Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019

Abstract

Background: Advanced practice providers (APPs) comprise an increasing proportion of the emergency medicine (EM) workforce, particularly in rural geographies. With little known regarding potential expanding practice patterns, we sought to evaluate trends in independent emergency care services billed by APPs from 2013 to 2019.

Methods: We performed a repeated cross-sectional analysis of emergency clinicians independently reimbursed for at least 50 evaluation and management (E/M) services (99281-99285, 99291) from Medicare Part B, with high-acuity services including Codes 99285 and 99291. We describe the outcome proportion of E/M services by acuity level and report at (1) the encounter level and (2) at the clinician level. We stratified analyses by clinician type and geography.

Results: A total of 47,323 EM physicians, 10,555 non-EM physicians, and 26,599 APPs were included in analyses. APPs billed emergency care services independently for 5.1% (rural 7.3%, urban 4.8%) of all high-acuity encounters in 2013, increasing to 9.7% (rural 16.4%, urban 8.8%) by 2019. At the clinician level, in 2013, the average rural-practicing APP independently billed 22.8% of services as high acuity, 72.6% as moderate acuity, and 4.5% as low acuity. By 2019, the average rural-practicing APP independently billed 36.2% of services as high acuity, representing a +58.8% relative increase from 2013. Relative increases in high-acuity visits independently billed by APPs were substantially greater when compared to EM physicians across both rural and urban geographies.

Conclusions: In 2019, APPs billed independent services for approximately one in six high-acuity ED encounters in rural geographies and one in 11 high-acuity ED encounters in urban geographies, and well over one-third of the average APPs' encounters were for high-acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision making.

Keywords: emergency medicine; nurse practitioners; physician assistants; rural health; visit acuity.

Figure 1.

Encounter-level E/M services billed by emergency clinicians across rural-urban designations and acuity levels. Note: Orange – Advanced practice providers; Blue – EM physicians; Brown – Non-EM physicians. Note: Panel A – High acuity services billed in rural designations; Panel B – High acuity services billed in urban designations; Panel C – Moderate acuity services billed in rural designations; Panel D – Moderate acuity services billed in urban designations; Panel E – Low acuity services billed in rural designations; Panel F – Low acuity services billed in urban designations. Note: As an example interpretation, in calendar year 2016 there were 1,556,693 high acuity encounters in rural designations. EM physicians performed 69.9% of those encounters, non-EM physicians performed 18.0%, and APPs independently performed the remaining 12.1%. Note: The numbers listed within the columns represent the proportions (%) that an individual clinician type contributed to total clinician encounters within that year, acuity level, and rural-urban designation.

Figure 2.

Clinician-level E/M services billed across rural-urban designations and clinician types. Abbreviations: APP, advanced practice provider; E/M, Evaluation & Management Note: Orange scale – Advanced practice providers; Blue scale – EM physicians; Brown scale – Non-EM physicians. Note: Panel A – % of E/M services billed by the average EM physician in rural designations; Panel B – % of E/M services billed by the average EM physician in urban designations; Panel C – % of E/M services billed by the average non-EM physician in rural designations; Panel D – % of E/M services billed by the average non-EM physician in urban designations; Panel E – % of E/M services billed by the average APP in rural designations; Panel F – % of E/M services billed by the average APP in urban designations. Note: As an example interpretation, in calendar year 2016, the average EM physician practicing in rural designations billed 50.5% of E/M services as high acuity (99285 or 99291), 47.3% as moderate acuity (99283 or 99284), and the remaining 2.3% as low acuity (99281 or 99282). The relative difference between 2013 (47.9%) and 2019 (54.8%) in high acuity billing for the average EM physician practicing in rural designations was +14.4.