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The nurse practitioner will see you now: advanced practice providers the physician gap.

With physician shortfall projections hovering at 63,000 by 2015, the promise of 32 million more Americans gaining health insurance, and a patient population rapidly aging and saddled with chronic disease, hospitals are scrambling to line up caregivers.

One strategy gaining momentum is the increasing use of nurse practitioners and physician assistants, clinicians who do much of the same work a physician does at about half the cost.

NPs and PAs commonly are called midlevel providers, though that term has its critics. The American Academy of Physician Assistants, the American Academy of Nurse Practitioners and several other organizations say it implies a lower level of service. They prefer such terms as advanced practice providers.

NPs and PAs, found among almost all medical and surgical settings, often are a patients primary provider, particularly in rural areas. Much of their practice areas overlap, and they are trained similarly in diagnosing and treating medical conditions, ordering tests or therapy, counseling patients and families, and prescribing medicine. PAs must be supervised by physicians by law; NPs are licensed to practice independently in some states, though laws vary widely.

What's universal is the potential to spend less for services physicians typically provide. Savings come in the form of lower salaries and lower liability insurance, the ability to add more patients to the schedule and the potential to free up doctors to take care of higher-risk procedures.

Salaries for the two professions are similar: NPs make on average $89,450 in base salary, according to 2009 AANP salary data. For PAs, the median salary is $87,500, according to the AAPA. Both are less than half the annual salary for a physician who treats adults.

Medicare reimbursement also works in favor of a hospital using advanced practice nurses, says Tricia Marriott, director of reimbursement policy for the AAPA.

"The first struggle most hospitals have is figuring out how to get reimbursed for the work the PA is doing," she notes. "You bill Medicare as a professional under the PA's national provider-identifier number. You get reimbursed under Medicare at 85 percent of the physician rate. However, you're not paying that PA 85 percent of the physician's salary. You're typically paying them less than that. So, for the same work that a physician would have to do, you're actually getting paid more for the PA's work" NPs are reimbursed the same way.

By delegating duties such as daily rounds and admissions to mid-levels, "the physician can go and take care of the higher-risk, higher-energy admissions, medical interventions and procedures," she adds.

Advanced practice nurses also can help in a casualty event such as an ice storm when ankle fractures pour in. While a doctor may be on call for several hospitals, a PA or NP could take care of the X-rays, decide whether to medicate the patient and make a huge difference in length of stay or waiting times, Marriott says.

"I've been in that situation where I had to beg for FTEs ... to add extra people in the operating room so the surgeons could get two more total joint replacements done in a day," Marriott says. "Think about the facility fee and the revenue for those two extra cases in a day. And what was the cost of that PA's salary for the day?"

Essential Rural Caregivers

Bobbe Teigen, CEO of Paynesville Area Health Care System in central Minnesota, says availability of NPs and PAs is particularly important in rural settings like her own where one health care provider sees about 1,000 patients and hiring a physician may take a year or two.

Paynesville increasingly is hiring NPs and PAs for the hospital and outlying clinics, and the system now has about a 1-to-1 ratio of advanced practiced nurses to physicians, Teigen says.

Many of Paynesville's advanced practice nurses have their own patients and run their own clinics. By law, PAs must have some level of supervision by a physician, but the amount of supervision varies by state and doesn't always mean they have to be in the same room.

"You get out in a very rural area--you may have only a couple of physicians and they're trying to run a 24/7 emergency department," she says. "The physicians can't cover all those shifts, so they often depend on mid-levels and communicate carefully with them."

Teigen says her organization invests about six months to a year in "training them, getting them up to speed and building their confidence."

Recruiting Becomes Competitive

Advanced practice hiring even has increased in areas that have not had great difficulty in finding and retaining enough physicians.

Ron Byerly, director of the Advanced Practice Council at Geisinger Health System in Danville, Pa., says there has been a surge in hiring NPs and PAs even though Geisinger hasn't been hit too hard by the physician shortage. In this fiscal year, Geisinger has hired 62 of the 66 new budgeted advanced practice positions, more than twice the number hired in the previous fiscal year.

Ratios of advanced practice providers to physicians are determined by state law, and needs also vary by hospital department. For example, Geisinger has 15 physicians and two physician assistants in the internal medicine outpatient clinic, but six physicians and 12 PAs in neurosurgery, Byerly says.

