US dermatologists call for more oversight of nurse practitioners and physician assistants

BMJ 2014; 349 doi: (Published 20 August 2014) Cite this as: BMJ 2014;349:g5253
  1. Michael McCarthy
  1. 1Seattle

US dermatologists have called for more oversight and regulation of nurse practitioners and physician assistants, after a study found that they were performing millions of dermatology specialty procedures without physician supervision.1

Nurse practitioners and physician assistants were first envisioned to be mid-level healthcare providers who would typically work under a physician’s oversight. The aim was for these professionals to increase the number of primary care providers and improve access to care, particularly in rural and other underserved areas. But in recent years many states have expanded nurse practitioners’ and physician assistants’ scope of practice and allowed them to practice independently.

In the study Brett Coldiron of the University of Cincinnati, Ohio, and Mondhipa Ratnarathorn of the TriHealth Good Samaritan Hospital, also in Cincinnati, looked at Medicare billing from 2012 by nurse practitioners and physician assistants who billed independently, indicating that they had provided the care without physician oversight. The article was published online by JAMA Dermatology.

Looking only at procedures for which at least 5000 claims had been made that year, the study found that nurse practitioners and physician assistants billed independently for a total of 4 780 651 procedures, 54.8% of which were in the specialty area of dermatology. This included destruction of premalignant, malignant, and benign skin lesions, skin biopsies, and shaving and removal of skin lesions.

“The breadth and frequency of dermatologic procedures independently performed and billed by mid-level providers are extraordinary,” Coldiron and Ratnarathorn wrote. They questioned whether nurse practitioners and physician assistants had the diagnostic qualifications to distinguish between benign and premalignant lesions or the clinical training to safely perform skin biopsies.

In an accompanying editorial H Ray Jalian, of the University of California in Los Angeles, and Mathew M Avram of Massachusetts General Hospital in Boston, noted that although dermatologists completed nearly 10 000 hours of clinical training during their three years of residency, “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.”2

They added, “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.”

But Tay Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners, defended the number of dermatological procedures being performed by nurse practitioners and physician assistants. “These are very common procedures in primary care: freezing warts, removing skin tags and treating moles,” she said. “Nurse practitioners and physician assistants are trained to provide these primary care services.”

Kopanos said that the association leadership was disappointed by the article and by the editorial’s “alarmist” tone. “When you look at outcomes, you don’t see significant differences in the outcomes of care in these areas of care whether they’re provided by physicians, nurse practitioners or physician assistants,” she said.

Restricting access to nurse practitioners and physician assistants would hurt patient care, Kopanos argued. “In some states, it can take three to nine months to get in to see a dermatologist. That puts patients at risk.”


Cite this as: BMJ 2014;349:g5253


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