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

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Is it time for your practice to add a midlevel provider?

From the May 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

When the University of Maryland began telling its hospital employees to get their care through the university five years ago, the internal medicine practice was swamped. It didn't take long before everyone—patients and physicians alike—was unhappy.

To resolve the problem, the group hired a physician assistant (PA) to see patients who needed appointments within 48 hours for ailments such as colds, allergies and sinusitis. Patients, happy to be seen so quickly, have accepted that they see a PA, said Louis Joseph Domenici, MD, an internist who runs the seven-physician group.

A growing number of PAs and nurse practitioners (NPs)—often referred to as midlevel providers—work in internal medicine practices around the country, giving physicals, writing prescriptions, ordering tests, managing chronic diseases, educating patients about diet and going on hospital rounds.

Like the University of Maryland physician group, some internal medicine practices hire these providers to improve patient access, particularly for acute care patients. Others hope to boost revenue, improve the quality of life for physicians by reducing their workload or free physicians from routine complaints to concentrate on more complex—and more interesting—cases.

But experts say that a physician group contemplating adding a midlevel provider needs to look carefully at its practice and at state, hospital and insurance regulations. Just as important, if the strategy is to work, physicians must be committed to making that provider part of the team.

Here are some steps to help determine if your practice should hire a midlevel provider and what you can expect if you do hire one:

  • Evaluate your practice. The first step is to determine whether your practice really needs a PA and/or NP. Need is based on how busy you are, how busy you want to be and whether patient access is a problem. Though the median internal medicine practice had 0.13 midlevel providers per full-time equivalent internist in 1997, according to Medical Group Management Association (MGMA) figures, there is no set ratio of NPs or PAs to physicians. Experts have seen it work in both solo and group practices.

If access is your motivation, first consider less expensive ways to improve patient flow, said Gary Matthews, president of Physicians HealthCare Advisors, a consulting firm in Atlanta.

For example, if you're scheduling patients in the old stream-appointment method—15 minutes per patient—you might reduce backlogs with a so-called "modified wave" approach that permits you to see several patients simultaneously. Or you could adjust schedules so that more time is free for walk-ins on Monday and Friday, popular days for last-minute calls.

  • Crunch the numbers. If you still think you need another provider, hiring a midlevel is less expensive than adding another physician. You can expect to pay NPs and PAs about $60,000 a year, although this number varies by market and by practice type. That means a hefty savings over the median pay for internists, who earned $139,905 in 1997 (the latest MGMA numbers available).

To calculate the cost or benefit, consider that the median gross charges for NPs in 1997 were $151,504 and the median PA charges for primary care were $205,204, according to MGMA's 1998 Physician Compensation and Production Survey. Apply your collection percentages (typically about 75% in internal medicine) to these benchmarks to estimate the cash they'll bring in.

Then calculate the total cost—not just the salary and benefits—of a midlevel provider: rent associated with the exam rooms this provider will use, for example, and variable expenses per visit such as laundry, medical supplies and drugs.

  • Give your new help some support. A significant cost and productivity variable is the issue of giving midlevel providers support staff.

"The physician extender should receive support similar to physicians," said Elizabeth Woodcock, an Atlanta-based consultant with MGMA Health Care Consulting Group. "If I have a primary care physician assistant, that person should be allocated a support staff, phone coverage, etc."

For example, Theda Care, an Appleton, Wisc.-based group that has 21 locations, hired three NPs (one part-time) for an internal medicine practice with six physicians (not all full-time) in January 1998 to improve access and increase its patient base. The NPs have varying roles: geriatrics (one does rounds at nursing homes), acute care and management of chronic conditions such as diabetes.

The practice provided each NP with a medical assistant and increased the hours of a part-time phlebotomist. The practice also changed physician schedules from four and a half days to four, expanding hours by beginning earlier in the day and ending later in the day; this gave everyone office space and access to exam rooms to see patients.

The result: The group more than doubled the number of new patients, and each NP is making the practice more than $40,000 in additional revenue, said Sharon Hanks, director of physician services.

  • Look beyond revenue. Though you should know the financial ramifications of hiring a midlevel provider, boosting revenue isn't the only reason to hire one.

At St. Luke's Internal Medicine in Boise, Idaho, the three PAs provide access and continuity to acute care patients so they don't have to wait or end up in emergency rooms when the 18 physicians are booked.

It may even be worth losing some money on an NP or PA who frees you from working 14 hours a day or boosts the quality of care by performing some functions that physicians admit they often have neither the time nor the inclination to do—such as educating the patient and dealing with family issues. Patients may even be more willing to open up to midlevels.

NP Susan Waldrop Donckers recalled a patient who came in with some aches and pains. When she sat down with him, it became obvious that he was depressed but had never discussed it with his physician. She evaluated the patient for depression and put him on an antidepressant. That took care of the pain.

"I think he just felt comfortable" talking about it, said Ms. Donckers, who works at Fort Lewis Family Practice, part of the Lewis Gale Clinic in Salem, Va. "Sometimes the doctor will have 10 or 15 minutes. I generally have 20 or 30."

  • Learn to let go. Experts suggest you get to know your midlevel practitioners' scope of practice—then let them get to work.

"What doesn't work right is when the physician treats the midlevel as an overpaid nurse and won't let the midlevel maximize his or her medical skills," Mr. Matthews said. "The opposite is also true where the physician is hands-off—do whatever you want. Sometimes midlevels will exceed their limitations."

Ms. Donckers said she knows an NP who was hired by physicians who held on too tightly to their patients. "The person didn't stay," she said. "It wasn't challenging. He didn't have enough patients to see."

