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Lack of standardization?

Dermatology TimesDermatology Times, September 2018 (Vol. 39, No. 9)
Volume 39
Issue 9

Discordance between increase in billed procedures vs increase in number of patients.

The number and scope of dermatologic procedures performed by advanced practice professionals is increasing, which suggests a need to report and follow outcomes and support optimal training, writes Myron Zhang, M.D., and colleagues in JAMA Dermatology.

Dr. Zhang and colleagues examined how the scope of skin procedures performed by advanced practice professionals, such as nurse practitioners and physician assistants, has changed over the years. It is clear that nurse practitioners and physician assistants are seeing more patients today, but researchers were curious to know what specific procedures they were conducting.

They found the total number of all dermatologic procedures conducted by advanced practice professionals increased from 2.69 million of 30.7 million in 2012 to 4.54 million of 33.9 million in 2015. The percentage of these procedures performed by advanced practice professionals also rose from 8.8 percent to 13.4 percent during the same time period.

The most common procedure performed by advanced practice professionals in 2015 were destructions of benign neoplasms (3.6 million), followed by biopsies (788,834) and destructions of malignant neoplasms (48,982). The numbers of patch tests, removals of benign and malignant neoplasms, intermediate and complex repairs, flaps, and surgical pathologic specimen examinations also increased each year from 2012 through 2015.

This was a three-year study that analyzed data from the Medicare Provider Utilization and Payment Data that includes outpatient procedures paid by Medicare Part B in the United States.

The authors of the current study, published online July 11, said their results are a catalyst for further study of patient outcomes.


Advanced practice professionals were also found to independently bill for a large number of procedures: nearly 5 million in the 2012 Medicare population, of which 55% were dermatologic, according to a previous study by other authors in JAMA Dermatology.

Lindsay Strowd, M.D., FAAD, of Wake Forest Baptist Health in North Carolina, pointed to a discrepancy in the study.

“What the authors found was a discordance between the increase in billed procedures and the increase in number of Medicare patients. For example, they cited a 68% increase in number of performed skin biopsies by advanced practice professionals, but only a 1.3% increase in number of Medicare enrollees during the same three-year period,” said Dr. Strowd who was not affiliated with either study.

Additionally, the rate of increase in performed procedures “was significantly higher than their physician counterparts,” Dr. Strowd says. “The article raises the questions of cost, value and appropriateness of procedures performed in this cohort. Furthermore, the authors raise concerns over limited or non-existent training requirements for advanced practice professionals to perform more complicated cognitive skill-based procedures such  as patch testing and complex skin flaps.”

The study found that the numbers of patch tests, removals of benign and malignant neoplasms, intermediate and complex repairs, flaps, and surgical pathologic specimen examinations by advanced practice professionals increased each year from 2012 through 2015.


“I think the results of the study echo concerns voiced by some physician fellows of the American Academy of Dermatology regarding the lack of standardized oversight of advanced practice professionals and potential for misuse of healthcare resources,” Dr. Strowd says. “The study suggests over recent years more advanced practice professionals are treating skin conditions and are increasingly performing more complex procedures. One statistic from the study that was particularly poignant, although not necessarily surprising, was advanced practice professionals performing twice the number of skin biopsies to diagnose a skin cancer compared to physicians.”

Dr. Strowd believes that advanced practice professionals can be trained to properly perform many of the outpatient dermatologic procedures routinely performed by a dermatologist. “However, the overseeing physician must ensure advanced practice professional training is longitudinal and comprehensive to ensure the safety and care of our patients,” she says. “There are certain procedures within dermatology that require very extensive and specific training that I feel may not be appropriate for advanced practice professionals to perform independently, without having completed similar training to a board-certified dermatologist. Though it is outside the scope of this article, similar concerns exist for the utilization of advanced practice professionals for cosmetic procedures.”

Still, Dr. Strowd points out that advanced practice professionals provide an important service to patients and are valuable members of the patient care team. “I believe most dermatologists view the role of the advanced practice professionals as providing efficient and value-based follow-up care for specific dermatologic diseases under close supervision of a board-certified dermatologist,” she says.

A higher advanced practice professionals to dermatologist ratio, along with a rapidly escalating number of procedures performed by advanced practice professionals, suggests a trend toward less oversight of advanced practice professionals and an expansion of their role beyond what is perhaps the safest and effective patient care, according to Dr. Strowd. “It is ultimately the responsibility of the overseeing physician to ensure employed advanced practice professionals are providing care in an appropriate practice setting,” she says.

The study authors agree that uniformity in training and credentialing of advanced practice professionals is needed. “The core competencies defined for nurse practitioners do not mention a dermatology curriculum or surgical training,” they wrote.

Two limitations of the study are that it is restricted to the Medicare population and assumes that the clinician under whom the procedure is billed is the one who performed it.


Zhang M, Zippin Z, Kaffenberger B. “Trends and Scope of Dermatology Procedures Billed by Advanced Practice Professionals From 2012 Through 2015,” JAMA Dermatology. DOI:10.1001/jamadermatol.2018.1768. Published online July 11, 2018.

Coldiron B, Ratnarathorn M. “Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting,” JAMADermatology. 2014;150(11):1153-1159.

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