The nephrology provider workforce has a supply and demand imbalance. There are an estimated 37 million Americans with chronic kidney disease (CKD), half a million dialysis patients, hundreds of kidney transplant patients, and an untold number of acute kidney injury (AKI) patients (Centers for Disease Control and Prevention, 2019; National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases, 2019). To care for this massive population, there are 10,000 practicing nephrologists in the United States with another 777 in research and/or administration (American Board of Internal Medicine, 2016). This means that each clinically practicing nephrologist needs to evaluate, treat, and care for >3,500 patients with CKD in addition to patients with AKI, end-stage renal disease (ESRD), renal transplantation, and those hospitalized with a myriad of nephrology-related complications requiring consultation or management. Most nephrology patients have an average of five comorbidities and 5 to 15 daily medications with follow-up done on a 30- to 90-day cycle (National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases, 2019). Because of the demand for patient care, physician assistants (PAs), clinical nurse specialists (CNSes) and NPs have been recruited to help manage patients with kidney disease.
Before 2000, PAs and NPs practiced in nephrology, but not to the extent seen in other specialties (American Board of Internal Medicine, 2016). In 2004, the Centers for Medicare and Medicaid Services (CMS) changed billing/collections for dialysis (hemodialysis [HD], home hemodialysis [HHD], and peritoneal dialysis [PD]) (Anumudu & Erickson, 2020). Before 2004, payment for management of dialysis patients was billed on a “bundled” capitated monthly payment system (CMP) that did not require a specific number of face-to-face visits. In some areas of the country, where distances made visits difficult, it was not unusual for a dialysis patient to go months without seeing a nephrologist, and all management was performed through phone between the nephrologist and the nurses at the unit (Erickson et al., 2013). This fragile population has a high rate of hospitalizations and mortality; patients are hospitalized an average of 2×/year and have a mortality rate of 20% per year (Erickson et al., 2014). Recognizing this, CMS instituted regulations requiring weekly face-to-face visits for HD and monthly face-to-face visits for HHD and PD. It was hoped that the revised reimbursement plan would reduce morbidity and mortality in this vulnerable population (Anumudu & Erickson, 2020). The nephrology community recognized this was impossible to do while covering their clinics/offices and hospitalized patients. A compromise was reached allowing the nephrology PA, CNS, or NP to substitute for the physician in the weekly dialysis unit visits while billing at the full CMP as long as the nephrologist saw the patient 1x/mo for HD and quarterly for HHD or PD. If there were only PA/NP/CNS visits during the entire month, reimbursement would be at the usual 85% level (Anumudu & Erickson, 2020).
This created an explosion of job opportunities for PAs, CNSs, and NPs in nephrology. In response to the growing numbers of nephrology PA/NPs with their unique needs, in 2008, the National Kidney Foundation (NKF) created the Council of Advanced Practitioners (NKF/CAP), so the APs (as they are referred to collectively) could share and learn from each other. As part of outreach, a biannual survey of job descriptions, reimbursement, and benefits has been conducted. Researchers hoped to see if there was a standardization of the job that nephrology PAs/NPs do over time throughout the United States. We report on the 10-year longitudinal data from the NKF/CAP salary and benefits surveys.
Institutional Review Board approval was obtained from University of California Santa Barbara and Baylor, Scott, and White. Ten years of biennial survey data, from 2010 to 2020, were analyzed using descriptive statistics. Owing to differences in methodology in 2016, 2016 data were excluded. In each of the surveys of interest: 2010, 2012, 2014, 2018, and 2020, respondents anonymously reported job descriptions, sites of service, salary, and benefits through an online survey link sent through email (Chart 1, Supplemental Digital Content 1, available at http://links.lww.com/JAANP/A87). Reminders were sent weekly through January, February, and March of each survey year to all AP members of the NKF with instructions to share the link with all nephrology APs, regardless of membership in NKF. The link was also shared through electronic mailing lists with the American Academy of Nephrology PAs (AANPA) and American Nephrology Nurses Association (ANNA). Clinical nurse specialist data were removed from the full analysis because of small sample sizes.
Because this survey was anonymous, it is a snapshot of the PA or NP in nephrology and did not follow individual respondents sequentially. Participants numbered 216 (2010), 287 (2012), 249 (2014), 107 (2016), 293 (2018), and 322 (2020). Nephrology advanced practitioners are more likely to be NPs rather than PAs (50%, 56%, 67%, 68%, and 79% for 2010, 2012, 2014, 2018, and 2020, respectively). The PA workforce (at the time the data was collected) was more evenly split male and female but due to the higher number of NPs in the cohort (who are predominantly female), there is a predominance of females in nephrology. For both PAs and NPs, the largest percentage are master's prepared and predominantly White (82% to 87% stable over the decade). Nephrology PAs and NPs tend to be older than the average PA or NP, with the largest group of practitioners in 2010 between 50 and 60 years old (y/o), but this does not translate into more experienced PA/NPs. In the 2010 data, the percentage of PA/NPs with less than 5 years' experience roughly matched the number with 5–10 years' experience (33% and 34%, respectively) and was significantly lower than the practitioner with 16 or 20 years' experience (6% and 10%, respectively). In 2012 and 2014, the percentage with 5–10 years' experience (33% and 40%, respectively) was higher than those with <5 years' experience (25% and 23%, respectively). However, in 2018 and 2020, the largest groups were again those with <5 years' experience (29% and 33%, respectively). Although the nephrology PA/NP may tend to be slightly older (the largest grouping is always in the 40–50 y/o range), they do not seem to be more experienced as a PA and/or an NP.
