ORIGINAL ARTICLE
Expanding Roles of Nurse Practitioners and Physician Assistants As Providers of Nonvascular Invasive Radiology Procedures Richard Duszak Jr, MDa,b, D. Gail Walls, MSN b,c, Jennifer M. Wang, PhD d, Jennifer Hemingway, MSa, Danny R. Hughes, PhDa,e, William C. Small, MD, PhDb, Michael A. Bowen, MSN b Abstract Purpose: To evaluate national trends in nonvascular invasive radiology procedures performed by advanced practice providers (APPs), focusing specifically on nurse practitioners and physician assistants. Methods: Nonvascular invasive radiology procedures commonly performed by APPs at our 2 largest hospitals were used to identify procedure groups for national trends analysis. We mapped categories of services annually to then-current Current Procedural Terminology codes from 1994 to 2012 and identified national Medicare Part B beneficiary paid claims frequency using Physician Supplier Procedure Summary Master Files. Trends were studied for APPs, radiologists, and all providers nationally for 7 categories of service: paracentesis, thoracentesis, fine-needle aspiration (FNA), superficial lymph node biopsy, abdominal biopsy, thoracic biopsy, and abdominal drainage. Results: Of 1,352 nonvascular invasive procedures performed by APPs at our facilities over a 1-year period through August 2013, a total of 1,161 (85.9%) fell into the 7 defined categories. Between 1994 and 2012, national Medicare claims by APPs increased dramatically for all of these categories: paracentesis from 0 to 17,967; thoracentesis from 119 to 4,141 (þ3,379%); FNA from 0 to 3,921; superficial lymph node biopsy from 0 to 251; abdominal biopsy from 1 to 1,819 (þ1,818%); thoracic biopsy from 0 to 552; and abdominal drainage from 37 to 410 (þ1,008%). Overall, volumes increased for both radiologists and all providers, with the total fraction of national services performed by APPs increasing from 0% to 10.7% for paracentesis, 0.1% to 5.7% for thoracentesis, 0% to 2.1% for FNA, 0% to 1.4% for superficial lymph node biopsy, 0% to 1.7% for abdominal biopsy, 0% to 1.0% for thoracic biopsy, and 0.1% to 1.2% for abdominal drainage. Conclusions: Although APPs perform a relatively small portion of commonly performed nonvascular invasive radiology procedures nationally, paid Medicare claims for those services have increased dramatically over nearly 2 decades, and at a faster pace than that for all providers as a whole. Given the multiple hurdles involved in obtaining Medicare reimbursement, that growth indicates increasing acceptance of APPs as procedure service providers at the institutional credentialing, state licensure, and payer policy levels. Key Words: Advanced practice providers, midlevel practitioners, nurse practitioners, physician assistants, interventional radiology, imaging guided procedures, biopsy, drainage J Am Coll Radiol 2015;12:284-289. Copyright 2015 American College of Radiology
INTRODUCTION Although much attention in health care reform discussions has focused on cost and quality, access to health care services remains a critical public policy issue. Many US citizens face a
Harvey L. Neiman Health Policy Institute, Reston, Virginia. Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia. c College of Nursing, University of South Alabama, Mobile, Alabama. d Department of Biology, University of Central Arkansas, Conway, Arkansas. e Department of Health Administration and Policy, George Mason University, Fairfax, Virginia. Corresponding author and reprints: Richard Duszak Jr, MD, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA 30322; e-mail: [email protected]. b
challenges achieving timely access to health care services, and this disproportionately affects minorities, those with lower incomes, and those residing in rural areas [1]. With a US population that is both growing and aging, and a fundingconstrained graduate medical education system little able to expand, some are predicting that the country’s demand for physician services may soon exceed its physician supply [2,3]. Formerly termed midlevel practitioners, advanced practice providers (APPs) likely will be an integral component of the solution to this predicted provider-access gap. Primarily representing nurse practitioners (NPs) and physician assistants (PAs), this professional group is in increasing demand by medical practices and health care systems nationwide [4]. Much attention has focused on the expanding roles of APPs
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Table 1. Categories of nonvascular invasive procedures used for Medicare claims analysis Procedure Paracentesis Fine-needle aspiration Abdominal biopsy Thoracentesis Abdominal drainage Superficial lymph node biopsy Thoracic biopsy
CPT Codes 49080, 49081, 49083 88170, 88171, 10022 47000, 50200, 49180 32000, 32421, 32555 49021, 49041, 49061, 47011; 49020 (only through 1996); 49040, 49060, and 47010 (only through 1997) 38505 32400, 32405
Number 471 285 223 63 58 43 18
% Total 34.8 21.1 16.5 4.7 4.3 3.2 1.3
Note: CPT codes reflect those utilized to define each service group from 1994 through 2012. Numbers and percentages reflect those procedures (of 1,352 total) performed by radiology advanced practice providers over a recent 1-year period in the authors’ health care system. CPT ¼ Current Procedural Terminology.
in the primary care setting [5,6], but involvement of APPs in critical care, surgery, and a variety of other specialty services is increasing as well [7-9]. Interventional radiology practices are increasingly utilizing APPs to provide both clinical and procedural services [10-12]. With regard to the latter, a dramatically expanded role of APPs as providers of central venous access services has recently been reported [13]. We believe that the role of APPs as primary operators for a variety of minor nonvascular invasive procedures historically performed by radiologists has expanded dramatically as well. To our knowledge, however, this hypothesis has not been tested using national administrative claims or registry data. Our aim, therefore, is to study the expanding role of APPs as providers of invasive procedures commonly performed by radiologists, using aggregated Medicare claims files.
