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.
“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.
“The practice needs to thoroughly understand the legal environment early in the process,” says John Nelson, MD, MHM, hospitalist director at Bellevue (Wash.) Medical Center, partner in Nelson Flores Hospital Medicine Consultants, and SHM cofounder. “NPPs are not a ‘hospitalist lite’ that can function entirely like a hospitalist.”
Hospital bylaws, which can vary greatly by city, county, or state, are another important consideration before you hire an NPP.
“In some areas, NPPs may not be able to practice in the ICU,” Dr. Wilson says. “In others, the physician may be required to see the patient instead of consulting with the NPP. The idiosyncrasies of the individual hospital’s bylaws may impact the efficiency of the NPP/MD team.”
Environmental variables—namely, the personality of the physicians within the practice—should be considered before you head down the NPP path. It makes little practical or financial sense to spend the time and effort of hiring an NPP if the physicians still insist on doing all the work.
“[It’s] one of the most significant factors in successfully integrating an NPP program,” Dr. Wilson says. “Will [physicians] be able to tolerate some degree of uncertainty when letting others see their patients? Are they open to adapting to different practice styles? 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.”
Some physicians hesitate to work with NPPs, while others welcome the extra help and unique experience NPPs offer. Experts agree that forcing NPPs on a physician is not a good idea. They also agree that, especially when beginning a new program, group directors should let physicians who are interested in working with NPPs take the lead. As NPP use in the group matures, many of those who were at first unwilling can decide that there is a place for NPPs in their practice.
Case Mix Is Key
The types and kinds of patient seen might limit the use of NPPs in hospitalist practice. “Our experience is that acuity and complexity of the care, especially as it relates to diagnostic and therapeutic decision-making, makes it difficult for NPPs to function independently,” Dr. Parekh says.
Dr. Wilson agrees. “Depending on the specific attributes of the setting, a service with both high-complexity and high-acuity patients may be a more challenging environment to realize the efficiencies of NPPs,” he says. “There is a relationship between complexity, acuity, and physician involvement.”
Even so, a continuum of NPP use in HM practice is achievable. For example, as a patient improves, an NPP might be able to take on a larger role in treatment by participating in discharge planning. In more acute patients, the NPP can save valuable physician time by coordinating with consultants, staying on top of treatments, and consolidating clinically important data for the physician.
Many Models in Use
Historically, the widespread use of alternative providers began in 2004 as a result of the changes to resident duty-hours. The restrictions created a workforce gap, which led to a large number of new positions in hospitals nationwide. Many of HM’s early adopters essentially went with what they knew.
“We work in teams where the physician, NPP, and nurse see a group of patients similar in function to an attending, resident, and RN,” Genzink says. “We see ‘our’ patients in a collaborative fashion.”
There are other models that have proven successful in the correct setting. Some HM groups use specialist NPPs to cover specific clinical areas, such as orthopedics or oncology. This not only develops a cadre of providers with excellent understanding of their patients, but it also frees up physician time for more acute and complicated patients.
“Our physicians depend on us helping them get patient care completed more efficiently, so that length of stay is acceptable, and to enhance continuity of care,” says Whitehead, the American Academy of Nurse Practitioners’ liaison to SHM. “Having an NPP visit the patient daily, documenting progress, greatly enhances communications between physicians and consultants.”
Other groups have NPPs specialize by function—for example, they cover all admissions or work mainly with discharging a patient. Some groups have the physician see the patient on admission, work out a care plan, then turn over management to the NPP. Many agree that most NPPs are best utilized by having them cover specific shifts, such as overnight call or on a swing shift, to help during peak demand.
Monetary and Time Commitments
The financial impact of NPPs on a hospitalist practice depends on many factors. Groups will need to look not only at the salary and benefit costs associated with the position, but also how best to fit that person into the billing system.
