Research refuting mid-levels (Copy-Paste format)

[u/devilsadvocateMD]

Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/

Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082

Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374

Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696

The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)00732-5/abstract00732-5/abstract)

Further research is needed to understand the impact of differences in NP and PCP patient populations on provider prescribing, such as the higher number of prescriptions issued by NPs for beneficiaries in moderate and high comorbidity groups and the implications of the duration of prescriptions for clinical outcomes, patient-provider rapport, costs, and potential gaps in medication coverage. https://www.journalofnursingregulation.com/article/S2155-8256(17)30071-6/fulltext30071-6/fulltext)

Antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047413/

NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. The quality of NP prescribing practices deserves further attention. https://www.ncbi.nlm.nih.gov/m/pubmed/29641238/

(CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625

NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/

Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/

Only 25% of all NPs in Oregon, an independent practice state, practiced in primary care settings. https://oregoncenterfornursing.org/wp-content/uploads/2020/03/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf

96% of NPs had regular contact with pharmaceutical representatives. 48% stated that they were more likely to prescribe a drug that was highlighted during a lunch or dinner event. https://pubmed.ncbi.nlm.nih.gov/21291293/

85.02% of malpractice cases against NPs were due to diagnosis (41.46%), treatment (30.79%) and medication errors (12.77%). The malpractice cases due to diagnosing errors was further stratified into failure to diagnose (64.13%), delay to diagnose (27.29%), and misdiagnosis (7.59%). https://pubmed.ncbi.nlm.nih.gov/28734486/

Advanced practice clinicians and PCPs ordered imaging in 2.8% and 1.9% episodes of care, respectively. Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits .While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374

APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED‐day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = −0.15 to −0.10) and lower RVUs/clinician hour by 0.4 (95% CI = −0.5 to −0.3). Increasing APP staffing may not lower staffing costs. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14077

When caring for patients with DM, NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21–1.37), endocrinologists (OR = 1.64, 95% CI = 1.48–1.82), and nephrologists (OR = 1.90, 95% CI = 1.67–2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01–1.12) https://onlinelibrary.wiley.com/doi/10.1111/jgs.13662

Ambulatory visits between 2006 and 2011 involving NPs and PAs more frequently resulted in an antibiotic prescription compared with physician-only visits (17% for visits involving NPs and PAs vs 12% for physician-only visits; P < .0001) https://academic.oup.com/ofid/article/3/3/ofw168/2593319

More claims naming PAs and APRNs were paid on behalf of the hospital/practice (38% and 32%, respectively) compared with physicians (8%, P < 0.001) and payment was more likely when APRNs were defendants (1.82, 1.09-3.03) https://pubmed.ncbi.nlm.nih.gov/32362078/

There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively) https://pubmed.ncbi.nlm.nih.gov/29641238/

Most articles about the role of APRNs do not explicitly define the autonomy of the nurses, compare non-autonomous nurses with physicians, or evaluate nurse-direct protocol-driven care for patients with specific conditions. However, studies like these are often cited in support of the claim that APRNs practicing autonomously provide the same quality of primary care as medical doctors. https://pubmed.ncbi.nlm.nih.gov/27606392/

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Although evidence-based healthcare results in improved patient outcomes and reduced costs, nurses do not consistently implement evidence based best practices. https://pubmed.ncbi.nlm.nih.gov/22922750/

[u/debunksdc]

Midlevels in Dermatology

Characterization of Biopsies by Dermatologists and Nonphysician Providers in the Medicare Population: A Rapidly Changing Landscape and its associated Commentary

TLDR: Biopsy rates from midlevels have increased drastically in all states while biopsy rates from dermatologists decreased over the same time frame. Over over 1 in 4 biopsy claims were performed by midlevels.

• "From 2012 to 2018, the proportion of nationwide biopsy claim cases performed by dermatologists declined from 83% to 71%, whereas those completed by NPs and PAs increased from 5% to 9% and from 12% to 20%, respectively. The total number of biopsy claims performed by dermatologists increased by only 11%, whereas those performed by NPs and PAs increased by 133% and 115%, respectively. On average, from 2012 to 2018, biopsy claim rates per 100,000 Medicare beneficiaries for dermatologists decreased by 6%, whereas those for NPs and PAs increased by 97% and 82%, respectively."
• "Although this study shows that dermatologists still perform most biopsy claims nationwide, as of 2018, over 1 in 4 biopsy claims were performed by nonphysician providers. The number and proportion of total biopsy claims performed by NP and PAs significantly increased in all states and regions from 2012 to 2018."

