Nurse practitioners and physician assistants are a fast-growing part of the medical marketplace, getting paid more often for procedures people generally associate with doctors, such as electrocardiograms, pelvic exams and even helping with heart bypasses, a USA TODAY analysis of federal data finds.
Medicare billing records show 15% more nurse practitioners and 11% more physician assistants received payments in 2013 than in 2012 for all types of care. During that same year, the number of general practice physicians paid by the insurance program for the elderly and disabled dropped by 5%.
Experts say this reflects the rising influence of non-physician caregivers in a changing health care system beset by doctor shortages and now taxed even more by a growing number of patients gaining insurance through Obamacare. It also shines light on the high-level care that NPs and PAs have been providing for many years. Until now, that’s been largely under the radar, but is revealed with the release of government payments to health care providers, which clearly show these caregivers are a growing force in medicine.
“We weren’t seen before, but we were doing these things,” says Elizabeth Visone, a nurse practitioner in Connecticut. “(Critics) would say: You can’t do these procedures and you shouldn’t do these procedures. But we were doing them.”
Replacing chest tubes, interpreting EKGs and caring for trauma patients with severe problems like aortic aneurysms are typical duties for Kristen Guida, a night-shift NP at a trauma center in Hartford, Conn. Lumbar punctures of the lower back and cystoscopies to check the urinary tract are commonly handled by physician assistants, who also assist doctors in complicated operations because “the surgeon only has two hands,” says Todd Pickard, director of physician assistant practice at The University of Texas MD Anderson Cancer Center.
“A lot of people misunderstand the roles of PAs and NPs,” he says. “With PAs, it sounds like we fetch a prescription pad and get coffee for physicians, and that’s not what we do at all.”
Among USA TODAY’s findings:
- In 2013, non-physician caregivers billed for office visits, as well as high-severity ER visits and pelvic exams for NPs; and tissue biopsies, X-rays and complicated surgical procedures for PAs. Nearly 900 PAs were paid for heart artery bypasses and another 950 for spinal fusion procedures, as “first assistants” to doctors in these operations.
- NPs increasingly provide psychotherapy for Medicare patients and their families. More than 1,000 nurse practitioners billed for a total of nearly 200,000 psychotherapy visits in 2013. “We have many more psychiatrists not taking insurance,” says Visone, adding that NPs tend to provide mental health care to “the underserved, the disabled and the elderly.”
- Overall, Medicare payments in 2013 totaled $1.5 billion for nearly 65,000 nurse practitioners and $1 billion for about 50,000 physician assistants. Those payment totals were up 16% for NPs and 12% for PAs from the previous year. General practice physicians, meanwhile, saw total payments drop 7.6%.
The main driver of these trends is rapid growth in the sheer numbers of non-physicians in health care. The ranks of NPs grew from 60,000 in 1999 to 171,000 in 2013; and the ranks of PAs grew from 83,466 in 2010 to 101,977 in 2015, according to their respective trade organizations. By contrast, a study conducted this year for the Association of American Medical Colleges says the doctor shortage is expected to reach 46,000-90,000 physicians by 2025.
As the number of non-physician caregivers has grown, the government has also been cracking down on incorrect, fraudulent or careless Medicare billing. Experts describe three acceptable ways to bill — under a provider’s own number, with a physician as a co-managed visit if they see a patient together, or under the physician’s name if the non-physician is carrying out a treatment plan put in place by the doctor. NPs and PAs generally receive 85% of what doctors get for office visits.
Visone says she’s heard of doctors — although none she works with — who would bill under their own names inappropriately to get the bigger payment. Officials from the U.S. Centers for Medicare and Medicaid Services say they are encouraging health care providers to bill under their own “national provider identifiers.”
Ultimately, having more non-physicians provide care should save taxpayers money, says Tay Kopanos, a vice president for the American Association of Nurse Practitioners. Michael Powe, a vice president for the American Academy of Physician Assistants, agrees, saying, “each time a PA is used for the same thing (a physician would do), it’s a cost-savings to Medicare.”
Kopanos and other NPs say the Medicare billing data informs a long-running debate with physicians about whether NPs should be able to practice more independently and perform high-level procedures on their own. While PAs always work in teams with doctors, NPs started making real headway toward gaining more independence in the run-up to the Affordable Care Act.
“Independent practice and team-based care take health care delivery in two very different directions,” says Andrew Gurman, AMA president-elect. “One approach would further compartmentalize and fragment health care delivery, while team-based care fosters greater integration and coordination.”
As the debate continues, PAs and NPs say the demand for their services is growing fast. Jeffrey Katz, a family practice PA in North Carolina and president of the PA academy, says he’s constantly busy. A recent day included checkups for a three-day-old baby, an 80-year-old patient with numerous chronic diseases, and a constant stream of patients of varying ages in between.
Melissa Lamaster, a nurse practitioner in Louisville who works in an NP-only office run by KentuckyOne Health, says her days are much the same. She routinely performs physicals, diagnoses disease and writes prescriptions — all the while educating patients about their health. Some arrive apprehensive about seeing her rather than a doctor, she says, but in the end, “I have never had one not be happy with my care.”
On a recent morning, Lamaster balanced 6-month-old Kelsey Ducette on her knee, listening to her heart and talking to her custodial aunt, Erica Ducette. They discussed developmental milestones, vaccinations and feeding, with Lamaster describing how to freeze homemade baby food in ice-cube trays. By the end of the appointment, Ducette was ready to make Lamaster the baby’s regular care provider.
Marilyn Rantz, a nursing school professor at the University of Missouri, says NPs are as good as doctors at providing care within their scope of practice, “and in many areas, they’re helping improve health.”
Physicians and non-physicians “are both good,” Rantz says. “They both have roles, and Lord knows people have enough health care needs to go around.”