The Evolving Role of Advanced Practice Providers in Spine Care: A National Analysis of Utilization, Reimbursement, and Access.

Abstract

Retrospective database study. To characterize national trends in advanced practice provider (APP) utilization, reimbursement, and procedural roles in spine care, and assess regional variation relative to provider shortage areas. Advanced practice providers (APPs), including physician assistants (PAs) and nurse practitioners (NPs), are increasingly integral to surgical care delivery in the United States. With rising demand for spine services and persistent physician shortages-particularly in underserved regions-APPs have expanded their clinical and procedural responsibilities. However, national patterns in APP participation and financial sustainability within spine care remain underexplored. Medicare claims from 2005-2016 were retrospectively analyzed using the PearlDiver database. Spine procedures involving APPs were identified through CPT codes and modifier flags, categorized as assistant-at-surgery, imaging, or injections. Claims were aggregated by year, region, and modifier type. Geographic analyses incorporated Health Professional Shortage Area (HPSA) scores to evaluate workforce disparities. Financial trends were assessed through total charges, reimbursements, and reimbursement-to-charge ratios. Utilization trajectories were projected through 2030. APP-managed spine claims increased 7.8% annually and are projected to rise 74% by 2030. Growth occurred across diagnostic (73%), therapeutic (74%), and perioperative (103%) service categories. Geographic variation was substantial, with over half of states demonstrating composite HPSA-adjusted utilization scores below 0.4, concentrated in the South and Southeast. Despite rising utilization, reimbursement-to-charge ratios declined for most services-falling 54% for imaging and 44% for injections-while assistant-at-surgery reimbursements increased 14%. APPs are assuming a rapidly expanding role in spine care, particularly in regions with significant provider shortages. Yet declining reimbursement relative to charges threatens long-term financial sustainability. Strategic scope-of-practice optimization, equitable reimbursement reform, and targeted workforce deployment are needed to ensure continued access and equity in spine care delivery. III.