Historically, the widespread use of alternative providers began in 2004 as a result of the changes to resident duty-hours. The restrictions created a workforce gap, which led to a large number of new positions in hospitals nationwide. Many of HM’s early adopters essentially went with what they knew.
“We work in teams where the physician, NPP, and nurse see a group of patients similar in function to an attending, resident, and RN,” Genzink says. “We see ‘our’ patients in a collaborative fashion.”
There are other models that have proven successful in the correct setting. Some HM groups use specialist NPPs to cover specific clinical areas, such as orthopedics or oncology. This not only develops a cadre of providers with excellent understanding of their patients, but it also frees up physician time for more acute and complicated patients.
“Our physicians depend on us helping them get patient care completed more efficiently, so that length of stay is acceptable, and to enhance continuity of care,” says Whitehead, the American Academy of Nurse Practitioners’ liaison to SHM. “Having an NPP visit the patient daily, documenting progress, greatly enhances communications between physicians and consultants.”
Other groups have NPPs specialize by function—for example, they cover all admissions or work mainly with discharging a patient. Some groups have the physician see the patient on admission, work out a care plan, then turn over management to the NPP. Many agree that most NPPs are best utilized by having them cover specific shifts, such as overnight call or on a swing shift, to help during peak demand.
Monetary and Time Commitments
The financial impact of NPPs on a hospitalist practice depends on many factors. Groups will need to look not only at the salary and benefit costs associated with the position, but also how best to fit that person into the billing system.
Salary and benefit comparisons are fairly straightforward: The State of Hospital Medicine: 2010 Report Based on 2009 Data, produced by SHM and the Medical Group Management Association, shows median total compensation for adult hospitalists at $215,000 per year; NPP compensation is around $87,000.1
The general cost of benefits (health insurance, retirement, etc.) is fairly typical throughout a hospitalist practice, so there should be little difference between a new FTE hospitalist or NPP. Other considerations, including office space and support staff, would be roughly the same if the group hired a physician. The cost of continuing education and malpractice insurance likely will be less with an NPP, but it is best to check before making a new hire.
After the outgo has been established, the next step is to look at the differences in reimbursement for NPPs vs. physicians. Here, again, the math gets tricky. The Centers for Medicare & Medicaid Services (CMS) pay NPPs at 85% of the physician rate for a specific diagnosis. However, if there is direct physician involvement, the claim can be filed as “shared billing” and reimbursed at 100%.
For some hospitalist practices, adding NPPs is an easy decision to make. Dr. Parekh says his group already has policies in place that require a physician to see the patient every day. In that case, no extra physician time is necessary, so shared billing makes sense. Other hospitals’ bylaws might have similar requirements.
For practices in which the NPP is able to work with less oversight, it might be better to bill at 85% rather than use the physician time to meet shared-billing criteria. Even in practices with greater NPP autonomy, such variables as case mix and patient acuity might enter into the equation. If the patient is sick enough that the physician is involved for a significant amount of time, then shared billing probably is best.