METHODS This HIPAA-compliant study of aggregated Medicare claims data from CMS-designated public use files was deemed to be exempt from review by our institutional review board. Our goal was to identify categories of nonvascular invasive radiology procedures that are potentially representative of the spectrum of those performed nationally by APPs. Thus, we reviewed deidentified procedure summary volume data for fiscal year 2013 (September 1, 2012 through August 31, 2013) from the 2 largest hospitals in our clinical authors’ academic health care system where APPs perform minor image-guided invasive procedures. Central venous access services comprised approximately one-third of all procedures; given that the expanding role of APPs for these services was recently studied [13], we excluded these services from our analysis. Using internal operational clinical service categories, we identified all nonvascular procedures performed by APPs at those facilities, focusing on 7 groups that comprised 85.9% of those services (Table 1). National Medicare claims-tracking methodology was based on that previously utilized for other imaging-guided Journal of the American College of Radiology Duszak, Walls, Wang n NP and PA Procedures
invasive procedures [13-15]. We acquired annual Medicare Physician Supplier Procedure Summary (PSPS) Master Files from 1994 through 2012 from CMS. PSPS Master Files aggregate Part B Medicare billing claims submitted by physicians, APPs, and all other providers nationally. Data fields include codes for procedure and provider specialty, and they include the number of procedures for which claims were submitted and paid. These data were retrospectively compiled and aggregated by CMS in designated public use files that contain no individual patient or physician identifiers or diagnosis information. PSPS Master Files include all claims for all beneficiaries in the traditional Medicare fee-for-service program, which currently represents approximately 71% of all Medicare supplementary medical insurance enrollees [16]. Although Medicare enrollment increased over the past 2 decades, that growth has largely involved private Medicare managed care programs; thus, Part B enrollment has remained relatively stable (32.3 and 33.0 million in 1994 and 2012, respectively) [16]. Health care providers are identified within PSPS Master Files with self-reported specialty and profession codes. For the purposes of this study, services by those with specialty codes for NPs (specialty #50) and PAs (#97) were grouped into an APP category. Services designated with codes for diagnostic radiology (#30), nuclear medicine (#36), and interventional radiology (#94) were grouped into a radiologist category. Because CMS does not recognize radiologist assistants as independent providers [17], this provider category has no specialty code; thus, physician-supervised services involving such professionals cannot be identified. In a manner similar to that described elsewhere [13], we mapped defined procedure categories over time, annually from 1994 to 2012, to then-current Current Procedural Terminology codes, which allowed us to describe these categories of services in a variety of radiology department settings. As code granularity permitted, we specifically excluded codes in which imaging guidance is explicitly 285
20,000
18,000
16,000
Frequency of procedures
14,000
12,000
Paracentesis Thoracentesis Fine needle aspiraƟon
10,000
Superficial lymph node biopsy Liver, renal & other abdominal biopsy 8,000
Lung, mediasƟnal & pleural biopsy Abdominal abscess drainage
6,000
4,000
2,000
0
Year
Fig 1. Annual number of services rendered by APPs, by procedure category, to Medicare Part B beneficiaries, from 1994 to 2012.
excluded. The code-mapping methodology is outlined in Table 1. Trends were analyzed and reported. Data analysis was performed with SAS 9.1 (SAS Institute, Inc., Cary, North Carolina) and Excel 2010 (Microsoft, Redmond, Washington).
RESULTS Of 1,352 nonvascular procedures performed by APPs at our facilities in 2013, a total of 1,161 (85.9%) were included in the 7 defined categories. Paracentesis (40.1%; 471 of 1,161); fine-needle aspiration (FNA; 24.2%; 285 of 1,161); abdominal biopsy (19.0%; 223 of 1,161); and thoracentesis (5.4%; 124 of 1,161) together comprised 89.8% of these categorized procedures (Table 1).
APP Services Between 1994 and 2012, national Medicare claims by APPs increased dramatically for all categories: paracentesis from 0 to 17,967; thoracentesis from 119 to 4,141 (þ3,379%); FNA from 0 to 3,921; superficial lymph node biopsy from 0 to 251; abdominal biopsy from 1 to 1,819 (þ1,818%); thoracic biopsy from 0 to 552; and abdominal drainage from 37 to 410 (þ1,008%). These trends are illustrated in Figure 1. 286
Radiologist Services Claims by radiologists increased as well for all categories: paracentesis from 13,276 to 139,144 (þ948%); thoracentesis from 17,488 to 35,787 (þ105%); FNA from 2,271 to 96,504 (þ4,149%); superficial lymph node biopsy from 452 to 14,951 (þ3,208%); abdominal biopsy from 46,449 to 86,423 (þ86%); thoracic biopsy from 45,033 to 54,060 (þ20%); and abdominal drainage from 15,085 to 33,356 (þ121%).
