NPP utilization in the
future of US healthcare
An MGMA Research & Analysis Report
Full report
March 2014
Do You Ask Yourself These Questions?
Do I
need an
NPP?
$
How do we
transition the
patients?
How do
I pay
them?
Who should
I hire?
NP or PA?
What’s the
appropriate
staffing
amount?
What’s
the
difference?
Where do
I find
NPPs?
Should I hire
full time,
part time,
or contract?
How do we
recruit & retain
them?
How do we
use them?
How do I get
reimbursed
for their
work?
$
Will they
fit the
culture?
©MGMA. All rights reserved.
NPP utilization in the future of US healthcare
Healthcare organizations use nonphysician providers (NPPs) to extend the therapeutic reach of physicians,
increase patient satisfaction and add clinical revenue to the bottom line. Roles for these skilled individuals
are expanding as the number of physicians shrinks
(especially in primary care), the population of seniors
expands and the Affordable Care Act (ACA) makes
$
healthcare accessible to more than 10 million more
Americans . NPPs are assuming a pivotal place in
1
the future of healthcare.
NPPs are trained and licensed practitioners who
provide clinical care. The majority of which have
a master’s degree level of education, but this is
INCREASE
PATIENT
SATISFACTION
EXTEND
THERAPEUTIC
REACH OF PHYSICIANS
ADD
CLINICAL
REVENUE TO
THE BOTTOM LINE
dependent on the practitioner specialty2. Some —
such as certified registered nurse anesthetists, physician assistants or surgeon’s assistants (first assists) —
function under the direct supervision of a physician. Others may work more independently, such as nurse
practitioners, optometrists and physical therapists.3 All NPPs can bill insurers for their services, either
incident-to4 the care provided by an overseeing physician or as independent practitioners when permitted
by their state licensure.
MGMA developed this content based on the analysis of both internal as well as external data.
It is intended to reflect findings that are indicative of the results of this research.
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3
In clinical medical practice, NPPs typically:
5
Provide on-call
and hospital
care
Provide patient counseling,
education and coordination
of care
Obtain patient histories
and perform physical exams
Chart all pertinent
clinical findings
Participate in
clinical meetings
Order and/or perform
diagnostic and therapeutic
procedures and tests
Assist scheduling staff
with patient triage
Develop, implement and monitor
the effectiveness of treatment plans
Assist physicians
with in-office and
hospital surgical
procedures
Develop working
diagnoses
Make appropriate
patient referrals to
practice physicians
and other healthcare
providers
NPPs=Nonphysician providers, midlevels and/or nonphysician practitioner
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4
They handle administrative duties in the practice, as well. NPPs may:
Report to the practice administrator for personnel matters;
Coordinate operational issues with the clinical manager, such as patient scheduling, tasks
performed by medical assistants and nurses, and patient flow matters;
Complete the provider section of managed care referral forms for specialty care and/or
diagnostic testing;
Complete the clinical portion of third-party payer inquiries and disability forms as required; and
Help order medical supplies and equipment.6
Similar to other positions, NPPs provide important teamwork
functions in the practice. They:
Work with whomever and wherever necessary to get a job done;
The American Academy of
Physician Assistants (aapa.org)
Proactively support company policies, philosophies and decisions;
and the American Association of
Take opportunities to positively influence support staff;
Nurse Practitioners (aanp.org)
Facilitate a shared expectation of success within the support staff
team, setting an example when circumstances warrant it;
PA and NP scopes of practice
provide detailed information on
and variables by state.
Accept constructive suggestions from management team; and
Actively participate in solving problems.7
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5
Data from at least the last 15 years indicate that medical practices in the United States have been
increasing their use of NPPs. The 2004 MGMA Cost Survey Report showed that the number of fulltime-equivalent (FTE) NPPs per FTE physician increased in virtually every type of single-specialty
group, and that more practices altogether were using NPPs. A look at the MGMA DataDive
2013: Cost and Revenue Module shows that Cardiology, Family Medicine, and Orthopedic Surgery
practices have still seen an increase in NPPs per FTE physician over the last 5 years.
