As primary care doctors perform fewer procedures, PAs and NPs are doing more of them

Nurse practitioners and physician associates are performing more office-based procedures, while family medicine doctors are performing fewer of them, new research shows.

The data doesn’t signify that those two trends are directly related. But it likely speaks to certain underlying shifts in healthcare: more procedures being referred out of primary care to specialists, the growing use of urgent care for medical concerns, and more team-based care that incentivizes each clinician to work at the top of their license.?

“We’re in a situation where the nature of the interaction between PAs and physicians is more collaborative than directed,” said study author Robert McKenna, DMSc, MPH, PA-C , a professor at Marshall B. Ketchum University. “The key takeaway is that PAs and NPs are competent practitioners who are helping to fill the gap left by the shortage of physicians.”

McKenna and his co-authors published the results of their findings in the Annals of Family Medicine and presented them at the annual meeting of the American Academy of Physician Associates in May. (“Physician associate” is the profession's preferred term after a 2022 name change .)

What they found was that the number of family physicians filing claims for commonly-recommended procedures declined 42% between 2014 and 2021 . In contrast, the number of NPs and PAs who filed claims for those same procedures increased 74% over the same period.?

Of course, the number of NPs and PAs in the workforce also grew during that time period. But for PAs in particular, the increase in claims submitted was 1.5x higher than the growth in the number of clinicians.

The study — which used Medicare Part B data matched against National Provider Identifier numbers? — did have one major limitation. It couldn’t identify where the PAs and NPs were working.?

“For a majority of that workforce, [PAs and NPs] are not in primary care offices; they are in sub-specialty offices,” said Yalda Jabbarpour , a family medicine physician and director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. “It doesn't surprise me that they would have higher rates of procedures only because subspecialties themselves just happen to have higher rates of procedures.”

McKenna said that he understands why some physicians might take exception to the data. But he noted that he saw similar results when he looked at the numbers for urology and endocrinology procedures.

“What [this research] does do is kind of paint this broad view of a dynamic that's occurring,” he said. “We're in a situation right now where there are not enough physicians, period, to manage the health of all U.S. citizens.”

Many of the procedures identified in the study were relatively straightforward — things like wart removals, casting broken bones, suturing wounds and steroid injections. What the data couldn’t show was whether doctors might be sending these cases to advanced-practice providers in the same practice.

“It could be that they're having the PA and NP do those procedures on their behalf while they spend their time dealing with more complex patients,” McKenna said.

Yet procedures in primary care have been decreasing overall, according to Jabbarpour, who said the data doesn’t surprise her, despite its limitations. She attributes the shift to health systems buying up independent physician practices.

“For those big hospital systems, it’s more cost efficient to have primary care serve as a referral base to the specialists who do the procedures,” she said. “They make more money that way.”

The study also couldn’t account for differences in practice settings, like whether PAs and NPs were working in an office or urgent care. Fewer people are going to primary care doctors for their medical needs and are instead turning to urgent care centers, which tend to be staffed with PAs and NPs.

Like in specialty care, urgent care centers can command higher reimbursement rates. As patients move away from primary care practices, healthcare costs go up, Jabbapour said.

Yet PAs and NPs can also open up new revenue streams for physician practices, McKenna noted, by allowing them to see more patients with shorter wait times for appointments.?

“We’re seeing the people they don’t have the bandwidth to see,” he said. “Most physicians welcome the help and see us as collaborators, not competition. And we’re not competition.”