Services by All Providers of All Specialties The frequency of these services rendered by all providers of all specialties combined increased for most procedure groups: paracentesis from 69,980 to 167,171 (þ139%); thoracentesis from 150,572 to 72,872 (e51.6%); FNA from 60,123 to 183,688 (þ206%); superficial lymph node biopsy from 5,733 to 18,475 (þ222%); abdominal biopsy from 79,272 to 104,849 (þ32%); thoracic biopsy from 57,732 to 55,733 (e3%); and abdominal drainage from 30,015 to 34,404 (þ14.6%).
Proportions of All Services As a fraction of all categorized services by all providers of all specialties, services rendered by APPs increased disproportionately Journal of the American College of Radiology Volume 12 n Number 3 n March 2015
between 1994 and 2012: from 0% to 10.7% for paracentesis; 0.1% to 5.7% for thoracentesis; 0% to 2.1% for FNA; 0% to 1.4% for superficial lymph node biopsy; 0% to 1.7% for abdominal biopsy; 0% to 1.0% for thoracic biopsy; and 0.1% to 1.2% for abdominal drainage. The fraction of services rendered by radiologists, who now represent dominant service providers, increased disproportionately as well: from 19.0% to 83.2% for paracentesis; 11.6% to 49.1% for thoracentesis; 3.8% to 52.5% for FNA; 7.9% to 80.9% for superficial lymph node biopsy; 58.6% to 82.4% for abdominal biopsy; 78.0% to 97.0% for thoracic biopsy; and 50.3% to 97.0% for abdominal drainage.
DISCUSSION We used national Medicare claims data from 1994 through 2012 to study the expanding role of APPs as providers of minor nonvascular invasive procedures common to radiology practices. In all 7 procedure service categories studied, paid Medicare claims—zero for 4 of 7 categories in 1994— increased dramatically. Depending on the particular service category, APPs now perform between 1% and 11% of these procedures nationwide. Radiologists, in comparison, perform as many as 97%. Expanding roles of APPs have been highlighted in various contexts, many focusing on primary care [5,6]. But, at the other end of the clinical spectrum, APPs also care for the sickest of the sick, with studies reporting expanding APP roles in critical care units [9,18] and teaching hospitals [7,8]. Within radiology, most published APP attention has focused on roles supporting an interventional service [11,12,19,20]. In some practices, roles have been particularly narrow (eg, interventional oncology) [21], but more general noninterventional radiology roles have been described as well [22,23]. Data on specific APP services and categories of services, however, have been sparse, and remain largely institution specific. The expanding national role of APPs as providers of services commonly performed by radiologists has been mentioned, largely in passing, in the context of paracentesis and thoracentesis [15] and central venous access procedures [13], but to our knowledge, no study has specifically targeted APPs as providers of various nonvascular invasive procedures. To that end, we believe that this article provides support for the benefit of having APPs performing these services and—for the radiologists and facilities that employ them—shows that APP involvement in such services is increasingly becoming the norm. In addition, the authors hope the article will help practices striving to overcome political and other implementation barriers, by providing evidence that local APP serviceexpansion initiatives are aligned with national trends. As nonphysicians enter service arenas traditionally dominated by physicians, concerns regarding quality and Journal of the American College of Radiology Duszak, Walls, Wang n NP and PA Procedures
safety are not unexpected [24]. Emerging data in selected clinical scenarios, however, show not only APP quality comparability, but also actual improvement in outcomes. For example, APP service expansion has been associated with reduced clinic wait times, shorter hospital and intensive care unit lengths of stay, decreased durations of ventilator dependency, and earlier removal of Foley catheters with reductions in urinary tract infections [25-27]. With specific regard to nonvascular invasive abdominal procedures, more recent work has demonstrated comparable outcomes between trained APPs and physicians for both paracentesis and liver biopsy procedures [28,29]. Such longitudinal clinical data will become increasingly important as health care systems and policymakers seek to match service demands with qualified-provider supply. Rigorously evaluating changes in APP credentialing and scope of practice requirements on a national level is challenging. The Balanced Budget Act of 1997 liberalized payment for APPs nationally [30] and thus likely influenced APP service growth beginning in 1998. But institutions and states each have unique rules and regulations defining APP scope of practice, which change over time, and no coordinated registries have been established to facilitate tracking. For this reason, Medicare service payment was chosen as a novel surrogate metric. Since Medicare, by both law and operational precedent, will only pay for services for which providers are both licensed and credentialed [31], any expansion of paid services by Medicare affirms expansion of these prerequisites. Therefore, we believe that paid Medicare claims are a reasonable marker of multi-stakeholder acceptance of APPs as providers of these procedures. The expansion of APPs into service lines historically dominated by physicians creates both opportunities and challenges for radiology practices. More providers may translate into improved patient access and, if unencumbered by competing diagnostic radiology work responsibilities, APPs may actually be able to deliver more-personalized care in a less rushed manner than radiologists. Additionally, channeling procedures in a radiology department to specific individuals— rather than to sundry radiologists across the entirety of a practice—may result in increased workflow standardization and associated improvements in outcomes, similar to those already described in targeted intensive care settings. Despite these benefits, however, radiologists who engage APPs should be mindful to not relinquish all patient contact opportunities completely, lest they accelerate the commoditization of the specialty and further fuel stereotypes of the “invisible radiologist” [32]. Similarly, the short-term arbitrage appeal of expanding traditional physician services through use of less costly nonphysician providers could have long-term payment policy implications. As professional payments are calculated on a resource basis, and currently 287
valued using physician labor, continued national shifts of procedures from physicians to less costly APPs could result in devaluation of these services—for radiologists and APPs alike [33]. As with any retrospective analysis of claims data, our analysis has limitations. First, aggregated Medicare claims data do not permit study of clinical service delivery nuances (eg, patient acuity, guidance modality, coincident conditions or services). We have selected groups of services, based on our own institutional experience, that we believe are representative of the spectrum of services rendered by radiology APPs in other communities. We are well aware, however, of considerable regional variation in APP scope of practice. Second, because of the nature of Medicare claims data, APP employers cannot be identified. Although some services were likely performed under the supervision or employment of nonradiologists, we believe that the targeted procedure groups are typical ones for many radiology practices. Our goal, however, was to study nonvascular invasive APP procedures that are commonly performed in radiology practices, not necessarily those that definitely were. Third, because our study utilized Medicare data, we are unable to comment on trends in services to other insurance populations or the uninsured. Nonetheless, we have no specific reason to expect that trends in other payer populations would substantively diverge from those identified. Finally, although aggregated claims data are very useful for high-level longitudinal trends analyses such as ours, they do not include individual patient- or provider-level information and thus do not lend themselves to outcomes or quality analyses (eg, identification of complications, repeat procedures). Future studies focused toward these goals would best be performed using institutional clinical or registry data.
