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Nurse practitioners, physician assistants, and other nonphysician providers - don’t call ’em midlevels - are becoming commonplace in today’s practices. But if you want them to succeed, you have to be careful when introducing them to your office.
Primecare Medical Group hired its first nurse practitioner 20 years ago, at a time when it needed some help but didn’t have quite the patient base for another full-time physician.
Today, four of the practice’s six providers are NPs. Jim King, one of Primecare’s physicians, and the president-elect of the American Academy of Family Physicians (AAFP), says part of the reason is the difficulty of recruiting doctors to rural locations like Selma, Tenn., where the practice is based.
“An NP or PA [physician assistant] can be very helpful when the physician has a full schedule and [patients] have acute-care needs,” agrees Tom Weida, a family physician with Hershey Medical Center’s University Physician Group in Pennsylvania. His 12-provider office has one of each.
Thanks to these so-called nonphysician providers - a term that also applies to nurse-midwives - patients “can get high-quality care and [get faster] access,” says Weida.
While physicians must supervise the work of nonphysician providers, the relationship between them is often more collaborative than authoritative, and although varying state regulations dictate some of the care parameters, you have significant latitude in what you deem an appropriate supervisory level.
The usage of nonphysician providers is growing sharply - one-third over the past five years for family practices and more than 20 percent for nearly all single-specialty groups - according to Medical Group Management Association data. By and large, the results have been positive for both patients and practices.
Might a nonphysician provider satisfy your needs over a full-fledged physician, who will cost more and probably be more difficult to recruit and retain? Are there distinct financial benefits? And, most importantly, will your patients accept a nonphysician as a “real” provider?
Yes, yes, and yes. If you do it right.
So, what do they do?
PA and NP duties overlap to a large extent. “Folks will use them for acute care, chronic care, physicals, well visits,” says Weida. Other possible tasks within the scope of PA and NP responsibilities include ordering and interpreting lab tests, performing hospital rounds, prescribing drugs (except in Indiana; other states mandate certain restrictions), and even taking call. Some PAs also perform minor surgeries or serve as first assist to a surgeon, while many NPs take the lead on patient education. “Our NP is in charge of our patient education committee,” says Weida. “She helps manage the patient education materials on our bulletin boards.”
The exact functions assigned to your NP are largely up to you. “There are many ways an NP or PA can be utilized,” Weida says. “In our clinic, we let them see patients. In other clinics, they see patients, but the doctor follows up with each patient.” Regardless, count on a nonphysician provider to help shift the nature of your workload, allowing you to focus on more complex patient concerns. “We accept them into the team and have them do a full range of services, which is consistent with the [concept of the] personal medical home, which we advocate,” Weida says.
With so much similarity, which is right for your practice? That depends on your exact circumstances. If you perform many minor surgeries, such as mole removal, perhaps you should go with a PA. If you champion preventive healthcare, maybe an NP makes more sense. Or your decision may be purely geographical. “No PAs here,” says King of his rural location.
Will patients accept them?
Most of your patients will welcome a nonphysician provider on your staff, particularly after reaping the main benefit: “They can usually get an appointment sooner,” notes King. “Most of the patients receive the NP quite well, as long as they know she is working with a physician. They’re comfortable knowing the NP can go talk to the doctor for anything.”
In fact, about 10 percent of patients in King’s practice prefer to see the NP exclusively. Then again, about an equal number insist on a doctor under all circumstances. “I do have some patients who refuse to see an NP and want to work with the doctor,” says King “Each person decides on his own comfort level.” For the rest, the decision is a question of problem magnitude: “If they have chest pain, they’ll want to see the doctor. For a cold, they’re comfortable with the nurse practitioner.”
In time, nonphysician providers will establish their own patient panels, although ultimately all of these patients are under a supervisory physician’s guiding eye. Make the option available to your patients when they call in for appointments, training your staff to be attuned to those who object to seeing a nonphysician provider. Most will be amenable to the idea - especially if they can be seen faster - but never force a hesitant one, as this will erode physician-patient trust. Avoid any unhappy surprises in the exam room by making sure your schedulers always inform patients which provider they’re going to see.
Finally, realize that whatever a patient settles on as right for him, the decision is not personal, says Weida. “There are some patients who won’t see an NP or PA, but there are some who don’t want to see me, either.”
Don’t call ’em midlevels
Emotions can run high in the semantics department. Sometimes referred to as “midlevels” or even the more patronizing “physician extenders,” most nonphysician providers perceive these terms as somewhat demeaning.
Accepting your nonphysician provider as a full-fledged contributor to your practice will go a long way toward ensuring success. “What’s important is that the NP be a part of the team, so they can bounce ideas off the physician readily and have an interplay in terms of management,” says Weida. “We have weekly faculty meetings - ‘faculty’ avoids the term ‘provider’ - and [nonphysician providers] are part of that group. So when we’re discussing changes to the practice, they are part of it.”
The attitudes of the senior physicians have a profound effect, trickling down through the rest of your staff and to your patient base. Embrace the concept of nonphysician providers, treat them as team members, and everybody benefits. “It’s a team model that works best for patients,” says Weida.
But you will benefit too. The AAFP notes that incorporating nonphysician providers reduces patient backlog by handling many noncritical cases. This offloading of “routine” work frees you to concentrate on more complex patient concerns, which means you’ll be coding higher more often. And a nonphysician provider exacts less of a financial burden on the practice - about 75 percent of a physician’s salary - so the differential reimbursement on low-complexity cases is greater than if a physician did that work.
There are other ways to increase reimbursements via nonphysician providers, including billing to Medicare on an “incident-to” basis (make sure you fully understand all the prerequisites of doing so). The result of all this? Higher practice income.
A nonphysician provider’s interpersonal skills may actually be the most important litmus test for patient acceptance. As the first HMO to employ a nonphysician provider in 1970, Kaiser Permanente has been scrutinized for the quality of care these providers give for many years. One such study, released in the late 1990s and based on 30,000 respondents, found that 89 percent to 96 percent of patients were satisfied with the care they received from a nonphysician provider. When it came to communication skills - a crucial factor in patients’ perception of the quality of care they receive - nonphysician providers received high marks. Patients even tended to forget about a nonphysician provider’s actual credentials once they trusted their provider.
Many studies have stressed the link between patients’ satisfaction levels and the relationship skills of their providers, including physicians. Nonphysician providers tend to excel at this, due to their likely involvement in patient education, but “a lot depends on the individual and their interpersonal skills,” says Weida. “You can have the most brilliant physician or NP and if the social skills aren’t there, the practice won’t flourish.”
Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in The Washington Post and Notre Dame Business magazine. She can be reached at firstname.lastname@example.org.
This article originally appeared in the March 2007 issue of Physicians Practice.