Are Your Health Care Costs Too HIGH?

As contracts are made for employee health benefits, many are finding costs increased this year to the point that employers feels they cannot offer benefits unless employees pay more of these costs.1-5 Employees of small businesses now find themselves among the uninsured (5000 employees in 500 firms in Dane County, 2,500 employees in 380 firms in Green and Jefferson County).6 The uninsured are two to three times less likely to seek care for serious symptoms, such as a mass in the breast, blurred vision, and chest pain, four times as likely to postpone needed care and are hospitalized 50% more for avoidable hospital conditions compared to those with insurance.7-8


Health care costs in Milwaukee are 55% higher than in other Midwestern cities, in part because of higher fees charged by physicians and hospitals.3 Proposals to resolve inequitable Medicare payments to hospitals in other states as well as deal with prescription drug costs are being considered at both the state and national level. As these proposals are considered, how can we reduce other costs, such as routine office visits?


Are you allowed to choose your health care provider?


Often for routine office visits people can choose to see an Advanced Practice Nurse (APN). APNs include certified nurse midwives (CNMs), nurse practitioners (NPs), clinical nurse specialists (CNSs) and certified registered nurse anesthestists (CRNAs). These masters prepared and nationally certified nurses can provide 80-90% of care in office visits with equal or better quality compared to physicians, as demonstrated in numerous studies over the last 20 years.9-14

The lower costs associated with nurse-midwifery care are due to:

_ lower rates of technological intervention

_ shorter lengths of stay in hospitals

_ lower payroll costs for staff model HMOs 15-24

Nurse practitioners and clinical nurse specialists provide added value related to more effective health maintenance and case management, ordering less costly antibiotics and reducing hospital costs. 25-30

The comparative overhead costs for various providers are shown below.31



Physician

NP

OB

CNM

Psychiatrist

Psychologist

( Saunders)

Physical

Therapist

Salary

$180,000

$72,000

$275,000

$ 80,000

$150,61016

$55,000

$55,000

Malpractice

7,000

900

25,000

7,000

3,65017

1,000

?


For a clinic with 10 providers:


1) 10 physicians = $1,870,000

  1. 2 physicians + 8 NPs = $951,200 ($918,800 savings in ONE clinic)


There are 9,604 physicians in the state of WI - we rank 26/50 in numbers per capita overall and are above the national average in primary care physicians.31 If we were to have the highest quality, most cost effective staff mix across the state (8 APNs; 2MDs rather than a predominately physician staff) the savings would be about $904, 696,800 a year.


It would seem to be more cost effective if employees saw a psychologist or PT directly rather than first seeing a physician. Steve Saunders Ph.D., MU Psychology offered the following synopsis of the inter-related issues involved:


"Copays and deductibles have been shown to influence utilization, for example, as the RAND Health Insurance Experiment (e.g., Wells, 1995) found that utilization of outpatient mental health care is responsive to cost sharing. Patients who had relatively high financial responsibilities for care utilized less care. Gabel (1997) reported that compared to patients with zero copayment, patients with a $5 copayment had 11% fewer visits to primary care doctors.


Some insurance plans allow patients to access specialty health services directly. Many plans, however, require that patients see or obtain permission from a "gatekeeper," who decides whether to authorize or allow such care. Three common gatekeeper

structures utilized by MC plans include: obtaining a referral from the patient's primary care physician (PCP); undergoing intake at a centralized office; or, allowing the particular provider  who is usually provided with a set of rules  to determine whether care is needed.


Gatekeeper influence both help seeking and treatment utilization. Martin et al. (1989) randomly assigned over 1100 families to one of two similar health plans. One plan used gatekeepers, the other did not. Over the next year, ambulatory care charges and the likelihood of seeing a specialist were lower in the gatekeeper plan. Rohrer et al. (1996) found that substance abuse patients who were required to seek referral from a centralized intake were less likely to attend treatment than patients who did not go through centralized intake (27% vs. 48%). Related to this, research suggests that reducing the time to treatment entry improves the likelihood of treatment entry and enhances ultimate treatment outcome (e.g., Miller & Heather, 1998)."


Based on information compiled by Donald Neumann Ph.D., PT, thirty-four states in the United States currently have some form of direct access intervention by a physical therapist. In Wisconsin, as of April 2002, licensed physical therapists are allowed to treat patients without a referral from a physician in four areas: schools, home-health care, nursing homes, and any arena that involves a specified set of musculoskeletal and athletic-related problems. In March 2002, a new bill has passed both the Senate and House and is awaiting signature by the governor of Wisconsin. This bill expands the practice-without-referral status of physical therapists. Regardless of the present law, however, Medicare and most insurance companies reimburse patients for physical therapy (PT) only if a physician initiates a referral.