TAKE-HOME POINTS n
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Although APPs nationally perform a relatively small portion of the nonvascular invasive procedures commonly performed by radiologists, paid Medicare claims for those services have increased dramatically over nearly 2 decades, and at a faster pace than for all providers as a whole. Depending on the particular category of service, APPs nationwide now perform between approximately 1% and 11% of nonvascular invasive procedures commonly performed by radiologists. Given the numerous hurdles involved in obtaining Medicare reimbursement, that percentage growth suggests an increasing national acceptance, by institutional credentialing bodies, state licensure boards, and payers alike, of APPs as providers of these services.
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REFERENCES 1. Ramirez E, Ohlhausen MK. Policy perspectives. Washington, DC: National Academies Press; 2014. 2. Association of American Medical Colleges (AAMC). The complexities of physician supply and demand: projections through 2025 Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: http://www.innovationlabs.com/pa_future/1/background_docs/ AAMC%20Complexities%20of%20physician%20demand,%202008. pdf. Accessed September 12, 2014. 3. Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med 2013;88:468-74. 4. Robeznieks A. Physician assistant, nurse practitioner workloads expected to increase. Modern healthcare. Available at: http://www. modernhealthcare.com/article/20140218/BLOG/302189995. Accessed September 7, 2014. 5. Hooker RS, McCaig LF. Use of physician assistants and nurse practitioners in primary care, 1995-1999. Health Aff (Millwood) 2001;20: 231-8. 6. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Aff (Millwood) 2010;29:893-9. 7. Reines HD, Robinson L, Duggan M, O’Brien BM, Aulenbach K. Integrating midlevel practitioners into a teaching service. Am J Surg 2006;192:119-24. 8. Bahouth M, Esposito-Herr MB, Babineau TJ. The expanding role of the nurse practitioner in an academic medical center and its impact on graduate medical education. J Surg Educ 2007;64:282-8. 9. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med 2008;36:2888-97. 10. Siskin G. Outpatient care of the interventional radiology patient. Semin Intervent Radiol 2006;23:337-45. 11. Rosenberg SM, Rosenthal DA, Rajan DK, et al. Position statement: the role of physician assistants in interventional radiology. J Vasc Interv Radiol 2008;19:1685-9. 12. Taylor K, Sansivero GE, Ray CE. The role of the nurse practitioner in interventional radiology. J Vasc Interv Radiol 2012;23:347-50. 13. Duszak R, Bilal N, Picus D, Hughes DR, Xu BJ. Central venous access: evolving roles of radiology and other specialties nationally over two decades. J Am Coll Radiol 2013;10:603-12. 14. Duszak R, Parker L, Levin DC, Rao VM. Placement and removal of inferior vena cava filters: national trends in the medicare population. J Am Coll Radiol 2011;8:483-9. 15. Duszak R, Chatterjee AR, Schneider DA. National fluid shifts: fifteenyear trends in paracentesis and thoracentesis procedures. J Am Coll Radiol 2010;7:859-64. 16. CMS. Data from the 100 percent denominator file, 2012. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/MedicareMedicaidStatSupp/Downloads/2013_ Section2.pdf. Accessed September 12, 2014. 17. Ellenbogen PH, Hoffman TR, Short BW, Gonzalez A. The radiologist assistant: what radiologists need to know now. J Am Coll Radiol 2007;4:461-70. 18. Edkins RE, Cairns BA, Hultman CS. A systematic review of advance practice providers in acute care: options for a new model in a burn intensive care unit. Ann Plast Surg 2014;72:285-8. 19. Stecker MS, Armenoff D, Johnson MS. Physician assistants in interventional radiology practice. J Vasc Interv Radiol 2004;15:221-7. 20. Beach D, Swischuk JL, Smouse HB. Using midlevel providers in interventional radiology. Semin Intervent Radiol 2006;23:329-32. 21. Hong K, Georgiades CS, Hebert J, Wahlin T, Mitchell SE, Geschwind J-FH. Incorporating physician assistants and physician extenders in the contemporary interventional oncology practice. Tech Vasc Interv Radiol 2006;9:96-100. 22. Blackmore CC, Hoffer EK, Albrecht E, Mann FA. Physician assistants in academic radiology: the Harborview experience. J Am Coll Radiol 2004;1:410-4.
