On August 11, 2014, the Journal of the American Medical Association Dermatology (JAMA) published an original investigation into the billing practices of mid-level providers such as PAs and NPs. Unfortunately, the article, called “Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting” was filled with inaccurate information about PA education levels and proper incident-to billing standards.
Immediate Past President of the SDPA, Jennifer Winter, MSPAS, PA-C, with support of the Board of Directors of the SDPA, wrote and submitted a thorough rebuttal to JAMA and the author, Dr. Brett Coldiron, president of the American Academy of Dermatology (AAD). Ms. Winter carefully laid out the erroneous arguments of the article and provided detailed corrections to the mistakes.
The AAD also issued a press release stating that the JAMA article “was authored by Brett Coldiron, MD, FAAD, in a private capacity and does not represent an official Acadamy-sanctioned article.” They also stated that the AAD “supports a dermatologist-led care team. We know that many dermatologists employ and appropriately supervise nurse practitioners and physician assistants as part of their integrated team to help provide care for an expanding number of patients, and we support this practice.”
You can read Ms. Winter’s rebuttal to the JAMA article below.
Letter to the editor of JAMA Dermatology
I am writing in response to an article published in JAMA Dermatology on August 11, 2014 titled “Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting.” My name is Jennifer Winter and I am a Dermatology Physician Assistant. I feel qualified to respond to this article and it’s inaccuracies due to my experience. I have worked with the same dermatologist since 1989, as a PA since 2000. I am also the Immediate Past President of the Society of Dermatology Physician Assistants (SDPA) and while the opinions in this article are my own, I have the support of my Society.
The article covers many issues and I will try to cover each in turn. The first assertion is that PAs were originally envisioned to provide care in underserved areas. This is true and I currently practice in an area that is underserved with respect to dermatology care despite a dermatology residency in my state. It is a 3 month wait for new patients in my practice for both physicians and PAs, though a newly hired physician will ease this somewhat. Many dermatologists are in a similar situation of needing to work with PAs and NPs in order to care for all the patients who need dermatologic care.
Medicare’s incident-to rules are somewhat complex and often misunderstood. The full text of the Medicare Benefit Policy Manual can be found here with incident-to rules in section 60. The AAD has a nice summary as well.
The rules describe the situations which will permit billing a PAs services as incident-to, however there is no discussion of what allows for independent billing as the article claims. Any clinic services that do not meet incident-to guidelines are billed independently by the PA and paid at 85% of the physician fee schedule. Only established problems that have had a care plan developed by the physician then managed by the PA can be billed as incident-to and billed under the physicians NPI at 100% of the physician fee schedule. So if I see a new patient and do the history and physical exam, even if the physician also examines the patient and contributes to developing a differential, the services cannot be billed as incident-to under Medicare rules. In order to qualify for incident-to rules, the physician would have to see all new patients and then transition them to a PA for ongoing management. This model disrupts continuity of care for patients and is not satisfying for patient, physician or PA. It also limits new patient access to what the physician can handle.
The 15% cut on Medicare billing that I take due to billing virtually all my services independently is offset by the continuity of care that I provide to my patients and the fact that I can see more patients if I do not have to wait for the physician to see any new problems that always seem to arise. I do not bill independently because I am not being supervised, I do it because the requirements for billing incident-to are not worth the extra 15%. I have at least one and generally 2-3 physicians on site and I have superb back up by my physicians. I have also had superb training and after all, this article appears to be primarily concerned with the possibility that inadequately trained providers are caring for dermatology patients. Unfortunately the numbers don’t take into account the level of training of the performing provider and the concern is based on a faulty understanding of the incident-to rules.
Now that we have clarified that independent billing of Medicare services does not require that the performing provider be unsupervised, the issue is who is using those codes referenced in the article. Dermatology is a procedure based specialty so it is not surprising that of the codes listed, over 50% are dermatological. That does not mean that dermatology providers are the only ones providing these services. We are all well aware that primary care providers of all types are making a determination of precancerous vs benign and performing cryotherapy. While the article focused on PA and NP billing of these codes, any dermatologist who has precepted for family practice residents is well aware that even those who are physicians and are qualified and board certified to practice medicine without supervision, are ill prepared to perform many of these same procedures without additional training. Better to collaborate with the more available PAs, train them well so that they can make sound medical decisions and then let them care for patients. This will reduce the backlog of patients who might otherwise turn to primary care to handle issues, better cared for in a dermatology office.
I do not disagree with the authors that physicians have many more clinical hours upon completing residency, than PAs do upon completion of PA training. I cannot speak to the 500-900 hours listed for NP training, but PA training includes 2000 hours of clinical experience. I am not suggesting that a new graduate or a PA new to derm should be let loose to make significant decisions without direct oversight. However, dermatologists were once non-dermatologists and had to learn all those skills. Just because a PA has not been through the same full medical school training, does not mean they would not be capable of learning the same skills and applying them to benefit patients. It was Sir William Osler who said “We miss more by not seeing than by not knowing”.
I agree that having more consistent and streamlined regulation of not only PAs and NPs, but also physicians would help ensure a consistent standard of care and protect patients. I also agree that having mandatory reporting of complications could put patient safety concerns to rest, but only if all providers were subject to such reporting, including physicians. Having data on only PAs or NPs without comparing to physicians providing similar services will not allow a determination of increased complications, only that complications occur. A reference point is needed. Malpractice claims often serve as an indicator of unhappy patients and do not always point to poor medical care. Articles such as this one may serve to undermine the public trust in PAs. This may increase the risk of malpractice which is likely to impact the supervising physician as well as the PA.
Adequate training of PAs in dermatology is paramount to protect the patient. It is the duty of the supervising physician to allow increased autonomy only when appropriate to the level of experience and training of the PA. In all 50 states PA practice is allowed only in association with a supervising physician. Lack of formal training has been a criticism of derm PAs. The SDPA has worked with the AAD to increase educational opportunities for PAs and appreciate the ongoing and increasing support we are receiving from the AAD. Perhaps we can work together to develop a document that can track the training of derm PAs to alleviate that concern. Something like the Milestones Assessment for Dermatology Residents might be something dermatologists would be comfortable with.
The AAD estimates that up to 50% of its members employ PAs and NPs. It is imperative that we work together to address concerns instead of undermining the confidence of the public and other health care providers in our care. The future of our specialty and the care of our patients depend on it.
I welcome the opportunity to discuss this article or any concerns you may have and thank you for the time and consideration you have given.
Respectfully,
Jennifer Winter, MSPAS, PA-C