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Medicare Patients Often See Nurses Instead Of Doctors For Skin Problems

Nurse practitioners and physician assistants are taking on more and more responsibility for primary care these days. And an analysis of Medicare data finds many of these health care providers are performing procedures you might not have expected.

Among the more than 4 million procedures for which office-based nurse practitioners and physician assistants independently billed Medicare in 2012, more than half were for dermatological surgeries.

That's not surprising to Ken Miller, president of the American Association of Nurse Practitioners. He said older patients, such as those on Medicare often have skin problems, such as "boils, skin tags and warts."

The study, published in the JAMA Dermatology, focused on procedures that included radiological exams, setting casts and injecting anesthetic agents for which these providers billed more than 5,000 times a year.

"I think that's where you're going to see the majority of procedures that are occurring both in primary care and in some of the other specialties like geriatric clinics," he said.

The study's lead author, Dr. Brett Coldiron, a dermatologist and clinical assistant professor at the University of Cincinnati, said while the "intent for mid-level nurse practitioners was to give primary care," the level of surgical billing implies that they may be doing more.

He said those mid-level providers – PAs and NPs - "are doing invasive procedures and surgery. I'm not sure they were trained to do that."

But practitioners who perform specialized procedures often have received additional training, according to Miller. "If they find something that is out of their scope, they will refer," he said. "It's the same thing that primary care physicians do."

The analysis found that a majority of procedures billed by nurse practitioners and physician assistants relate to dermatology, a trend Coldiron said could stem from the frequency of dermatological procedures being performed in offices rather than hospitals, along with the higher rate of skin cancer among the older patients Medicare covers.

The nurse practitioners performing specialized dermatological procedures often have received extra training, Miller said, and they often attend "the same symposiums and conferences dermatologists actually attend."

"If they're in the same subspecialty of dermatology, they may be doing these procedures because that's how they've been trained," he said.

He thinks no more than 3 or 4 percent of nurse practitioners actually end up specializing in a specific area of care. But all nurse practitioners will often see patients with dermatological conditions, and the treatments they require are usually not "extraordinary," he said.

Coldiron said while the mid-level providers may have received extra training within a relevant specialty, many likely lack the expertise of doctors who have done a residency within the field. "If nurses are going to practice surgery, that's not [nursing] – that's medicine," he said.

Nurse practitioners and physician assistants have been suggested as a potential solution to shortages in primary care physicians.

The study cautioned that a boost in mid-level providers performing surgical procedures could lead to more cases of malpractice, a concern Coldiron said suggested a need for greater regulatory oversight of nurse practitioners and physician assistants.

But that kind of argument is a "red herring," Miller argued.

"There have been no real studies out there that show nurse practitioners are less safe than physicians," he said. "What we're all trying to do," he added, "is we're trying to provide the best care and the best quality of care."

Copyright 2014 Kaiser Health News. To see more, visit