The reason is clear: Practices with NPPs typically perform better financially, generating higher
physician income. MGMA data from 2004 show that “except for family practice, physicians in the
single specialties studied had higher compensation when their practices had NPPs.”8 Eight years
later, the MGMA DataDive 2013: Physician Compensation and Production Module shows physician
compensation is still higher for practices with NPPs, including those in Family Medicine.
Cardiology: Invasive
Total Compensation
in Single Specialty
Practices
Cardiology: Invasive-Interventional
Cardiology: Noninvasive
Family Medicine (with OB)
No NPPs
Has NPPs
Family Medicine (without OB)
Orthopedic Surgery: General
Pediatrics: General
$0
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
©MGMA. All rights reserved.
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6
Settings for NPPs
Medical practices
of all types
As Becker’s Hospital Review noted in 2010, “Over the last
30 years, roles of midlevel providers have expanded well
beyond the primary care environment. Today, midlevel
providers work in hospitals, emergency
departments, inpatient and outpatient surgical
Emergency
departments
Hospitals
facilities and in specialty practices such as
cardiology and oncology, as part of the team
that serves patients receiving ongoing
treatment. It is often a midlevel
Urgent-care
centers
provider who monitors fragile
Surgery
centers
Community
health centers
diabetics, sees cancer patients
between treatments, sets bones
in the ED or closes for the
doctor after surgery.”9
Clinics located
in retail sites
Nurse-managed
medical centers
Phone
triage services
Rural
healthcare
facilities
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7
Urgent care centers
Urgent care centers, where walk-in patients can receive ambulatory medical care
outside of a hospital emergency room, provide another significant source of NPP
employment. Urgent care centers continue to proliferate, with 9,000 across the
nation at the start of 2013.10, 11 As employers of NPPs, urgent care centers offer
flexible schedules and competitive pay. Urgent care centers focus on primary
acute medical problems at the lower end of the severity spectrum12 and share
characteristics of emergency and primary-care facilities.
“Retail” clinics
So-called “retail clinics” located in grocery stores, Walmarts and other shopping
hubs have opened a new market to NPPs. These facilities, catering to walk-in
patients with nonemergent conditions, are almost exclusively staffed by NPPs and
offer inexpensive, convenient care for many routine medical situations. According
to the ConvUrgentCare Report, the country had 1,603 retail clinics at the end of
2013 compared with 1,417 at the end of 2012. This growth rate of 13 percent is a
significant jump over the 4.6 percent increase in 2012.13
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8
Where NPPs are the only practitioners, facilities see
significantly lower operating and staff costs, although
revenue also drops. This may be because of fewer
$491,896
ancillaries, procedures, and shorter office visits than
typically seen in the office with physicians.
$383,140
$197,979 $209,161
$252,563
$171,685 $177,636
$78,930
NPP Retail Clinics vs.
Physician Primary Care
Practices
Total general
operating cost
Per NPP
Source: MGMA Cost and Revenue: Special
Analysis: 2013 Report Based on 2012 Data
Total
operating cost
Custom Analysis — Retail Clinics:
Only Nonphysician Providers, No Physicians
Total support
staff cost
Total
medical revenue
Per FTE physician
Reported in Primary Care Report: All Primary Care
Practices, Hospital/IDS Owned
©MGMA. All rights reserved.
