Last month, I recommended considering new and innovative roles for the non-physician providers (NPPs) (see The Hospitalist, September 2008, p. 61.). In this column I’ll discuss the economic and patient satisfaction issues related to NPPs in hospitalist practice.
Economics of NPPs
My experience suggests many practices follow a similar line of reasoning when adding NPPs: “We have six physician hospitalist FTEs and need to expand further, yet recruiting additional MDs is difficult. Perhaps we should add one or more NPPs instead. That should work out well economically since NPPs have lower salaries. After all, it seems to work for heart surgeons and orthopedists.”
This kind of reasoning has two flaws. The practice is, in essence, deciding to add NPPs because that process may be easier than finding additional MDs. The practice should instead consider what work needs to be done and decide whether there is a genuinely valuable role for an NPP.
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Secondly, just because it makes financial sense for some specialties to add NPPs doesn’t mean it does for hospitalist groups. The salary gap between orthopedists or cardiac surgeons and NPPs is huge. The salary difference between a physician hospitalist and an NPP is much more modest.
From a strictly financial analysis, which ignores the many benefits of NPPs that don’t appear on financial statements, an NPP needs to increase the efficiency of an orthopedist or cardiac surgeon by only 10% to 20%. That same NPP would need to increase the efficiency of a hospitalist by more like 50%. (I estimated the percentages to illustrate the point. You should conduct a more-detailed analysis of your own situation to determine accurate percentages.)
I’ve worked with practices that have incorporated NPPs but failed to think carefully about their optimal roles. These staff end up functioning in a mostly clerical role, doing tasks such as faxing discharge information to PCPs, retrieving records from outside facilities, or handling billing functions for the doctors. Those practices should either change the NPPs’ roles or use the money to instead hire clerical help. That would leave money for other purposes, such as creating a more aggressive physician recruiting effort or hiring MDs to moonlight.
Local Factors Govern Economics, Practice
In addition to financial considerations surrounding NPPs, keep in mind licensure. Nurse practitioners are licensed as independent practitioners. Physician assistants are not. The laws governing scope of practice for both of these professionals vary from state to state. Additionally, hospital bylaws govern the boundaries of what NPPs can do without supervision. Two hospitals in the same community might have completely different rules. It is important to understand the state and individual hospital regulations that govern NPPs where you practice.
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. In the latter case, Medicare and other payers typically reimburse at 85% of the rate customarily paid to MDs for the same service.
Patient Perception of NPPs
Patients are increasingly more accepting of NPs and PAs. This seems especially true in settings with clear distinctions between the role of NPP and MD.
For example, my wife is perfectly happy to see a nurse practitioner for routine gynecological care, such as Pap smears. She knows the obstetrician handled the delivery of our children and is available anytime she’s needed.
My neighbor was pleased with his open-heart surgery experience and spoke glowingly of the NP who made rounds daily and assisted during the surgery. He knew the MD surgeon performed most of the operation but left the perioperative care up to the NP.