Non-Physician Providers Critical to Hospital Medicine Practices
In “Maximizing NPPs in Hospitalist Practices” (Practice Management, October 2008, p. 69), John Nelson, MD, implies a financial advantage to hiring nurse practitioners (NPs) rather than physician assistants (PAs):
“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. Medicare and other payers typically reimburse at 85% of the rate customarily paid to MDs for the same service.”
Dr. Nelson: Do you mean to imply NPs providing hospitalist coverage should function independently, without any physician supervision, oversight, or input? I do not know of any hospitals that allow NPs to admit and manage patients independently, despite their independent practice status. In my opinion, it would be detrimental to patient care to allow non-physician providers to provide completely independent, unsupervised hospital care.
In addition, I know of no hospital practice setting that requires a physician to be physically present during a PA’s exam. In all hospital practice settings that I am aware of, a supervising or attending physician (not necessarily the one on the PA’s license), must see the patient at some time each day, not necessarily at the same time as the PA.
In that scenario, the physician pays a brief visit to the patient to corroborate the PA’s exam and plan. The physician then writes a brief, seen-and-agreed note, and can bill 100% of the Medicare reimbursement, not the 85% for a NP visit. How this compares economically depends, of course, on relative salaries. But it provides physician oversight of the NPP, which assumedly will improve quality of care (though I have no studies to cite to that effect).
Do you have some other reason for your anti-PA, pro-NP bias? Is your personal experience colored by working with more competent NPs, in your opinion, and less competent PAs? Perhaps that would make for a more interesting, better-defined column.
Richard Buckberg, PA-C, Maine Medical Center, Portland, Maine
SHM’s Non-Physician Provider (NPP) Committee was delighted to see the recent article by Dr. Nelson, MD, regarding the use of NPPs in hospital medicine. These columns spotlighted HM’s increasing utilization of NPPs, a role that only is expected to increase in number and breadth, based on the increasing need for competent, comprehensive care of the acutely ill.
Dr. Nelson made many excellent points that may benefit from some clarification or expansion. Dr. Nelson states a PA “will nearly always require a physician being physically present during some portion of the patient visit and co-signing chart notes and orders.” This is incorrect, and seems to imply PAs are more difficult to assimilate into practice than NPs. Depending upon variability in legal limitations and hospital bylaws, both PAs and NPs may see a patient without a physician present. In order to bill for a shared visit and receive 100% reimbursement, the attending physician needs to have a face-to-face encounter with that patient at some point in the day and document a portion of the evaluation and management (e.g., history, physical exam, or medical decision-making).
Alternatively, in most states, both NPs and PAs can see patients independently and bill for their services at 85% of the physician’s Medicare rate. Obtaining 100% reimbursement for NPP services when using the shared billing model is efficient and simple. Though variability exists, more specifically in hospital culture, utilization of these roles can positively impact the bottom line of reimbursement. Therefore, it is essential to understand all of the regulations before developing a business model incorporating NPPs.
Dr. Nelson also points out that using NPPs in a clerical fashion, such as discharge planning, is not optimizing the NPPs capabilities. This point is well taken. If clerical assistance is needed, hire the appropriate discipline.
He also says in order to integrate and maximize the benefit of the NPP to a particular practice, a careful analysis of the needs of the practice should be performed prior to hiring. This will allow both physicians and the NPP to have clear expectations. An emphasis should be placed on the importance of recognizing the level of experience will likely impact the role. For example, utilizing a new graduate in a short-stay observation unit with limited diagnoses and treatments may make sense, but utilizing an NPP as a nocturnist, cross-covering and independently admitting patients, would require an NPP with years of experience. It is crucial to hire the right NPP with the right qualifications and experience for the job.
Dr. Nelson states patient satisfaction may decline by adding NPPs to the practice. Rather than focusing on possible dilution of a patient experience with the addition of another healthcare provider, one should instead consider the potential of adding another perspective to the team. Two providers with unique educational backgrounds and insight may indeed be better than one. Utilization of NPPs can increase face time with patients, subsequently increasing patient satisfaction. Additionally, research in outpatient settings shows no difference in patient satisfaction between physicians and NPPs; more research in inpatient settings needs to be performed.
We encourage HMG directors to refer to our expanded section on SHM’s Web site, “Practice Resources,” which has a wealth of information regarding NPP utilization. The NPP committee will be hosting two courses at the annual meeting, “The Basics: Can NPs/PAs Meet Our Needs,” and “Advanced Concepts: Three Different Practice Models.”
Jina Saltzman, PA-C, University of Chicago Medical Center
Dear readers: My main goal in writing the column was to indicate that NPs and PAs could be valuable contributors to many hospitalist practices. Yet, many practices fail to create the optimal role for them, one that contributes to patient outcomes, efficiency and economic health, and provides a rewarding role for the NPP.
I do not have an anti-PA, pro-NP bias. My intention was not to take sides regarding whether PAs or NPs are more skilled or better for patients. I think that is a function of the individual, much more than their training certificate (same with MDs). I did not intend to imply “nurse practitioners providing hospitalist coverage should function independently, without any physician supervision, oversight, or input.”
Lastly, I did make a factual error regarding the differences in physician supervision required for NPs and PAs. Saltzman’s letter above addresses the error. TH