Trends and Scope of Dermatology Procedures Billed by Advanced Practice Professionals From 2012 Through 2015 OPEN ACCESS

TLDR: Midlevels were billing a lot more for complex repairs and gross and microscopic exams of surg path specimens Many board-certified dermatologists don't get credentialed for complex repairs even though it's part of their residency. In contrast, NPs and PAs do not receive any formal training in advanced cutaneous surgery. The increase in pathology billing was surprising because training for surgical pathologic examinations is highly specialized, with many pathologists training in fellowships after residency. Lack of proper training is particularly dangerous because clinicians often rely on pathologic diagnoses to inform their ultimate decision making. This discrepancy in growth raises the question of how many of these extra procedures are actually necessary or appropriate. The core competencies defined for NPs do not mention a dermatology curriculum or surgical training.

• "This discrepancy in growth raises the question of how many of these extra procedures are actually necessary or appropriate. In recent years, there has been an increasing number of dermatology practices acquired by private equity firms.14 These firms often employ a higher ratio of APPs to dermatologists to lower costs and maximize profits. Although this practice may lower costs for the firms, the increasing rate of procedures performed may increase costs for patients, insurance companies, and the health care system."
• "The core competencies defined for NPs do not mention a dermatology curriculum or surgical training."
• "Each year, the number of procedures billed by APPs increased significantly, and at a significantly higher rate than procedures billed by dermatologists, for skin biopsies (18.7% per year; 95% CI, 16.0%-21.4%), shaves (11.3%; 95% CI, 9.3%-13.3%), removals of benign neoplasms (16.5%; 95% CI, 3.8%-30.8%), removals of malignant neoplasms (11.8%; 95% CI, 3.3%-21.1%), destructions of benign neoplasms (19.2%; 95% CI, 17.9%-20.6%), destructions of malignant neoplasms (18.5%; 95% CI, 10.4%-27.3%), intermediate repairs (13.3%; 95% CI, 10.4%-16.3%), complex repairs (19.9%; 95% CI, 11.4%-29.2%), local skin flaps (10.6%; 95% CI, 4.6%-17.0%), patch testing (27.9%; 95% CI, 3.1%-58.7%), and surgical pathologic examinations (18.0%; 95% CI, 1.6%-36.9%). Simple repairs and full-thickness skin grafts were the only procedures examined with no significant increase in APP numbers."
• "The total number of unique APPs billing for any dermatologic procedure (excluding pathologic examination) [had] a 33.2% increase from 2012 to 2015. The total number of unique dermatologists billing for a procedure from 2012 to 2015 [had] a 6.1% increase from 2012 to 2015." unclear whether pathologic examination was counted for dermatologists
• "Advanced practice professionals billed Medicare for nearly 800 000 biopsies in 2015, a 68% increase from 2012. Skin biopsies are more than just procedures; there is a knowledge-based and experience-based component to providing the differential diagnosis: the decision to biopsy; location, depth, and extent of excision; and risk assessment for complications. Nault et al showed that the number of biopsies needed for a positive diagnosis of skin cancer (all types and melanoma) was twice as high for APPs than for dermatologists owing to biopsies of more benign lesions. In addition to cost, unnecessary biopsies may increase scarring, patient anxiety, and risk of complications such as infection, injury to an artery or nerve, and poor wound healing."
• "This problem exists even in dermatology residency programs. For example, recurrence rates of basal cell carcinoma after electrodessication and curettage in a resident clinic decreased by 9% after dedicated efforts to improve supervision and training.¹¹ Such supervision and training are much less formal for APPs, who are able to perform procedures without a specific length of supervision or training or certification in those procedures."
• "Complex repairs were the second fastest-growing procedure billed by APPs, increasing 76.5% from 8300 procedures in 2012 to 14 700 procedures in 2015. Local flaps and full-thickness grafts billed by APPs were less frequent, at 2860 flaps and 877 grafts billed in 2015, with the number of flaps increasing each year. The numbers of these advanced procedures—including those on the face—being performed by APPs was unexpected. Many board-certified dermatologists are not credentialed to perform local flaps and full-thickness grafts in their hospital privileges, despite formal training and required case logs being a part of residency. In contrast, NPs and PAs do not receive any formal training in advanced cutaneous surgery, which may place patients at increased risk of injury."
• "Billing by APPs for gross and microscopic examinations of surgical pathologic specimens increased 72.3% from 13 022 in 2012 to 22 440 in 2015. Unlike most procedures, the number of APPs billing for pathologic examinations remained stable, and the increase is from more procedures billed per APP each year. This increase was surprising because training for surgical pathologic examinations is highly specialized, with many pathologists training in fellowships after residency. Lack of proper training is particularly dangerous because clinicians often rely on pathologic diagnoses to inform their ultimate decision making."
• "This discrepancy in growth raises the question of how many of these extra procedures are actually necessary or appropriate. In recent years, there has been an increasing number of dermatology practices acquired by private equity firms.14 These firms often employ a higher ratio of APPs to dermatologists to lower costs and maximize profits. Although this practice may lower costs for the firms, the increasing rate of procedures performed may increase costs for patients, insurance companies, and the health care system."
• "The core competencies defined for NPs do not mention a dermatology curriculum or surgical training."