Geisinger offers incentives beyond base salary. Advanced practice providers get pay incentives based on such benchmarks as patient satisfaction and their use of patient portals in the system's electronic medical record.

"In my experience, it's relatively unusual for advanced practitioners to get any incentives," Byerly says.

Henry Ford Health Care System in Detroit long has recognized the value of advanced practice providers in complementing the physician staff, says Folusho Ogunfiditimi, manager of the Mid-Level Provider Program at Henry Ford. The health system has increased its numbers of NPs and PAs by about 50 percent over the past five years, he says, fueled partly by the opening of a new hospital whose inpatient staff primarily is made up of advanced practice providers.

Ogunfiditimi says the cost-benefit analysis makes sense even with lengthy acclimation periods. It can take up to a year before advanced practice providers feel comfortable in their roles. While they have the educational and clinical background to adapt quickly to clinical demands, whether in previous roles as RNs, EMTs or surgical techs, they have to learn the delivery side of the profession, he says.

"As a practitioner you know that if a patient has this symptom I can treat it with this or that. But what they don't show you is how you deal with a patient who doesn't have adequate insurance," Ogunfiditimi says.

It's becoming increasingly difficult to recruit NPs and PAs, he says. While it's still easier to recruit advanced practice providers than physicians, the time from the start of recruiting to getting someone in the door is about three months, Ogunfiditimi says. It will become more challenging, just as it is for physicians--especially in primary care--if the incentives don't improve, he says.

Janet Baer-Lile, owner of Cornerstone Medical Recruiting in St. Louis, agrees that advanced practice providers are gaining power at the negotiating table. She started Cornerstone two years ago to recruit only those kinds of providers after working in physician recruitment and noted the climbing demand. Hospitals may need to get more creative in job offers to land the best NPs and PAs, Baer-Lile says. More of them will be looking for incentives such as signing bonuses--at least $5,000, she says--and help with repayment of school loans.

"These are master's-trained individuals who have put a big financial investment into their career. They need help," Baer-Lile says.

Debate Over Scope of Practice

Not all providers think expanding the use of advanced practice nurses is a good idea, and opposition has led to limits on how NPs and PAs can practice. State laws vary widely in what substances can be prescribed by these providers, whether they can practice independently, what procedures they are permitted to perform and how many a physician may directly supervise. For example, NPs can't prescribe controlled substances in Florida and Alabama, and some states require full physician supervision of NPs, whereas in other states NPs can operate without physician involvement.

"If an NP [in Alabama] has a patient who has pain, they are unable to really treat that patient appropriately because of the restrictions on their practice," says Penny Kaye Jensen, president of AANP. "That patient would have to then find another provider--a physician--to treat the pain. That person might have to present to the emergency room because they can't get the care they should really be able to get from one provider."

The Institute of Medicine weighed in on this issue in its 2010 report "The Future of Nursing: Leading Change, Advancing Health." Among its conclusions were that current laws in some states were hampering the ability of advanced practice nurses to contribute to innovative health care delivery solutions.

The IOM called on the federal government to get rid of outdated scope-of-practice variances and reform advanced practice nursing by disseminating best practices across the country and creating incentives for their adoption. States with broader nursing scopes of practice have experienced no deterioration of patient care, the IOM noted.

The American Medical Association is fighting proposals in about 28 states that are considering steps to expand what nurse practitioners can do. In a statement in response to the October IOM report, the AMA said it is "committed to expanding the health care workforce, so patients have access to the care they need when they need it. With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage."

What's Best for Your Community?

While it may not be the only answer, adding NPs and PAs has been shown to enhance care and extend the provider pool for a health system strained by demand.

More than 14,000 NPs and PAs graduate each year, and the numbers in clinical practice have doubled in the last 15 years. Their appeal may increase now that the Accreditation Council on Graduate Medical Education restrictions have gone into effect, reducing the number of continuous duty hours first-year residents can work. Shifts that now span 24 hours will be capped at 16 hours, and another provider will need to pick up the slack.

