It is an understatement to say that there is a nationwide shortage of doctors. Efforts at the national and state levels, such as in Massachusetts, to provide health insurance for everyone has aggravated the shortage problem. We now have an insured populace that can’t get access to timely health care.
At first glance, one might say this is great for the medical profession, but not so. Primary care and specialty doctors alike are stretched to the limit with appointment schedules extending further out. Meanwhile, the costs of administering health care continue to outpace increases in reimbursement rates. Federal and state programs and legislation to increase reimbursements and offer incentives for young people to enter the medical field are still in the early stages and may take years to come to fruition. Therefore, doctors need to find ways to increase revenues while still maintaining the quality of health care services rendered to patients.
One of the most effective ways many practices are finding relief is by recruiting non-physician practitioners (NPPs). In the past decade there has been a proliferation of NPPs employed in doctors’ offices and facility settings. There are numerous categories of NPPs, including nurse practitioners (NPs), certified nurse midwives (CNMs), physician assistants (PAs), certified nurse anesthetists (CNAs), physical therapists (PTs), audiologists, and the list goes on. Within these categories you may find additional areas of subspecialties, such as hematology, oncology, cardiology, pediatrics, and more, depending on the level of education, training, and certification.
A doctor can work only a finite number of hours and see only a limited number of patients in a given time period. Utilizing NPPs enables doctors to leverage their services and sometimes even expand the range of services they can provide.
The success of hiring NPPs depends on the way in which they are utilized in the practice. Many are underutilized, and some are utilized in a non-compliant manner. If trained and utilized properly, they should, depending on the specialty, generate collected revenue of two and a half to three times their direct compensation. But if they are not utilized in accordance with federal and state regulations, i.e., not properly supervised, it could spell disaster for the medical practice.
The purpose of this article is to provide some general guidelines to assist doctors in making the best utilization of NPPs, including determining how to select the right NPP, how to utilize them in a compliant manner, and how to integrate them into your practice.
What Can They Do?
NPPs are health care providers. As such, they are also revenue generators for the practice. Utilizing them for non-patient care, such as in administrative support roles, is as much of a waste as using a doctor to schedule patient visits. Such non-clinical utilization should only happen when there are no patients waiting to be seen. In other words, it should be the exception, not the norm.
They can render whatever services they are qualified for by knowledge, training, and clinical skills acquired, including the evaluation, diagnosis, and treatment of patients with diseases and adverse health conditions. They can manage therapeutic regimens for acute and chronic problems associated with diseases and conditions. Some can also issue written or oral prescriptions for controlled substances or other medications. All NPPs who prescribe controlled substances must register with the DEA, and some need a state controlled-substances license.
All of the above must be within the scope of practice as permitted by the state or other jurisdiction under which they are licensed to practice. For example, the scope of practice for NPs, CNMs, and CNAs in Massachusetts can be found on the Web site www.mass.gov, by searching for ‘boards of registration.’ A list will follow to choose from.
Select ‘Board of Registration in Nursing,’ and you will find that agency’s site. Select ‘Rules and Regulations,’ and you will find CMR 244-4.00, “Mass. Regulations Governing the Practice of Nursing in the Expanded Role.” If you select ‘Physician Assistant.’ you would find the site of the Board of Registration of Physician Assistants and eventually locate CMR 263-5.04, “Scope of Services Which May Be Performed.”
Generally, most services rendered by NPPs are E/M services, minor office-based procedures, and ancillary diagnostic procedures. Of course CNMs, PAs, and CNAs also may perform in hospital and other surgical settings.
How to Choose an NPP
Deciding on what type of NPP to recruit for your practice obviously hinges on your specialty, but there are some grey areas and overlap. For example, a certified midwife can perform deliveries, whereas a nurse practitioner generally can’t. However, both a CNM and an NP can see obstetric and gynecology patients in the office setting. Nurse practitioners are licensed to work independently in some states, whereas physician assistants require some level of physician supervision. Also, you should check with your third-party payers to determine their reimbursement policies toward the various NPP categories.
A good start is to develop a job description that specifies exactly what responsibilities and duties you expect that individual to do, whether you expect the NPP to do hospital rounding, take call, work independently at times without supervision, or build his or her own panel of patients. You should also include prescribing levels you would like the NPP to have.
NPPs are licensed professional health care providers. As such, they should be afforded the appropriate level of courtesy, cooperation, and respect from the support staff. Before introducing the new practitioner, doctors should share their objectives and expectations with the support staff.
The introduction of the NPP should be well-advertised in the local media, on the practice Web site, and throughout the medical community and patient base with direct mail, including a photograph, a brief CV, and a description of the patient services the NPP can provide. Adding the NPP to the practice signage, inside and outside, as well as on the practice stationery should be done as soon as practical and, ideally, prior to the NPP’s first day of practice.
Instruct support staff on how to book appointments for the NPP. Call patients who are scheduled weeks away and offer to have them seen much sooner by the NPP. If patient visits are running late, offer patients the opportunity to be seen right away by the NPP rather than waiting another half-hour or more to see the doctor.
Doctors initiating a plan of care should introduce the NPP to the patient for followup visits, always giving the patient the option of waiting and seeing the doctor instead.
Be sure the NPP has adequate resources and facilities to do what is required, including availability of exam rooms, medical assistants, and private office space, even if it is shared with other practitioners.
The practice should set targets for patient visits and income generation so that the NPP knows what the expectations are. Frequent meetings with the NPP should be initially scheduled to monitor performance, review and set goals, and maintain an ongoing training program.
All doctors and support staff in the practice need to be on board with this and committed to making it a mutually rewarding and pleasant experience.
James B. Calnan, CPA, is partner-in-charge of the Health Care Services Division of Meyers Brothers Kalicka, P.C., certified public accountants and business consultants, in Holyoke; (413) 536-8510.