Working with non-physician providers

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As physicians look for new ways to increase productivity, they might consider the benefits of employing physician assistants (PAs) and nurse practitioners (NPs). Trends indicate these types of advanced practice providers (APPs) are filling gaps in patient care and helping to extend the doctor’s reach. 

NPs and PAs can:

• Work with varying degrees of autonomy, increasing access and freeing up the doctor’s schedule for more complex patients.

• Spend extra time with patients, improving satisfaction scores.

• Monitor wellness, improving the practice’s quality metrics.

• Provide billable services, boosting practice revenue.

There are some practical distinctions between PAs and NPs. Essentially, PAs follow a medical model of training and focus on pathology, diagnosis, and treatment, while NPs follow a nursing model and concentrate on wellness and the impact of the diagnosis and treatment on the patient. 

Joseph E. Scherger, MD, MPH, vice president for primary care at Eisenhower Medicine Center in Rancho Mirage, Calif., and a Medical Economics editorial advisor, says in a busy primary care office, the typical model is one in which the doctor and APP “co-practice.” 

Under this model, patients are stratified according to complexity, and the physician delegates care for the less complex cases to the APP. Additionally, the APP might provide follow-up care for a complex patient the physician has already seen. 

“Think of the APP as an extension of the doctor-that’s why doctors hire them-to meet the added demand,” Scherger says. 

By taking on a variety of care delivery tasks, APPs can help reduce physician burnout, he says. However, new NPs and PAs shouldn’t be expected to start seeing patients on day one, he says. Practices should allow at least a month’s time for integration, during which APPs should shadow the doctor and become familiar with the practice, the workflow, and the patient population.

Significant workforce

According to the American Association of Nurse Practitioners (AANP), there are more than 248,000 NPs licensed in the United States, and 86.6 percent are certified in primary care. There are 123,000 PAs , and about 25 percent are practicing in primary care, according to the National Commission on Certification of Physician Assistants.

Each state’s scope-of-practice regulations define how PAs or NPs may deliver care. The broadest scope allows NPs to see patients, diagnose, order tests, deliver treatment, and prescribe medications for routine patient visits without physician oversight. PAs ­require supervision established through “collaborative agreements” with physicians-written documents that define the practice’s model for care delivery and how or when the physician should be involved in the patient’s care. AANP offers a state-by-state online resource citing regulations for NPs, and American Academy of Physician Assistants (AAPA) offers similar information for PAs in a guidebook for members.

Generally, a PA is subject to a state’s board of medicine regulations, while an NP will be governed by a state’s board of nursing regulations, says Kevin Ryan, JD, a member of the law firm Epstein Becker Green.

“Even though the professional acts of the physician assistant and the nurse practitioner may be very similar, the supervision and collaboration requirements, if any, may be very different between the two,” Ryan says.

In 22 states and the District of Columbia, NPs have full practice authority, according to Joyce Knestrick, PhD, APRN, president of AANP. Among states that have restrictions, the degree of supervision varies widely. For example, nine states limit the number of NPs a physician can supervise. 

“We think removing these practice barriers would be helpful to all of us in healthcare,” Knestrick says. She believes full practice authority for NPs increases access for patients while also helping practices improve quality metrics tied to value-based payment because NPs are able to spend extra time with patients.

Jonathan Sobel, DMSc, MBA, president of the AAPA, says the organization is similarly advocating for more independent practice authority for its members. “We want to see that relationship maximized without the administrative oversight regulated or legislated,” Sobel says. “We want physicians to be able to define what’s right for their practice.”

Physician responsibility

Generally speaking, scope-of-practice regulations are leaning toward greater independence for APPs as a direct response to nationwide provider shortages, but the specific provisions are ever-evolving, says Kim Hoppe, clinical risk management and patient safety specialist for Coverys, a medical professional liability insurer.

“Sometimes the physicians themselves depend too much on the NPs and PAs without understanding the full scope of their ability to practice,” says Hoppe. “I’ve also seen NPs and PAs get very comfortable with their good relationship with the patient, resulting in ‘scope creep.’ They may be practicing above their scope of practice, certification, or education, and the physician may not be astutely aware of that.”

In states where NPs can practice independently, the physician wouldn’t have liability for the NP’s actions. However, a PA is almost always required to have a collaborative agreement with a physician, according to Ryan. 

“In states that require oversight and collaboration agreements, the risk to the physician will depend on whether the physician met the statutory obligations for oversight as well as the requirements in the collaboration agreement,” he says.

If the physician is required to audit 10 percent of the PA’s charts on a regular basis, for example, liability would be related to whether the physician fulfilled the obligation. Ryan says risk for supervising physicians is minimal when they meet their contractual and state requirements.

Consequences for noncompliance on the part of the overseeing physician could include licensure action by the state board of medicine. Additionally, he says, the physician could be named in a malpractice case if he or she failed to provide the required supervision and if the APP acted beyond the allowed scope of practice and caused harm to the patient.

Hoppe says it’s best for practices to create written agreements between the physician and the APP. The content of the agreements should include details such as prescribing authority when permitted by the state, how often the physician and APP will interact, and how the physician will be involved in patient care when needed. Providers also should outline a contingency plan for instances when the supervising physician isn’t available, she says.

Some medical boards require that the practice file the written agreement with the state, while others allow the agreement to be a living document, kept at the practice level and updated as needed.

But physicians must be realistic about how much time and attention is necessary when using APPs. For example, when a chronic condition is not under control, a PA would likely hand off the patient to the doctor, according to AAPA.

Reimbursement reality

Full-time PAs and NPs earned a median annual salary around $105,000 in 2017, according to both AAPA and AANP. Scherger says with APP compensation equaling about half that of a physician, “they usually more than pay for themselves.”

Billing guidelines (Section 4112.1 and 4112.2) from the Centers for Medicare and Medicaid Services detail how and when an APP can bill for services for Medicare patients. Commercial plans often follow the lead of Medicare, but practices should verify any additional requirements, Hoppe says.

She cautions that improper billing of services can result in rejected claims, lost reimbursement, or even fraud investigations. “It’s muddy water,” Hoppe says, “and it can be hard to understand those rules.”

Medicare reimburses PAs 15 percent less than a physician for the same services, according to AAPA’s Sobel. However, he believes, adding a PA to the practice who can work independently and bill independently-even at the lower rate-produces a net gain in reimbursement.

“That 15 percent is offset big time,” he says. “You just have to do the math to figure out how many patients the PAs can see, if they are seeing new patients, and how they are expanding access to care for the overall practice.”