Adding Nonphysician Providers

Atlanta Obstetrics and Gynecology has employed nurse-midwives in its practice since the early 1980s, but it doesn't think of them or its nurse practitioners as "physician extenders" or "supplemental providers." As far as managing physician Harry McFarling is concerned, the nonphysician providers, who outnumber the doctors two to one, are a vital part of the practice, offering the kind of relationship-based healthcare that many patients demand but that physicians often don't have time to provide.

"We're an urban practice with a pretty sophisticated population - a lot of women here are very informed about healthcare, and they wanted options," says McFarling of the practice's decision in 1983 to add nurse-midwives. "We were just coming out of the period when husbands weren't even allowed in the delivery room with their wives, and it wasn't too long after the women's movement had really started in earnest."

So the practice added nurse-midwives in response to patient requests for more personal service, not simply as a way of easing the burden on overworked doctors. Because the practice has maintained that philosophy over the years, McFarling says the relationships between the physicians and nonphysicians have been excellent.

And that civility, not always achieved in practices that add so-called midlevel providers, has in turn led to happier patients and a healthier business, says McFarling. Patients can see an MD if they want to, but feel pampered by their nurse-midwives and nurse practitioners, who often can make more time to listen and may have developed special clinical interests and competencies, such as adolescent gynecology.

"In professional terms, it's about giving people options in their healthcare," McFarling maintains. "It's not about shifting lower levels of care to nonphysicians in order to free up time for physicians. And I think that's the biggest difference in our case."
Such an approach can make the difference in your office, too. When physicians define their new midlevel's role ahead of time, and view them as part of the healthcare continuum, instead of as "doctors' helpers," everyone is happier and can be more productive.

That isn't to say midlevels - NPs, physician assistants, and nurse-midwives, among others - can't ease the burden on overworked doctors, or shouldn't be expected to add capacity to a practice stretched to its rafters. On the contrary, many practices have found them to be an excellent way to do just that - and less expensively than adding another MD. Midlevels make less money - than doctors, are easier to place, and don't need to be made partners in a practice.

But adding a nonphysician provider isn't as easy as hiring a receptionist. After all, they'll be taking care of your patients - monitoring wellness, recommending treatment, prescribing medications, and in some cases, delivering babies. Your practice can be held responsible for the quality of care they provide, so if you're considering adding a midlevel, plan ahead.

Check state and payer rules

States' opinions vary widely on what clinical skills different midlevel providers have - and therefore, on what they should and shouldn't do. Some states, for example, allow NPs to serve as a patient's primary-care provider for managed-care billing purposes; others don't. Some allow NPs to prescribe medications; others don't.
(See www.deadiversion.usdoj.gov/drugreg/practioners/index.html for midlevel prescribing authority by state.)

Of course, physicians must know more than whether their midlevel can prescribe medications; check with your state medical board to get the scope of practice for whatever type of midlevel you're bringing in. You also should scrutinize your payer contracts; they might require that you get your new midlevel credentialed before billing for services.

"It's very important to not only speak to your lawyer - or at least your medical society's legal advice line - but also to speak to your malpractice carrier," says Debi Croes, principal of the Croes-Oliva Group, a healthcare consulting firm in Burlington, Mass. "There are liability issues, and not every physician's lawyer is up to speed on all the aspects."

"There has been a kind of 'push-me, pull-you' between the groups that represent the midlevels and the physicians, because the midlevels feel they deserve more responsibility apart from the physicians," says healthcare attorney Bob Wilson of Smith, Moore in Raleigh, N.C. "That really has been a cultural issue within the medical community," one that's become more acute as more practices turn to midlevel providers, he adds.

What if a patient complains to the medical board about your midlevel's service? Your practice can be investigated, says Wilson. But you can make your life easier, even if your midlevel has made a mistake, by demonstrating that your practice understood the allowable scope of her practice, sought to ensure that she remained within it, and followed reasonable supervisory policies.

"Medical practices don't want to spend a lot of time working on policies and procedures," he says. "But it really is a good idea to establish internal mechanisms that you can show a medical board, for instance, that you have in place a structure that ensures compliance with state regulations. ... That's been valuable to many practices."

Perceptions and planning

Start by examining your attitude about midlevels, and those of your partners. Practices are wise to consider the perception gap that can exist between physicians and nonphysicians over just what it means to be a nurse-midwife, PA, or NP. Nurse-midwife Amy Rousseau, PhD, director of Fletcher Allen Health Care's Claire M. Lintilhac Nurse-Midwifery Service in Burlington, Vt., bristles at being characterized as a midlevel provider, because "I'm not at a midlevel," she says.

