NPPs Can Bring Financial and Clinical Dividends

The rate at which medical practices are employing non-physician providers (NPPs)—healthcare professionals such as nurse practitioners and physician assistants—is increasing. According to an analysis by the Medical Group Management Association, since 2008, the number of full-time equivalent NPPs per full-time employed physician has increased by 11%.

That news isn’t surprising to Jerome Wilborn, MD, national medical director of post-acute services for IPC The Hospitalist Company, who has seen the growth first hand.

“In 4 years, our company has gone from about 60 mid-levels to well over 350,” Wilborn says. “The number of physician assistants and advanced practice nurses is growing at a very brisk pace.”

And the clinical and financial benefits they provide to medical practices are significant.

Growth factors

Wilborn says one of the key factors in the growth of NPP usage is healthcare reform. As the healthcare landscape changes, there are more things physicians need to do to focus on good quality outcomes, he explains. However, there are only so many physicians and so many hours in a day, and having extenders who can interface with patients and help deliver those outcomes, is part and parcel why they’re in such demand.

As an example, Wilborn points to the post-acute space, where his organization has grown tremendously.

“Post-acute used to be less than 6% of our business, and now it’s over 30% of our business, and that’s just in the last 5 years,” he explains. “And in the post-acute space, mid-levels have existed there for a long time. They deal with geriatric patients, who have a lot of needs. Physicians, traditionally, who have outpatient practices or they round in the hospital can’t really devote the time to these seniors who need the care. And so as we’ve grown in the post-acute space, what has happened is, we’ve concomitantly grown, and dramatically increased our number of mid-level providers.”

The landscape is changing in other ways, too. Wilborn explains that there are now states where advance practice nurses no longer need to have a collaborative, state board-approved relationship with a physician.

“You can now have the nurse practitioner go out to the nursing home and provide care, and she doesn’t have to have a legal binding and collaborative and supervising physician,” Wilborn says. “Change is happening.”

Financial benefits

In addition to clinical benefits, employing NPPs offers financial advantages. Wilborn points out these physician extenders are able to see additional patients in various settings, to, in effect, augment a physician’s reach. For example, if a physician has 40 patients in a hospital, assisted-living or nursing facility, he or she can’t really see all 40 patients in one day. But a NPP could see 15 of those patients.

“Ultimately, you’re now able to provide more care,” Wilborn says. “But you are also able to collect on the billing. That’s how physicians can, and often do, grow their practice.”

Many NPPs are also clinically oriented, Wilborn says, and as such can “dig in and make sure some of the core measures are being met.” That clinical approach enables them to “bring a different calculus to the table. And practices can benefit from that.”

Making it work

Successfully integrating a NPP into a medical practice depends a lot on the supervising physician, Wilborn says. Physicians need to understand the role of the NPP and how best to utilize them. Unfortunately, he adds, not all physicians do.

“In the private practice realm, that’s where the physician leadership supervision really starts to manifest itself in terms of how well an NPP can do,” he says. “In the private practice world, NPPs are supervised, but we work collaboratively as a team. And by working together as team, we learn how to implement the use of an NPP.”

Wilborn emphasizes that there’s a big difference between supervision and collaboration. Supervision, he says, means looking over someone’s shoulder and reviewing documentation. Collaboration occurs when a NPP is speaking with a family, and the family needs to talk to the doctor. The NPP tells the doctor what is clinically going on with the patient, because the physician hasn’t had the chance to know that information.

Most importantly, says Wilborn, the physician needs to have a good relationship with the NPP.

“This is someone you’re working with,” he says. “That’s the formula we use at IPC. We bring our mid-levels in, supervise them, collaborate with them, and make them part of our pod meetings. That builds the foundation to hire more and more mid-levels.”