- Nurse practitioners (NPs) and physician assistants (PAs) can offer vital support to organizations undergoing their value-based care transitions, especially as providers start to develop population health management teams.
With an expansive scope of practice and a strong connection with patients, these advanced practice practitioners (APPs) healthcare organizations simply cannot afford to treat highly qualified NPs and PAs as second-string members of the care team.
In a population health management environment, where resources are often scarce and every employee must always function at the top of his or her license, NPs and PAs offer more flexibility for seeing patients without compromising on quality or outcomes.
But misunderstandings about the role and value of APPs persist in many organizations, said panelists at the recent Value-Based Care Summit: Population Health event in Dallas.
“We deal with the question of what NPs and PAs can do at a practice quite a lot,” said Bianca Belcher, MPH, PA-C, Director of the Center for Healthcare Leadership and Management at the American Academy of PAs.
“Both groups can diagnose, prescribe, and manage patient populations as far as treatment protocols. A lot of times we are the primary treatment option for patients, as well as the formal or informal coordinators of care.”
Nurse practitioners and physician assistants are found in a variety of settings and take on a number of critical responsibilities, agreed Joyce Knestrick, PhD, APRN, C-FNP, FAANP, President of the American Association of Nurse Practitioners. But NPs tend to be found most often in the primary care setting.
“We have over 244,000 NPs in the US today, and almost 80 percent practice in primary care,” she explained. “A large percentage of those in primary care practice in rural and underserved areas.”
Source: Xtelligent Media
NPs differ slightly from their PA colleagues in that the educational program is based in a nursing model, Knestrick added, which lends itself well to the primary care environment.
“Coming from a nursing model, holistic care, prevention and health promotion are always the tenets of our profession,” she said.
“Our programs are primarily community-based, so that the student is educated and has their preceptorships within their community. That helps them become an integral part of their community, and they understand the culture and the nuances of those needs.”
But NPs have much to offer the acute care and specialty environment as well, pointed out Kristan Langdon, DNP-c, MSN, NP-C, who works in cardiology at the Emory Women Heart Center at Emory Healthcare.
“Traditionally, NPs have had more of a community focus, and PAs have worked more an acute care focus. Over time, those lines have become blurred and you’re starting to find nurse practitioners in more settings,” she said.
“Within my organization, I’m seeing patients independently, but also within the team construct. I help manage patients along the care continuum with my physician colleagues, and I am especially involved in the transitions of care from the hospital to the outpatient setting.”
Both NPs and PAs can provide almost the entire scope of services delivered by MDs or Doctors of Osteopathy (DOs). The Medicare definition of services provided by PAs and NPs boils down to “services that are otherwise provided by an MD or DO,” said Belcher.
“That means they’re the same services that physicians are providing,” she noted. “There’s no special list of things that PAs can do or NPs can do. It’s all the same stuff. These aren’t the tasks that your medical assistants or your front desk staff are doing. These are tasks that are otherwise done by a physician.”
But that concept can sometimes be poorly communicated within organizations, leaving NPs and PAs with a bit of an image problem for patients.
“We do tend to face some issues with marketing our skills to patients,” Belcher said. “Cleveland Clinic is one organization that has tackled this exact problem. It used to be that when a patient called in and asked to see Dr. Smith, they were told, ‘Well, his first appointment is three months out. We could put you with one of the mid-levels instead.’”
“If I’m a patient, I’m immediately going to say, ‘I don’t want to see a mid-level provider. I want a high-level provider! I only want the best, and clearly a mid-level can’t provide that.’”
Cleveland Clinic spent a great deal of time and money retraining the call center staff to show NPs and PAs in a more positive light.
“They started to ask, ‘Would you like first available appointment with our PA, Jane? She’s highly trained and has been here for years, and she can do this, this, and this for you. The first available appointment with her is tomorrow. Or if you want to wait, you can have Dr. Smith in three months.’”
