What can midlevels do for you?

September 5, 2008

Long viewed as an unaffordable luxury, physician midlevels, such as nurse practitioners and physician assistants, can improve patient care-and your practice's bottom line.

Key Points

Primary care physicians are under tremendous pressure to keep costs down and income up. Though there aren't a lot of new ways to do this, it may be time to consider an approach that's growing in acceptance: hiring midlevels such as nurse practitioners (NP) and physician assistants (PA).

Calculating the total savings of midlevels is complicated by the extra costs of support staff and required physician supervision. A 2004 study at Kaiser Permanente Georgia (KPG), a group model HMO, is one of the most detailed assessments of savings from using midlevels. When NPs and PAs were used for at least 75 percent of visits, KPG saved 3.1 percent per visit in adult primary care and 2.1 percent per visit in pediatrics.

In many practices, midlevels often start at 7 or 8 a.m., when doctors are still making rounds in the hospital, and they may also work evenings and weekends. Some NPs are willing to work half-days, coming in early in the morning or staying late into the evening.

Since midlevels are paid less than physicians, they can spend more time with patients. Centennial Valley Pediatrics in Louisville, Colorado, has four physicians and three NPs. The NPs see patients an average of five minutes longer than the doctors.

Doctors with midlevels learn to delegate work, to be part of a health-care "team"-a buzzword among medical educators, who argue that medicine has become too complicated for the individual physician to function alone. They envision physicians as managers of a medical team. That's why primary care physicians must consider whether their practice styles and philosophies are conducive to having midlevels. (See related story, "Before you hire.")

WHERE MIDLEVELS SHINE

Most midlevels work in family medicine, which accounts for 25 percent of all PAs and 41 percent of NPs. The KPG study showed that the primary adult diagnoses seen by midlevels were sore throats, sinusitis, ear infections, rhinitis, joint or limb pain, neck or back pain, diabetes, and asthma.

"A physician doesn't have to see allergies, colds, and lacerations," says Diane Noton, MD, a solo family physician in Saratoga, Wyoming, who employs two PAs and treats adults and children.

Noton says new patients prefer to see a physician, but they don't object to seeing midlevels in exchange for a same-day appointment. Patients can choose between seeing a PA that day or wait a day or two to see her. They usually opt to see the PA.