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Understanding Scope of Practice


Many practices use midlevel providers to care for patients with routine complaints. But it’s important to understand their legal scope of practice and necessary level of supervision.

To Philip Bain, an internal-medicine doctor with Dean Health System in Madison, Wis., the midlevel providers who administer care at his clinic aren’t just treating patients. They’re helping to solve one of the biggest challenges in healthcare today.

“When I started practicing in 1988, physician assistants and nurse practitioners were not commonly used, but over the course of time I’ve become a big advocate for them,” he says. “I don’t see more general internal-medicine doctors entering primary care anytime soon so using midlevels is one way to deal with the physician shortage. It’s an answer to a vexing problem.”

Indeed, the cadre of more than 200,000 midlevel providers that work in healthcare today provide a valuable service to the industry, enabling practices to expand their service offerings, improve patient satisfaction, and get their doctors back to the business of medicine. “Midlevels allow us to have more time to see the sicker, more complicated patients, because they can see the single-problem, more straightforward cases,” says Bain.

The other benefit of midlevel providers, of course, is that they provide cost-effective care, because they’re trained to perform most of a physician’s scope of practice at a fraction of the cost. Nationally, physician assistants and nurse practitioners both earn about $90,000 a year compared with family-medicine doctors, for example, who earn more than twice that amount. From a recruiting perspective then, the case for hiring a midlevel provider at many growing practices seems clear.

Yet, while NPs and PAs bring many of the same skills to the table, they are not one and the same. Before you solicit resumes, you’ll need to educate yourself on the differences in their educational backgrounds and areas of expertise. You should also develop a plan to integrate your new hire into the fold, which includes adequate training and supervision.

Breanna Elliott, director of recruiting for Merritt Hawkins & Associates, a healthcare staffing firm in Dallas, says that many of her clients who are looking for a midlevel to function independently opt for a nurse practitioner, since they are licensed to work autonomously. Those focused on a teamwork approach, however, more often request a PA, which requires varying degrees of physician supervision depending on state laws. “Some of the practices I work with are open to either, they just want the most qualified candidate,” says Elliott. “Others want someone to come in and be totally autonomous, so they ask for a nurse practitioner.”

Scope of practice

To ensure your practice hires the right midlevel for the job, it helps to compare their scope of practice. The American Academy of Nurse Practitioners says NPs are independent practitioners certified to diagnose and treat acute and chronic conditions such as diabetes, high blood pressure, infections, and injuries. They can prescribe medication in all 50 states, update charts, manage patients’ overall care, and provide patient counseling - all without physician supervision. More than 70 percent of NPs work in primary care, because “we really like the ability to work with patients over time and educate them,” says Mary Jo Goolsby, director of research and education for the AANP in Austin, Texas. “It’s something we are taught and bring with us from our nursing background. We do a lot of disease prevention counseling.”

Nurse practitioners have completed formal education beyond that of a registered nurse through nursing schools, including advanced coursework in pathophysiology, pharmacology, and clinical diagnosis. In addition to clinical care, nurse practitioners focus on health promotion, helping patients make healthy lifestyle choices.

NPs typically specialize in family practice, acute care, family health, oncology, pediatric health, psychiatric or mental health, and women’s health. Sub-specialties may include allergy and immunology, cardiovascular, endocrinology, neurology, and orthopedics. Most have master’s degrees and many have doctorates, bringing with them an average of 10 years nursing experience, says Goolsby.

Physician assistants, meanwhile, are trained to coordinate patient care, from delivering care and providing patient education to dealing with the patient’s family. “These are things traditionally that physicians had time to do and that’s where PAs can really step in to help,” says Jennifer Hohman, assistant director of professional affairs for the American Academy of Physician Assistants, noting PAs are capable of performing up to 80 percent of the physician’s scope of practice. “It’s a great blend and it tends to make the patients a lot happier.”

PAs require some degree of supervision from a physician in all 50 states. Some states require a designated physician to review all of the PA’s charts, while others require only 10 percent chart review. Yet, the term “supervision” should not turn practices off, says Hohman. By law, she notes, the PA and supervising physician must be in constant dialogue with each other about their patients, but that doesn’t mean being physically together. The whole idea of the PA, she adds, is to act as an extender of physician care - a flexible part of the team whose role can be customized by the physician.

Indeed, state law grants physicians the authority to determine how best to integrate PAs into their team and how much to delegate. The AAPA provides an overview of state laws and regulations on its Web site. Depending on state laws, for example, PAs may be authorized to obtain histories, perform physical exams, order and perform diagnostic and therapeutic procedures, formulate a working diagnosis, develop and implement a treatment plan, assist at surgery, counsel patients, and make referrals. They are also authorized to prescribe medicine in all 50 states.