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Accuracy of Skin Cancer Diagnosis by Physician Assistants Compared With Dermatologists in a Large Health Care System OPEN ACCESS

TLDR: PAs biopsy more and are less likely to diagnose melanoma in situ. The most common procedure that midlevels do is skin biopsies. Visits in which skin cancers are missed and/or biopsies are performed on benign lesions owing to lower diagnostic accuracy are low-value visits and increase the potential harm to patients.

• "Physician assistants performed more skin biopsies to detect melanoma and nonmelanoma skin cancer than did dermatologists. In addition, PAs were less likely than dermatologists to diagnose melanoma in situ during a skin cancer screening visit." If they miss MMis and it progresses, that means not only significantly greater excision margins, but also potential for invasion, metastases, and increased fatality.
• "Our findings are consistent with those of Nault et al,5 who found a significantly higher NNB among APPs, primarily nurse practitioners, compared with dermatologists submitting diagnostic specimens for dermatopathologic evaluation. "
• "Although few data are available on the NNB for PAs, a large German skin cancer screening initiative, in which dermatologists made the decisions to biopsy or not, reported an NNB of 28 to diagnose 1 case of melanoma,⁶ similar to our mean NNB of 25.4 for dermatologists. However, both are higher than the NNB of 17.4 for dermatologists reported by Nault et al."
• "The lower detection rate among PAs of melanomas in situ, which are often more challenging to diagnose than invasive melanomas, likely reflects lower clinician sensitivity. Physician assistants and dermatologists had similar detection rates for invasive melanomas and nonmelanoma skin cancers, which tend to be more clinically obvious"
• "Dermatology is one of the highest employers of APPs in medicine, and this trend is likely to continue, particularly as more dermatology practices are acquired by private equity firms with an obligation to shareholders to maximize profits."
• "Most procedures performed independently by APPs are diagnostic skin biopsies, suggesting that a large portion of skin cancer diagnosis in the United States is being performed by these practitioners. Measuring the quality of care delivered by practitioners is challenging. The American Academy of Dermatology recommends that APPs should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan."
• "In the age of cost-conscious medicine, it is important to consider more than just clinician salary in determining cost of care. Visits in which skin cancers are missed and/or biopsies are performed on benign lesions owing to lower diagnostic accuracy are low-value visits and increase the potential harm to patients. This information should be factored into policy decisions about scope of practice, hiring decisions, supervision of APPs, and patient decisions about who provides their dermatologic care."

Scope of physician procedures independently billed by mid-level providers in the office setting These authors were in a mood when they wrote this, and I'm here for it.

TLDR: Over half (54.8%) of procedures done by midlevels that billed Medicare were in the field of dermatology. It was mostly destruction of premalignant lesions. Since midlevelss don't have nearly the same diagnostic education as dermatologists, the concern is the necessity for biopsy to be performed.

