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Building better care teams with non-physician providers


As the numbers of nurse practitioners and physician assistants surge, primary care physicians can improve patient care and increase revenue by bringing them into the fold.

Amid an intensifying shortage of physicians in primary care and some specialties, hiring a nurse practitioner (NP) or physician assistant (PA) could alleviate some overflow and boost revenue while enabling physicians to augment patient access to providers. But creating a well-run clinical team requires successful coordination among physicians,  NPs and PAs.

The United States faces a projected shortage of more than 130,600 physicians by 2025, including 65,800 primary care doctors, according to the Association of American Medical Colleges. Demand will surge as the aging population increases and as millions of uninsured patients gain coverage under the Affordable Care Act.

These shifts in the provider workforce mean many practices and medical groups increasingly are hiring nurse practitioners and physician assistants to help improve the care they provide and increase their revenue streams. This movement is encouraged by new care models that call for better team-based care.

“The rapid expansion in the use of new primary care models, such as the patient-centered medical home, has potentiated the need for more skilled clinicians from all healthcare disciplines, especially nurse practitioners and physician assistants,” says David A. Fleming, MD, FACP, president of the American College of Physicians and chairman of the department of medicine at the University of Missouri School of Medicine in Columbia, Missouri.

With too few doctors to fulfill current and future needs in some rural and urban areas, “physicians are a very precious resource.” Because of their lengthy and costly training, “we need to use them in the very best way possible,” says Phyllis Arn Zimmer, MN, FNP, president of the Nurse Practitioner Healthcare Foundation in Bellevue, Washington. This means allocating time for physicians to handle complex cases that require advanced diagnostic and treatment expertise.

Nurse practitioners can provide general primary care for adults and children-for example, by performing well-woman exams and helping patients and families manage chronic illnesses. “A healthcare provider’s role isn’t to be the director of a patient’s care,” Zimmer says. “For many years, the provider made the diagnosis and told the patient what to do. We’re really evolving away from that thinking-and trying to empower patients to make their own informed decisions.”

In a well-run practice, guiding patients toward healthcare decisions becomes an outgrowth of a successful partnership between doctors and nurse practitioners or physician assistants. The best partnerships consider combined strengths and expertise in determining how best to address patients’ needs, says John McGinnity, MS, PA-C, DFAAPA, president of the American Academy of Physician Assistants and program director of physician assistant studies at Wayne State University in Detroit.

Employing a physician assistant allows a doctor to focus on more complex cases, reduce patient waiting times, and raise a practice’s income by 18%, McGinnity says. “What doctor wouldn’t want an extra week of leave each year, a better bottom line, higher patient satisfaction, and stronger patient outcomes?” he adds.

A nurse practitioner also can be a major asset in managing patient flow. Even a busy practice can accommodate more patients, says John Giampietro, MD, an internist who works with his wife, Susan Apold, PhD, ANP-BC, a nurse practitioner, in New Rochelle, New York.

Next: 5 ways to minimize liability


“Patients are happier when they can be seen more frequently-in time. Everybody’s thing today is drive-through medicine, so the nurse practitioners can certainly increase access to care. Nobody wants to wait,” says Giampietro, who has been in private practice since 1985. “You drive down the highway and the advertisements for the emergency room are 15-minute waiting.”

In New York and some other states, nurse practitioners may take a patient’s medical history, perform a physical exam, order tests to confirm or disprove a suspected diagnosis, and prescribe medicine independently. Apold sees her own patients and bills under her name, with Medicare reimbursing at a rate of 85% of the amount paid to a physician for the same service, she notes, citing an example for comparison.

Before joining her husband’s practice as a nurse practitioner in 1997, she worked as a registered nurse in hospitals and home health, and taught nursing. “We talk a lot when we’re seeing patients,” Apold says. “It’s very mutual, very collaborative.”

That collaboration goes both ways. It never hurts for a doctor to ask for a physician assistant’s or nurse practitioner’s input. “I always tell people to keep your mind open, because since we’re all committed to helping patients do better, we each have something to add,” says Reid Blackwelder, MD, FAAFP, board chairman of the American Academy of Family Physicians.