Another important distinction, says Hohman, is that PAs are trained in the medical model using the same facilities, same teachers, and sometimes even the same classes as the physicians - which helps to cultivate a homogeneous approach to patient care. Their educational program emphasizes treatment and diagnosis, taking 26.5 months to complete. The first year is comprised of essential classroom courses including microbiology, anatomy, medical ethics, pathology, and physiology. PAs then perform a year of clinical rotations in private practice and institutional settings.

A slim majority (26 percent) of PAs practice in family and general medicine, while 25 percent work in surgery and surgical subspecialties. Another 16 percent work in internal medicine, while 11 percent are in emergency medicine. PAs are also found in pediatrics, occupational medicine, obstetrics and gynecology, and dermatology.

Integrating the midlevel

Once you’ve decided which type of midlevel to hire, you’ll have to determine how best to incorporate them into your staff. PAs, of course, will require a supervising physician, who must be educated on his or her responsibilities under state law. Whether you opt for a PA or NP, the doctor must also decide how much of their scope of practice to delegate, which may change over time.

Roland Goertz, president-elect of the American Association of Family Physicians and chief executive of the Family Health Center in Waco, Texas, says his practice uses the teamwork model for all midlevels they employ. Under his approach, each PA or NP is paired with a physician, a nursing assistant, and an office staff person to create a team. “It’s not about one person; it’s about the group of people taking care of a patient,” he says. “We want people who want to be part of the team concept and understand their role in providing care.”

Though PAs and NPs differ slightly in their scope of practice, Goertz says his office recruits both for midlevel positions, focusing on individual strengths and weakness rather than title. All require training to bring them up to speed with the policies and procedures of the practice. “We acknowledge that there are differences between NPs and PAs, but there are a lot of differences in their training, too,” he says, referring to the fact that some have gone through a formal classroom education and others utilize distance-learning courses. “So we try to level that out during the interview process. We try to find out what they know and what they still need to learn, and we look for people who understand their role in providing care and want to be part of the team.”

Dean Health Systems also integrates midlevels, both PAs and NPs, using the patient-centered medical home approach, in which each member of the team performs at the highest level of her training. Bain’s office divides the staff into “pod teams,” which consist of one physician, one midlevel provider, two “roamers” (or medical assistants) and one practice nurse. As the model evolves, however, Bain believes the pods will eventually include a one-to-two ratio, with one physician and two midlevels, plus the ancillary team members. “In the old days, we had a supervising physician for every midlevel, but now we have all the physicians in our group sign a practice agreement for coverage or supervision of all our midlevels,” he says, noting the process helps improves continuity of care.

The goal at his clinic, of course, is for all patients to see their own physician, says Bain. When that doctor is unavailable, the patient is then directed to the midlevel provider within that pod. The third choice is another physician in that pod and the fourth choice is a PA or physician in another pod. “We have a target patient panel of 1,900 patients per doctor, but we found that when you add a PA or NP to the team you add half that again - making it a total of 2,700 patients per pod,” says Bain.

Educate your patients

However, Bain stresses that hiring midlevel providers and utilizing them effectively are two different things. Practices need not only provide for adequate supervision, but also take steps to educate patients on how their PAs or NPs can benefit them. “Some patients still say, ‘Nope, I just want to see the doctor.’ But most patients are becoming more open to the team concept, and they like the midlevels because many times they have faster access to them,” says Bain, noting neither the NP nor PA is better than the other. “My next available appointment might be four weeks away, whereas an NP might be available to see them today.”

Dean Health System typically leaves their midlevel’s schedules open so that half the time they’re available for acute care cases and the other half they’re dedicated to follow-up appointments. To help promote the team concept of patient care, Bain says, the clinic includes a picture of the whole healthcare team in every exam room. “Our business cards also include the name of the patient’s primary doctor on the front, along with the names of everyone on that team, because patients need to understand that it doesn’t make any sense for them to call the doctor for medication refills when a medical assistant might be able to provide that,” he says. “We mobilize different members of the team for different tasks.”

As the healthcare industry evolves and patients become older and sicker, Bain says he believes midlevel practitioners will become increasingly more critical to lowering costs and improving care. “Patients are getting older, sicker, and their problems are more complicated,” says Bain, noting patients also demand more of their caregivers these days than they once did. “The physician of old would often dictate the course of treatment for the patient and the patient would say, ‘Whatever you think doc.’ Very few asked any questions. That type of paternalistic approach would not fly at all today.”

By using midlevels to educate patients, provide routine care, and assist with coding and documentation, physicians will be better positioned to bring their expertise to bear, focusing on chronic disease management and more complex diagnoses. And that, says Bain, is good for patients. “Medicine has changed over time and we need to be creative in our approach to delivering care,” he says. “It’s kind of folly to think that patients’ entire healthcare needs can be compressed into a standard 15-minute office visit, or physical exam, once a year.”

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 12 years. Her work has appeared on CNNMoney.com, Bankrate.com, and Healthy Family magazine. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the April 2010 issue of Physicians Practice.

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