Billing records reveal changes
Non-physicians are doing more and more. “The surgeon only has two hands.”
You might expect a physician to interpret your electrocardiogram, perform a lumbar puncture on your back or do your pelvic and breast exam. But increasingly, the caregiver handling such tasks may not be a doctor.
A USA TODAY analysis of Medicare billing records reveals a huge jump from 2012 to 2013 in the numbers of nurse practitioners and physician assistants receiving payments for all sorts of care — at the same time as the number of general practice physicians paid by the government insurance program dropped.
Replacing chest tubes, interpreting EKGs and caring for trauma patients with severe problems such as aortic aneurysms are typ- ical 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 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.
Though non-physician caregivers have handled such procedures for years, more of them are working in health care these days, and they are becoming more visible, as the Medicare data reveal.
“A lot of people misunderstand the roles of PAs and NPs,” Pickard 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.”
The main driver behind the Medicare billing increase is rapid growth in the sheer numbers of non-physicians. 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 cracked 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 comanaged visit if they see a patient together, or under the physician’s name if the non-physician carries out a treatment plan put in place by the doctor.
NPs and PAs generally receive 85% of what doctors get for office visits, and some say they’ve heard of doctors billing under their own names inappropriately to get bigger payments for a practice. Officials from the U.S. Centers for Medicare and Medicaid Services encourage providers to bill under their own names.
Having more non-physicians provide care should save taxpayers money, says Tay Kopanos, vice president for the American Association of Nurse Practitioners.
Michael Powe, vice president for the American Academy of Physician Assistants, says, “Each time a PA is used for the same thing (a physician would do), it’s a cost savings to Medicare.”
Kopanos says the Medicare data inform a long-running debate with physicians about whether NPs should be able to practice more independently and perform high-level procedures on their own. Though PAs always work in teams with doctors, NPs gained more independence in the run-up to the Affordable Care Act.
“With PAs, it sounds like we fetch a prescription pad and get coffee for physicians, and that’s not what we do at all.”
Todd Pickard, University of Texas MD Anderson Cancer Center