Everyone involved in a patient’s care also shares responsibility and potential liability. It is critical for a doctor “to incorporate appropriate communication, recognize limits of training and experience, create opportunities for teaching, and support the continued clinical growth of each person,” says Blackwelder, a family physician in Kingsport, Tennessee. “Perhaps the most important part of team care is making sure that any team member is never put in a situation beyond their training, experience or competence.”

Nurse practitioners can perform up to 90% of the functions that family practice physicians undertake. There are about 500 nurse-managed clinics across the country, primarily in inner city and rural areas, says Ken Miller, PhD, RN, CFNP, president of the American Association of Nurse Practitioners. Each clinic manages about 5,000 patient visits annually.

Last year, nurse practitioners handled more than 900 million patient visits. The number of nurse practitioners is growing. In June, the association’s figures, compiled from nursing boards’ data, accounted for more than 192,000 nurse practitioners-an increase from 189,000 early this year.

Next: Liability concerns


Liability concerns

Bringing non-physician providers onboard can increase liability risks for a practice.

While nurse practitioners are sued for malpractice at a lower rate and for lower judgements than physicians, practices must be aware that physicians can have increased liability, because a supervising physician inevitably will be drawn into a lawsuit involving a nurse practitioner or physician assistant.

Licensed by state nursing boards, nurse practitioners are liable for their own actions and can be sued for malpractice. While a physician may be called in as a co-defendant, he or she is not responsible for the nurse practitioner’s negligence, Miller says.

Lawsuits against nurse practitioners and physician assistants are uncommon, but most cases filed against them also name the supervising physician. Settlements that exclude the physician are rare, according to PIAA, formerly known as the Physician Insurers Association of America.

The association conducted a national review of closed claims from 1985 to 2013 involving “advanced practice providers”-which included only nurse practitioners and physician assistants. Indemnity payments averaged $243,136 (unadjusted to present value)-higher than the $227,215 average for all healthcare specialties.
Family practice and internal medicine topped the list of closed claims and paid claims, but this may reflect the larger number of advanced practice providers in these fields. Diagnostic errors are the most prevalent medical liability claim involving these providers, the association reports.

Physicians should take steps to protect themselves from a liability standpoint when integrating nurse practitioners or physician assistants into their practices, and these actions should begin before hiring. Steps include:

  • Rules and regulations for these providers are different in each state, so physicians must understand the supervision and scope-of- practice rules of their state.

  • Before hiring, make sure any candidate has the required credentials and has met all of the state’s educational and licensing requirements. This is not a one-time action: physicians must continuously monitor their employees to ensure their professional license remains in good standing.

  • When hiring, make sure you notify your malpractice insurance carrier. Professional associations for nurse practitioners and physician assistants recommend that these providers maintain their own malpractice policies as well.

  • A well-developed set of written protocols for the non-physician provider is critical, and may be required depending on the supervision rules of the state. These protocols should include instructions for how to handle cases they will commonly see.

One of the best ways to prevent problems is to foster an environment where questions and interaction are encouraged between physicians and the providers they supervise.

Next: Degrees of independence


Degrees of independence
Laws governing the scope of practice and level of independence for nurse practitioners and physician assistants vary from state to state. Some regulations specify that a physician must be present on the premises during office appointments, while others do not.

“The trend is toward less ‘over-the-shoulder supervision,’ and telecommunication is often permitted,” says Jim Cawley, MPH, PA-C, a professor of prevention and community health and physician assistant studies at The George Washington University in Washington, D.C.

How much independence a physician assistant may exercise often depends on the individual structure of a practice and a doctor’s willingness to delegate responsibility. Some doctors feel more comfortable delegating than others. “The most effective practice arrangements I’ve seen is where that happens,” Cawley says. His research shows that the longer a physician assistant works with a specific doctor, the greater the autonomy.

“Medical sociologists have labeled this progression ‘negotiated performance autonomy’ and suggest that it is an ideal descriptor of the PA-physician dyad in clinical practice,” he explains. “PAs are major economic assets to physician practices, but their employment needs appropriate supervision in conformance with state medical practice laws that have protection of the public as their basis.”

