Helping hands

The nation's healthcare system is said to be facing a physician shortage just as 30 million uninsured individuals are about to enter the patient pool and threaten to overload an already stressed system.

The answer, say some, is better and wider use of nurse practitioners and physician assistants, sometimes called “physician extenders” or “mid-levels,” who can handle routine procedures and office visits, which would allow doctors more time to see new patients or those with more complex conditions.

That's the theory at least, and the phrase in vogue now is to have mid-levels “practice to the top of their license.”

In practice, however, the picture is murky, as licensing requirements and scope of practice limits can vary widely, and “top of their license” can have a different definition from state to state and office to office. While the underlying desire is to maintain flexibility, no one appears eager to draw any bright lines.

In such a climate, turf wars are inevitable. The most public of these is the fight between primary-care doctors and the retail clinic industry, whose facilities are usually staffed by NPs and which recently added the management of chronic conditions onto their list of services—much to the chagrin of the American Academy of Family Physicians. But smaller battles are also likely to break out in some practices where physician compensation is based on productivity and that productivity gets diminished by a physician assistant mostly earning a straight salary.

When the American Medical Association's House of Delegates meets next month, one of the items before it will be a resolution introduced by the Medical Society of the State of New York, which notes how the federal government and insurance companies are promoting the use of physician extenders “in an effort to save money,” and how these extenders lack the medical school education and residency training needed to “examine, diagnose and treat” patients.

A representative from the MSSNY could not be reached for comment, but its resolution calls on the AMA to study government or managed-care programs where mid-levels practice independently and “insist that there be Level I evidence to demonstrate that there is no diminution in the quality of patient care by programs that use nonphysician extenders.”

This is somewhat surprising as Ann Davis, a physician assistant and senior director for state advocacy for the American Academy of Physician Assistants, says New York has one of the better PA licensing laws in the nation. Other states she cited were Alaska, Arizona, California, Michigan, North Carolina and Wyoming. The fact that these states have large rural expanses is not a coincidence, she says.

“People in rural communities are very pragmatic in how they need to allow physician assistants to get in there to do what needs to be done,” Davis says, adding that, in 1978, she was the first PA to practice in Flagstaff, Ariz. “Wyoming and Alaska, in particular, have led the nation in PA utilization—even though they don't have PA schools.”

Davis, however, highlights North Dakota and Rhode Island as perhaps being the most PA-friendly states because their physician-assistant licensing laws contain all six of the key elements that the AAPA says a state physician assistant practice act should contain.

These elements are using “licensure” as a regulatory term (not “registration”); full prescriptive authority; scope of practice determined at the practice site; adaptable supervision requirements; chart co-signature requirements determined at the practice site; and the number of physician assistants a physician may supervise is determined at the practice level.

In North Dakota this year, state lawmakers passed legislation that eliminated the requirement that nurse practitioners need to collaborate with a physician in order to prescribe medications. Although opposed by the North Dakota Medical Association, the bill passed the state Senate 33-11 and the state House 85-7 before being signed by Gov. Jack Dalrymple on April 1.

“You want state laws to allow people to provide all the care they are able to provide without having barriers that serve no purpose other than to deny people care,” Davis says.

To promote flexibility, instead of “practicing to the top of their license,” Davis says the AAPA puts it another way. “We prefer to say ‘practice to the top of your training and experience,'” she says, adding that—with new technology constantly being introduced—“having a list of laws stating what PAs can and can't do doesn't apply anymore.”

A representative from the American Academy of Nurse Practitioners could not be reached for comment.

Kim Mobley, managing principal at physician compensation consulting firm Sullivan, Cotter and Associates, says mid-level providers are best suited for underserved areas or busy practices. In more low-volume practices, especially if the mid-levels are on salary and doctors have productivity-based compensation, there can be issues where the physician extenders are taking away the relative value units used to calculate physician Medicare pay.

“Physicians who are at full capacity, they're pretty comfortable,” Mobley says. “But how do you expand the use of mid-level providers and have them work to the top of their license without taking money from physicians? If PAs start doing a couple of procedures, physicians may say, ‘You're taking my easily earned RVUs.' ”

According to Mobley, the trend toward more physicians being employed by hospital systems is complicated by the presence of physician extenders.

“We're seeing a lot of physicians becoming employed and moving into a medical group,” she says. “But if we put our physicians into a medical group, where do we house our mid-level providers? If the health system bills for their service, they might get a different rate than if they were with the medical group.”

Mobley says the arrangement also can affect how doctors can bill for their supervision of physician assistants and nurse practitioners.

She predicts that soon more mid-level providers will have more incentives built into their compensation, and that—as mid-levels become more specialized—their compensation structure will begin to reflect even more the specialty of their supervising physician. “I wouldn't be surprised if they started providing some sort of on-call pay,” Mobley says.

Cynthia Dunn, a principal with the Medical Group Management Association Health Care Consulting Group, says mid-level compensation and scope of practice are all over the map.

“Some people are really turning to mid-levels as they realize the value they bring,” Dunn says. “But there is still a lot of struggle, because there is no set standard out there.”

Issues being wrestled with include whether mid-levels are assigned to a specific doctor or do they handle general duties at a practice or hospital? Do they go on rounds? And can they take on-call rotations? Dunn says.

