DOs weigh effective use of physician extenders in delivering quality care

Although some doctors worry about the expanding scope of practice of nurse practitioners and physician assistants, mid-level clinicians are helping many osteopathic physicians thrive financially and provide better care in today’s red-tape-burdened medical climate.

As the nation’s health care system shifts toward the patient-centered medical home model of care and more and more Americans become insured as a result of the Affordable Care Act, NPs and PAs will become even more important members of physician-led teams, say several prominent members of the osteopathic medical profession. But they stress the need for caution when hiring, training, supervising and deploying physician extenders.

A nurse practitioner or physician assistant can be hired for less than half the cost of a primary care physician, though the pay and practice rights of NPs and PAs vary by state. When used in primary care, NPs and PAs are paid comparably, averaging roughly $90,000 a year.

Physician extenders can help physicians care for a larger volume of patients without having to add another doctor, but a practice needs to be busy to make hiring them worthwhile. And the duties of NPs and PAs need to be thoughtfully assigned.

“Nurse practitioners and physician assistants should not be taking blood pressure readings for the patients they see, for example,” says AOA Trustee Richard R. Thacker, DO, a general surgeon in Tallahassee, Fla. “The best use of mid-levels is to have them work like physicians. You need them to be reviewing charts, taking patient calls and seeing patients.”

Family physician Steven D. Brushwood, DO, of Gower, Mo., notes that nurse practitioners see fewer patients per day than doctors do because of being trained in the nursing model of practice, which stresses wellness promotion.

“I average about 25 patients a day, while my nurse practitioner sees 15 to 20 patients a day, which is just productive enough to cover her own expenses,” Dr. Brushwood says. “Because of their training, nurse practitioners are natural educators. They tend to sit down with patients and talk with them more about their health and medical interventions.

“They are especially valuable in working with patients who have chronic medical conditions, but you need to factor in their lower productivity when making hiring decisions and assessing a practice’s potential profitability.”

Ins and outs

Although he practices in a group with other general internists, Dr. Thacker discovered years ago that he couldn’t ask his partners to tend to his patients when he was out of town attending professional meetings.

“My partners were there to cover emergencies and were helpful in the hospital. But they were very busy with their own patients, so they couldn’t help me with the day-to-day ins and outs of my practice,” he says.

Dr. Thacker chose to hire NPs because they don’t require the degree of supervision that PAs do in Florida. “You supervise nurse practitioners, but you don’t have to be in the same building with them. You don’t have to sign off on their work at the end of each day,” he says.

In Iowa, on the other hand, physician assistants may be supervised remotely for brief periods, says Kevin de Regnier, DO, a solo family physician in Winterset. His two PAs keep his practice running when he travels on short trips in his role as the vice president of the American College of Osteopathic Family Physicians. The PAs consult with Dr. de Regnier by phone and refer more difficult cases to a local hospital clinic, which has agreed to provide coverage.

Dr. Thacker’s two NPs enable him to maintain a complex practice that includes a busy office, many hospitalized patients, and the management of patients in nursing home, assisted living, hospice and rehabilitation facilities. “My practice is unusual for a general internist in that I do so much outside of the office,” he says. “So I have one nurse practitioner solely based in the office, while the other sees patients externally. Nurse practitioners are very effective at visiting folks in assisted living facilities and nursing homes. This arrangement has worked out very well.”

Do’s and don’ts

Hiring the right mid-level clinician for one’s practice is critical, cautions Dr. Thacker. He prefers to hire NPs who’ve had years of clinical experience as nurses before obtaining their advanced nursing degrees. “I would not hire a nurse practitioner who had not been a nurse,” he says. But today, many individuals enter doctor of nursing practice (DNP) programs right after obtaining baccalaureate degrees in nursing. Their clinical nursing experience is often minimal, Dr. Thacker notes.

Physician assistants also tend to have less clinical experience than in the past, when most had served as medics in the military before entering PA training programs, according to Dr. Thacker.

Younger, less-experienced mid-level clinicians obviously require more training and supervision, he says. Physicians who don’t have the patience to train physician extenders and who resent interruptions during the day probably should not hire them, he advises.

