered primary care services furnished by the eligible provider.

Based on data regarding all the Medicare PCIP recipients in 2011 and 2012 we observe that in 2011 there were 162,342 providers that received the PCIP, with the majority of physicians specialized in family medicine and internal medicine (Exhibit 3). Also, nurse practitioners account for more than half of non-physician recipients in both 2011 and 2012. Finally, there was an increase in the number of physician PCIP recipients across all eligible specialties in the second year the payment was in effect. The number of all eligible types of non-physician PCIP recipients also increased. These estimates are consistent with the statistics reported by CMS35.

Exhibit 3: Number of PCIP Recipients under Medicare by Specialty, 2011-2012

Specialty Year 2011 Year 2012
Total 162,342 185,312
Physicians 121,140 133,880
Internal Medicine 54,062 62,554
Family Medicine 63,227 66,560
Pediatrics 2,711 3,426
Geriatrics 1,140 1,340
Non-Physicians 41,202 51,432
Clinical Nurse Specialist 466 ,
Nurse Practitioner 27,698 33,940
Physician Assistant 13,038 16,899

Note: Actual PCIP recipients; eligibility based on conditions 2 years prior to the PCIP payment year.

The specific PCIP-eligible services and their corresponding Current Procedural Terminology (CPT) codes are as follows: (1) office and other outpatient visits (99201 through 99215); (2) nursing facility, domiciliary, rest home, or custodial care (99304 through 99340); and (3) home services (99341 through 99350).

Medicare claims data include the Healthcare Common Procedure Coding System (HCPCS) corresponding to each claim submitted by providers. Since level I of HCPCS codes is comprised of CPT codes, HCPCS codes associated with claims can be used to determine bonus-eligible E&M services.

The key questions that we examined using the Medicare data include:

  • What is the aggregate number of Medicare PCIP recipients?

  • What proportion of primary care providers qualify for the PCIP?

  • What are the characteristics of primary care providers who qualify for the PCIP?

  • How many eligible claims were submitted by PCIP eligible providers?

  • What is the impact of Medicare incentive payments on services provided, patients seen, providers accepting Medicare, and other related outcome measures?


35 Source: Center for Medicare and Medicaid Services (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf)

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