How physicians build care teams
In terms of compensation, physician assistants are typically salaried employees of the practice. Their payment arrangements often include bonuses and additional incentives.

As for reimbursement from insurers, Cawley says, a practice generally has two options: billing for the physician assistant’s service under the “incident to” clause of Medicare regulations and collecting 100% of the physician’s fee, or billing with the physician assistant’s name under Medicare Part B and receiving 85% of that amount.

At Arizona Arthritis and Rheumatology Associates, John Tesser, MD, and his team of three physician assistants share clinical work to manage the high-volume case load. Due to a shortage of rheumatologists, this approach helps meet the needs of patients in the Phoenix area who suffer from a variety of rheumatic disorders. Delegating is an essential ingredient in optimizing the workflow and revenue of a burgeoning practice, Tesser says.

A physician assistant in Tesser’s office obtains a new patient’s history, performs a physical exam, and formulates a differential diagnosis and treatment plan. After reviewing this information, Tesser visits the patient along with the physician assistant and fine-tunes the diagnostic work-up and plan for therapy.

“They know rheumatology extremely well, and they’re very seasoned,” he says of his physician assistants. One of them has worked with him for 26 years, and two others for 11 years each. “I’m really just confirming much of what they find most often.”

Also, practicing medicine this way is more productive. “As I can delegate much of the lower-level documentation and review of incoming data, it unburdens me so that I have the time to perform the higher-level decision-making critical to patient care,” Tesser says. “And it enhances revenue in the practice.”

Tesser is on the premises, so he bills under his name when one of the physician assistants sees a patient in the office. Each physician assistant earns a base salary and a percentage bonus above a certain threshold, depending on how much revenue comes into the practice, Tesser says.

On subsequent visits, patients typically alternate between seeing Tesser or a physician assistant, but he’s available to his staff at all times for brief counsel. In complex cases, he sees a patient through the initial stages until the condition stabilizes. “I’m always the anchor for the team,” he explains. At the end of the day, he reviews all physician assistants’ notes on new patients and many returning patients before signing off on them.  

 “As a team, we can see many more patients and extend rheumatology care and expertise to the community,” he says. For new employees, however, Tesser recommends that physicians allow physician assistants to “shadow” them while seeing patients.

Kevin Maben, MD, works closely with two nurse practitioners as a general pediatrician in Rio Rancho, New Mexico, as part of Presbyterian Healthcare Services in Albuquerque. Half of the week he functions as a pediatrician, the other half as a medical informaticist for the health organization’s electronic health record system, EpicConnect.

Maben works in both capacities from the pediatric clinic. On the days when he’s not scheduled to see patients-Tuesdays and Fridays-the nurse practitioners serve as “access providers” for in-office urgent care. This includes “same-day sick visits-anything a parent may call for,” Maben says, whether it’s a suspected cold, flu, asthma exacerbation or other complaint.  

These types of last-minute appointments help prevent unnecessary visits to an urgent care facility or an emergency room. The patient incurs a lower copay, and the healthcare system benefits from a cost savings.

Sometimes a nurse practitioner may consult with a pediatrician when there are lingering doubts about an appropriate course of action. A pediatrician also should feel free to tap a nurse practitioner’s expertise. In a recent situation, Maben says, the culprit causing severe pain appeared to be appendicitis, and the office referred the patient to a hospital.

“It’s very similar to what happens between pediatricians; we ask each other’s opinion,” he explains. It may help to have “another pair of eyes to look at” a rash, for example.

Nurse practitioners also have the authority to sign school forms, such as an action care plan for a child or adolescent who suffers from asthma, he says. For pediatric patients with type 2 diabetes, pre-diabetes or obesity, nurse practitioners can educate about the benefits of proper nutrition and exercise. Before the fall semester, nurse practitioners help with a flurry of requests for school and sports physicals.

Whatever the task at hand, physicians overseeing nurse practitioners, physician assistants and other personnel must ensure that patient care is evidence-based, competent and safe, says Fleming.

“Physicians have always had some level of accountability for the practice and behavior of other members of their healthcare team, when it comes to the welfare of the patients for whom they are collectively responsible,” he says.

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