In Some Specialties, In-Office Surgeries Blur

One of the hopes embedded in the Affordable Care Act was to expand the role of nurse practitioners and physician assistants in addressing the nation’s shortage of primary care providers. But a new study questions whether that’s actually happening in doctors’ offices.

Of the more than 4 million procedures office-based nurse practitioners and physician assistants independently billed more than 5,000 times in a year to Medicare – a list including radiological exams, setting casts and injecting anesthetic agents – more than half were for dermatological surgeries.

That’s not surprising, according to Ken Miller, president of the American Association of Nurse Practitioners, because when patients are older, skin problems such as “boils, skin tags and warts” are pretty typical.

“I think that’s where you’re going to see the majority of procedures that are occurring both in primary care and in some of the other specialties like geriatric clinics,” he said.

The Aug. 11 study, published in the JAMA Dermatology analyzing 2012 Medicare claims, is suggesting that nurse practitioners and physician assistants should face higher regulation if performing surgical procedures. 

The study’s lead author, Brett Coldiron, M.D. a dermatologist and clinical assistant professor at the University of Cincinnati, said while the “intent for mid-level nurse practitioners was to give primary care,”  the level of surgical billing implies that may not necessarily be true.

He said those mid-level providers – PAs and NPs - “are doing invasive procedures and surgery. I’m not sure they were trained to do that.”

But practitioners who perform specialized procedures often have received additional training, according to Miller.

“If they find something that is out of their scope, they will refer – and it’s the same thing that primary care physicians do,” he said.

The study’s analysis found that a majority of procedures billed by nurse practitioners and physician assistants relate to dermatology specifically, a trend Coldiron said could stem from the frequency of dermatological procedures being performed in offices rather than hospitals, along with the higher rate of skin cancer among the older patients Medicare covers.

The nurse practitioners performing specialized dermatological procedures often have received extra training, Miller said, and they often attend “the same symposiums and conferences dermatologists actually attend.”

“If they’re in the same subspecialty of dermatology, they may be doing these procedures because that’s how they’ve been trained,” he said.

He thinks no more than 3% or 4% of nurse practitioners actually end up specializing in a specific area of care.  But all nurse practitioners will often see patients with dermatological conditions, and the treatments they require are usually not “extraordinary,” he said.

Coldiron said while the mid-level providers may have received extra training within a relevant specialty, many likely lack the expertise of doctors who have done a residency within the field. “If nurses are going to practice surgery, that’s not [nursing] – that’s medicine,” he said.

Nurse practitioners and physician assistants have been suggested as a potential solution to shortages in primary care physicians, providers whose roles were emphasized in the ACA. But both Coldiron and Miller suggested that may not be the case in practice.

It would be a mistake to treat any one kind of health care provider as a silver bullet to fix primary care shortages, Miller said. Though he expressed concern that particular geographic areas may lack sufficient access to primary care, nurse practitioners or physician assistants can’t fill that gap, he said.

What “health professionals are all trying to provide is quality care that is convenient and accessible,” he said, adding that, “there is not enough primary care out there, and there is not one discipline out there” to meet patient needs.

The study cautioned that a boost in mid-level providers performing surgical procedures could lead to more cases of malpractice, a concern Coldiron said suggested a need for greater regulatory oversight of nurse practitioners and physician assistants.

But that kind of argument is a “red herring,” Miller argued.

“There have been no real studies out there that show nurse practitioners are less safe than physicians,” he said. “What we’re all trying to do,” he added, “is we’re trying to provide the best care and the best quality of care.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.