May 2016 article by Rob Rohatsch
Making the Strategic Provider Staffing Decision
Throughout my career as an emergency medicine physician and as an entrepreneur in urgent care medicine, I have had the pleasure of working with many nurse practitioners (NPs) and physician assistants (PAs) in various staffing models. In the emergency department (ED) during residency, they were typically assigned to a section of the department where lower acuity cases were triaged. In my program, they were almost exclusively NPs. They functioned fairly independently from the physicians but had full access when they had questions. Their scope of practice in the ED was controlled by the triage nurse with protocols established based on the chief complaint of the patient. There are some studies that suggest nearly 15% of all patients seen in an ED are seen by either a PA or NP. After residency, as an attending physician in emergency medicine, I worked with primarily PAs under two different staffing models. In one large urban ED, I worked with PAs assigned to a ‘fast-track’ area of the ED and had patients triaged to them in a similar manner to my residency experience. In a smaller ED I worked in, I worked along side a PA and we saw patients in an alternating fashion with no triaging based on acuity. My experience as an ED physician indelibly etched in my mind their value in an acute care setting.
The US health care system is the most costly in the world, accounting for an estimated 20% of the gross domestic product by 2020. In an attempt to mitigate this alarming statistic, the Institute for Healthcare Improvement (IHI) developed the Triple Aim framework in 2007.
Improving the patient experience
Improving the health of populations
Reducing the per capita cost of health care
So how can we as operators of walk in healthcare services work towards the IHI goals? Can something as simple as a staffing model change yield improvements in all three areas? How do the policies of payers, government agencies, and other competing interests confound the ability to make a strategic decision on provider staffing models? A review of the literature on the subject provides some interesting results. There is a paucity of data regarding the use of NPs and PAs in the urgent care setting. However there are many studies that examine their role in both primary care and the emergency departments. NPs and PAs have been used in emergency departments for many years. Recently the use of these providers has plateaued representing as high as 40% of the workforce in some EDs.
As the on-demand sector increasingly shifts into payer and health system models, this staffing decision becomes strategic because their platform is based on core, often unvetted assumptions on provider staffing. Payer, system, and/or state-level regulatory requirements for an on-site physician at all times can derail profitability targets. Decisions pertaining to how an operator should staff a center in the on-demand sector directly impacts, and is directly impacted by, these goals. If a physician, PA, or an NP can each meet the goals of routine visits, how should a center be staffed?
With the Affordable Care Act in full swing, PAs and NPs are assuming a pivotal place in the future of healthcare. Dino Soriano is the CEO and founder of ClinicalMatchMe, a preceptor NP/PA matching company that pays providers to work with NP students doing their clinical rotation requirements. He states it this way, “ I place NPs and PAs all over the country for the sole purpose of helping them finish their training. The real benefit, however, is that the business model really serves as an on-the-job interview. I get feedback all the time from physicians that tell me they found real value in working with NPs and PAs. Many of these rotations end up in a job offer.” For the purposes of this article, we will be using the commonly accepted term of NPP (non-physician provider) to refer to PAs and NPs. Where studies only looked at one or the other, I will reference the individual specialty.
Improving the patient experience
There have been multiple studies looking at patient satisfaction, which clearly is improved using NPPs. However, the triple aim does not address patient satisfaction in a vacuum. It is about the patient experience, which includes the six dimensions of the Institute of Medicine’s concept of the patient experience; safe, effective, patient-centered, timely, efficient, and equitable. Many scholarly articles exist that indicate NPPs provide equivalent, and in many cases, superior patient satisfaction that touches on all six dimensions of the patient experience. In several large health systems we have worked with as well as private operators, it is often that one or two NPPs consistently obtain the highest patient satisfaction scores and even earn the highest net promoter score which we know leads directly to profits and growth within an organization. According to Dr. Eric Powell, Medical Director for AppleCare Immediate Care in Georgia, “ Years ago, people wanted to see doctors. Now that has all changed. Patients have accepted that NPs and PAs provide great care and that has been beneficial to our model. The patient perception of their care is equivalent to when being provided by a physician.”