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23. Bowen MA, Torres WE, Small WC. Nonphysician providers in radiology: the Emory University experience. Radiology 2007;245: 3-6. 24. Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev 2009;(66 Suppl):36S-89S. 25. Spisso J, O’Callaghan C, McKennan M, Holcroft JW. Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30:660-5. 26. Russell D, VorderBruegge M, Burns SM. Effect of an outcomesmanaged approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care 2002;11:353-62. 27. Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med 2003;31:2752-63.
28. Gilani N, Patel N, Gerkin RD, Ramirez FC, Tharalson EE, Patel K. The safety and feasibility of large volume paracentesis performed by an experienced nurse practitioner. Ann Hepatol 2009;8:359-63. 29. Murphy FB, Walls G, Tridandapani S, et al. Comparison of imageguided nonfocal hepatic biopsies performed by physicians and nurse midlevel providers. J Am Coll Radiol 2014;11:1059-63. 30. Department of Health and Human Services Office of Inspector General (DHHS). Medicare coverage of non-physician practitioner services. Washington DC: DHHS; 2001. Available at: https://oig.hhs. gov/oei/reports/oei-02-00-00290.pdf. Accessed September 12, 2014. 31. US Social Security Administration. Compilation of the social security laws, 2013. Available at: http://www.ssa.gov/OP_Home/ssact/title18/ 1861.htm. Accessed July 10, 2014. 32. Glazer GM, Ruiz-Wibbelsmann JA. The invisible radiologist. Radiology 2011;258:18-22. 33. Thorwarth WT. Reimbursement risks with radiologist extenders: There is no free lunch! J Am Coll Radiol 2004;1:405-9.
Erratum In the article titled: Evolving paradigm for imaging, diagnosis, and management of DCIS by Colin J. Wells, MD, Cristina O’Donoghue, MD, Haydee Ojeda-Fournier, MD, Hanna E. G. Retallack, MD, Laura J. Esserman, MD, that was published in the December 2013 issue of the JACR (2013;10:918-923), Hanna E. G. Retallack’s credentials were erroneously reported as MD. Ms Retallack is a student in an MD/PhD program, and her highest degree should have read “AB”.
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Expanding Roles of Nurse Practitioners and Physician Assistants As Providers of Nonvascular Invasive Radiology Procedures Richard Duszak Jr, MDa,b, D. Gail Walls, MSN b,c, Jennifer M. Wang, PhD d, Jennifer Hemingway, MSa, Danny R. Hughes, PhDa,e, William C. Small, MD, PhDb, Michael A. Bowen, MSN b Abstract Purpose: To evaluate national trends in nonvascular invasive radiology procedures performed by advanced practice providers (APPs), focusing specifically on nurse practitioners and physician assistants. Methods: Nonvascular invasive radiology procedures commonly performed by APPs at our 2 largest hospitals were used to identify procedure groups for national trends analysis. We mapped categories of services annually to then-current Current Procedural Terminology codes from 1994 to 2012 and identified national Medicare Part B beneficiary paid claims frequency using Physician Supplier Procedure Summary Master Files. Trends were studied for APPs, radiologists, and all providers nationally for 7 categories of service: paracentesis, thoracentesis, fine-needle aspiration (FNA), superficial lymph node biopsy, abdominal biopsy, thoracic biopsy, and abdominal drainage. Results: Of 1,352 nonvascular invasive procedures performed by APPs at our facilities over a 1-year period through August 2013, a total of 1,161 (85.9%) fell into the 7 defined categories. Between 1994 and 2012, national Medicare claims by APPs increased dramatically for all of these categories: paracentesis from 0 to 17,967; thoracentesis from 119 to 4,141 (þ3,379%); FNA from 0 to 3,921; superficial lymph node biopsy from 0 to 251; abdominal biopsy from 1 to 1,819 (þ1,818%); thoracic biopsy from 0 to 552; and abdominal drainage from 37 to 410 (þ1,008%). Overall, volumes increased for both radiologists and all providers, with the total fraction of national services performed by APPs increasing from 0% to 10.7% for paracentesis, 0.1% to 5.7% for thoracentesis, 0% to 2.1% for FNA, 0% to 1.4% for superficial lymph node biopsy, 0% to 1.7% for abdominal biopsy, 0% to 1.0% for thoracic biopsy, and 0.1% to 1.2% for abdominal drainage. Conclusions: Although APPs perform a relatively small portion of commonly performed nonvascular invasive radiology procedures nationally, paid Medicare claims for those services have increased dramatically over nearly 2 decades, and at a faster pace than that for all providers as a whole. Given the multiple hurdles involved in obtaining Medicare reimbursement, that growth indicates increasing acceptance of APPs as procedure service providers at the institutional credentialing, state licensure, and payer policy levels. Key Words: Advanced practice providers, midlevel practitioners, nurse practitioners, physician assistants, interventional radiology, imaging guided procedures, biopsy, drainage J Am Coll Radiol 2015;12:284-289. Copyright 2015 American College of Radiology
INTRODUCTION Although much attention in health care reform discussions has focused on cost and quality, access to health care services remains a critical public policy issue. Many US citizens face a
Harvey L. Neiman Health Policy Institute, Reston, Virginia. Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia. c College of Nursing, University of South Alabama, Mobile, Alabama. d Department of Biology, University of Central Arkansas, Conway, Arkansas. e Department of Health Administration and Policy, George Mason University, Fairfax, Virginia. Corresponding author and reprints: Richard Duszak Jr, MD, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA 30322; e-mail: [email protected]. b