But no one provider model will work for all hospitals, says Pamela Thompson, R.N., CEO of the American Organization of Nurse Executives, an American Hospital Association subsidiary, the guiding principle is that having coverage doesn't mean you have access," she says. "Hospitals need to look at how best to meet the needs of the population they serve. In some areas that's going to be by increasing the number of primary care physicians. In some cases that will be by increasing the team that cares for the patient."

Thompson adds, "If we do our planning based on what we've identified as the needs of the community--what our patients require in order to receive the quality care that we want to provide for them--we can design our systems around meeting that and putting in place the best providers for that care."--Marcia Frellick is a freelance writer in Chicago.

RELATED ARTICLE: Quality, continuity in the ICU.


Nurse practitioners and physician assistants have been used increasingly in intensive care units with promising results, says Ruth Kleinpell, R.N., director of the Center for Clinical Research and Scholarship at Rush University Medical Center in Chicago.

She co-authored a review of the literature in 2008 for Critical Care Medicine and found that research shows that integrating NPs and PAs into intensive care units enhances patient care and that outcomes are similar to those of resident physicians.

One driver of those results, Kleinpell says, is that NPs and PAs offer continuity of care in overseeing admission, management and discharge planning as opposed to care under medical residents and fellows who are rotated in and out of settings as they train.

"Also, by virtue of their background and training ... they are used to educating patients and families," she notes.

Beyond direct patient care, Kleinpell says advanced practice nurses are improving quality and safety with quality-improvement projects by teaching colleagues and by making sure evidence-based best practice protocols are being used.

The benefits of integrating NPs and PAs come without added liability costs to hospitals, she says. "Actually, there's some thought that patients and families are more satisfied and less likely to bring up litigation because there's someone there who's coordinating their care and educating more," she says.--MARCIA FRELLICK

RELATED ARTICLE: Bringing peace to turf wars.

The success of physician assistants and nurse practitioners in delivering quality, cost-effective patient care has much to do with their relationship with physicians.


Because duties overlap and because advanced level providers are growing in numbers and influence, hospitals must be clear before an NP or PA is hired as to how the relationship with physicians will work--everything from what duties will be performed to how schedules and billing will be handled.

"Generally the physicians will welcome the help, but you need to have a very frank conversation up front," says Tricia Marriott, director of reimbursement policy for the American Academy of Physician Assistants. A physician needs to be aware that if a PA or NP is assigned a task, they will bill for it. Some physicians will not be comfortable with that and will decide to do a task themselves. Others will happily delegate.


Learning together is one way to increase teamwork, Marriott says. "We only practice what the physician delegates to us and what the physician knows how to do. If he learns a new procedure he should be bringing his PA along, and in my experience, that's what happens."

Even when advanced practice nurses know what needs to be done, physicians must be engaged in the decisions and be respected as "captain of the ship," she says. Mutual respect, she says, has grown now that physicians are starting to receive more training alongside PAs and NPs.

Penny Kaye Jensen, president of the American Academy of Nurse Practitioners, says interprofessional teams learning together, rather than in parallel but separate tracks, is crucial to patient-centered care. A pilot program to establish Centers of Excellence in Primary Care at five selected Veterans Administration centers starts later this year and is an example of that kind of training, she says. Each center will be federally funded at a level of approximately $1 million per year for five years.

"Our system will have a nurse practitioner student actually co-managing panels with medical residents and working as a team. Within the VA system it's called patient-aligned care teams, but on the outside it's called the medical home model," Jensen says.

Ron Byerly, a physician assistant at Geisinger Health System in Danville, Pa., says he sees turf wars not so much between physicians and advanced practice nurses but between NPs and PAs, who traditionally have competed for jobs and salaries. Twenty years ago, he says, PAs made more than NPs for doing the same job, but that has since leveled out.

Byerly helps lead the Advanced Practice Council at Geisinger, a group established almost two years ago to help resolve such issues. Collaboration starts with having three directors--one each for NPs, PAs and certified registered nurse anesthetists--with equal access to the administration.

"We decided right from the start that we were going to close that chasm to recognize our differences and recognize that 90-plus percent of what we do, especially between nurse practitioners and PAs, is so similar that it's not worth an argument," he says.--MARICA FRELLICK
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Title Annotation:WORKFORCE
Author:Frellick, Marcia
Publication:H&HN Hospitals & Health Networks
Date:Jul 1, 2011
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