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Since the passing of the Congressional Balanced Budget Act in 1997,1 the scope of practice of mid-level health care providers, namely nurse practitioners and physician assistants (hereinafter “mid-level providers”), has rapidly expanded. While originally envisioned to improve access to primary care in underserved areas under the supervision of a physician, mid-level providers have expanded their scope of practice and are now able to bill independently for the procedures they perform. In their article “Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting,”2 Coldiron and Ratnarathorn present data regarding common procedures billed independently by mid-level providers. Using the 2012 Medicare Physician/Supplier Procedure Summary Master File, provided annually by the Centers for Medicaid Services (CMS), this study identified the most common Current Procedural Terminology (CPT) codes billed independently by mid-level providers. Of the over 4 million procedures performed independently, nearly 55% of codes performed were in the area of dermatology. The most commonly performed dermatologic procedures are destruction of 2 to 14 premalignant lesions (CPT 17003) and biopsy of a single lesion (CPT 11100). Mid-Level Providers in Dermatology Understandably, many physicians are increasingly using mid-level providers within their practice to meet rising demand. Among dermatologists, almost 30% reported using a mid-level provider within their practice, a 40% increase over the preceding 5 years.3 Most mid-level providers who practice within dermatology practices provide medical dermatology services. Further utilization of mid-level providers could conceivably decrease wait times and provide increased access to dermatologic services in the appropriate setting. Indeed, the increasing number of mid-level providers may help fill the currently unmet demand for dermatologic services.4 The American Academy of Dermatology (AAD) provides resources for hiring and training mid-level providers. A position statement from the AAD states that “at certain times, and under the supervision of a board-certified dermatologist, the practice of dermatology requires a team approach and may include other providers.”5 An interesting finding of this study is that most procedures independently billed by mid-level providers were within the specialty of dermatology. The initial intent of such providers was to expand primary care services to ensure timely access and ease wait times. Of the nearly 5 million independently billed procedures performed, approximately 2.6 million were dermatologic procedures. Perhaps financial motivations have swayed mid-level providers to perform more highly reimbursable procedures such as cryotherapy or skin biopsies. Ironically, many of the CPT codes cited in this study, including destruction for premalignant and benign lesions, are facing challenge by CMS with the concern of overutilization by physicians as well as mid-level practitioners. Training Requirements Dermatologists complete nearly 10 000 hours of clinical training throughout a residency that spans over 3 years of in-depth education in basic science, skin structure and function, and various aspects of medical dermatology, cutaneous oncology, dermatopathology, and dermatologic surgery. In contrast, mid-level providers complete between 500 and 900 hours of clinical training, spanning multiple clinical specialties, and surgical procedures are usually not part of this training.6,7 Many mid-level providers who are employed by dermatologists are trained by their respective supervising physicians. While the AAD has recommendations regarding the training of nonphysician providers, there are neither specific training guidelines nor examination processes to verify the qualifications of said providers. Those who are practicing independently may have received little to no formal, supervised training. Currently, there is no governing board and little if any oversight for the independent practice of medical procedures by mid-level providers. In contrast, the American Board of Dermatology has a rigorous process for dermatology trainees involving evaluations, procedure logs, and a comprehensive board examination. Moreover, following board certification, maintenance of certification requires ongoing self-assessment and peer evaluations. Perhaps a more comprehensive approach would hold all providers who practice and bill independently to the same standard. Individuals performing the procedures should meet benchmark qualifications to provide said services. This would be a great step forward in standardizing the quality of care delivered to dermatology patients. Supervision, Liability, and Transparency The AAD position statement advocates for on-site supervision of mid-level providers, with the exemption of extenuating circumstances.5 But this AAD position has no authority over mid-level providers, nor does it have any legal standing. The large number of unsupervised, billed procedures raises a concern for the quality of dermatologic health care. As we move more and more to outcomes-based evaluations of health care delivery in the era of the Affordable Care Act, it is crucial to determine if procedures performed by independent nonphysician providers have more adverse outcomes. While no safety data exist regarding increased risk for injury for medical dermatologic procedures performed by mid-level providers, a recent study determined that 40% of the cases of laser-induced injury lawsuits involved laser surgery by nonphysicians.8 This risk was even more apparent when the procedure was performed outside the medical setting and/or without a supervising physician identified. This increase in injury and the concomitant increase in numbers of nonphysician providers suggest that there may be some inherent risk of inadequately trained individuals performing procedures without direct medical supervision. In fact, the proportion of lawsuits involving nonphysician laser surgery increased between 2008 and 2011 from 37% to 78% of all laser surgery lawsuits. Importantly, this was far out of proportion to the number of laser surgery procedures being performed by nonphysicians.9 Further studies are needed to investigate whether this same phenomenon applies to medical dermatology procedures cited by Coldiron and Ratnarathorn,2 where the potential for serious patient harm is even greater, eg, the misdiagnosis or delay in diagnosis of skin cancers, to name only 1 major concern. The consequences for misdiagnosis or delay in