Improving the health of a population
A recent article in BMJ concluded that NPs in primary care roles have equivalent or better clinical outcomes than physicians in ambulatory care settings. Additionally, the Institute of Medicine has recommended eliminating the restrictions on NPs that impact their ability to provide care. None of this is new. In 1986 the Office of Technology Assessment concluded that “within their area of competence, NPs, PAs and CNMs (certified nurse midwives) provide care whose quality is equivalent to that of care provided by physicians.” Anecdotal evidence is abundant in the urgent care field with many healthcare institutions and larger private operators, many backed by private equity dollars, moving to a mixed model of physicians and NPPs. Dr. Jeannie Kenkare, chief medical officer for PhysicianOne Urgent Care in Connecticut and New York stated, “Some of our best providers in terms of quality of care are PAs and NPs. We still have a legal and ethical obligation to supervise them, and we do, but our chart review results are clear; our PAs and NPs provide outstanding care to our patient population.” Some institutions have adopted procedures that allow substantial oversight until the NPP has exhibited a proficiency in the skill sets necessary to work alone in an urgent care setting. Dr. Nandini Koka, Medical Director for Inova Health System Urgent Care in northern Virgina describes her onboarding program this way, “In bringing on an experienced NP, we provide a robust 2 week training program. Then we have the NP work along side a specific physician trainer for several months before allowing them to work at a site alone. We focus on hiring experienced NPs and have found that the quality of the care we provide is great.” Having well run, efficient urgent care centers contributes to the health of a population. Dr. Kenkare pointed out, “This is about access. If we build in efficiencies through creative staffing models, that only helps our company grow and allows us to provide even more access to our population base.”
Reducing per capita health care costs
There are plenty of data to suggest that overall costs of healthcare go down with NPPs in comparison to physicians. This might seem intuitive given the pay differential between the two professions. But there is more to it. Other factors trend favorable to NPPs in the economics such as supply utilization, readmission data, etc. Much of this data is from the emergency medicine world. Again, there is a paucity of data within urgent care medicine, but much can be extrapolated from the emergency medicine literature. In one study describing the economic impact of NPPs in an emergency department, the following data points were discussed. The average cost of an emergency medicine NPP in 2014 was $114,000 per year, or about 25-35% of a board certified emergency physician. In this particular institution, the NPP saw 1.6 patients per hour or about 80% of the productivity of a physician. When adjusting the cost of a NPP for this variance in productivity there is a 50% decrease in the cost of care using only these two factors. There is no doubt that the utilization of NPPs yields a reduction in overall health costs. Physicians need not worry, their salaries across all specialties goes up in practices that utilize NPPs. The data in this are clear. In general terms, if you utilize NPPs in your practice, you will take home more money.
How do PAs and NPs differ?
The training and ability of both disciplines are similar. The largest difference lies in a cultural gap and often, practice expectations, which can directly impact how your operation performs. On a state by state basis, NPs are being granted more and more autonomy to practice in a solo environment, so their job satisfaction in an ED or a busy urgent care center that is double staffed, may not rise to their expectations due to a culture geared toward solo practice. However, as a solo practitioner in a single provider staffed urgent care center a NP may find career satisfaction. PAs on the other hand, seem to be comfortable with career goals that take them along parallel paths with physicians, often being used to leverage a physician’s workload. “We don’t really see much of a difference in PAs and NPs.” Dr. Powell said, “we view them both as an extension of the physician.” Some health systems have made a strategic decision to use either just PAs or just NPs due to constraining legislative and payer policies. “We use exclusively NPs in our centers. We came to that decision not because we felt there was a disparity in ability, but because regulatory requirements forced our hand.” said Nandini. The bottom line here is that when you control for experience, PAs and NPs can both handle the clinical complexities seen in the on-demand setting on an equal basis. Dr. Kenkare, who employs both PAs and NPs mentioned, “Experience trumps everything. If I have a PA in front of me with 8 years experience and a new grad NP, there is no contest.”
Number practicing in the U.S.
