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Helping Hands

With more patients and fewer physicians, endocrinology practices are looking for ways to expand their census and still maintain quality. Many are seeing advanced practitioners (AP) such as nurse practitioners (NP) and physician assistants (PA) as the answer.

“Our endocrinologist had been in the practice for a year or so, and her practice was already almost full,” says Dan Strauch, chief executive officer of Olean Medical Group, a multi-specialty practice in Olean, NY. “In our area, it is difficult to recruit physicians, and it has been easier to find APs. It is a win-win allowing us to open additiona patient slots and expand our endocrinology services.”

Adding advanced practitioners takes some planning. It is a complex decision involving state-level licensing and practice laws, the bylaws and credentialing rules of local hospitals, and a maze-like group of federal and private insurance payment rules.

Independent Practice

“APs can function independently in many states,” says Jane Kapustin, PhD, CRNP, BC-ADM, an NP at the University of Maryland Medical Center for Diabetes and Endocrinology, Baltimore. “In an endocrinology practice, we can see and manage most patients. This not only means the practice can see more patients, but also frees the physician to manage the very sick and complex patients that really require a doctor’s attention.”

Advanced practitioners can also substitute for physicians when they are out of the office.

APs are generally in the office Monday through Friday,” notes Kapustin. “We can fill in the gaps seeing people on an expedited basis, refilling prescriptions, and cover for the physician when they are somewhere else.”

NP/PA Education and Practice

Nurse practitioners (NP) are first registered nurses with clinical experience. They are enrolled in an advanced degree program, which results in a master’s degree. Some may decide to complete a doctorate. Generally, the state board of nursing regulates NPs. In some areas, both the nursing and medical licensing authorities may oversee them.

PAs are trained in a model closely resembling traditional medical education, albeit a much-truncated version. There is currently some variability in their education level, although more states are requiring at least a master’s degree. Practice and legal matters most often are the responsibility of a state’s medical board.

“Both groups are very well trained to provide care for those with chronic diseases such as diabetes,” Kapustin says. “Studies show APs’ outcomes are similar to those associated with physicians, and that patients readily accept them with most maintaining a long-term relationship.”

Look at Needs

First off, the practice should take a close look at its needs and which discipline will best address them. It may be that when the requirements are put to paper, adding a physician is the answer. Other times the AP comes out ahead. In both instances, you now have a better grasp of the skillset the practice requires and a basis for candidate evaluation.

Sorting out the limits of an AP’s practice is another important early consideration when deciding if this is a viable option for the practice. Make sure those involved in making the decision understand what an AP can (or perhaps even more importantly) cannot do in your state, and how that fits with the needs of the practice.

Practice Environment

Environmental issues — specifically the personality of physicians making up the practice — have to be assessed early. It makes no sense from either a financial or practical view to spend a lot of time and effort to find and train an AP if the doctors are still going to do all of the work.

Some physicians will be able to tolerate a degree of uncertainty when letting others see “their” patients. Some are hesitant to work with APs while others welcome the extra help and unique experiences offered by advanced practitioners.

Experts agree that forcing APs on a doctor is never a good idea. Especially when establishing a new program, the group should let those who are interested in working with others take the lead. As use of these ancillary workers mature, many of those who were reluctant at the beginning may decide that there is a place for APs after all.

Although often less of an issue in this specialty, hospital credentialing is another important consideration. Idiosyncrasies of an individual hospital’s bylaws have an impact on the efficiency of the physician/AP team. If the practice is affiliated with more than one hospital, it should be noted that what the AP is allowed to do at one might not be allowed at the other.

Financial Considerations

One of the final steps in deciding if an AP will benefit the practice is to look at the financial side. The AP will have many of the same costs and overhead as a physician. They would generally need the same level of staff, an office, and the same associated expenses as a physician. Two areas of savings are that APs have a lower salary and usually their medical malpractice insurance is less.

There may also be a short-term increase in expenses related to training an advanced practitioner to where they can practice independently. This can vary depending on the experience and background of the AP

“When hiring an endocrinologist, we feel that they all come out of their fellowships with roughly the same amount of training,” says R. Clark Perry, DO, FACE, medical director of endocrinology for the Community Physician Network in Indianapolis. “Many times the AP will not have the same depth of understanding in the specialty area. It is going to take some extra time, training, and patience on the physician’s part to assist in the education that is needed in the shared responsibility model we use.”

Billing Can be Complicated

Outgo must, of course, be offset by income. Here the calculations are not straightforward. Medicare and Medicaid will reimburse an AP under their personal identification number at 85% of the physician rate. If the physician is directly involved in care, it’s possible under the federal programs to bill the service “incident to” the physician at 100% of the doctor’s rate.

Many commercial insurers credential APs individually. In that case, the insurer usually pays 80% to 85% of the physician fee schedule. However, under some contracts, insurance companies may still allow incident to billing. The rules and regulations for this kind of billing are very specific, so it is important that the practice, and their coding staff, fully understand them.

“In our office we did not feel comfortable using the incident to option,” Perry says. “We have many different offices, and it’s too hard to make sure that the physician who wrote the initial care plan for the patient is in the same office at the same time. For the many endocrinology practices that have a single office, it may be easier.”

The revenue generated is likely to depend on the individual group’s specific mix of patients and payment plans. Some companies may only reimburse one way while others may give you an option.

“The pro forma calculation boils down to whether a person can cover their expenses,” Strauch says. “These patients need to be seen somewhere, and if they can’t see our doctors, it is much better for both them and us that they see our APs.”

— Ullman, RN, MHA, is an Indiana-based freelance writer with nearly 30 years of experience. He wrote about how to get research published in the March issue.

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