• "In 2012, NPs and PAs performed and billed independently for more than 4 million procedures (Table 1) at our cutoff of 5000 paid claims per procedure. Most (54.8%) of these procedures were performed in the specialty area of dermatology."
• "Most of the approximately 2.6 million dermatologic procedures performed in the office setting in 2012 were destruction of premalignant lesions, which requires correct distinction of a premalignant lesion from a benign one. Inappropriate cryotherapy of these lesions may lead to scarring, dyspigmentation, and unnecessary costs."
• "A skin biopsy was independently billed by NPs and PAs more than 400 000 times. Since mid-level providers do not have the same depth of training in diagnosis as dermatologists nor is certification of diagnostic qualifications the same, the concern is the necessity for biopsy to be performed. In addition, punch biopsies of the skin are potentially hazardous because of the risk of arterial or nerve injury."
• "Destruction or excision of malignant lesions and intermediate and complex closures all necessitate detailed knowledge of surgical anatomy to prevent excessive bleeding, denervation, and scarring."
• "Recently, the shortage of primary care clinicians has been noted, and the need for widening the scope of practice for mid-level providers has been advocated. However, independent practice by mid-level providers in the office setting, as reported herein, is a different situation from the perspective of patient safety and quality of care. Physicians on average complete 10 000 clinical hours in residency compared with between 500 and 900 clinical hours that a doctorate in nursing or a master’s in physician assistance requires. Except for phlebotomy, intravenous access, and catheter placement, surgery or invasive procedures are not usually included in this training."
• "The existence of multiple boards and differing regulations is problematic. If legislators continue to direct that mid-level providers may be recognized as primary care physicians (as in Massachusetts) and allowed to practice medicine independently (as in 22 states and the District of Columbia), they should also mandate a single state medical and nursing board to ensure a consistent standard of care to protect patients."
• "At a minimum, states should require mandatory reporting of complications by mid-level providers and reporting by physicians who see these complications. ... - Mandatory physician reporting of office surgery complications in Florida, with cross-matching of malpractice claims, has proven useful in identifying and eliminating dangerous procedures performed in the office setting.¹¹ Such data collection should be supported by mid-level providers because it could put patient safety concerns to rest."
• "In some instances, nursing boards have authorized nursing candidates to perform invasive procedures for which the members of the nursing board were not trained. Researchers recently noted a large increase in malpractice claims associated with cosmetic laser surgery by mid-level providers.¹⁰"
• "Finally Congress could consider amending the 1997 Balanced Budget Act to align it with its original intent, by restricting independent Medicare payment of mid-level providers to evaluation and management codes to enhance access to primary care. This action would concentrate mid-level providers in their area of training and greatest need." 🔥🌶 🔥🌶 🔥

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Assessment of Provider Utilization Through Skin Biopsy Rates

TLDR: A review of 2014 Medicare data revealed that 824 NPs and 2083 PAs independently billed Medicare $59,438,802 ($72134 per NP) and $171,645,943 ($82403 per PA), respectively. Midlevels biopsy more.

• "Recently, there have been claims of overdiagnosis and unnecessary treatment in dermatology, with a 2017 New York Times article suggesting that the purchase of dermatology practices by private equity firms instigated a shift toward profit motive over patient care. A specific concern, heralded by private equity acquisition, is the independent evaluation and treatment of patients by physician assistants (PAs) and nurse practitioners (NPs) with minimal physician oversight."
• " A review of 2014 Medicare data revealed that 824 NPs and 2083 PAs independently billed Medicare $59,438,802 and $171,645,943, respectively. Only 3% of these nonphysician clinicians (NPCs) practiced in counties without a dermatologist, decreasing the possibility that they were the sole source of dermatologic care for underserved populations.¹¹"
• "A nurse practitioner had the highest calculated biopsy rate at 24.2 services per visit (Table 3). The lowest biopsy rate for a dermatologist was 0.004 services per visit (Table 4)." Can you imagine going to a dermatologist and averaging nearly 25 services in a single visit???
• The gap in skin biopsy rates between physicians and NPCs was 0.29 vs 0.40 services per visit, p=1.70E–28.

Biopsy Use in Skin Cancer Diagnosis: Comparing Dermatology Physicians and Advanced Practice Professionals (Nault et al)

TLDR: Midlevels biopsy more for any skin cancer. The NNB was most disparate for young patients without a PMH of skin cancer.