110,200 as of 2012, according to the Bureau of Labor Statistics (BLS).
86,700 as of 2012, according to the BLS.
The mean annual wage, as of May 2013, was $95,070, or $45.71 per hour for NPs, according to the BLS.
Annual mean wages for PAs, as of 2013, were $94,350, or $45.36 per hour, the BLS reports.
Expected job growth
34 percent from 2012 to 2022, much faster than average for all occupations, according to the BLS.
38 percent from 2012 to 2022, much faster than average.
Anticipated number of new positions available by 2022
Currently, NPs need a minimum of a master’s degree from an accredited school to become licensed within a state. Even though the American Association of Colleges of Nursing (AACN) has recommended that the new NP standard be the Doctor of Nursing Practice (DNP) by 2015, states still just require a master’s or graduate degree.
PA’s need a minimum of a master’s degree from an accredited medical school or center of medicine to seek licensure.
A NP can seek a master’s or DNP from a nursing school, although the DNP is suggested by the AACN. In the U.S., there are 92 DNP programs available for nurse practitioners.
170 physician assistant programs, most of which were master’s degrees, were available in 2012, according to the BLS.
NPs typically choose a specialty area and need to complete 500 didactic hours and between 500 to 700 clinical hours.
PAs are trained as generalists and typically need to complete about 1,000 didactic hours and more than 2,000 clinical hours.
NP programs typically will be accredited through the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing, Inc. (ACEN). Click here to search for CCNE accredited schools.
PA programs are accredited through the Accreditation Review Commission on Education for the Physician Assistant, Inc.
Certification and Licensing
PAs need to pass the Physician Assistant National Certifying Examination (PANCE) available through the National Commission on Certification of Physician Assistants (NCCPA).
A RN license, a master’s or graduate degree and national certification are generally needed to seek state licensure.
A master’s degree from an accredited school and national certification are generally needed to seek state licensure.
NPs seek licensure through a state board of nursing or board of medical examiners.
PA seeks licensure through a state medical board, board of medical examiners or similar.
Details about the Job
NPs generally work with physician oversight. However, currently 250 practices in the U.S. are operated solely by NPs, and legislation is being pushed to expand the number of states that allow NPs to work autonomously from 16 to 30, according to The Washington Post.
PA cannot work independently of physicians.
Average number of prescriptions written per week
46.58 in 2013, according to a survey done by Advance Healthcare Network
49.76 in 2013
Average number of patients seen per week
56.28 in 2013, per the Advance study
61.11 in 2013
Average number of years in practice
8.9 years, per Advance Healthcare Network
11.97 in 2013
According to Clinical Advisor, the average salary in 2015 among all NPs is $99,471. The average salary among all PAs is $105,013. There are multiple surveys out there that look at national trends, however NPP salaries are driven from more geographic pressures such as payer policies on reimbursement, supervisory requirements, disparity in the number of training programs in the area, etc. Typically, NPPs will demand a slightly higher salary than their counterparts in a primary care setting due to weekend, evening, and holiday requirements. NPPs make slightly more in an ED than in an urgent care setting. Many urgent care operators have a bonus structure in place and use it for both physicians and NPPs. “We ask a lot from our NPPs. We ask them to work by themselves and function as independent as possible,” Kenkare said “so why not bonus them in the same manner as we do physicians?”
Obviously, the question of supervision is very state and payer specific. In a double coverage situation with an NPP as the second provider along side a physician, it would be quite easy to meet even the most restrictive state supervisory requirement. Things get more complicated once a supervising physician is not in the same office at the same time. In this second scenario, assuming state law around supervision is being met, a mechanism to allow real-time communication between the supervising physician and the NPPs must be established. Real-time Skype or “FaceTime”-like technologies allow for communication between the physician and the NPP. Regardless of state law, physician supervision should depend on several things: An NPP’s training, education and experience, the nature of the practice setting, the percent of complex cases seen, and the supervisory skill of the physician. According to Dr. Kenkare, “Our goal is to provide clinical coverage with 75% NPPs and 25% physicians so that one physician is supervising three NPPs. This exceeds the state supervision requirement ofa 1:6 ratio.”
