Secondary Logo

Journal Logo

Musings: Blog of the JAAPA Editorial Board


Blog of the JAAPA editorial board.

Monday, May 16, 2016

Physician assistants and nurse practitioners in outpatient surgical offices

Brian T. Maurer, PA-C
In the May issue of JAAPA, Salibian and colleagues present an independent research study that examines the use of PAs and NPs in outpatient surgical subspecialty settings.

The investigators draw their data from the National Ambulatory Medical Care Survey published annually by the CDC. Although these data are dated (they stem from surveys conducted in 2007-2008), the results are still somewhat shocking, unsettling at best: PAs and NPs were involved in only 5.9% of outpatient surgical subspecialty office visits, and the percentage of patients evaluated by PAs or NPs alone turned out to be a paltry 1.1%. Interestingly, PAs and NPs often saw the same diagnoses alone (which I take to mean without a supervising surgeon physically present) as their physician counterparts.

The authors conclude that PAs and NPs “have a minor prevalence in the ambulatory surgical workforce during the time period studied.” On a brighter note, the authors argue that “further integration of these providers into the outpatient setting may help optimize efficiency in ambulatory surgical care.”

Because the current rate of surgeons entering the healthcare workforce has been deemed insufficient compared to the projected need, expanding the roles of PAs and NPs could theoretically improve overall access to quality surgical care, and at the same time lower its costs.

This study harkens back to arguments that first surfaced in the medical literature 30 years ago: namely, that expanding the roles of PAs and NPs would improve access to quality care and lower costs. Although the PA and NP workforce has grown exponentially over time, to my knowledge no definitive study has demonstrated that using these providers has actually lowered the cost of medical care.

A closer look at Salibian and colleagues’ data might provide the astute critical reader with a clue as to why this has not occurred. NAMCS data are gleaned from ICD-9-CM diagnostic and procedure codes. The authors allude to the likelihood that most of these diagnostic encounters might have been billed “incident to” the supervising surgeon. It is only required that the surgeon be present in the office during the medical encounter to justify billing at this level. Many of these encounters may have been billed in this fashion, effectively skewing the true incidence of care rendered by PAs and NPs.

Were PAs and NPs generating revenue in less than 6% of office-based surgical encounters, it would not be economically feasible for surgeon employers to keep them on the payroll.

One wonders how such scenarios may play out in the future medical marketplace, as we move from solo-fee-for-service toward universal value-based care.

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Share this blog post on Facebook or Twitter using the buttons below!

Facebook Twitter