Even experienced NPs and PAs require supervision, Dr. Thacker stresses. “Some physicians don’t do this very well. They expect extenders to hit the ground running. But this has backfired,” he says. “Nurse practitioners and PAs who’ve been allowed to practice with little or no supervision sometimes come to believe that they are equivalent to physicians and entitled to comparable practice rights, when they have nowhere near the depth of education and training that physicians have.”

While he values his NPs, Dr. Thacker does not allow them to have their own patients. Any patients they see are his.

“Every patient will see me either on the first visit or, when that isn’t possible, the second visit,” Dr. Thacker says. “Typically a nurse practitioner should be seeing a patient in a follow-up visit after a treatment plan has already been created.”

Physicians often use NPs in the ongoing care of patients with chronic health conditions, such as diabetes mellitus and asthma. For other conditions, however, such as chronic pain, psychiatric problems and sleep disorders, NPs can be less efficient because of state restrictions on their ability to prescribe controlled substances.

Patients with a number of comorbidities are best seen by physicians, says Barbara E. Walker, DO, a family physician in Wilmington, N.C. Because the population is aging and life expectancies are increasing, “many patients today are very complex, with multiple disease states,” she says. “They may have diabetes, hypertension and cardiovascular disease. Being able to recognize whether a new symptom is related to these diseases or whether something else is going on requires the additional clinical training of a physician.”

A retired colonel in the U.S. Army, Dr. Walker has worked extensively with physician assistants, who have long been used in the military, and she has worked with NPs in North Carolina, a pioneering state in the medical home model of care.

Although PAs and NPs are often used interchangeably in primary care, she says each clinician type has its own strengths.

PAs may have an edge in handling acute ailments, according to Dr. Walker, who is an AOA trustee. Their training is more standardized than NPs’ and includes a more consistent clinical component, she says. Those she worked with in the military, who had years of clinical experience behind them, “were excellent diagnosticians and had excellent skills.”

“A lot of acute care issues—respiratory illnesses and minor illnesses in patients with less-complex disease states—can easily be handled by PAs,” Dr. Walker says. “Nurse practitioners, on the other hand, are excellent educators who can help physicians care for complex patients. And they are effective in the day-to-day management of patients.” Many physicians delegate administrative functions to NPs.

Dr. Walker contends that given the shortage of physician extenders, as well as physicians, it isn’t feasible to expect NPs and PAs to have considerable prior clinical experience. “As it is, there aren’t enough to meet our needs,” she says.

Vital team members

With the demand for evidence-based care and administrative burdens increasing dramatically, primary care physicians don’t have time to do all that they need to do, notes John B. Bulger, DO, the chief quality officer of Danville, Pa.-based Geisinger Health System, which has a primary care network. Consequently, physician-led interdisciplinary teams, or medical homes, have become increasingly vital, and NPs and PAs are key members of those teams, he says.

“Physicians are trained for and are better at making higher-level decisions about patients,” Dr. Bulger says. “This gives them the most professional satisfaction, and it makes sense from a competency standpoint. Physicians should be developing treatment plans for complex diabetic patients, for example, as opposed to making sure that the hemoglobin A1c test has been ordered.

“It’s not that physicians can’t do these things, but there isn’t enough time in the day for physicians to do all that they are supposed to do. If you have a patient with diabetes, high blood pressure and heart disease sitting in front of you—and there are 65 things you are supposed to do during that 20-minute vist—nothing is ever going to get done.”

Physician extenders also enable primary care practices to have longer hours, accept same-day appointments and see walk-ins. More convenient access to care helps keep patients who are not seriously ill out of emergency departments, which lowers health care costs. “And patients are better off seeing someone in the office who knows them and has access to their medical records, as opposed to going to the ER,” Dr. Bulger adds.

When nurse practitioners and physician assistants are effectively used, physicians are more satisfied with their own interactions with patients, Dr. Bulger says. “What physicians want to do is talk to complex patients about plans of care, asking, ‘How are we going to work through this? How are we going to get you to the best health we can?’

“Physicians don’t want to spend their day making sure patients got their flu shots.”