In 2004, the hospitalist group at the University of Michigan Health System in Ann Arbor faced a manpower problem: In a refrain common to hospitalist groups around the country, changes in duty-hour regulations were making it harder for medical residents to continue to provide inpatient coverage at the same levels as before.
Addressing the issue was difficult for the HM group and hospital administrators; they were going to need a significant number of new providers, and qualified physicians were in short supply. To address these issues, the HM group chose to add nonphysician providers (NPP) to their service.
“NPPs had worked at UM for a long time in other areas,” says Vikas Parekh, MD, SFHM, associate director of hospitalist management. “We had just created a new service that was hiring new people and thought NPPs would help in providing services.”
Hiring NPPs helped solve the University of Michigan’s problem, and the tactic has helped solve manpower issues at numerous HM groups around the country. But deciding whether your HM group should hire physicians, NPPs—usually nurse practitioners (NPs) and physician assistants (PAs)—or some combination of the two will not be easy. It is a complex decision, one that requires following state-level licensing and practice laws as well as local hospital bylaws and federal and private insurance payment rules. Such decisions also mean HM group directors need to keep in mind case mixes and the personalities of the physicians in the practice.
“There is no one-size-fits-all solution,” says Mitchell Wilson, MD, SFHM, corporate medical director for Eagle Hospital Physicians in Atlanta. “Not all environments are well-suited to NPP practice. Even when it is, you can’t just throw an NPP into the mix on their own with the expectation they will be successful.”
Whether it’s covering admissions, streamlining discharges, or working as an integral part of a care team, NPPs can be the solution expanding HM groups are looking for.
The thing we see most often in practices that use NPPs to their advantage is the recognition that there is an important role for the nonphysician at the bedside.—Mitchell Wilson, MD, SFHM, corporate medical director, Eagle Hospital Physicians, Atlanta
“Our physicians depend on NPPs to help them complete patient care in a more efficient manner and work to enhance continuity of care,” says Mary Whitehead, RN, APRN-BC, FNP, of Hospital Medicine Associates in Fort Worth, Texas. “We lower physician rounding time so patients are seen sooner and tests are requested sooner. In addition, the patients really appreciate the extra time we can spend with them.”
Trained, Licensed, Available
NPs must be registered nurses with clinical experience before they can enroll in an advanced degree program, which usually results in a master’s degree or doctorate. Generally, a state board of nursing, or a state board jointly with the state medical board, regulates NPs.
PAs are trained in more of a traditional medical model. They have a variable education level all the way up to a PhD, although more states are requiring at least a master’s degree. Practice and other legal parameters most often come under the authority of state medical boards.
NPPs can provide additional medical expertise to patients, says Ryan Genzink, PA, a physician assistant with Hospitalists of Western Michigan in Grand Rapids and the American Academy of Physician Assistants’ medical liaison to SHM. “One of the challenges faced by physicians is that they often have to be in two places at once,” he says. “There is a recognition that teams provide better care for complicated patients.”
NPPs generally practice under the supervision of a physician hospitalist. Some states allow a greater degree of independence for NPs. However, most NPs and PAs are required to have a practice agreement outlining their responsibilities and the amount of oversight required (see Table 1, p. 39). There is no such thing as a “fire and forget” NPP.