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9
Some health systems are partnering with retail clinic operators, thereby boosting
retail clinics’ profile in the public eye. For example, in late 2013, Henry Ford Health
System, based in Detroit, signed an agreement with MinuteClinic, part of CVS
Caremark Corp., to “to meet an expected increase in patient demand” from the ACA.14
Henry Ford is providing physician medical directors to 14 MinuteClinics in metro
Detroit to oversee clinical work and supervise NPs. Health system patients can visit the
MinuteClinics as they would any other approved provider. Patients — and the health
system — benefit from increased access to care from Henry Ford caregivers.15
In a variant of the retail clinic theme,
CoxHealth, a health system based in
Springfield, Mo., has opened its own
NP-staffed clinics in WalMart stores as
“Retail health clinics are turning into a boon for
physician assistants who prefer to work in primary
part of its response to the expected
care but do not necessarily want to be involved
surge of patients created by the ACA.16
with a private practice or hospital setting.
At this point, there is so much work available they
really have quite a few choices when searching
for employment.”17 The same holds true for
nurse practitioners.
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10
Nurse-managed medical centers
Some healthcare analysts suggest that
nurse-managed medical centers, usually
affiliated with academic health centers,
could help meet the nation’s increased
demand for primary care services in the face
of a shortage of primary care physicians,
an influx of newly insured patients under the
ACA and the aging baby boom population.
“Nurse-managed health centers, also known
as nursing centers or nurse-led clinics,
provide a full range of primary care and some
specialty services. They are managed and
operated by nurses, with nurse practitioners
(many of whom are or will become doctors of
nursing practice) functioning as the primary
providers.”18
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11
Does our practice need NPPs?
NPPs allow practices to care for more patients and free physicians
to perform work that only physicians can do. Because NPPs spend
more time with patients than physicians for routine visits, they
can increase the depth of the provider-patient relationship and
enhance patient satisfaction.
How do you decide whether
your practice needs NPPs?
Consider where your organization stands in relation
to the U.S. physician shortage, the influx of senior
patients as the baby boom generation ages and
the millions of Americans who have gained health
insurance through the Affordable Care Act.
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12
Particularly worrisome is the projected shortage of
primary care physicians as demand for those services
Projected shortage of
primary care physicians
65,800
increases. By 2015, the Association of American
45,400
Medical Colleges forecasts the United States will have
29,800 fewer primary care physicians than it needs.19
29,800
This translates into a shortfall of about 135 million
ambulatory visits annually (right).
4,534
2015
Median ambulatory
encounters per year
2,939
2,077
2020
2025
Source: Association of American Medical Colleges
NPPs offer80000
one way to accommodate the demand,
as they can70000
handle many types of routine primary
60000
care visits on
their own. The graph (left) compares
50000
productivity
for NPs and PAs in primary care settings.
Family practice —
ambulatory
only
Nurse
practitioner
Physician
assistant
(primary care)
Source: MGMA Physician Compensation and Production Survey:
2010 Report Based on 2009 Data
40000in the 2013 report, ambulatory
Most recently
encounters30000
for nurse practitioners increased
20000primary care physician assistant
to 2,242 while
encounters10000
decreased to 2,763.
0
©MGMA. All rights reserved.
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13
As Laura Palmer, FACMPE, an MGMA senior industry analyst notes, “Perhaps the most important thing
you can do before you hire an NPP is to thoroughly research what your state allows them to do. State laws
governing NPPs’ scope of practice can vary significantly. As an example, APNs [advanced practice nurses]
in 17 states can diagnose and treat patients without physician supervision, whereas physician assistants
work under the supervision of physicians in all settings.”20
“The state guidelines will usually be outlined in the occupations code, medical practice acts, advisory
boards and the rules for delegation of prescriptive authority,” Palmer notes.
Regardless of state law, physician supervision should depend on:
An NPP’s training, education and experience;
The nature of your practice;
The complexity of your patient population; and
The supervisory style of particular physicians.21
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14
How do we use NPPs?