The American Physical Therapy Association (APTA) is fighting to change this trend of reimbursement by third party payers. The stance of the APTA is to have physical therapy totally reimbursable, without a physician=s referral, as long as the level of PT practice is in accord with the Practice Act of each state. This professional status is similar to that of dentists, podiatrists and chiropractors.


The official policy of the APTA is that all entry-level physical therapists are trained at the doctoral level by 2020. Approximately 25% of schools in the country offers the Doctor of Physical Therapy (DPT) degree. Another 25% of schools are in transition to the DPT, including Marquette University. As of March 2002, less than 1% of physical therapists have a DPT degree.


The doctoralBlevel education is designed to increase the ability of the physical therapist to function as an independent practitioner. Physical therapy, as a first level provider of health care services, will not replace the services of the physician, but would require therapists to identify when a medical problem is beyond the scope of the PT=s knowledge base. In this case, PTs would refer patients to the appropriate medical providers, including physicians. The ultimate objective of the APTA is that individuals would be able to obtain physical therapy services without a physician=s referral and that these services would be reimbursed by a third party payer.


In summary, the APTA web site sites three factors when considering direct access to physical therapists:


1- Direct access eliminates the burden of unnecessary visits to physicians to access physical therapy.


2- Direct access to physical therapists does not promote over-utilization or increase the cost of health care.


3- Liability insurers and the Federation of State Boards of Physical Therapy affirm that direct access does not jeopardize the health, safety, or welfare of the patient seeking services from a PT without referral.


Average national salary = $50,000-60,000 (median), based on data supplied by APTA.


In summary


To reduce costs we recommend that APNs, psychologists, and PTs be included in health plan provider panels, so employees can choose the more cost effective, high quality health care. No one is suggesting that health care be done without physicians, we all acknowledge that the best quality care is a team effort. However, allowing MU employees to access APNs, Psychologists, and PTs directly offers potential cost savings as well as identifies the contributions these MU alumni make to high quality health care.





Select References


1. Associated Press. (October, 31, 1999). Health care costs shift to workers, study shows. (Available at http://www.jsonloine.com/bym/News/oct99/insure0113199a.asp).

2. Borowski, G.J. (August 24, 2000). City property tax rate will rise, budget office says. (Available at http://www.jsonline.com/bym/news/Metro/aug00/taxes25082400a.asp).

3. Manning, J., & Romell, R. Feb. 10, 2002. Medical costs 55% above Midwest average Area providers simply charge more, study says. Milwaukee Journal Sentinel. (Available at http://www.jsonline.com/news/Metro/feb02/19229.asp).

4. (Feb. 20, 2002). INSURANCE COSTS Lower premiums would relieve budget shortfall. The Morning Mail Milwaukee Journal Sentinel.(Available at http://www.jsonline.com/news/editorials/feb02/21931.asp).

5. Pommer, M. (Feb. 20, 2002). Broad review ordered of health insurance for state employees. Capitol Times.

6. The Capitol Times, October 10, 2000. Also reported in HMO: Company says no more coverage for businesses outside Dane County. (Available at http://www.jsonline.com/Wi/101000/wi  hmodemise101000193444.asp.

7. Baker DW, Shapiro MF, Schur CL.(2000). Health insurance and access to care for symptomatic conditions. Archives of Internal Medicine. 160(9):1269-74.

8. How does not being insured hurt? The Coalition for Wisconsin Health ( Vol. 4, Winter 2001) p. 5.

  1. American Academy of Nurse Practitioners. (1993). Scope of practice for nurse practitioners. Washington, D.C.: Author.

10. American College of Nurse Midwives. (1992). Core competencies for basic nurse-midwifery practice. Washington, D.C.: The College.

11. American Nurses Association. (1995). Nursing's social policy statement. Washington, D.C.: The Association.

  1. Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W-Y, Cleary, P.D., Friedewald, W.T., Siu, A.L., Shelanski, M.L. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. JAMA, 283(1), 59-68.

  2. National Association of Clinical Nurse Specialists. (1998). Statement on Clinical Nurse specialist practice and education. Glenview, IL: The Association.

  3. HCFA Fact Sheet.(January 17, 2001). Physician supervision of Certified Registered Nurse Anesthetists. ( Available at: http://www.aana.com/press/2001/011800hcfa.asp).

  4. Bell KE, Mills JI. Certified nurse-midwife effectiveness in the health maintenance organization obstetric team. Obstet Gynecol 1989; 74:112-116.

