DALLAS—As changing financial realities force healthcare to intensify its focus on patient satisfaction, streamlined habits, and higher patient volumes, there has never been a better time to consider adding advanced practice providers (APPs) to a medical practice, said members of a panel session at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, which was held in Dallas in September.
“We live in an ever-moving target of healthcare,” said panel moderator Kristi Gidley, PA-C, a physician’s assistant, administrative director, and supervisor of advanced practice providers in the department of otolaryngology at the University of Alabama in Birmingham. Under the Affordable Care Act, there are approximately 12 million newly insured people, many of whom have plans with high deductibles. That has created a “climate where the payers and patients are quite sensitive to the value and the cost of medicine,” she said.
APPs, who are physician assistants and nurse practitioners, can improve patient flow through the practice, helping to produce shorter wait times, greater patient satisfaction, higher numbers of patients, and better documentation that can lead to higher reimbursement, panelists said.
Physician assistants are trained as generalists, with approximately 1,000 didactic hours and more than 2,000 clinical hours. A master’s degree is required, and they’re certified by the National Commission on Certification of Physician Assistants and licensed through state medical boards.
Nurse practitioners, who often choose a specialty area, complete approximately 500 didactic hours and 800 clinical hours. A master’s degree is required, as with physician assistants. They are licensed and certified through state medical boards. While some specialty post-graduate fellowships are offered, most practical training is done on the job.
Hiring, training, and supervising APPs is usually worth the investment, panelists said. The tasks that APPs handle cover a wide range, and the degree to which they work independently from physicians depends on their skill and comfort level, as well as the comfort level of the physicians with whom they work. There tends to be a progression to more complex tasks and greater independence over time.
Nuances of Training
Scott Stringer, MD, chair of otolaryngology and communicative sciences at the University of Mississippi in Jackson, advised that it is important to hire an APP carefully. “You need to choose well early,” he said. “It just depends on the person and the background and the experience, but clearly to get someone to a high function can [take] up to two years.”
The training at his center follows an arc of observational learning in which APPs first spend time with physicians to understand the nuances of otolaryngology. Then, the training moves to a “shared” model in which APPs begin to gather and synthesize information and implement documentation. Finally, training moves to a “collaborative” approach, in which APPs act more independently but still work in conjunction with physicians.
Having APPs in a practice can essentially push everyone to the top of their game, he said. “I think we all know the buzz words ‘top of the license,’” he said. “We need advanced practice providers to work at the top of their license, nurses working at top of their license, (and that) can drive otolaryngologists to work at the top of their license, too.”
Panelists acknowledged that adding APPs to a practice requires some finesse in handling the social dynamics. “Some of our physicians work well with advanced practice providers; others don’t,” Dr. Stringer said. “They’re just all different.”
In 2010, there were no independent clinics run by APPs in Dr. Stringer’s department. Now, seven to 12 general otolaryngology APP clinics exist, opening up 70 to 120 patient appointment slots per week, said April Hunt, MSN, NP-C, the lead APP at the University of Mississippi Medical Center. This means higher patient volumes, fast appointment times, and freed-up appointment slots for physicians, she said.
APPs in the department recently started to take emergency and inpatient calls and provide four hours of coverage daily. The department is also working on establishing an APP residency in otolaryngology. “To do this, we really have to have strong support from everyone involved,” Hunt said. “Introducing your APP when you walk into a room—introducing them as providers and part of the care team to the patients—is so important. It builds trust and gives them confidence.”
Marie Gilbert, PA-C, the medical liaison between the American Academy of Physician Assistants and the AAO-HNS, emphasized the importance of understanding “incident to” billing, in which APPs provide certain follow-up care. For care to be considered “incident to,” the patient must have been originally seen by the physician when the plan of care was made. The APP handles the re-check of that problem, while a physician is physically present in the office suite. In that scenario, the re-check visit can be billed under the provider number of the physician who is present and is paid at 100% of the physician’s fee schedule. Any other scenario is not considered “incident to.”
APPs can see new patients, perform re-checks, order work-ups, run clinics, take pre-operative histories and conduct physicals, handle post-operative visits, and act as first assistants during surgical procedures. The practice can bill for those things. Procedures APPs can be involved in run the gamut from cerumen disimpactions to tympanostomy, said Gilbert. “It depends on what the PA’s and NP’s experience and training are up to and what the physician delegation will allow,” she added. “Some physicians don’t want their APPs doing any procedures at all.”
To show the financial effects an APP can have, Gilbert described a PA who is paid $106,000 a year. Using a conservative estimate of $150 of income for every physician visit that’s made available for every post-operative visit that the PA conducts instead, a practice can net an additional $400,000 a year or more, she said. That factors in the extra office visits the PA handles, as well a CME allowance, additional insurance costs for the PA, and other considerations.
Smart Hiring Is Key
Jerry Schreibstein, MD, an otolaryngologist at a Springfield, Mass.-based private practice with 6.5 full-time-equivalent otolaryngologists and between 1.5 and three PAs depending on the current staffing level, said their training includes a variety of techniques.
The physicians shadow the PAs, and the PAs use online tools available through the AAO-HNS, observe in the operating room, and observe the speech pathologist and the audiologist, and, along the way, they have to learn the idiosyncrasies of the half-dozen physicians in the practice.
At Dr. Schreibstein’s practice, there is always a physician on site and all new patients are seen and evaluated by a physician, while the PAs handle common problems such as epistaxis, sinusitis, cerumen, and hearing loss. “If you don’t let them synthesize the information and you solve the problem for them, they will never learn,” he said. “I always challenge them: What are you going to do?”
When it is hiring, the practice has to decide whether to hire a new graduate or someone with experience, while taking into consideration why the APP wants to work in otolaryngology, whether this is a first or second career, and what their expectations are for their schedule. “Hiring an advanced practice provider is like hiring any other employee or physician,” he said. “They’re people, and there are going to be good and bad experiences. The important thing is going to be the interview process and shadowing.”
Tom Collins is a freelance medical writer based in Florida.