According to the AAPA's 2009 National Physician Assistant Census Report, 28% of PAs were taking on-call rotations.

Compensation issues often revolve around bonus incentives such as meeting quality or productivity targets, but Dunn says some practices don't allow mid-levels to see the charges and revenue they contribute to the organization.

“Some practices say, ‘We can't tell you how much you bring in,' ” she says.

Dunn adds that, particularly with surgeries, it can be difficult to calculate the value a PA brings to the equation, and so the benefits may fall under the “quality of life” umbrella. She says, for example, some payers will not cover the cost of having a PA in the operating room, but the PA's presence may allow a surgeon to do more surgeries.

According to the AAPA, there are almost 89,000 people eligible to practice as PAs nationwide, with almost 75,000 actually doing so. According to the American Academy of Nurse Practitioners, there are about 140,000 NPs currently in practice. The average PA educational program takes 26.5 months to complete and, after completing an accredited program, PA candidates must pass a national certifying test. The AANP says NPs first finish a four-year program to obtain a nursing degree, followed by two to four years of additional training.

Both professions are gaining a higher profile. Individuals in the news recently included Bob Donaldson, an NP and clinical director of emergency medicine at 25-bed Ellenville (N.Y.) Regional Hospital, who was elected president of the critical-access hospital's medical staff. Also, at 66-bed Col. Florence A. Blanchfield Army Community Hospital in Fort Campbell, Ky., a May 13 ceremony was held dedicating the Capt. Sean P. Grimes Physician Assistant Training Center. Grimes died March 4, 2005, in Iraq when the vehicle he was riding in hit a bomb. He is believed to be the first military PA killed in action.

NPs received a lot of attention when retail clinics emerged as a new healthcare setting in the early 2000s and saw early explosive growth. But despite the attention over how many of these clinics are staffed and run by NPs, they do not appear to be a major factor in NP employment. In the AANP's 2009 membership survey, only 3.4% of the almost 2,268 respondents said a retail clinic was their main practice setting. While this was a jump compared with the 2006 figure of 0.4%; it was still relatively insignificant compared to the top two settings: private physician office, 26.3%; and hospital inpatient, 9.5%.

In a larger survey conducted by the AANP in 2009-10, only 2% of the almost 14,000 respondents said their main practice setting was a retail clinic—compared with 27.9% who worked in a private physician office. (According to the AAPA's 2009 National Physician Assistant Census, only 0.2% of PAs work in a retail clinic.)

In 2006, the American Academy of Family Physicians and the retail- or “convenient-care” clinic industry had come to something of a truce, with the AAFP drawing up a set of standards that many of the market's major players agreed to follow. One of those standards was a “well-defined and limited scope of clinical practices.”

The AAFP changed its stance early last year after some retail clinics expanded their scope to include management of diabetes and hypertension, and the organization came out in opposition to nurse practitioners at these clinics providing diagnosis, treatment and management of chronic medical conditions.

“We did have a common agreement with the major retail clinics, but that was dissolved,” says Dr. Roland Goertz, president of the AAFP. “We firmly believe the healthcare system's problems are a result of uncoordinated care and a lack of communication. The creation of more fragmented access points does not fix the ills we are trying to fix.”

That said, Goertz says mid-level providers are needed and that NPs and PAs can be valuable members of a physician-led medical home team. “The primary-care workforce shortage has been around for years, and we're glad that people are finally concerned about it and want to help fix it—so to speak—but we believe it should be done in a coordinated way,” he says. “The patients want doctors and nurses and PAs all working together, not separately, and the patient-centered medical home allows that to be done.”

Goertz also has his own take on NPs and PAs “working to the top of their license.”

“The world out there confuses competency and training with licensing and credentialing,” he says. “When someone says ‘to the top of their license,' it's not the same as to the top of their training. The patient-centered medical home model says every nurse on the team uses their competency and their training to the top of their ability to make the care the best it can be. Often, it's what's right for the patient vs. what's right for the business model.”

Donald Fisher, president and CEO of the American Medical Group Association, says it's appropriate for mid-level providers at retail clinics to provide chronic-condition management—if the facility is linked with a local primary-care practice or health system.

“It's appropriate if it works for the patient,” he says. “The problem is when they're not connected and there's not a built-in referral system and oversight.”

Fisher says wider use of NPs and PAs solves several problems including alleviating the primary-care physician shortage and improving the primary-care experience, which has evolved into something that is unsatisfying for the patient and doctor alike.

“A schedule filled with 15-minute appointments is not rewarding,” Fisher says, adding that it's also a frustratingly short time to deal with a patient who has three or more co-morbid conditions—for both parties. “Patients don't feel like they get a fair shake.”

Fisher's vision for a primary-care office involves most routine visits being handled by NPs and PAs, while doctors see new patients and are otherwise “on call” to step in and take as much time as needed with patients who have complex conditions.

“Patients love it when they have the full attention of the physician,” Fisher says.

“You could really expand your capacity this way,” he says. “PAs and NPs are well trained and competent, and the idea here is, ‘Let's use them to their full capacity,' or—as I like to put it—to the top of their license.”