While the role of nurse practitioners (NPs) and physician assistants (PAs) in hospital medicine is far from uniform, data from the 2016 State of Hospital Medicine Report show that a majority of hospital medicine groups utilize NPs or PAs. Over the past decade, the percentage of hospital medicine groups that include NPs or PAs has grown from about 20% in 20051 to 65% in 2015.2
Dr. Huang
I suspect a large part of this growth is fueled by demand continuing to outstrip supply for hospitalist physicians and continued increases in hospitalist salaries. In academic institutions, restrictions in house staff duty hours over the past decade no doubt also contributed to the growth of NP and PA utilization.
How Should HM Groups Use NPs and PAs?
In addition to obtaining group buy-in prior to deploying NPs or PAs in a hospital medicine group, a thoughtful consideration about the role of NPs or PAs in providing care is perhaps most important. Even with careful planning, groups should expect implementation of an NP or PA model to require lead-in and training time.
The fact that NPs and PAs have been adopted by so many groups suggests that practices have found increased value; however, models vary widely. In some practices, NPs or PAs work side by side with hospitalists, assisting with documentation, meeting with patients and families, and implementing an agreed-upon management plan. In this model, NPs and PAs may also add value by helping with time-consuming discharges, freeing hospitalists to attend to other patients and thus improving productivity, bed flow, and perhaps also job sustainability.
Other groups have found niche roles for NPs or PAs, including but not limited to providing cross-coverage, performing procedures, triaging admissions, staffing observation units, and developing expertise in a specific clinical area such as consultative medicine or orthopedics.
How to Bill
Figure 1. How Nurse Practitioner/Physician Assistant Work Is BilledSource: Society of Hospital Medicine’s 2016 State of Hospital Medicine Report
Depending on the model adopted, groups must also decide whether it is advantageous for NPs or PAs to bill for services independently versus as shared services under the supervising physician’s provider number. The Centers for Medicare & Medicaid Services reimburses NPs and PAs who bill independently at 85% of the physician rate. Nonetheless, some groups may find it more cost-effective for NPs or PAs to bill independently given the substantial salary differential compared to hospitalists. Data published in the 2016 State of Hospital Medicine Report show that NPs and PAs bill independently 47.9% of the time (see Figure 1).
At the University of California, San Diego, we’ve found that our PAs added the most value when working one-on-one with a single hospitalist rather than with multiple physicians. Specifically, our PAs have added to the capacity of our non-teaching service, typically implementing a plan of care developed cooperatively with the hospitalist but also managing a select cohort of patients independently during times of excess volume. By increasing capacity, our PAs have also allowed us to avoid calling in a backup hospitalist during high census periods.
References
- Society of Hospital Medicine. 2006 State of Hospital Medicine Report.
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed October 23, 2016.