HEALTH

Non-physicians take on growing role in medicine

Laura Ungar
@laura_ungar

Nurse practitioner Melissa Lamaster balanced 6-month-old Kelsey Ducette on her knee and listened to her heart with a stethoscope before discussing developmental milestones, vaccinations and feedings with Kelsey’s aunt. She even passed along a tip about freezing homemade baby food in ice-cube trays.

By the end of the appointment, aunt Erica Ducette, who has custody of Kelsey, was ready to make Lamaster the baby’s regular care provider.

Nurse practitioners, as well as physician assistants, are a fast-growing part of the medical marketplace, providing care some people associate more often with doctors, a USA TODAY analysis of federal data found.

Medicare billing records show 15 percent more nurse practitioners and 11 percent more physician assistants received payments in 2013 than in 2012 for all types of care, including high-level procedures such as electrocardiograms, pelvic exams and even helping with heart bypasses. During that same year, the number of general practice physicians paid by the insurance program for the elderly and disabled dropped 5 percent.

Experts say this reflects the rising influence of non-physicians in a changing health care system long beset by doctor shortages and now taxed even more by a growing number of patients gaining insurance through the Affordable Care Act. And it shines light on types of care that nurse practitioners and physician assistants have been providing for many years — until now, largely under the radar.

Before, “nurse practitioners were not being seen for what we were doing,” said Lamaster, who works at a nurse practioner-only office run by KentuckyOne Health, where she performs physicals, diagnoses disease and writes prescriptions.

The data analysis shows nurse practitioners billed for high-severity emergency room visits, pelvic exams and many other high-level procedures, and physician assistants billed for tissue biopsies, X-rays and complicated surgical procedures in which they assisted doctors.

While physician assistants generally practice in teams with doctors, nurse practitioners may practice independently. And a law enacted in Kentucky last year gives those who have finished a four-year collaboration with a physician the right to prescribe common drugs, such as blood pressure and diabetes medicines, without having an agreement with a doctor.

The main driver of these trends is rapid growth in the sheer numbers of non-physicians. Nationally, the ranks of nurse practitioners grew from 60,000 in 1999 to 171,000 in 2013; and the ranks of physician assistants grew from 83,466 in 2010 to 101,977 in 2015, according to their respective trade organizations.

By contrast, a study conducted this year for the Association of American Medical Colleges says the physician shortage is expected to reach 46,000 to 90,000 physicians by 2025. Kentucky faces acute doctor shortages, especially in rural areas. A 2013 study by Deloitte Consulting found the state needed 3,790 more doctors, including 183 additional primary-care physicians, to meet demand even before the Affordable Care Act.

As the numbers of non-physicians have grown, the government also has been cracking down on incorrect, fraudulent or careless Medicare billing — encouraging health care providers to bill under their own names. Doctors generally receive 15 percent more than non-physician caregivers for office visits, and experts say a small number would bill under their own names when a nurse practitioner or physician assistant really should have billed for the care.

Lamaster said she and her nurse practitioner colleagues bill under their own “national provider identifiers” and provide basically the same care as family practice physicians. Typical days include managing patients’ high blood pressure and diabetes — all the while educating patients about their health. Some patients arrive apprehensive about seeing her rather than a doctor, she said, but in the end, “I have never had one not be happy with my care.”

Recently, Lamaster saw Dawn Heuglin, 45, for a second visit, referring her for an abdominal ultrasound to help diagnose gall bladder problems.

“She’s very thorough in answering my questions, and I like details. She listens,” said Heuglin, of Taylorsville, Ky. “I think it’s great that (nurse practioners) are expanding on their own. It gives us more options.”

Reporter Laura Ungar, who also covers public health for USA Today, can be reached at (502)582-7190 or on Twitter @laura_ungar. USA Today Data Journalist Meghan Hoyer contributed to this story.