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The mission of the Harvey L. Neiman Health Policy Institute® is to establish foundational evidence for health policy and radiology practice that promotes the effective and efficient use of health care resources and improves patient care.

December 18, 2014

Would You Let A Nurse Practitioner Do That Procedure On You?

I would—depending on the procedure, of course.

So too would hundreds of thousands of Americans. And the same holds true for physician assistants as well. Over the last two decades, the number of minor invasive imaging-guided procedures performed by nurse practitioners (NPs) and physician assistants (PAs) has skyrocketed.

In a study recently published online in the Journal of the American College of Radiology, colleagues from the Neiman Health Policy Institute, Emory University, and I mined Medicare claims data from 1994 through 2012, focusing on imaging-guided procedures widely considered within the domain of radiologists—services like paracentesis, thoracentesis, and fine needle aspiration biopsies. What we found was that the relative roles of radiologists (compared with other specialists) expanded over time. That’s no surprise. But, so too did the relative roles of NPs and PAs—by orders of magnitude.

Take paracentesis procedures, for example: in 1994, Medicare paid for not a single service performed by either an NP or PA. In 2012, they paid out claims for almost 18,000 procedures. For this and other services, a picture (or a graph over time, in this case) says a thousand words:

Rich press NP 12182014

Context is critical. Some 25 years ago, when I graduated from medical school, the concept of non-physicians providing services typically performed by physicians was foreign at best. Over the ensuing years, there has been outright hostility in many markets to NPs and PAs practicing at all. And, talking about them performing invasive procedures was sheer heresy.

But times have changed. Slowly and deliberately, NPs and PAs have shown their value as important members of the care delivery team as they have increasingly gained credibility and acceptance. All the while, their legislative, regulatory, and operational scopes of practice have increased. For some imaging-guided services in supportive and structured environments, evidence is now emerging demonstrating similar outcomes to services performed by physicians.

As our society seeks to control rampant healthcare spending, using NPs and PAs—who are paid by Medicare at 85% of the physician fee schedule—might seem a no brainer. The same services with the same outcomes at a lower price, right?

But, some caution is in order. In another recent work by our group, we noted that NPs and PAs in the outpatient setting are 1.3 times as likely to order diagnostic imaging as primary care physicians. Although subsequent economic modeling remains to be done, it’s quite possible that some—if not all—of that 15% savings will be offset by increased downstream diagnostic testing.

And so, as our society continues to study and debate the optimal role of NPs and PAs as important members of our delivery teams, the policy goal seems clear: “the right care by the right clinician.” If Medicare trends reflect the right trends, then radiology practices not leveraging the skills and talents of these capable healthcare professionals may soon find themselves behind the times.


Richard Duszak, MD, FACR

Richard Duszak, MD, FACR

Richard Duszak, MD, is Affiliate Senior Research Fellow, Harvey L. Neiman Health Policy Institute, and Vice Chair for Health Policy and Practice, Department of Radiology and Imaging Sciences, Emory University School of Medicine. Follow him on Twitter @RichDuszak.

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