"I'm at the optimal level of the type of care I provide. ... It's not like I'm an 'almost doctor.' I'm a complete midwife. It may be just semantics, but it's a point that a lot of people miss - they think we're 'physician extenders,' or that we can do things up to a certain point and then the doctor has to take over. And I don't really see our role that way."

So, how do you see your nonphysician provider's role? How does he or she see it? Are you sure your views are aligned?
Like shared perceptions, planning is essential. The hurried approach to hiring nonphysician providers almost always leads to problems down the line. Croes says if she has seen it once, she's seen it a hundred times: Overworked physicians who rush too quickly into adding new providers, figuring they can lighten their workload without dramatically lightening their wallets.
"In primary-care practices, physician assistants and NPs are wonderful ways to increase access," she says. "The nonphysician provider can do the kind of work that physicians don't want to do, are finding it time-wasteful to do, or aren't getting done because they just feel they are too busy. ... But the biggest mistake I see is when groups just say, 'Let's hire a nurse practitioner,' without first articulating why they need one, or what the NP's role will be."
What can go wrong when practices add nonphysician providers haphazardly? Aside from the legal exposure, which can be grave, patient care and staff harmony can suffer in a variety of ways:

• The nonphysician provider winds up with too many patients, not enough, or the wrong kind. Practices often add providers to help deal with patient overflow, but if they fail to conduct a capacity analysis, they may find their new hire's schedule is full only during certain busy times, or that she isn't qualified to treat many of the types of patients overloading the schedule. And if the new provider and the scheduling staff don't get the message about which patients she should see, there may be trouble.
• Supervision of the midlevel provider can be uneven or nonexistent, and the new hire can become frustrated. It's best if physicians decide on a supervisory policy in advance. The degree of supervision will vary by specialty and by the person's training and experience, but regular chart reviews and in-person meetings are a good idea.
• Billing and credentialing problems can accompany a new hire when practices don't first examine their payer contracts. Some payers won't reimburse for work done by nonphysicians; others require practices to clear additional administrative hurdles.
• Acrimony can build between the nonphysician provider and other staff, particularly nurses who suddenly find themselves lower in the practice pecking order. It isn't necessary (though it would be nice) to ensure that every staff member is on board with the idea of adding a midlevel provider, but physicians should articulate why the hire is necessary, and what the new individual's role in the practice will be.

Avoid costly mistakes

Many practices figure they'll simply start handing off all the day-to-day cases to their new midlevel, saving the medically complex cases for the doctors. This isn't a bad idea - after all, doctors are trained for the medically complex, midlevels for the medically common - but sometimes they fail to draw the line between what's appropriate for a nonphysician provider in their practice and what isn't. Doctors within a group should discuss and come to an agreement on this beforehand.

Other practices want their new provider to serve as a backup, seeing patients who want to be seen on a same-day basis when it's impossible to squeeze them into a physician's schedule. That's fine, too, as long as the group's physicians remember that not all same-day cases are clear-cut; some require a physician's eye.

"It's not a mistake to hire a midlevel, but it's a huge mistake without a plan," says Croes. "What I've found is that practices get into these relationships that no one knows how to manage, and it often takes a year or more to correct. And that's usually a costly year."
At Urban Medical Group in Jamaica Plains, Mass., the nurse practitioners "are sort of first call, and the physicians are more like consultants," says practice administrator Emily Brower. The 10-physician group manages 14 NPs, most of whom work in the field at nursing homes or doing home visits for elderly patients. In the office, patients usually prefer to see their doctor, with the four NPs filling in the scheduling gaps.

But at nursing homes, where many of Urban Medical's patients live, patients mostly think of their NP as their primary healthcare provider, and they insist on seeing her. That's true even though the nursing home patients see an MD weekly, as part of the practice's policy of having a doctor and NP conduct weekly rounds together, says Brower.

"The NPs have different skills," she explains. "They have nursing skills, and they have very good relationship skills. And when a patient is chronically ill and nearing the end of life, those relationship skills really have an opportunity to shine through."

Bob Keaveney, associate editor for Physicians Practice, can be reached at bkeaveney@physicianspractice.com

This article originally appeared in the March 2003 issue of Physicians Practice.