More than nine times out of ten, patients would pick the first available appointment, said Belcher.
“There are still people who only want to see their physician, and that makes perfect sense. But if they’re offered a choice between waiting weeks for that and seeing an NP or a PA tomorrow, chances are they’re going to grab the opportunity, especially if it’s something that simply can’t wait that long. Just changing the language makes a huge difference.”
However, the financial challenges NPs and PAs typically face may be a little more difficult to overcome, said Knestrick.
“Within many health systems, the PAs and NPs are not coded to show that they delivered certain services,” said Knestrick. “That makes it very difficult for organizations to understand the value that they’re contributing, both from a patient care perspective and from a revenue and reimbursement perspective.
“We need to collect that data on what we do so that we’re not viewed as a cost center instead of a group that can bring profit.”
Langdon agreed that the language of billing and coding can be just as impactful as the words used to patients.
“What I see a lot is that the APP work has been embedded under the physician and billed ‘incident to,’ even if that is not appropriate,” she said. “As we change our dynamics of care and the roles of providers in different care environments, we should work on utilizing everyone at the top of their license.”
Emory has a section in the EHR that records the rendering provider, she continued, creating a tracking option for each member of the care team.
“So even if you’re seeing the patient in an ‘incident to’ capacity, your name is still tagged for every patient as the rendering provider. At least you’re able to track productivity that way.”
A robust mechanism for recording productivity and share of labor will be key for collecting important data about how care teams function and how organizations can optimize their financial strategies, said Knestrick.
“Whether we’re working independently in a clinic or within a larger health system, we have to show that our value-add is important to the practice as well as the patient,” she said.
“If we can be clear about who is providing which services, it will help organizations understand the cost of care and how to further increase quality.”
Recognizing each member of the care team for the value that he or she adds to the whole is critical for maintaining collaborative relationships with colleagues, the panelists stressed.
“Most organizations have gotten much better at creating a culture that welcomes APPs and utilizes them well,” said Langdon.
“All of the physicians I work with fully support NP and PA practice. Our cardiovascular service line is really run by the APPs. Without them, the physicians would lose revenue because they could not be doing the surgeries and offering the highly specialized services they’re trained for – there wouldn’t be any time. It’s a very important partnership where we all rely on each other.”
The same holds true in primary care, said Knestrick.
“I work in a state where I’m not required to be supervised or have a collaborative agreement of any sort, and my clinic is primarily run by NPs and PAs. However, I’m always collaborating with physicians. There’s always a benefit to getting input on something that might be outside of my individual scope or experience.”
“If I need a consult from cardiologist or neurologist, or if I just want to talk to someone about my line of thinking to make sure I covered all the bases, my colleagues are there for me. Collaboration within teams is important regardless of your role.”
APPs aren’t the only members of the care team that are often underutilized, she added.
“If you don’t currently have an APP on staff but you do have an RN, you might want to make sure that you are using that person to the first extent of her licensure as well,” suggested Knestrick.
“If you’re using that RN to put patients in a room and take a blood pressure, you’re probably not using her to the full extent that you could be. The RN has a lot to offer as well. Oftentimes, the patient will tell the RN more than they will tell the physician or even the PA, and you don’t want to lose out on that valuable information and relationship.”
Delegating more responsibility to non-physician members of the care team could be a promising way to fit in all of the population health management tasks required to cope with challenging populations and rising incidences of chronic disease.
“Take a look at your population to see if there is a certain condition or need that would be a good fit for an independent clinic run by an NP or PA,” advised Belcher. “Diabetes management and hypertension tend to be among the initial use cases.”
“If new patients aren’t getting in for six months and the wait for a routine appointment is 90 days, a second provider or dedicated clinic might be able to reduce those wait times. You have to make sure that everyone’s ready to practice independently and that your organization is comfortable with that, but it can significantly increase your capacity and will likely improve your patient satisfaction.”