SGEM#393: You Down with APP, Yeah You Know Me

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Date: February 17, 2023

Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023

Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and Assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

Case: You are an administrator responsible for staffing emergency departments (EDs) in a health care system comprising both urban and rural locales. The hiring pool includes emergency medicine trained physicians, non-emergency trained physicians, and advanced practice providers (physician assistants and nurse practitioners). Prior to your hiring search, you wonder how many patient encounters are being seen by each type of physician or advanced practice provider. You also wonder the breakdown of visit acuity being seen by the different provider types.

Background: Advanced practice providers (APPs), primarily physician assistants (PAs) and nurse practitioners (NPs), make up more of the emergency medicine (EM) workforce each year (1-4). While APPs have traditionally focused on low-acuity patient encounters, as ED visit volumes and physician shortages increase, APPs are seeing more complex, high-acuity patients (5-6).

In the United States, policies have been implemented to permit more independent APP practice, with or without direct physician support. This increase in independent service provision by APPs and change in practice pattern to more high-acuity patients has not been formally assessed (7-8).

There is concern regarding the expanding practice pattern of APPs, and a March 2022 Guideline by the American College of Emergency Physicians (ACEP) stated that PAs and NPs should not perform independent, unsupervised care in the ED setting (9). Given current workforce limitations, it is not feasible to continue current 24/7 staffing models in certain EDs and communities without APPs (1,3).

Similarly, many rural Canadian emergency departments have reduced their open hours or closed over recent years due to inadequate staffing (MacLean’s Magazine – Dr. Alan Drummond) There are both NPs and PAs working in Canadian EDs currently and we could see their role increase in the future should staffing shortages increase.

The SGEM has done two previous podcasts on APPs in the ED. These focused on productivity, safety and diagnostic testing differences between emergency physicians and APPs (SGEM#308 and SGEM#316).

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Clinical Question: How has the role of APPs in the provision of emergency care changed in recent years?

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Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023

• Population: Emergency care providers including emergency physicians, non-EM physicians and APPs (Physician assistants, nurse practitioners, certified nurse midwives, certified registered nurse anesthetists) who provided fee-for-service Medicare in the United States emergency departments from 2013 to 2019.
  • Exclusion Criteria: Providers who received less than 50 total reimbursements within a study year for evaluation services reflecting typical emergency critical care codes.
• Exposure: Patient encounters by APPs
• Comparison: Patient encounters by Physicians
• Outcome:
  • Primary Outcome: Proportion of high acuity encounters independently billed by different emergency clinician types over time.
  • Secondary Outcomes: Variation in clinicians seeing high acuity encounters based on geography (urban vs. rural). Proportion of Evaluation Management services provided by each clinician that were high, moderate or low acuity in comparison to the total number of cases seen.
• Type of Study: Observational study using a repeated cross-sectional analysis of emergency clinicians using the Centers for Medicare & Medicaid Services (CMS) Provider Utilization and Payment Data Practitioners Public Use File (PUF),

This is an SGEMHOP and we are pleased to have the lead author on the show. Dr. Cameron Gettel is an Assistant Professor in the Department of Emergency Medicine and a Clinical Investigator at the Yale Center for Outcomes Research and Evaluation. In these roles, he primarily conducts geriatric-related and health services research

Authors’ Conclusions: “In 2019, APPs billed independent services for approximately 1 in 6 high acuity EDencounters in rural geographies and 1 in 11 high acuity ED encounters in urban geographies, and well over one-third of the average APPs’ encounters were for high acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision-making.”

Quality Checklist for Observational Study:

1. Did the study address a clearly focused issue? Yes
2. Did the authors use an appropriate method to answer their question? Yes
3. Was the cohort recruited in an acceptable way? Yes
4. Was the exposure accurately measured to minimize bias? Yes
5. Was the outcome accurately measured to minimize bias? Yes
6. Have the authors identified all-important confounding factors? No
7. Was the follow up of subjects complete enough? Yes
8. How precise are the results? N/A
9. Do you believe the results? Yes
10. Can the results be applied to the local population? Unsure
11. Do the results of this study fit with other available evidence? Yes
12. Funding of the Study – Institutional funding from a variety of sources including SAEM, ABEM, National academy of Medicine and others.

Results: They identified 84,477 unique clinicians provided at least 50 emergency department services during one of the 2013 to 2019 study years. There were 47,323 EM Physicians, 10,555 Non-EM Physicians and 26,599 APPs.

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Key Results: APP independent billing for all encounter types increased over time and close to double in rural areas compared to urban practices.

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• Primary Outcome: Proportion of high acuity encounters independently billed APPs increased from 5.1% to 9.7%
• Secondary Outcomes:

• APPs billed more high acuity independently in rural geographies, increasing from 7.3% in 2013 to 16.4% in 2019.
• APPs also billed more high acuity encounters in urban areas, increasing from 4.8% in 2013 to 8.8% in 2019.
• Conversely, EM physicians billed more rural high acuity encounters in 2013 (74.5%) compared to 2019 (66.6%). EM physicians also billed more high acuity urban encounters in 2013 (88.5%) than in 2019 (85.5%).
• There was a much larger relative difference in the number of encounters billed as high acuity between 2013 and 2019 by APPs as compared with EM physicians.
• Critical care encounters were increasingly billed independently by APPs from 2013 to 2019, increasing from 1.1% to 2.9%

Listen to the SGEM podcast to hear Cameron respond to our five nerdy questions.

1. Billing: How do we prove that people are getting sicker rather than we are billing more “aggressively”?

2. Critical Care: What about the interpretation of what is critical care, can this vary by provider type (eg. an APP may consider a pneumonia critical care, while an EM physician at a major trauma centre considers it a comprehensive visit or equivalent)

3. Non-EM Physicians: Why are there ophthalmologists, psychiatrists, family medicine and other specialties included in this study?

4. Database Accuracy: This study only looked at Medicare fee-for-service beneficiaries. In addition, you could not separate out split/shared billing between the APP and physician. How do you think that may have impacted the results?

5. External Validity: This was a large US based study. How do you think the results would apply to other health care systems around the world like in Canada?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions.

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SGEM Bottom Line: APPs are becoming an increasing part of the emergency department workforce in the United States and billing for more high acuity patient encounters.

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Case Resolution: You determine that your hiring strategy will include APPs as well as physicians. APPs will be providing critical care and be seeing high acuity patients. You use this information to balance hiring of APPs and EM physicians in your urban and rural sites.

What Do I Tell the Staff? We are looking how to safely staff our urban and rural emergency departments. This will be a difficult process and adapt over time. We need to ensure that patients get the right care, by the right clinician. Their safety is a top priority, and we are all on “Team Patient”. A variety of metrics will be followed to monitor this implementation and ensure we get the right balance of APPs and physicians.

Keener Kontest: Last weeks’ winner was Albert Homs. He knew Wilt Chamberlain held the title for most double-doubles in NBA history.

Listen to the SGEM podcast this week to hear the keener question. If you know the answer, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on APPs? Tweet your comments using #SGEMHOP.  What questions do you have for Cameron and his team, ask them on the SGEM blog? The best social media feedback will be published in AEM.

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Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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References: