Physician Extenders Boost Efficiency (http://www.medscape.com/PFNPublishing/Phy

August 2, 1999

Given that a large percentage of visits to PCPs are for musculoskeletal

conditions it seems to me this is a huge opportunity for PTs. This is a

great example of why we need direct access. If we can become primary

care providers for musculoskeletal conditions we will have taken a major

step forward. Take note of the salaries for PAs and NPs.

Is anybody out there doing this already?

Physician Extenders Boost Efficiency

Delmar

Inc.]

Physicians struggling to meet the demands of managed care may find

that adding a nurse practitioner or physician assistant to the staff

eases

the burden, say physicians.

" Because of managed care, we needed to increase the volume of

patients we see, " says Dr. Fleming, of Shreveport, La., senior

partner of a nine-physician family practice.

In his area, managed care accounts for about 35 percent of the market,

but is growing " by leaps and bounds, " he says. The practice hired its

first physician assistant (PA) about 18 months ago and has since hired

another.

Not only have the PA's improved access to medical care by allowing

more patients to be seen, but they have improved the quality of care

provided. " Patients with acute illnesses are able to get an appointment

sooner. It allows me to spend more time with the patients I need to, "

he says.

Providing Basic Care

PA's can take histories and vital signs, perform routine exams on

children and adults, simple suturing, the removal of skin lesions and

cryotherapy, and provide well-woman exams, including Pap smears

and breast exams. They also handle phone calls from and to patients,

Dr. Fleming says.

The PA he works with is a woman, and there are a considerable

number of women patients who prefer that she provide routine

well-woman exams, he notes.

PA's, obviously, do not earn as much as physicians and, says Dr.

Fleming, " there's no question that having them on staff is

cost-effective. " According to a recent survey conducted by the

American Academy of Physician Assistants, the median income for PA's

working full-time is $62,175.

Dr. Fleming says that health-insurance plans cover services provided

by PA's. As for malpractice insurance, the PA's were added to the

physicians' policy. " There was a little increase per year, and the

policy

covers the specific services they provide, " he says.

Adding a physician extender to the practice has been a similarly

positive experience for Dr. Ira Monka, a family physician in Cedar

Knolls, N.J., where 60 to 70 percent of patients are covered by

managed-care plans.

About two years ago, Dr. Monka hired a nurse practitioner (NP), Molly

Lawrence, and now has three NP's. The practice has another family

physician, an internist and a cardiologist.

" More patients can be seen by having nurse practitioners in the office,

and it's cost-effective, " Dr. Monka says.

Ms. Lawrence explains: " I'm available for quick appointments -- for

patients who need to be seen within 24 hours. This makes the flow of

patients go quicker and is more time-efficient. Physicians are freed up

to see patients with more serious and chronic illnesses. "

Besides primary-care clinical services, Ms. Lawrence helps manage the

care of nursing-home patients, shares call with physicians and sees

hospital patients once weekly.

NP's, she estimates, earn between $60,000 and $100,000. Her services

are covered by health insurance plans, Dr. Monka adds, but unlike

PA's, NP's have their own medical malpractice insurance.

Dr. Fleming selected a PA because their training focuses on working as

an extension of the physician. PA programs run about 110 weeks,

compared with 155 for a typical medical school program, according to

the American Academy of Physicians Assistants.

NP's are registered nurses with advanced education and clinical

training in a healthcare specialty area. They practice under the rules

and regulations of the Nurse Practice Act of their state, according to

the American Academy of Nurse Practitioners.

In his experience, says Dr. Fleming, PA's seem to excel in clinical

skills,

while the NP's he has worked with excel in patient education.

Although the addition of NP's and PA's is a relatively new concept to

many private practices, it is a longstanding tradition at some large

HMO's. Kaiser Permanente in California, for instance, has employed

NP's since the early 1970's.

" We have almost 6,000 physicians, roughly 1,200 NP's and about 300

PA's, " says Dr. Alan Elliott of San Diego, a family physician with

Kaiser,

who is regional coordinator of professional education for physician

extenders.

About 60 percent of the chief complaints that patients present within

primary care can be handled by physician extenders, who work in

collaboration with physicians, not independently, he says.

NP's and PA's are used interchangeably, Dr. Elliott says. In primary

care, they handle routine problems, such as colds and flu. They do not

make hospital visits, he says, " but we use them extensively in nursing

homes. " They have modified prescriptive authority, which varies widely

among various states, he adds.

Where physician extenders most improve the quality of care, Dr. Elliott

believes, is in care management. " For patients with a chronic disease,

such as diabetes, they follow protocols and tend to be a bit more

thorough and persistent on follow-up than most physicians, " he says.

Kaiser also conducts extensive patient surveys and has found that

when asked about satisfaction, NP's and PA's score essentially the

same as physicians, Dr. Elliott says. Surveys indicate that NP's and

PA's

are " definitely helpful " when it comes to scheduling patient

appointments, he notes. " I think they satisfy patients and are very

cost-effective here. I assume they would be in private practice, too, "

he

adds.

Some physicians speculate that because physician extenders can

enhance patient satisfaction by improving access to care and help a

practice operate more efficiently, they might also help garner

managed-care contracts.

Jack Burke, vice president, corporate medical director's office, Harvard

Pilgrim Health Care, is a well-respected managed-care company that

has two staff-model sites in New England and contracts with private

practices ranging in size from two to over 600 physicians. He believes

that the presence of NP's and PA's is a growing trend, although " it may

make sense for some practices and not others. " He would not say that

employing physician extenders would make a practice more appealing

to a managed-care plan, but agrees that they can make important

contributions.

" In practices with a relatively fixed revenue stream, NP's and PA's

represent an opportunity to use a professional that's not compensated

at as high a level as a physician, " Mr. Burke says, and, in that way,

contribute to cost-effectiveness.

" We've learned that patients who have had encounters with PA's and

NP's are typically highly satisfied, " he says. " Patients who don't want

to

see them tend to be those who haven't had experience with them. "

Dr. Fleming adds: " I have a patient here and there who wants to see

me instead of the PA, and that's fine. Generally, most patients

appreciate the fact that the PA allows them to be seen more quickly. "

For practices that want to add a physician extender to the staff, Drs.

Fleming and Monka advise getting to know the candidates very well

before hiring.

Dr. Fleming's practice had developed a relationship with a local PA

training program, and PA's interned in the practice before it hired one.

The first NP hired by Dr. Monka had been a patient in his practice who

proposed the idea. " If the practice is small, hire someone with

experience, " he advises. " The transition will be easier. "

To make the relationship work, Ms. Lawrence says that open

communication is imperative. NP's and PA's must feel comfortable

asking questions and sharing concerns with physicians.

Mr. Burke says the only potential disadvantage he sees to having an NP

or PA in a practice would be if physicians rely on them inappropriately.

The role of the NP or PA and the care of patients must be clearly

spelled out. Physicians should avoid asking NP's or PA's to provide

care or take on responsibilities they are not comfortable handling, he

says.

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FromPhysicians Financial News® Physician Extenders Boost Efficiency Delmar

Physicians struggling to meet the demands of managed care may find that adding a nurse practitioner or physician assistant to the staff eases the burden, say physicians. " Because of managed care, we needed to increase the volume of patients we see, " says Dr. Fleming, of Shreveport, La., senior partner of a nine-physician family practice.

In his area, managed care accounts for about 35 percent of the market, but is growing " by leaps and bounds, " he says. The practice hired its first physician assistant (PA) about 18 months ago and has since hired another. Not only have the PA's improved access to medical care by allowing more patients to be seen, but they have improved the quality of care provided. " Patients with acute illnesses are able to get an appointment sooner. It allows me to spend more time with the patients I need to, " he says.

Providing Basic CarePA's can take histories and vital signs, perform routine exams on children and adults, simple suturing, the removal of skin lesions and cryotherapy, and provide well-woman exams, including Pap smears and breast exams. They also handle phone calls from and to patients, Dr. Fleming says. The PA he works with is a woman, and there are a considerable number of women patients who prefer that she provide routine well-woman exams, he notes. PA's, obviously, do not earn as much as physicians and, says Dr. Fleming, " there's no question that having them on staff is cost-effective. " According to a recent survey conducted by the American Academy of Physician Assistants, the median income for PA's working full-time is $62,175. Dr. Fleming says that health-insurance plans cover services provided by PA's. As for malpractice insurance, the PA's were added to the physicians' policy. " There was a little increase per year, and the policy covers the specific services they provide, " he says. Adding a physician extender to the practice has been a similarly positive experience for Dr. Ira Monka, a family physician in Cedar Knolls, N.J., where 60 to 70 percent of patients are covered by managed-care plans. About two years ago, Dr. Monka hired a nurse practitioner (NP), Molly Lawrence, and now has three NP's. The practice has another family physician, an internist and a cardiologist. " More patients can be seen by having nurse practitioners in the office, and it's cost-effective, " Dr. Monka says. Ms. Lawrence explains: " I'm available for quick appointments -- for patients who need to be seen within 24 hours. This makes the flow of patients go quicker and is more time-efficient. Physicians are freed up to see patients with more serious and chronic illnesses. " Besides primary-care clinical services, Ms. Lawrence helps manage the care of nursing-home patients, shares call with physicians and sees hospital patients once weekly. NP's, she estimates, earn between $60,000 and $100,000. Her services are covered by health insurance plans, Dr. Monka adds, but unlike PA's, NP's have their own medical malpractice insurance. Dr. Fleming selected a PA because their training focuses on working as an extension of the physician. PA programs run about 110 weeks, compared with 155 for a typical medical school program, according to the American Academy of Physicians Assistants. NP's are registered nurses with advanced education and clinical training in a healthcare specialty area. They practice under the rules and regulations of the Nurse Practice Act of their state, according to the American Academy of Nurse Practitioners. In his experience, says Dr. Fleming, PA's seem to excel in clinical skills, while the NP's he has worked with excel in patient education. Although the addition of NP's and PA's is a relatively new concept to many private practices, it is a longstanding tradition at some large HMO's. Kaiser Permanente in California, for instance, has employed NP's since the early 1970's. " We have almost 6,000 physicians, roughly 1,200 NP's and about 300 PA's, " says Dr. Alan Elliott of San Diego, a family physician with Kaiser, who is regional coordinator of professional education for physician extenders. About 60 percent of the chief complaints that patients present within primary care can be handled by physician extenders, who work in collaboration with physicians, not independently, he says. NP's and PA's are used interchangeably, Dr. Elliott says. In primary care, they handle routine problems, such as colds and flu. They do not make hospital visits, he says, " but we use them extensively in nursing homes. " They have modified prescriptive authority, which varies widely among various states, he adds.

Where physician extenders most improve the quality of care, Dr. Elliott believes, is in care management. " For patients with a chronic disease, such as diabetes, they follow protocols and tend to be a bit more thorough and persistent on follow-up than most physicians, " he says.

Kaiser also conducts extensive patient surveys and has found that when asked about satisfaction, NP's and PA's score essentially the same as physicians, Dr. Elliott says. Surveys indicate that NP's and PA's are " definitely helpful " when it comes to scheduling patient appointments, he notes. " I think they satisfy patients and are very cost-effective here. I assume they would be in private practice, too, " he adds. Some physicians speculate that because physician extenders can enhance patient satisfaction by improving access to care and help a practice operate more efficiently, they might also help garner managed-care contracts. Jack Burke, vice president, corporate medical director's office, Harvard Pilgrim Health Care, is a well-respected managed-care company that has two staff-model sites in New England and contracts with private practices ranging in size from two to over 600 physicians. He believes that the presence of NP's and PA's is a growing trend, although " it may make sense for some practices and not others. " He would not say that employing physician extenders would make a practice more appealing to a managed-care plan, but agrees that they can make important contributions. " In practices with a relatively fixed revenue stream, NP's and PA's represent an opportunity to use a professional that's not compensated at as high a level as a physician, " Mr. Burke says, and, in that way, contribute to cost-effectiveness.

" We've learned that patients who have had encounters with PA's and NP's are typically highly satisfied, " he says. " Patients who don't want to see them tend to be those who haven't had experience with them. "

Dr. Fleming adds: " I have a patient here and there who wants to see me instead of the PA, and that's fine. Generally, most patients appreciate the fact that the PA allows them to be seen more quickly. "

For practices that want to add a physician extender to the staff, Drs. Fleming and Monka advise getting to know the candidates very well before hiring. Dr. Fleming's practice had developed a relationship with a local PA training program, and PA's interned in the practice before it hired one. The first NP hired by Dr. Monka had been a patient in his practice who proposed the idea. " If the practice is small, hire someone with experience, " he advises. " The transition will be easier. "

To make the relationship work, Ms. Lawrence says that open communication is imperative. NP's and PA's must feel comfortable asking questions and sharing concerns with physicians. Mr. Burke says the only potential disadvantage he sees to having an NP or PA in a practice would be if physicians rely on them inappropriately. The role of the NP or PA and the care of patients must be clearly spelled out. Physicians should avoid asking NP's or PA's to provide care or take on responsibilities they are not comfortable handling, he says.

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