While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.
All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.
Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].