乌鸦传媒

Actinic keratosis in the Medicare population has been increasingly treated by nurse practitioners (NPs) and physician assistants (PAs) at the same time as reimbursement rates have fallen, a review of claims data indicated.

In 2007, 4.0% of actinic keratosis cases were treated by NPs and PAs, which rose to 13.5% in 2015, reported Howa Yeung, MD, of Emory University School of Medicine in Atlanta, and colleagues in .

Dermatologists remained the predominant provider of treatment, but their share of cases declined commensurately over this period, from 88.1% in 2007 to 81.3% in 2015, during which the overall volume of actinic keratosis (AK) cases in Medicare beneficiaries increased by about 10%.

"Increasing trends in use of treatment for AK lesions remain despite adjustment for rising Medicare enrollment, likely owing to a combination of increasing incidence of AK in the Medicare population, early detection and treatment, and increasing access to [nonphysician clinicians]," wrote Yeung and colleagues.

"In contrast to rising use of treatment for AK lesions, Medicare payments for AK destructions decreased from significant fee-for-service reimbursement cuts," the investigators continued.

The study is representative of how challenging it is "to gain insights into the full scope of healthcare delivery through the limited lens of administrative healthcare data," Arash Mostaghimi, MD, MPA, MPH, of Brigham and Women's Hospital in Boston, and Adewole Adamson, MD, MPP, of the University of Texas in Austin, emphasized in an .

"Depending on one's perceptions about AKs, the dermatology workforce, and healthcare costs overall, the trends described by Yeung et al could be interpreted from distinct vantage points," the editorialists continued.

Holly Gunn, MD, MPH, of the University of Alabama at Birmingham, who was not involved with the study, told 乌鸦传媒 that the provider trend raises "a possibility that midlevel practitioners like physician assistants and nurse practitioners may have a lower threshold to treat actinic keratosis when compared to dermatologists and that they may be misdiagnosing patients. I certainly hope that is not happening, but further research will need to be done."

Gunn also noted other factors that could have influenced the results. "It is interesting that [the authors] measured the increasing number of Medicare patients, but they did not measure or comment about how those Medicare patients are getting older and living longer as well, which may be another reason for increased actinic keratosis treatments," she said.

Yeung and colleagues analyzed premalignant skin lesion destruction cases in Medicare Part B fee-for-service beneficiaries.

Overall, they put the number of actinic lesion cases per 1,000 beneficiaries at 917 in 2007, growing steadily to 1,051 in 2015. Over the same period, average inflation-adjusted payment declined from $11,749 to $10,942 per 1,000 beneficiaries as a result of repeated reimbursement cuts, Yeung and colleagues found.

"Notice that the use of actinic treatment is increasing but reimbursement for that treatment is decreasing," Gunn said. "In other words, we are working harder but getting paid the same amount or less. Which is likely why so many physicians are seeking new payment options other than insurance and government programs."