challenges achieving timely access to health care services, and this disproportionately affects minorities, those with lower incomes, and those residing in rural areas [1]. With a US population that is both growing and aging, and a fundingconstrained graduate medical education system little able to expand, some are predicting that the country’s demand for physician services may soon exceed its physician supply [2,3]. Formerly termed midlevel practitioners, advanced practice providers (APPs) likely will be an integral component of the solution to this predicted provider-access gap. Primarily representing nurse practitioners (NPs) and physician assistants (PAs), this professional group is in increasing demand by medical practices and health care systems nationwide [4]. Much attention has focused on the expanding roles of APPs
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Table 1. Categories of nonvascular invasive procedures used for Medicare claims analysis Procedure Paracentesis Fine-needle aspiration Abdominal biopsy Thoracentesis Abdominal drainage Superficial lymph node biopsy Thoracic biopsy
CPT Codes 49080, 49081, 49083 88170, 88171, 10022 47000, 50200, 49180 32000, 32421, 32555 49021, 49041, 49061, 47011; 49020 (only through 1996); 49040, 49060, and 47010 (only through 1997) 38505 32400, 32405
Number 471 285 223 63 58 43 18
% Total 34.8 21.1 16.5 4.7 4.3 3.2 1.3
Note: CPT codes reflect those utilized to define each service group from 1994 through 2012. Numbers and percentages reflect those procedures (of 1,352 total) performed by radiology advanced practice providers over a recent 1-year period in the authors’ health care system. CPT ¼ Current Procedural Terminology.
in the primary care setting [5,6], but involvement of APPs in critical care, surgery, and a variety of other specialty services is increasing as well [7-9]. Interventional radiology practices are increasingly utilizing APPs to provide both clinical and procedural services [10-12]. With regard to the latter, a dramatically expanded role of APPs as providers of central venous access services has recently been reported [13]. We believe that the role of APPs as primary operators for a variety of minor nonvascular invasive procedures historically performed by radiologists has expanded dramatically as well. To our knowledge, however, this hypothesis has not been tested using national administrative claims or registry data. Our aim, therefore, is to study the expanding role of APPs as providers of invasive procedures commonly performed by radiologists, using aggregated Medicare claims files.
METHODS This HIPAA-compliant study of aggregated Medicare claims data from CMS-designated public use files was deemed to be exempt from review by our institutional review board. Our goal was to identify categories of nonvascular invasive radiology procedures that are potentially representative of the spectrum of those performed nationally by APPs. Thus, we reviewed deidentified procedure summary volume data for fiscal year 2013 (September 1, 2012 through August 31, 2013) from the 2 largest hospitals in our clinical authors’ academic health care system where APPs perform minor image-guided invasive procedures. Central venous access services comprised approximately one-third of all procedures; given that the expanding role of APPs for these services was recently studied [13], we excluded these services from our analysis. Using internal operational clinical service categories, we identified all nonvascular procedures performed by APPs at those facilities, focusing on 7 groups that comprised 85.9% of those services (Table 1). National Medicare claims-tracking methodology was based on that previously utilized for other imaging-guided Journal of the American College of Radiology Duszak, Walls, Wang n NP and PA Procedures
invasive procedures [13-15]. We acquired annual Medicare Physician Supplier Procedure Summary (PSPS) Master Files from 1994 through 2012 from CMS. PSPS Master Files aggregate Part B Medicare billing claims submitted by physicians, APPs, and all other providers nationally. Data fields include codes for procedure and provider specialty, and they include the number of procedures for which claims were submitted and paid. These data were retrospectively compiled and aggregated by CMS in designated public use files that contain no individual patient or physician identifiers or diagnosis information. PSPS Master Files include all claims for all beneficiaries in the traditional Medicare fee-for-service program, which currently represents approximately 71% of all Medicare supplementary medical insurance enrollees [16]. Although Medicare enrollment increased over the past 2 decades, that growth has largely involved private Medicare managed care programs; thus, Part B enrollment has remained relatively stable (32.3 and 33.0 million in 1994 and 2012, respectively) [16]. Health care providers are identified within PSPS Master Files with self-reported specialty and profession codes. For the purposes of this study, services by those with specialty codes for NPs (specialty #50) and PAs (#97) were grouped into an APP category. Services designated with codes for diagnostic radiology (#30), nuclear medicine (#36), and interventional radiology (#94) were grouped into a radiologist category. Because CMS does not recognize radiologist assistants as independent providers [17], this provider category has no specialty code; thus, physician-supervised services involving such professionals cannot be identified. In a manner similar to that described elsewhere [13], we mapped defined procedure categories over time, annually from 1994 to 2012, to then-current Current Procedural Terminology codes, which allowed us to describe these categories of services in a variety of radiology department settings. As code granularity permitted, we specifically excluded codes in which imaging guidance is explicitly 285
20,000
18,000
16,000
Frequency of procedures
14,000
12,000
Paracentesis Thoracentesis Fine needle aspiraƟon
10,000
Superficial lymph node biopsy Liver, renal & other abdominal biopsy 8,000
Lung, mediasƟnal & pleural biopsy Abdominal abscess drainage
6,000
4,000
2,000
0
Year
Fig 1. Annual number of services rendered by APPs, by procedure category, to Medicare Part B beneficiaries, from 1994 to 2012.
excluded. The code-mapping methodology is outlined in Table 1. Trends were analyzed and reported. Data analysis was performed with SAS 9.1 (SAS Institute, Inc., Cary, North Carolina) and Excel 2010 (Microsoft, Redmond, Washington).
RESULTS Of 1,352 nonvascular procedures performed by APPs at our facilities in 2013, a total of 1,161 (85.9%) were included in the 7 defined categories. Paracentesis (40.1%; 471 of 1,161); fine-needle aspiration (FNA; 24.2%; 285 of 1,161); abdominal biopsy (19.0%; 223 of 1,161); and thoracentesis (5.4%; 124 of 1,161) together comprised 89.8% of these categorized procedures (Table 1).
APP Services Between 1994 and 2012, national Medicare claims by APPs increased dramatically for all categories: paracentesis from 0 to 17,967; thoracentesis from 119 to 4,141 (þ3,379%); FNA from 0 to 3,921; superficial lymph node biopsy from 0 to 251; abdominal biopsy from 1 to 1,819 (þ1,818%); thoracic biopsy from 0 to 552; and abdominal drainage from 37 to 410 (þ1,008%). These trends are illustrated in Figure 1. 286
Radiologist Services Claims by radiologists increased as well for all categories: paracentesis from 13,276 to 139,144 (þ948%); thoracentesis from 17,488 to 35,787 (þ105%); FNA from 2,271 to 96,504 (þ4,149%); superficial lymph node biopsy from 452 to 14,951 (þ3,208%); abdominal biopsy from 46,449 to 86,423 (þ86%); thoracic biopsy from 45,033 to 54,060 (þ20%); and abdominal drainage from 15,085 to 33,356 (þ121%).
Services by All Providers of All Specialties The frequency of these services rendered by all providers of all specialties combined increased for most procedure groups: paracentesis from 69,980 to 167,171 (þ139%); thoracentesis from 150,572 to 72,872 (e51.6%); FNA from 60,123 to 183,688 (þ206%); superficial lymph node biopsy from 5,733 to 18,475 (þ222%); abdominal biopsy from 79,272 to 104,849 (þ32%); thoracic biopsy from 57,732 to 55,733 (e3%); and abdominal drainage from 30,015 to 34,404 (þ14.6%).
Proportions of All Services As a fraction of all categorized services by all providers of all specialties, services rendered by APPs increased disproportionately Journal of the American College of Radiology Volume 12 n Number 3 n March 2015
between 1994 and 2012: from 0% to 10.7% for paracentesis; 0.1% to 5.7% for thoracentesis; 0% to 2.1% for FNA; 0% to 1.4% for superficial lymph node biopsy; 0% to 1.7% for abdominal biopsy; 0% to 1.0% for thoracic biopsy; and 0.1% to 1.2% for abdominal drainage. The fraction of services rendered by radiologists, who now represent dominant service providers, increased disproportionately as well: from 19.0% to 83.2% for paracentesis; 11.6% to 49.1% for thoracentesis; 3.8% to 52.5% for FNA; 7.9% to 80.9% for superficial lymph node biopsy; 58.6% to 82.4% for abdominal biopsy; 78.0% to 97.0% for thoracic biopsy; and 50.3% to 97.0% for abdominal drainage.