The two scenarios
Likely, the first time an operator will face the decision whether to use a NPP or not will occur once a certain volume of patients is being seen in a single site. Most private operators would be comfortable with single provider coverage until around 3.5-4 patients per hour. A good way to track this in your own system would be to track door-to-door time and overall patient satisfaction. When the clinic gets busy and one or both of these numbers starts to trend off the benchmark, then it is time to start thinking about additional coverage. Thought needs to be given to the fact that once that second provider is in place costs will rise in the form of the additional provider as well as the ancillary staff required to support him/her. In all likelihood, four-wall earnings will drop for period of time until an additional 5-6 patients per day are realized thereby mitigating the cost increase. The gain from the decision to add an extra provider is also realized in less tangible ways such as maintaining good door-to-door times, increased patient satisfaction due to more ‘face time’ with the patient, etc.
Let’s look at a different scenario. An operator of a multisite platform wants to better control costs without losing any clinical quality or diminishing the patient experience. Let’s assume a ten center operation has single coverage in all sites and none are at the threshold for a second provider. One model to consider would be to hire NPPs to establish a well-defined ratio of NPPs to physicians. For example, based on state laws and the skill set and experience of the NPPs being considered, it is determined that a 1:4 physician to NPP ratio is appropriate. At this point a plan to replace 80% of physician coverage with NPP coverage needs to be developed. This can be accomplished through physician attrition or more aggressive human resource tactics. Obviously the background and skill set of the NPPs must be considered and robust training must be accomplished prior to the roll-out. Also, the method and real-time practice of physician supervision must be considered in detail.
Billing and Reimbursement
Medicare reimbursement for services rendered by NPPs is determined by federal Medicare policy. However, Medicare defers to state law when determining scope of practice. There are two ways a practice can bill under Medicare: as “incident to” services under the supervising physician’s name and National Provider Identification (NPI), or directly under the NPP’s NPI. Medicare has strict rules regarding “incident to” billing that is billed at 100% of the physician fee schedule. Normal direct billing under the NPP’s NPI reimburses at 85%. Requirements to bill “incident to” are beyond the scope of this article. Private payers typically either enroll the NPP and have the practice bill under their own NPI and the group tax ID, or they do not enroll them and have the practice bill under the supervising physician’s name and NPI. It is paramount to check with each payer to see how reimbursement for NPP services might change the practice revenues. Most groups that have looked at this have determined that due to the decreased cost associated with NPPs, the economics still make sense.
Recent payer requirements – A change in the tide?
Might all this be changing? Recently, several payers have been changing oversight requirements that may be designed more to increase payer profits than to increase patient safety. Aetna and various BCBS plans have been requiring physician presence on-site during open hours for many recent contracts. This is inconsistent nationally, where Aetna clients (health systems operating health plans with an Aetna back office) and BCBS-affiliated centers are not held to this same standard. Given the move to flat rate structures, premised on an NPP model to provide lower cost structures, but then requiring high cost unnecessary staffing seems counterintuitive. The payers are out of alignment with their own goals, which publicly they would agree to under triple aim.
As the urgent care and on-demand sector continues to expand and mature, there has been mounting pressures to add additional providers. This can be done by adding another physician. But using a NPP may be a better option. By using a NPP as the second provider in a busy urgent care setting, you can increase the clinic’s accessibility, productivity, and revenue while contributing to excellent quality and the patient experience. We know from a review of the literature and interviews with national thought leaders in urgent care clinical staffing models that costs, quality of care, and the patient experience is, at worst, preserved, and at best, improved by using a NPP. Additionally, many large regionally dominating operators have adopted the model of a NPP run clinic with proper physician oversight resulting in a marked change to the bottom line with additional benefits of having a better patient experience and equal or better clinical outcomes. Strategically, the decisions around how to staff providers at slower clinics, whether to have an on-site physician at all times, and how to scale coverage with volume are intrinsic and critical to your success.