  5. Brown SA, Grimes DE. A meta-analysis of nurse practitioners and nurse-midwives in primary care. Nursing Research 1995; 44:332-339.

  6. Cherry J, Foster JC. Comparison of hospital charges generated by certified nurse-midwives' and physicians' clients. J Nurse Midwifery 1982; 27:7-11.

  7. M, Wolfe SM. Nurse -midwifery: the beneficial alternative. Public Health Reports 1997; 112:386-395.

  8. Giles W, Collins J, Ong F, MacDonald R. Antenatal care of low risk obstetric patients by midwives: a randomised controlled trial. The Medical Journal of Australia 1992; 157:158-161.

  9. Gravely EA, Littlefield JH. A cost-effectiveness analysis of three staffing models for the delivery of low-risk prenatal care. Am J Pub Hlth 1992; 82:180-184.

  10. Jackson D, Swartz W, Lang J, Ganiats T, Fullerton J, Ecker J. Outcomes from the San Diego Birth Center Study; presented at the Association for Health Services Research 15th Annual Meeting, Washington, DC, June 22, 1998.

  11. Knedle-Murray ME, Oakley DJ, Wheeler JRC, Peterson BA. Production process substitution in maternity care: issues of costs, quality, and outcomes by nurse-midwives and physician providers. Medical Care Review 1993; 50:81-112.

  12. Oakley D, Murray ME, Murtland T, Hayashi R, Anderson F, Mayes F, et al. Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstet Gynecol 1996; 88:823-829.

  13. Schimmel LM, Schimmel LD, DeJoseph JF. Toward lower cesarean birth rates and effective care: five years' outcomes of joint private obstetric practice. Birth 1997; 24:181-187.

  14. Peiper, B. & Dinardo, E. (2001). Health maintenance in a primary care clinic for urban, indigent adults. Journal of WOCN (Wound, ostomy, and continence nursing), 28, 129-40.

  15. Arnold L. Gennaro S. Kirby A. Atendido M. Laverty M. Brooten D.(1995). The perinatal evaluation center: a nurse practitioner service delivery model. Journal of Perinatal & Neonatal Nursing, 9,45 51.

  16. McCorkle R. Strumpf NE. Nuamah IF. Adler DC. Cooley ME. Jepson C. Lusk EJ. Torosian M. (2000). A specialized home care intervention improves survival among older post surgical cancer patients. Journal of the American Geriatrics Society, 48,1707 13.

  17. Birkholz, G., & Viens, D.C. (1999). Medicaid claims data comparisons for nurse practitioners, physician assistants, and primary care physicians in New Mexico. Journal of the American Academy of Nurse Practitioners, 11, 3-10.

  18. Erickson V. (2000). Prescriptive practices of nurse practitoners (NP) for acute otitis media (AOM). Program and abstracts of National Organization of Nurse Practitioner Faculties 26th Annual Meeting; April 13-16. Washington, DC. Session MR6

  19. Dahle KL, Smith JS, Wilson JR. (1998). Impact of a nurse practitioner on the cost of managing inpatients with heart failure. The American Journal of Cardiology, 82(5):686.

  20. WisTREC Utilization Committee. (January 2001). PAs, NPs, and CNMs Employment Guide. Wisconsin Area Health Education Center System. Available at: http://academic.son.wisc.edu/wistrec/for_employer/employer.html.

  21. Physician compensation survey - in practice three plus years. Retrieved 3/27/02 from: http://www.physicianssearch.com/physician/salary2.html.

  1. News in Risk Management. Available at: http://www.rmf.harvard.edu/news/news 11802 a1/index.html.

  2. Medical Malpractice Premium Payments for Individual Physicians, 2000. Available at: http://www.heartland.org/health/jan02/chart.htm

  3. Wisconsin State Profile in State Health Workforce Profiles p. 21 (Retrieved 3/27/02 from:

http://bhpr.hrsa.gov/healthworkforce/profiles/default.htm.

  1. Chaptman, D. (April 13, 2001). Tax burden remains heavy in Wisconsin. (Available at

http://www.jsonline.com/bym/news/apr01/free4041301a.asp).

  1. TriCouncil for Nursing Policy Statement. Strategies to Reduce the New Nursing

Shortage. (Available at: http://www.nln.org/aboutnln/news_tricouncil2.htm).





Prepared by Marilyn Frenn Ph.D., R.N.

Associate Professor Marquette University College of Nursing

President Wisconsin League for Nursing

(414) 288-3845 (O) Marilyn.Frenn@Marquette.edu Email

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