diagnosis, particularly of pigmented lesions, can have serious ramifications for patients. Studies to determine whether there is a difference in outcome for patients primarily cared for by unsupervised mid-level providers are lacking. While supervision laws vary from state to state, the onus is on the physician to ensure the safety of the patients under their care, whether it is provided directly or indirectly through another health care provider. Should an injury occur to a patient, the supervising physician is held liable under numerous legal doctrines, including respondeat superior (a legal doctrine holding the employer responsible for the action of their employee), direct liability, and indirect liability. Legal precedent generally holds the physician responsible; the physician is more likely to be named in a lawsuit, even if a procedure is performed by a nonphysician provider. Data regarding patient preference as to who should perform dermatologic procedures clearly indicate that the prevailing public opinion views board-certified dermatologists to be most qualified to diagnose skin cancer and perform surgical procedures on the skin.10 Despite this opinion, many patients are understandably unable to differentiate between certification of providers wearing white coats, with one study finding nearly 40% of the public mistaking a nurse practitioner for a physician.11 This underscores the need for transparency for patients to differentiate between various providers. Legislation in states such as Pennsylvania and California require clear identification of training, including certification, for all medical care providers.12 Such rules should be adopted nationally to ensure transparency and effective communication to patients of the qualifications of the individuals performing their procedures. Implications As the population grows, access to both primary care physicians and specialists is becoming more limited. To ameliorate this shortfall, it was envisioned that mid-level providers, working in conjunction with physicians, could serve to increase access to services and also decrease wait times. The findings of Coldiron and Ratnarathorn2 indicate that this is not happening in the way it was envisioned. In fact, an important dichotomy has emerged regarding the role of mid-level providers, particularly in the field of dermatology. Furthermore, the implication for patient safety of the increasing utilization of mid-level providers is unknown despite the millions of procedures they are performing annually. Clearly, well-designed studies regarding patient safety are needed. Moreover, in an era of more limited access to primary care, an assessment of whether the particular focus of independently billing, mid-level providers within the field of dermatology seems reasonable. Perhaps it is time for Congress to amend the 1997 legislation to adequately reflect the current practice of mid-level providers. The data from billed CPT codes suggests that mid-level providers have largely moved into subspecialty practices and are practicing outside the scope of their expertise. Clearly, this was not the intent of the original legislation and does not serve to increase sorely needed access to primary care. Moreover, if providers of varying certifications are performing procedures, they should be held to the same certification, malpractice coverage, and training requirements. Oversight for mid-level providers is lacking. Given the volume of procedures performed, perhaps state medical boards and the American Board of Medical Specialties should have their jurisdictions expanded to oversee mid-level providers providing specialty services, and the American Board of Medical Specialties should work with the governing organizations of mid-level providers to have cohesive certification for all. Back to top Article Information Corresponding Author: H. Ray Jalian, MD, Division of Dermatology, University of California, Los Angeles, 2020 Santa Monica Blvd, Ste 570, Santa Monica, CA 90404 (HJalian@mednet.ucla.edu). Published Online: August 11, 2014. doi:10.1001/jamadermatol.2014.1922. Conflict of Interest Disclosures: None reported. References 1. Balanced Budget Act of 1997. 42 USC §1395x(s)(2)(K), 1997. 2. Coldiron B, Ratnarathorn M. Scope of physician procedures independently billed by mid-level providers in the office setting [published online August 8, 2014]. JAMA Dermatol. 10.1001/jamadermatol.2014.1773.Google Scholar 3. Resneck JS Jr, Kimball AB. Who else is providing care in dermatology practices? trends in the use of nonphysician clinicians. J Am Acad Dermatol. 2008;58(2):211-216.PubMedGoogle ScholarCrossref 4. Kimball AB, Resneck JS Jr. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol. 2008;59(5):741-745.PubMedGoogle ScholarCrossref 5. American Academy of Dermatology. Position statement on the practice of dermatology: protecting and preserving patient safety and quality care.http://www.aad.org/Forms/Policies/Uploads/PS/PS-Practice%20of%20Dermatology%20Protecting%20and%20Preserving.pdf. Accessed July 19, 2014. 6. American Academy of Family Physicians. Primary care for the 21st century: September 18, 2012.http://www.aafp.org/dam/AAFP/documents/about_us/initiatives/AAFP-PCMHWhitePaper.pdf. Accessed July 19, 2014. 7. Martin G. Education and training: family physicians and nurse practitioners: June 12, 2012.http://www.aafp.org/dam/AAFP/documents/news/NP-Kit-FP-NP-UPDATED.pdf. Accessed July 19, 2014. 8. Jalian HR, Jalian CA, Avram MM. Common causes of injury and legal action in laser surgery. JAMA Dermatol. 2013;149(2):188-193.PubMedGoogle ScholarCrossref 9. Jalian HR, Jalian CA, Avram MM. Increased risk of litigation associated with laser surgery by nonphysician operators. JAMA Dermatol. 2014;150(4):407-411.PubMedGoogle ScholarCrossref 10. Bangash HK, Ibrahimi OA, Green LJ, Alam M, Eisen DB, Armstrong AW. Who do you prefer? a study of public preferences for health care provider type in performing cutaneous surgery and cosmetic procedures in the United States. Dermatol Surg. 2014;40(6):671-678.PubMedGoogle Scholar 11. American Medical Association. Truth in advertising: 2008 and 2010 survey results.http://www.ama-assn.org/resources/doc/arc/tiasurvey.pdf. Accessed July 19, 2014. 12. American Medical Association. Who's the doctor? new law requires transparency of medical credentials: AMA Wire: July 24, 2013.http://www.ama-assn.org/ams/pub/amawire/2013-july-24/2013-july-24-general_news2.shtml. Accessed July 22, 2014.
JAMA Dermatology – American Medical Association
Published: Nov 1, 2014
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