Respondents reported sites of service (Figure 1). Peritoneal dialysis sites are often geographically within an HD unit but are coded as separate for billing purposes by CMS. Sites of service were similar over the decade except for a dip in PD sites in 2018.
Although PA/NPs covered the hospital setting at similar rates at each point during the decade, the actual tasks and procedures performed changed from predominantly supplying patients' history and physicals (H&Ps) in 2010 to mainly consult services in 2020 (Figure 2). The PA or NP in hospital nephrology consults and/or manages patients in the ICU 13% to 15% of the time. Procedures by the nephrology PA/NP slowed during the decade which corresponded to a decline in procedures by nephrologists as a whole (Quigley et al., 2018).
Within the HD units, PA/NP job descriptions continue to hold stable (Figure 3). Initially, the CMP visit, which determines the reimbursement from CMS (85% vs. 100%), was completed by the nephrologist for the higher reimbursement. In 2018 and 2020, this was no longer true. The CMS form certifying the need for dialysis, colloquially called “the 2728,” mandates signature by a physician, although PA/NPs have signed these forms for years as noted by the NPI numbers on the forms (Figure 3). The dialysis units are required to perform H&Ps and quality and care plan meetings to maintain state and federal certification, and these are performed by a majority of the cohort. The utilization of the PA/NP to take call for the HD unit has increased over the decade.
In the PD area, the PA/NP is more likely to be managing the hospitalized PD patient, covering PD clinic or taking call for the PD staff rather than doing the monthly visit (Figure 4). All other tasks have either held stable or decreased over the decade.
In the cohort, there was a distinct increase in the mentoring, on-boarding, or training the new PA/NP over the period from 2010 to 2020 (Figure 5). This may be a result of the growing population of patients with CKD, the expanding role of PAs and NPs, and the aging PA and NP workforce leading to retirements.
Within the office/clinic, the nephrology PA/NP has moved over the decade to management of the more “complicated” patient (the posthospital and/or new patient with ESRD) as defined by nephrology (Figure 6). The PA/NP is more likely to see and manage the hospital follow-up and the new ESRD patient who is transferring into the practice. They are more likely to see the patient with CKD in a “clinic” type setting along with an increase in covering call for the office. They are less likely over time to manage primary care issues.
Base salaries have risen for nephrology PA/NPs over the past decade (Chart 1) as have benefits (Supplemental Digital Content 1, available at http://links.lww.com/JAANP/A87). Some common benefits that are specific to nephrology include access to a computer for charting from one dialysis unit to another and either a car reimbursement and/or a gas allowance for driving between units, the office(s), and the hospital(s). The average number of dialysis units that the nephrology PA/NP visits/week has stabilized at 3–4 with 100–150 HD patients/week under the purview of each PA/NP. This does not include the office, hospital, and/or PD patient load.
Nephrology is overwhelmed with the number of patients for both consults and/or management, including dialysis patients, AKI patients, transplant patients, intensive care unit (ICU) patients, and patients with CKD. The nephrology PA/NP has stepped in to fill this void. At the time PAs/NPs were incorporated into nephrology practices in 2004, the financial incentives were to use them in the dialysis unit with significant payments to practices by completing three of four visits/month (Figure 7). By 2020, the use of the nephrology PA/NP was more balanced with equal use in the office/clinic, dialysis unit, and hospital (Figure 2). Over time, the nephrology PA/NP has moved from the “simple to the complex” as defined by medical acuity required to evaluate and manage. Within the office, the nephrology PA/NP is no longer used for primary care management but instead does hospital follow-ups, ESRD initial management, and new patient consults.
When nephrology originally reached out to PAs and NPs, it was as a stop-gap measure, but these data show that the PA/NP is now an integral part of the practice, managing some of the most complicated patients seen in internal medicine. Salaries for PAs and NPs in nephrology have increased as patient medical acuity has increased. Benefits specific to nephrology include those needed for the job description: car and/or gas allowances, computers, and/or cell phones. One can argue that these are not really benefits as they keep one in closer contact with the dialysis units and/or office staff, but as close to half of all call is managed by nephrology PA/NPs, these benefits are an integral part of the job.
