American College of Physicians: Internal Medicine — Doctors for Adults ®

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Not getting enough clinical support? Try these changes

Practices are looking at non-physician providers to get more help-and increase their revenue

From the January 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Jennifer Fisher Wilson

Walter A. Kornienko, MD, could never find a nurse when he needed one.

The cardiologist and his three partners in Drexel Hill, Pa., had a staff of three part-time nurses, but all three were always too busy checking patients into rooms, measuring blood pressure and explaining medications and treatments to work alongside the practice's physicians.

The physicians felt they were getting no clinical support, the nurses felt overwhelmed and the office consistently ran behind schedule. The practice needed help, but adding more nurses—and increasing its staffing costs—was not an option.

Instead the practice changed the makeup of its clinical staff. Where it once employed three part-time nurses, it now has two part-time medical assistants handling much of the administrative work the nurses performed and one full-time nurse dedicated more to clinical work. The new arrangement actually costs less than employing three nurses, and when a cardiologist needs help from a nurse, he's more likely to get it.

"Things are better now," explained Marianne Armstrong, RN, who has worked at the practice for almost 20 years. "We're able to respond to patients more quickly and follow up more completely. I'm able to keep track of everything."

Practices around the country are discovering that by taking a closer look at their clinical support staff—and by adding non-physician providers as well as new types of team approaches to restructure their clinical support—they can not only care for patients more effectively, but also boost their revenues.

Refocusing nurses

In the past, physicians typically worked one-on-one with a registered nurse who directly helped the physician care for patients. But in today's busy, cost-conscious practices, such one-to-one relationships may not be the best way to staff an office.

"We are experiencing a trend where some practices are using cheaper employees to do the job," said Robert Connelly, a health care consultant with The Health Care Group in Plymouth Meeting, Pa., who helped Dr. Kornienko's cardiology group redefine the role of nurses and medical assistants.

Like Dr. Kornienko's office, Mr. Connelly explained, many practices have nurses doing work that could be performed by less skilled staff. He said that nurses should focus more on strictly nursing responsibilities—flushing catheters, administering chemotherapy or answering patient questions over the phone—while medical assistants and licensed practical nurses should perform duties that require less clinical training like pulling charts, greeting patients and taking blood pressure. And while medical assistants and licensed practical nurses have more limited training than nurses, they can perform much of an office's clinical support work.

Medical assistants train in accredited one-year certificate or two-year associate programs. (Although this education is voluntary, many employers require it.) Their administrative training focuses on duties such as updating and filing medical records, filling out insurance forms and scheduling appointments; their clinical training focuses on duties such as performing basic lab tests, taking vital signs, assisting during an examination, telephoning prescriptions to a pharmacy and changing dressings.

Although licensed practical nurses can also function well in an office, their training consists of 12 to 14 months of basic nursing care in a hospital setting. For this reason, medical assistants remain the more popular choice for the practice setting.

The cost savings that result from switching from nurses to medical assistants can be considerable. A 1996 salary survey conducted by Mr. Connelly's firm showed that a registered nurse with more than five years of experience made an average of $15.56 an hour, while licensed practical nurses and medical assistants made about $4 less an hour. That works out to an annual savings of at least $7,500 for a full-time employee.

But that doesn't mean you should go ahead and fire all your nurses. As Mr. Connelly cautioned, you'll still need a registered nurse to perform duties such as phone triage. In addition, nurses can also order prescriptions by phone and field many patient calls, eliminating unnecessary patient visits, an important cost control in managed care and capitated contracts.

Nursing advocates also point out that cost savings may come at the expense of lower staff retention. Judith Shindul-Rothschild, RN, PhD, an assistant professor at Boston College School of Nursing, said that registered nurses stay on the job an average of seven to nine years, while "unlicensed assistive personnel"—a term used by the American Nurses Association that includes medical assistants—stay an average of just 14 months. By keeping nurses on staff, she said, practices save on the costs of recruitment, employee training and orientation.

Increasing earnings

Practices that want to increase their earnings but can't afford to take on another physician have another option: hire a nurse practitioner (NP) or physician assistant (PA). Atlanta-based health care consultant Robert E. Atwater III, explained that unlike nurses, NPs and PAs can bill for procedures that are performed under physician supervision, typically defined as procedures performed while the physician is in the same office. They also have the authority in most states to prescribe medications and treatments, order tests and teach and counsel patients and families.

Robert J. Furlong, ACP Member, an internist in Miami Beach, Fla., hired an NP two years ago to complement his three-physician practice. "With the volume of patients we see and the severity of their illnesses, she's a very good addition," he explained. "And the patients love her."