DISCUSSION We used national Medicare claims data from 1994 through 2012 to study the expanding role of APPs as providers of minor nonvascular invasive procedures common to radiology practices. In all 7 procedure service categories studied, paid Medicare claims—zero for 4 of 7 categories in 1994— increased dramatically. Depending on the particular service category, APPs now perform between 1% and 11% of these procedures nationwide. Radiologists, in comparison, perform as many as 97%. Expanding roles of APPs have been highlighted in various contexts, many focusing on primary care [5,6]. But, at the other end of the clinical spectrum, APPs also care for the sickest of the sick, with studies reporting expanding APP roles in critical care units [9,18] and teaching hospitals [7,8]. Within radiology, most published APP attention has focused on roles supporting an interventional service [11,12,19,20]. In some practices, roles have been particularly narrow (eg, interventional oncology) [21], but more general noninterventional radiology roles have been described as well [22,23]. Data on specific APP services and categories of services, however, have been sparse, and remain largely institution specific. The expanding national role of APPs as providers of services commonly performed by radiologists has been mentioned, largely in passing, in the context of paracentesis and thoracentesis [15] and central venous access procedures [13], but to our knowledge, no study has specifically targeted APPs as providers of various nonvascular invasive procedures. To that end, we believe that this article provides support for the benefit of having APPs performing these services and—for the radiologists and facilities that employ them—shows that APP involvement in such services is increasingly becoming the norm. In addition, the authors hope the article will help practices striving to overcome political and other implementation barriers, by providing evidence that local APP serviceexpansion initiatives are aligned with national trends. As nonphysicians enter service arenas traditionally dominated by physicians, concerns regarding quality and Journal of the American College of Radiology Duszak, Walls, Wang n NP and PA Procedures
safety are not unexpected [24]. Emerging data in selected clinical scenarios, however, show not only APP quality comparability, but also actual improvement in outcomes. For example, APP service expansion has been associated with reduced clinic wait times, shorter hospital and intensive care unit lengths of stay, decreased durations of ventilator dependency, and earlier removal of Foley catheters with reductions in urinary tract infections [25-27]. With specific regard to nonvascular invasive abdominal procedures, more recent work has demonstrated comparable outcomes between trained APPs and physicians for both paracentesis and liver biopsy procedures [28,29]. Such longitudinal clinical data will become increasingly important as health care systems and policymakers seek to match service demands with qualified-provider supply. Rigorously evaluating changes in APP credentialing and scope of practice requirements on a national level is challenging. The Balanced Budget Act of 1997 liberalized payment for APPs nationally [30] and thus likely influenced APP service growth beginning in 1998. But institutions and states each have unique rules and regulations defining APP scope of practice, which change over time, and no coordinated registries have been established to facilitate tracking. For this reason, Medicare service payment was chosen as a novel surrogate metric. Since Medicare, by both law and operational precedent, will only pay for services for which providers are both licensed and credentialed [31], any expansion of paid services by Medicare affirms expansion of these prerequisites. Therefore, we believe that paid Medicare claims are a reasonable marker of multi-stakeholder acceptance of APPs as providers of these procedures. The expansion of APPs into service lines historically dominated by physicians creates both opportunities and challenges for radiology practices. More providers may translate into improved patient access and, if unencumbered by competing diagnostic radiology work responsibilities, APPs may actually be able to deliver more-personalized care in a less rushed manner than radiologists. Additionally, channeling procedures in a radiology department to specific individuals— rather than to sundry radiologists across the entirety of a practice—may result in increased workflow standardization and associated improvements in outcomes, similar to those already described in targeted intensive care settings. Despite these benefits, however, radiologists who engage APPs should be mindful to not relinquish all patient contact opportunities completely, lest they accelerate the commoditization of the specialty and further fuel stereotypes of the “invisible radiologist” [32]. Similarly, the short-term arbitrage appeal of expanding traditional physician services through use of less costly nonphysician providers could have long-term payment policy implications. As professional payments are calculated on a resource basis, and currently 287
valued using physician labor, continued national shifts of procedures from physicians to less costly APPs could result in devaluation of these services—for radiologists and APPs alike [33]. As with any retrospective analysis of claims data, our analysis has limitations. First, aggregated Medicare claims data do not permit study of clinical service delivery nuances (eg, patient acuity, guidance modality, coincident conditions or services). We have selected groups of services, based on our own institutional experience, that we believe are representative of the spectrum of services rendered by radiology APPs in other communities. We are well aware, however, of considerable regional variation in APP scope of practice. Second, because of the nature of Medicare claims data, APP employers cannot be identified. Although some services were likely performed under the supervision or employment of nonradiologists, we believe that the targeted procedure groups are typical ones for many radiology practices. Our goal, however, was to study nonvascular invasive APP procedures that are commonly performed in radiology practices, not necessarily those that definitely were. Third, because our study utilized Medicare data, we are unable to comment on trends in services to other insurance populations or the uninsured. Nonetheless, we have no specific reason to expect that trends in other payer populations would substantively diverge from those identified. Finally, although aggregated claims data are very useful for high-level longitudinal trends analyses such as ours, they do not include individual patient- or provider-level information and thus do not lend themselves to outcomes or quality analyses (eg, identification of complications, repeat procedures). Future studies focused toward these goals would best be performed using institutional clinical or registry data.
TAKE-HOME POINTS n
n
n
Although APPs nationally perform a relatively small portion of the nonvascular invasive procedures commonly performed by radiologists, paid Medicare claims for those services have increased dramatically over nearly 2 decades, and at a faster pace than for all providers as a whole. Depending on the particular category of service, APPs nationwide now perform between approximately 1% and 11% of nonvascular invasive procedures commonly performed by radiologists. Given the numerous hurdles involved in obtaining Medicare reimbursement, that percentage growth suggests an increasing national acceptance, by institutional credentialing bodies, state licensure boards, and payers alike, of APPs as providers of these services.
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Erratum In the article titled: Evolving paradigm for imaging, diagnosis, and management of DCIS by Colin J. Wells, MD, Cristina O’Donoghue, MD, Haydee Ojeda-Fournier, MD, Hanna E. G. Retallack, MD, Laura J. Esserman, MD, that was published in the December 2013 issue of the JACR (2013;10:918-923), Hanna E. G. Retallack’s credentials were erroneously reported as MD. Ms Retallack is a student in an MD/PhD program, and her highest degree should have read “AB”.
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