Outpatient Otolaryngology Procedures Performed by Nurse Practitioners and Physician Associates in the United States

Introduction: Workforce surveys document steady growth in nurse practitioners (NPs) and physician associates (PAs) in otolaryngology. However, procedures performed by NPs and PAs have been reported only in Medicare patients >65 years through 2017. A better understanding of the current procedural footprint of NPs/PAs can inform policy and promote access to care.

Methods: We queried Merative MarketScan Commercial Database for adults aged 18-64 who received 25 common outpatient otolaryngology procedures or services from 2009-2023. Professional claims were categorized by provider type, and temporal and geographic trends analyzed. Sensitivity analyses were performed excluding services overlapping with primary care (HPV vaccination, tobacco cessation counseling, and allergy testing and immunotherapy).

Results: Among 26,229,437 included claims, 4,223,987 (16.1%) were billed by NPs/PAs. The most common claims over the study period were allergy immunotherapy (38.2%), HPV vaccination (11.7%), nasal endoscopy (11.6%), tympanometry (11.2%), and flexible laryngoscopy (8.2%). The proportion of otolaryngology-specific claims attributable to NPs/PAs increased more than tenfold, from 1.09% in 2009 to 12.93% in 2023 (p < 0.001). Compared to physician billing, a significantly higher proportion of NP/PA claims were in rural areas (18.8% vs 12.7%; p< 0.001). NP/PA billing was more common in the North Central region (27.5% of all NP/PA claims vs 15.9% of all physician claims; p< 0.001). The highest percentage utilization of NP/PA procedural billing occurred in states with fewer otolaryngologists per capita, including North Dakota (67.7%), South Dakota (56.2%), and Montana (53.3%). NP/PA claims were more likely to be associated with high-deductible health plans (12.5% vs 5.5%; p< 0.001).

Conclusions: Outpatient otolaryngology procedures billed by NPs and PAs have increased over the past decade, particularly in regions with limited otolaryngology physician workforce capacity. This suggests NPs and PAs improve procedural access in underserved and rural areas.