Part of letting go is allowing the midlevel provider to become part of the group's team. Practices too often "pay $50,000 to $60,000 to hire them and do not attempt to integrate them into the practice," said William J. Mazzocco, president of Medical Administrative Support Services, an Altoona, Pa.-based consulting firm that specializes in recruiting and integrating midlevel providers. "You end up with a dissatisfied employer and in some cases a dissatisfied employee."

  • Know the laws. Scopes of practice vary by state. Some, like Delaware, allow PAs to prescribe controlled drugs, while others, like Alabama, do not. Prescription privileges for NPs—whether they can prescribe controlled substances and whether they need a physician's signature for prescriptions—also vary.

In addition, supervising or collaborative requirements vary by state and by whether the midlevel provider is a PA or an NP. Some states, for example, require NPs to have a written collaborative agreement with a physician while others do not; some states require more communication between the PA and physician than others.

For information on supervisory requirements and prescriptive authority for PAs in your state, contact the American Academy of Physician Assistants at 703-836-2272 or look on its Web site for a list of rules by state, www.aapa.org. For collaborative requirements and prescriptive authority for NPs, contact the American Academy of Nurse Practitioners at 202-966-6414.

  • Check reimbursement rules. Don't hire a midlevel provider until you know that your group of insurers will pay for the services.

Medicare reimburses in two ways—directly for the midlevel provider's service using his or her provider number or indirectly for the service as "incident to" a physician's service.

Midlevel providers who bill directly get 85% of what the physician would get for the same service from Medicare. If the service is billed as "incident to," it's at 100%, but restrictions apply: The physician must have seen that patient first for that ailment and the physician must be in the office when the service is rendered by the midlevel provider on subsequent visits.

Medicare carriers also vary in how they handle "incident to" billing. Some don't reimburse for it at all. Others only reimburse level one through level three office visits, Mr. Mazzocco said.

Medicaid rules vary by state. Many private insurers follow Medicare's lead, but here again the rules vary as to what services they will pay a midlevel for and to what degree. Check your contracts.

  • Help patients adjust. Though PAs and NPs are increasingly familiar, many patients will be seeing midlevel providers for the first time. You'll hardly get your money's worth if patients decide to wait to get an appointment with you.

Experts say physicians should take a proactive stance. Start by giving patients information in writing. St. Luke's Internal Medicine, for example, mails a brochure to new patients that explains what a PA is and includes photographs and backgrounds of both the physicians and the PAs. The practice also provides an information card that explains the PA's role that patients can take home.

You should also promote your PAs and NPs with patients, said Sandra E. D. McGraw, JD, principal with The Health Care Group, a consulting firm in Plymouth Meeting, Pa. Introduce patients to the midlevel provider before they leave. Say something like: "Have you met our PA? If you want to get in sooner next time, this is who she is."

Talk up the midlevel provider to your staff; your enthusiasm and support will affect their attitudes. The way the front office staff refers to the midlevel provider also influences perceptions, Ms. McGraw said. You don't want them to say "I can't get you in today; you have to see a PA but it's OK, they're almost a doctor." Instead, they should say something like, "Our PA John Shanahan can see you today." *

Bryan Walpert is a freelance writer in Denver.


What's in a name? A comparison of NPs and PAs

Physician assistant (PA) or nurse practitioner (NP)? To determine which might be a good match for your practice, first understand how they differ.

PA students come from a variety of occupational and educational backgrounds. PA programs generally require at least two years of college education and some previous experience in health care; they then train for about two years to become PAs. Nurse practitioners generally train first as RNs and typically have a master's degree.

As a result, their philosophies differ. PAs are trained along the medical model; they think like physicians. They tend to focus on diagnosis and are more procedure-oriented--removing moles, performing sutures, etc.

NPs are trained first as nurses and tend to pay more attention to psychosocial aspects of care—such as the family situation, stress, and focus on educating patients about diet and exercise—and managing chronic conditions such as hypertension and diabetes.

In some practices, PAs and NPs take on different roles. Albany Area Primary Health Care Inc., a group of 20 physicians at several rural clinics, an inner city clinic and a regional HIV clinic in Georgia, relies primarily on its 10 PAs for midlevel service (they tend to hire PAs because of ties to two nearby PA training programs).

PA Tim King evaluates new patients, takes histories, makes diagnoses, interprets tests and prescribes medications. He sees new patients and patients with acute problems and consults with a physician when he has a question.

The practice also has had several NPs over the years. One of them, who recently retired, decided about a decade ago to focus on women's health education. She doubled the number of Pap smears performed by the practice in a single year, said James Hotz, MD, an internist and the practice's clinical services director.

Still, PAs and NPs can provide similar services. "They pretty much do the same thing in this practice," said Carol Ash, DO, a pulmonologist who works with three cardiologists, an NP and a PA at Metuchen Heart Associates in Metuchen, N.J.

Elsewhere, differences often are determined more by the individual than the degree. The NPs and PAs at Gateway Medical Associates, a group of 20 internists and family practitioners at seven sites in Chester County, Pa., see scheduled patients every 15 to 30 minutes for similar complaints—acute care patients and follow-ups on chronic problems such as diabetes or hypertension. All have developed a log of patients who prefer to see them as their primary provider.

Several have carved out their own niche. One of the NPs is a diabetes educator. One PA, who has had experience in emergency care, family practice, psychiatric care, orthopedics, internal medicine and pediatrics, runs the weekend clinic.

"A lot of it has to do with their interest and their own educational experiences," said Geoffrey M. Burgess, MD, a family practice physician and president of Gateway.

In the end, the person's experience, education and personality will be more important than whether he or she is an NP or a PA. "Hire the individual," William J. Mazzocco, president of Medical Administrative Support Services in Altoona, Pa., said. "Hire the person who fits the job description, then worry about what's after his name."

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