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Maximizing NPPs in Hospitalist Practices


Last month, I recommended considering new and innovative roles for the non-physician providers (NPPs) (see The Hospitalist, September 2008, p. 61.). In this column I’ll discuss the economic and patient satisfaction issues related to NPPs in hospitalist practice.

Economics of NPPs

My experience suggests many practices follow a similar line of reasoning when adding NPPs: “We have six physician hospitalist FTEs and need to expand further, yet recruiting additional MDs is difficult. Perhaps we should add one or more NPPs instead. That should work out well economically since NPPs have lower salaries. After all, it seems to work for heart surgeons and orthopedists.”

This kind of reasoning has two flaws. The practice is, in essence, deciding to add NPPs because that process may be easier than finding additional MDs. The practice should instead consider what work needs to be done and decide whether there is a genuinely valuable role for an NPP.

Some Hard Data click for large version

click for large version

Secondly, just because it makes financial sense for some specialties to add NPPs doesn’t mean it does for hospitalist groups. The salary gap between orthopedists or cardiac surgeons and NPPs is huge. The salary difference between a physician hospitalist and an NPP is much more modest.

From a strictly financial analysis, which ignores the many benefits of NPPs that don’t appear on financial statements, an NPP needs to increase the efficiency of an orthopedist or cardiac surgeon by only 10% to 20%. That same NPP would need to increase the efficiency of a hospitalist by more like 50%. (I estimated the percentages to illustrate the point. You should conduct a more-detailed analysis of your own situation to determine accurate percentages.)

I’ve worked with practices that have incorporated NPPs but failed to think carefully about their optimal roles. These staff end up functioning in a mostly clerical role, doing tasks such as faxing discharge information to PCPs, retrieving records from outside facilities, or handling billing functions for the doctors. Those practices should either change the NPPs’ roles or use the money to instead hire clerical help. That would leave money for other purposes, such as creating a more aggressive physician recruiting effort or hiring MDs to moonlight.

Local Factors Govern Economics, Practice

In addition to financial considerations surrounding NPPs, keep in mind licensure. Nurse practitioners are licensed as independent practitioners. Physician assistants are not. The laws governing scope of practice for both of these professionals vary from state to state. Additionally, hospital bylaws govern the boundaries of what NPPs can do without supervision. Two hospitals in the same community might have completely different rules. It is important to understand the state and individual hospital regulations that govern NPPs where you practice.

A PA’s work will nearly always require a physician being physically present during some portion of the patient visit and co-signing chart notes and orders. Nurse practitioners, on the other hand, may be able to perform certain patient-care activities independently. In the latter case, Medicare and other payers typically reimburse at 85% of the rate customarily paid to MDs for the same service.

Patient Perception of NPPs

Patients are increasingly more accepting of NPs and PAs. This seems especially true in settings with clear distinctions between the role of NPP and MD.

For example, my wife is perfectly happy to see a nurse practitioner for routine gynecological care, such as Pap smears. She knows the obstetrician handled the delivery of our children and is available anytime she’s needed.

My neighbor was pleased with his open-heart surgery experience and spoke glowingly of the NP who made rounds daily and assisted during the surgery. He knew the MD surgeon performed most of the operation but left the perioperative care up to the NP.

Patients on a hospitalist service may not see things the same way. My neighbor understood he was hospitalized for the purpose of open-heart surgery done by the MD. He looked at the perioperative care outside of the operation as a secondary issue.

Most medical admissions managed by hospitalists don’t have such clear marquee events in patients’ eyes. So it may be less natural for patients to feel OK about how the hospitalist and NPP divide up care responsibilities. Look at it this way: As hospitalists, we have limited face time with patients, and must make good use of it to establish trust and rapport. When we add an NPP to the care team, we ask patients to develop trust and rapport with two providers instead of just one.

Imagine a patient recently discharged from a hospitalist practice. Her friend asks how it went and which doctor she saw. The patient responds, “I couldn’t figure out who was really in charge of my care. Dr. Nelson’s name was on my armband, but I rarely saw him. Instead, I saw his assistant (the NPP) most of the time.” I suspect that patient will be much less likely to report high levels of satisfaction with her care than one who just saw a hospitalist.

Though I’m concerned that it might be more difficult to keep patients happy when NPPs are part of a hospitalist practice, most practices report this hasn’t been a problem. I’m not suggesting that concern about patient satisfaction means you shouldn’t use NPPs in your hospitalist practices. However, patient satisfaction is an issue to consider when organizing your practice—and an NPP’s role in it—to provide the greatest benefit to your patients. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

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