I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.1 I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.
So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.
Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care.
Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes.
Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.
However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.1 Perhaps there is more concern here about ED physician job security than about independent billing!
Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.2 One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge.
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