Dr. Parekh
Table 1. MD vs. NP vs. PA
Experts say group directors and hiring managers should look carefully at contracts with private insurers, too. There most likely will be considerable variation in how each plan handles NPP claims.
Managing performance expectations can have an impact on the successful use of NPPs in a hospitalist practice. Setting realistic goals and groupwide understanding of what the NPPs’ roles will be is crucial. The practice should look at the work that needs to be done and decide if that work provides a genuinely valuable role for an NPP.
Hire for Need, Not Desperation
“The mistake I see most often is hiring an NPP because a practice is desperate for help,” says Martin Buser, MPH, FACHE, a partner in Hospitalist Management Resources, LLC, in San Diego. “Smart practices are looking at NPPs, evaluating where they do the most good, and then setting out their role and expectations based on these needs and the practice environment.”
Hiring mistakes can be compounded if the NPP is not a good match to the job description or group expectations. If the practice hires an NPP fresh out of school, the group will need to establish training and have the new hire work more closely with physicians. If, on the other hand, an NP has 10 years of experience in an ICU, or a PA has worked in the ED for the past five years, a higher level of autonomy can be granted sooner. However, NPPs with established backgrounds are almost as rare as experienced hospitalists (see “Integrating NPPs Into HM Practice,” p. 38).
Inevitably, there will be changes in the interactions between patients and the hospitalists, as both physicians and NPPs become more comfortable with the other’s practice style, as well as each other’s strengths and weaknesses.
MD-to-NPP Ratio Varies
The practice structure and optimal mix of NPPs to MDs is something that will be specific to the hospitalist group. “We don’t really have good studies on this subject,” Buser says. “I usually get worried when we exceed two NPPs to one MD.”
Others disagree. Dr. Parekh, who works in an academic center, says his group has been successful having one MD work with as many as three NPPs. At the other end, Dr. Wilson says his 10 years of experience suggest 1:1 is the most efficient ratio.
However, all of them agree that having one NPP work with more than one physician is not sustainable. The NPP will be less familiar with each doctor’s practice style, what kind of information they need, and how things should be presented. If two or more hospitalists share an NPP, there can be internal friction over division of the NPP’s time, as well as extending the time before the MDs have a good feel for the NPP’s strengths and weaknesses.
In the final analysis, the HM group has to look at the amount and type of work available. In some cases, it will make financial and clinical sense to bring on an NPP. Under other circumstances, an FTE hospitalist is the best fit.
“Sustainability, quality, and efficiency are the drivers for NPP/MD teams. Increasing pressure to offset program costs is not,” Dr. Wilson says. “You do it because it helps sustain the program, helps with recruiting, and effects your efficiency.” TH