Salary and benefit comparisons are fairly straightforward: The State of Hospital Medicine: 2010 Report Based on 2009 Data, produced by SHM and the Medical Group Management Association, shows median total compensation for adult hospitalists at $215,000 per year; NPP compensation is around $87,000.1
The general cost of benefits (health insurance, retirement, etc.) is fairly typical throughout a hospitalist practice, so there should be little difference between a new FTE hospitalist or NPP. Other considerations, including office space and support staff, would be roughly the same if the group hired a physician. The cost of continuing education and malpractice insurance likely will be less with an NPP, but it is best to check before making a new hire.
After the outgo has been established, the next step is to look at the differences in reimbursement for NPPs vs. physicians. Here, again, the math gets tricky. The Centers for Medicare & Medicaid Services (CMS) pay NPPs at 85% of the physician rate for a specific diagnosis. However, if there is direct physician involvement, the claim can be filed as “shared billing” and reimbursed at 100%.
For some hospitalist practices, adding NPPs is an easy decision to make. Dr. Parekh says his group already has policies in place that require a physician to see the patient every day. In that case, no extra physician time is necessary, so shared billing makes sense. Other hospitals’ bylaws might have similar requirements.
For practices in which the NPP is able to work with less oversight, it might be better to bill at 85% rather than use the physician time to meet shared-billing criteria. Even in practices with greater NPP autonomy, such variables as case mix and patient acuity might enter into the equation. If the patient is sick enough that the physician is involved for a significant amount of time, then shared billing probably is best.
Experts say group directors and hiring managers should look carefully at contracts with private insurers, too. There most likely will be considerable variation in how each plan handles NPP claims.
Managing performance expectations can have an impact on the successful use of NPPs in a hospitalist practice. Setting realistic goals and groupwide understanding of what the NPPs’ roles will be is crucial. The practice should look at the work that needs to be done and decide if that work provides a genuinely valuable role for an NPP.
Hire for Need, Not Desperation
“The mistake I see most often is hiring an NPP because a practice is desperate for help,” says Martin Buser, MPH, FACHE, a partner in Hospitalist Management Resources, LLC, in San Diego. “Smart practices are looking at NPPs, evaluating where they do the most good, and then setting out their role and expectations based on these needs and the practice environment.”
Hiring mistakes can be compounded if the NPP is not a good match to the job description or group expectations. If the practice hires an NPP fresh out of school, the group will need to establish training and have the new hire work more closely with physicians. If, on the other hand, an NP has 10 years of experience in an ICU, or a PA has worked in the ED for the past five years, a higher level of autonomy can be granted sooner. However, NPPs with established backgrounds are almost as rare as experienced hospitalists (see “Integrating NPPs Into HM Practice,” p. 38).
Inevitably, there will be changes in the interactions between patients and the hospitalists, as both physicians and NPPs become more comfortable with the other’s practice style, as well as each other’s strengths and weaknesses.
MD-to-NPP Ratio Varies
The practice structure and optimal mix of NPPs to MDs is something that will be specific to the hospitalist group. “We don’t really have good studies on this subject,” Buser says. “I usually get worried when we exceed two NPPs to one MD.”
Others disagree. Dr. Parekh, who works in an academic center, says his group has been successful having one MD work with as many as three NPPs. At the other end, Dr. Wilson says his 10 years of experience suggest 1:1 is the most efficient ratio.
However, all of them agree that having one NPP work with more than one physician is not sustainable. The NPP will be less familiar with each doctor’s practice style, what kind of information they need, and how things should be presented. If two or more hospitalists share an NPP, there can be internal friction over division of the NPP’s time, as well as extending the time before the MDs have a good feel for the NPP’s strengths and weaknesses.
In the final analysis, the HM group has to look at the amount and type of work available. In some cases, it will make financial and clinical sense to bring on an NPP. Under other circumstances, an FTE hospitalist is the best fit.
“Sustainability, quality, and efficiency are the drivers for NPP/MD teams. Increasing pressure to offset program costs is not,” Dr. Wilson says. “You do it because it helps sustain the program, helps with recruiting, and effects your efficiency.” TH
Kurt Ullman is a freelance medical writer based in Indiana.
- Medical Group Management Association and the Society of Hospital Medicine. State of Hospital Medicine: 2010 Report Based on 2009 Data. 2010. Philadelphia and Englewood, Colo.