Mid-level practitioners in dermatology: a need for further study and oversight

Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014

Importance

Nurse practitioners (NPs) and physician assistants (PAs) are nonphysician clinicians (NPCs) who can deliver dermatology services. Many of these services are provided independently. Little is known about the types of services provided or where NPCs provide independent care.

Objective

To examine characteristics of dermatology care for Medicare enrollees billed independently by NPCs.

Design, Setting, and Participants

Retrospective review of the 2014 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File, which reflects fee-for-service payments to clinicians for services rendered to Medicare beneficiaries. Clinician location was matched with county-level demographic data from the American Community Survey, US Census Bureau. Clinicians identified using National Provider Identifier as NPs or PAs with at least 11 claims for common dermatology-associated Healthcare Common Procedure Coding System procedure codes were included.

Main Outcomes and Measures

Total services provided by service type category, density of dermatologists and nondermatologists who perform dermatology-related services, and geographic location by county.

Results

Among the cohort of NPCs were 824 NPs (770 [93.5%] female) and 2083 PAs (1602 [76.9%] female) who independently billed Medicare $59 438 802 and $171 645 943, respectively. Dermatologists were affiliated with 2667 (92%) independently billing NPCs. Most payments were for non-evaluation and management services including destruction of premalignant lesions, biopsies, excisions of skin cancer, surgical repairs, flaps/grafts, and interpretation of pathologic analysis. Nurse practitioners and PAs billed for a similar distribution of service categories overall. A total of 2062 (70.9%) NPCs practiced in counties with dermatologist density of greater than 4 per 100 000 population. Only 3.0% (86) of independently billing NPCs practiced in counties without a dermatologist. Both dermatologists and NPCs were less likely to be in rural counties than in urban counties.

Conclusions and Relevance

Nonphysician clinicians independently billed for a wide variety of complex dermatologic procedures. Most independently billing NPCs practice in counties with higher dermatologist densities, and nearly all these NPCs were affiliated with dermatologists. Further study of NPC training and integration with the dermatology discipline is an important part of addressing the changing US dermatology workforce.