Original article
Expanding Roles of Nurse Practitioners and Physician Assistants As Providers of Nonvascular Invasive Radiology Procedures

https://doi.org/10.1016/j.jacr.2014.08.021Get rights and content

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 (+3,379%); FNA from 0 to 3,921; superficial lymph node biopsy from 0 to 251; abdominal biopsy from 1 to 1,819 (+1,818%); thoracic biopsy from 0 to 552; and abdominal drainage from 37 to 410 (+1,008%). 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.

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 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 funding-constrained 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 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, 8, 9.

Interventional radiology practices are increasingly utilizing APPs to provide both clinical and procedural services 10, 11, 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.

Section snippets

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

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).

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

Take-Home Points

  • 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

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      Organizations at which 100% of all affiliated physicians self-identified their primary specialty as diagnostic radiology, IR, or nuclear medicine (together “radiologists”) were categorized as “radiology practices.” By isolating all self-identified NPPs affiliated with those practices, NPPs employed by radiology practices could then be uniquely identified and thus distinguished in a manner that was not possible in earlier studies of the broader set of all NPPs nationally rendering radiology services [8,10]. Although former Physician Compare files have previously been used to study characteristics of radiology practices since the data set’s inception in 2014 [14,15], complete data for PAs were not reported in Physician Compare before 2017 (Medicare’s Quality Payment Program Service Center, personal communication, October 26, 2021), and thus, our analysis began thereafter.

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