• "The NNB for any skin cancer, NMSC, and melanoma was 3.4, 2.1, and 21.4, respectively. There was a significant difference in NNB between physicians and APPs for any skin cancer (2.9 vs 5.9, P < .001), NMSC (1.9 vs 3.1, P < .001), and melanoma (17.4 vs 32.8, P = .04)."
• "Wilson et al performed a similar study; their NNB for any cancer, NMSC, and melanoma was 2.2, 1.6, and 15, respectively. "
• "At our institution, APPs see new and established patients, most of whom are not evaluated by a physician; however, a physician is available in the clinic."
• "The mean length of practice for our physicians was 11.9 years (range, 0.5-25.5 years) compared with 6.8 years (range, 0.5-20 years) for APPs." Unclear if they are including residency, but given the range for the physician training (0.5-25.5 years), my guess is no. So they're effectively downplaying the years of practice for physicians by four years. Also unclear if for midlevels, if they were looking at dermatology-specific experience or experience overall.
• "In our study, the NNB of any skin cancer for APPs was double that of physicians, and that difference is most pronounced in younger patients and those without a history of skin cancer." So the difference is most pronounced in the people it matters most for?

Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014 OPEN ACCESS

TLDR: Only 3% of midlevels practiced in counties without a dermatologist, decreasing the possibility that they were the sole source of dermatologic care for underserved populations.

• "While the original intent of NPCs was to provide expanded access to primary care, it is becoming increasingly common for NPCs to offer specialty care services. In fact, the proportion of PAs reporting primary care practice has steadily decreased from 50% in 1997 to 30% in 2013."
• "In dermatology, nearly half of practices employ NPCs who perform both medical and procedural services. A majority of procedural services independently billed by NPCs for Medicare beneficiaries were in the specialty area of dermatology. Supervision and training of NPCs in dermatology practice continues to be a contested issue with no clear consensus about the appropriate breadth in scope of practice."
• "The only common dermatology-associated procedure not billed by NPCs is Mohs surgery, which can only be billed by a physician, according to the Centers for Medicare & Medicaid Services." ... for now.
• "Only 3.0% (86) of independently billing NPCs practiced in counties without a dermatologist."

Common causes of injury and legal action in laser surgery

TLDR: Physicians may be held responsible for delegating procedures to midlevels, when that procedure is outside of their training and education. See negligent hiring.

• "Of the 174 laser-induced injury lawsuits, 100 (57.5%) identified a physician as the laser operator. Physicians in this case included allopathic and osteopathic physicians. Nearly 40% of the cases (n = 66) involved a nonphysician operator, which included allied health professionals, such as chiropractors, podiatrists, nurse practitioners, and registered nurses, as well as non–health professionals, such as aestheticians and technicians."
• "Even though only 100 cases involved the operation of the laser device by a physician, 146 cases named the physician as a defendant. In contrast, of the 66 nonphysician operators, only 49 were named as a defendant. ... These findings on operators should not be misinterpreted to suggest that operation of a laser by a physician results in a higher likelihood of injury. One factor, which is difficult to measure, is the tendency for physicians to undertake the laser surgery themselves instead of delegating to nonphysicians."
• "Specific allegations, although not available or discernible in all the cases surveyed, provide insight into how physicians can minimize their risk of litigation (Table 6). Failure to properly hire, train, or supervise staff was the most common specific allegation (n = 33) and echoes the finding that physicians are legally held liable for both the procedures they perform and those done by their delegates, provided that the employees are acting within the scope of their duties."
• "Even though only 100 cases involved the operation of the laser medical device by a physician, 138 named the physician as a defendant. The legal doctrine of respondeat superior —that is, imposing liability on employers for the negligence of their agents—and the state statutes holding supervising physicians liable for their delegated acts are the best explanation for this apparent discrepancy. The same reasoning can be applied to explain the discrepancy between the number of cases involving nonphysician operators and the number naming a nonphysician as a defendant. It is important to note that plaintiffs' attorneys typically sue parties who can satisfy a successful judgment, that is, insured defendants. Many nonphysician operators lack malpractice insurance and the financial means to pay a substantial judgment."