NPs and PAs often handle follow-up visits and manage patients with chronic conditions. In some cases, they make hospital rounds and cover call. Studies have shown them to be cost effective and, in all but a few states, health plans reimburse 100%, or close to it, for NP and PA procedures billed through a physician. Medicare covers care provided "incident to" a physician, care that supports a physician's primary care and that is delivered while under physician supervision. The only catch: The physician must personally see these patients when they first visit the practice.

"Patients understand she's an extension of me," Dr. Furlong said of his NP. "She's not a substitute for me—I still peek my head in so that patients know I'm here—but I defer to her as far as who's in control of managing the patient's care."

While NPs or PAs are paid roughly $50,000 a year, they can generate up to $150,000 in revenues a year, Mr. Connelly said. Plus, they can free up a practice's physicians to treat the sicker patients who generate even higher fees. Research indicates that NPs with more than five years of experience make an average of $22.57 an hour; PAs make $24.81. Other data from the AMA show that physicians in solo practice who hired a practitioner such as an NP or PA increased net income from $186,900 to $220,000.

Robyn Curhan, director of advanced practitioners at TravCorps, a Boston-based placement agency that specializes in placing PAs and NPs in internists' offices, warns that for a PA or NP to fit into a practice, the physicians must have clear clinical expectations for that person and they need to be willing to provide supervision.

Maintaining quality

Experts say that the challenge in trying new staffing models is to strike a balance between reducing operational costs and maintaining the quality of patient care.

Sharp-Rees-Stealy Medical Group in San Diego is using a concept called modular nursing to reach that goal. The group is transforming clinical support staff at its various offices into single teams that work with all doctors in a practice. Where five nurses might have previously supported five doctors in a practice, for example, three nurses now do the job with help from a few medical assistants.

At the four-internist practice in San Diego, Calif., where Dan Brown, MD, works, one medical assistant used to work with one doctor and a licensed practical nurse helped everyone at the practice. But because the medical assistants lacked the training to handle many patient questions and were often too busy to assist the physicians, Dr. Brown found himself doing many of the duties traditionally handled by nursing staff. "I was staying here until eight o'clock at night making calls to patients," he said.

Today, however, three medical assistants and one registered nurse at the practice work with all four internists. The flexibility of the new system—all of the clinical support staff are free to help all four physicians—has resulted in a more efficient practice. "This has cut my after-hours work drastically," Dr. Brown said. "There's more free flow of work so people become less overwhelmed." The nurse supervises the medical assistants and performs the more critical care procedures and perhaps best of all, Dr. Brown said, "she has the training to deal with the 20 to 30 phone calls I receive a day."


Clinical support staff: a glossary of terms

When looking for clinical office staff, physicians have many choices. Here's a summary of the education and training of the most popular types of clinical support personnel.

Nurse practitioner (NP). NPs tend to emphasize health promotion, disease prevention and management of acute and chronic diseases. Typically, NPs are experienced registered nurses who complete a training program approved by the American Nurses Association and go on to earn a master's degree in advanced practice nursing. NPs practice with a degree of independence and in many states can write prescriptions, order diagnostic and lab tests, and teach and counsel patients. They can bill for their procedures performed under a physician's guidance. For information on integrating NPs into a medical practice or other information, call the American Academy of Nurse Practitioners at 512-442-4262.

Physician assistant (PA). PAs train in primary care through programs accredited by the American Medical Association and must pass a test given by the National Commission on Certification of Physician Assistants. Before enrolling in a PA program, most have substantial health care experience. PAs are licensed and can bill for procedures provided under the supervision of physicians. For information on PAs, including literature on credentialing PAs for hospital privileges, contract negotiations and job definition for PAs, call the American Academy of Physician Assistants at 703-836-2272.

Registered nurse (RN). RNs are licensed practitioners who have at least a two-year associate's degree or a four-year bachelor's degree in nursing from a state-approved program. In addition, they must pass a state licensing exam. Training focuses on the patient's response to health problems and caring for the whole patient. RNs provide triage and patient education, take histories and physicals and coordinate patient care.

Licensed practical nurse (LPN). Also referred to as licensed vocational nurses, LPNs typically have 12 to 14 months of post-high-school training. Their training focuses on basic nursing care in a hospital or other extended care setting.

Medical assistant. Medical assistants train in accredited one-year certificate or two-year associate programs. Although formal training education is voluntary, many employers require it. Training focuses on administrative duties such as updating and filing medical records, filling out insurance forms, scheduling appointments, as well as clinical duties such as performing basic lab tests, assisting during an examination, telephoning prescriptions to a pharmacy and changing dressings. Medical assistant training also typically includes study of health care law and ethics.

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