If physicians want to earn more money, it would seem the easiest option is to see more patients. It’s a simple idea, but quickly bumps up against reality: Even with extra effort, revenue is limited by available time.
One way to get around this is to add a physician extender—either a nurse practitioner (NP) or physician assistant (PA). An extender can help get more patients through the door by treating routine issues and performing checkups on chronic conditions, allowing the physician to focus on the most serious patient cases.
As the industry moves toward more value-based care, a greater emphasis on caring for patients with chronic illnesses can help improve quality scores and increase payments. While not cheap, an extender could help a practice grow revenue by up to 20%, experts say, but only if patient demand warrants the hire.
“It’s really important that practices always have [available appointments] for their patients,” says Judy Treharne, consulting executive for Columbus, Ohio-based Halley Consulting Group. “This is true not just for existing patients, but also for new patients because of the necessity for a practice to be growing.”
If the demand is there, extenders can also add significant profits to a practice’s bottom line, experts say. “Primary care doctors should make $20,000 to $45,000 in profit from an extender,” says Deb Phairas, MBA, president of San Francisco-based Practice & Liability Consultants.
Physician assistant or nurse practitioner?
While PAs are slightly more expensive, Treharne says skill set, not cost, should be the determining factor in the type of extender to hire.
NPs, because of their nursing background, typically have a lot of experience assessing and caring for patients in a clinic setting, making them a good fit for primary care practices. “Nurse practitioners have a tendency to be more education-focused,” says Phairas. “They want people to stay healthy and stay out of the office, so this could help you get points for quality measurements.”
Physician assistants tend to have less prior experience, but typically see more patients because they spend less time on patient education or wellness, Phairas adds.
Treharne says physicians should not wait until they are desperate to hire an extender, because it can take six months or more to find the right person and get them credentialed. Extenders, like physicians, need to be credentialed with health plans, which can take 90 to 120 days, not including the time spent reviewing resumes and interviewing applicants.
Hiring an extender should be approached in the same way as hiring a physician, Treharne says. “This is somebody that will be harder to unwind from the practice compared to if you made a bad decision about a receptionist.”
She suggests involving the supervising physician along with an office manager and key clinical support staff in the hiring process, and spending some informal social time with a candidate to test the group’s chemistry before making an offer.
The Medical Group Management Association has salary data that can set a starting point for negotiations, but compensation packages should also include productivity incentives whenever possible, says Treharne. Incentives can be based on relative value units (RVU) or whatever is an important growth-driver in the practice.
Besides salary and benefits, physicians need to consider whether there are enough exam rooms and support staff to make the extender successful. “I don’t recommend bringing in an extender without at least a medical or clinical assistant to support them so they can be productive,” says Treharne.
If exam rooms or administrative support have to be pulled away from physicians to support the extender, this could cancel out the original benefits of the hire.
Scheduling for success
There are different approaches to scheduling extenders to get the most benefit from them.
For example, a practice with a large population of elderly patients might have its nurse practitioner focus on COPD, dementia and other common age-related issues, helping the practice manage those patients, says Treharne. Other practices might choose to route same-day appointments to a physician assistant so the physician can focus on new patient appointments to start building a relationship.
In a value-based care environment, the better a physician understands their patient panel and how it affects their payments, the more benefit they can gain from extenders, says Treharne. For example, physicians who get rewarded for keeping patients out of the emergency department can use extenders to add office hours.
Similarly, practices with more older patients with chronic conditions can use extenders to provide access that results in more billing under transitional care and chronic care management codes.
For some smaller practices, however, it might make more sense to hire an RN to manage chronic care patients rather than a more expensive extender, Treharne says, depending on the makeup of the patient panel.
Because of the many ways extenders can help, in multi-physician practices it is important for all doctors to agree on how an extender will be used. “If everybody does it their own way, it makes it very confusing for the receptionist who is trying to schedule every one,” Treharne adds.
Phairas says patients should always meet with the doctor first, who can explain how NPs and PAs work, along with how they allow quicker patient access. But doctors need to be careful about pushing too much work on to the extenders, because doing so can damage the doctor-patient relationship.
“Never let a patient with an unresolved problem go more than three or four visits without seeing the doctor,” Phairas says. “You can’t just turn everything over to the extender.”