Ongoing barriers
There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”
On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.
If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.
Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.
Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.
Summary and future
In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.
References
1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.
2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.
3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.