As collected in the survey data, tasks and procedures do not differ by provider type (PA or NP), with most respondents stating that their practices use PAs and NPs interchangeably. However, there are twice as many nephrology NPs as PAs. Nephrology is unknown to many PAs, with the American Academy of Nephrology PAs reporting that fewer than 1% of PAs practice in nephrology. Many of the NPs reported that they had previously been dialysis nurses or managed dialysis patients, and therefore, nephrology is a more known option in the NP profession. The largest issue seen in nephrology is attracting and retaining the nephrology PA/NP. Interviews with the Renal Physician Association (RPA) note that it is very difficult to find an experienced nephrology practitioner (Oral communication, Kline Bolton, MD, Renal Physician Association Meeting, Washington DC, 2014). The pay scale of the nephrology PA/NP is low compared with other specialties, although that gap is closing. In nephrology, where more than 90% of reimbursement is single source (Medicare), there is not as much room for adjustment of pay scales. Exit interviews, as reported by the RPA, show that many of the experienced PA/NPs are moving to the hospitalist services due to quality-of-life considerations. This is also true for nephrologists (Quigley et al., 2018).
Certain results from the surveys of the nephrology PA/NP need to be highlighted. The decrease in PAs/NPs in PD may have been related to a national shortage of PD materials, which led to a decrease in new-start PD patients that lingered for 2 years in national data analyses (National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases, 2019; Davis & Zuber, 2014). This slowdown in PD patients led to a dip in trained PD nurses and a reduced use of PD. Tasks in the dialysis units include annual histories and physicals and attending or managing monthly care plan and quality care meetings; these are done more often by the PA or NP. As these items are required by federal statute but not reimbursed separately from the CMP, using PAs and NPs is less costly to the practice than having a physician perform these tasks. Regarding the 2728 CMS form that each new dialysis patient must have, no determination has been requested by either the PA or NP community to determine if a PA or NP signature is acceptable. For many years, many PAs and NPs have been signing these forms without incident, but as the more experienced PAs and NPs retire, the new PAs and NPs in nephrology may be less likely to sign the 2728. The increase in mentorship by the PA or NP in nephrology may be explained by the retirement of the more experienced PAs and NPs in nephrology and replacement with a less-seasoned practitioner. In 2010, Medicare announced that patients with stage 4 CKD (glomerular filtration rate [GFR] of 15 to 30 mL/min) who were Medicare beneficiaries would receive 6 hours of paid kidney education. These classes would be taught by physicians, PAs, or NPs. Initially, these classes were primarily taught by PAs and NPs with either self-developed modules or modules from national organizations (Zuber et al. 2019). However, education by PAs and NPs showed a drop in 2014 that cannot be explained by outside factors. Another issue for nephrology is that experienced nephrology PAs/NPs seems to be leaving the specialty at approximately the 10-year mark perhaps to education, hospitalist, and/or internal medicine practices. The loss of these experienced practitioners means that nephrology practices are often scrambling to cover a very fragile medical population with less experienced PAs/NPs. Yet if experienced PA/NPs are moving to a faculty position and/or back to general internal medicine, then their experience may lead to an increase in nephrology PAs and NPs in the future.
As the number of nephrology PAs and NPs cannot be confirmed by an independent source (CMS does not break down PAs and NPs by specialty), all calculations used the cohort as the denominator for statistical analysis. None of the data reported by the cohorts was independently confirmed as it is self-reported. As the data are anonymous, no attempt was made to independently verify the reported data. Each survey is cross-sectional rather than longitudinal, providing only point-in-time data, making the sequential follow-up of a particular PA/NP impossible. Because of the nature of the survey, with changing questions adapting to the need of the survey participants, quantitative statistical analysis was not possible (Davis & Zuber, 2009). As such, statistical analysis showing whether these changes are statistically significant trends could not be done. Because participation was voluntary, potential bias may exist based on those PAs and NPs. who participated.
Strengths include both the nationwide and multiyear coverage of the data. Data were comprehensive and detailed with highlights described here. These data have been identified by CMS and the nephrology community as the strongest and most comprehensive data on the nephrology PA/NP (Oral Presentation, American Society of Nephrology Kidney Week meeting, Successfully Collaborating with Advanced Practitioners, New Orleans, LA, 2017) (Davis & Zuber, 2009, 2014; Salsberg et al.,2015).
The use of PAs and NPs in nephrology has grown tremendously since CMS introduced a change in billing for dialysis patients. Although the PAs and NPs in nephrology originally managed only dialysis patients, this is no longer the case. PAs and NPs in nephrology now manage complex patients in the hospital, ICU, office, and dialysis units. With fewer medical residents graduating and passing nephrology boards (American Society of Nephrology, 2020), the nephrology PA/NP will continue to be an integral practitioner in the nephrology arena for the foreseeable future.
Acknowledgments:The authors thank the National Kidney Foundation Council of Advanced Practitioners for their assistance with the survey.
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