Getting optimal use out of your NPPs can boost revenue, increase efficiency and free your
physicians to focus on other patients. The MGMA Performance and Practices of Successful
Medical Groups: 2010 Report Based on 2009 Data, showed that 61 percent of better-performing
practices employ NPPs. Most recently the 2013 report reported an increase to nearly 68
percent. David Gans, MSHA, FACMPE, senior fellow, MGMA Industry Affairs, notes that
“In primary care practices, they can provide 80 percent or more of services with equal
or better patient satisfaction at a lower cost than a physician. Many times, NPPs have
fewer demands than physicians and are more readily available to patients.”22
To use your NPPs to their greatest advantage:
■■ Work with your physicians to determine their needs for
these colleagues (within NPPs’ scope of practice) — some
physicians may want more collaboration than others;
■■ Establish benchmarks to measure NPP performance, including
productivity, utilization and patient satisfaction; and
■■ Know the optimal number of NPPs for your practice — the
right number can increase productivity, lower overhead
and boost physician compensation, but too many NPPs per
physician can have the opposite effect.23
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15
Whom should I hire, an NP or PA? What’s the difference?
Physician assistants (PAs) and nurse practitioners (NPs) are perhaps the best-known NPPs.
However, the designation includes but is not limited to:
Certified
nurse
midwives
Certified
registered
nurse
anesthetists
Nonclinical
psychologists
Clinical
psychologists
Clinical
nurse
specialists
Physical
therapists
Occupational
therapists
Clinical
social
workers
Speech
pathologists24
NPPs work under a physician’s direct supervision or in collaboration with physicians. Some, such
as NPs, PAs, optometrists and physical therapists, may function more independently.25 They
fulfill roles in acute care, ambulatory care, hospital care, urgent care clinics, quick-access clinics
at retail sites, home care, surgical care and others across the healthcare continuum.26 Where
physicians are in short supply, such as rural areas, NPPs often provide services autonomously.
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16
In medical practices, the NPPs patients are most likely to
interact with are NPs and PAs. Typically, NPs and PAs:
are practitioners certified to
diagnose and treat
acute and chronic conditions
diagnose and
treat illnesses
prescribe
medications
prescribe
medications
order and interpret
lab tests
provide patient
education and
counseling
manage patients’ overall
care and counsel patients
without physician
supervision27
perform procedures
make rounds in hospitals
and nursing homes28
perform
physical
exams
assist in surgery
and are trained to
coordinate patient care29
NPPs’ scope of practice varies by state. For example, in Colorado, NPs can evaluate patients,
diagnose, order and interpret diagnostic tests, initiate and manage treatments and prescribe
medications under the authority of the state’s board of nursing. Florida requires that NPs
provide patient care under the supervision of an outside health discipline.30 In Michigan, PAs are
permitted to prescribe all DEA* Schedule II-V drugs, but Georgia restricts PAs prescribing to a
set formulary of Schedule III-V medications.31
*Drug Enforcement Agency
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17
What are some tips for getting started?
An administrator may be concerned that both physicians and patients may be unwilling to accept NPPs
as primary care-givers. Without an environment of collegial respect and cooperation — an accepting and
flexible organizational culture — your new NPPs may be reluctant to stay long at the practice.
To overcome reluctance on the part of physicians
and facilitate NPP integration, consider working with
clinical leaders to:
■■ Define clear roles for physicians and NPPs;
■■ Identify care gaps and delineate where and how NPPs can fill
them;
■■ Develop a thorough orientation program for NPPs, including
shadowing physicians for every type of patient they see;
■■ Document standing orders, protocols, collaborative agreements,
delegation and supervision agreements;
■■ Ensure that physicians understand the importance of delegating
to NPPs and that having these practitioners will allow physicians
to see more patients, not fewer; and
■■ Help physicians see NPPs as partners, not competitors.
32
To help patients accept NPPs in the practice:
■■ Have physicians send letters to their patients announcing
the NPPs’ hire and collaborative role in the practice. (As with
physicians, this is an opportunity to educate patients on NPPs’
roles and the increase in patient satisfaction they can bring);
■■ Have physicians introduce the NPPs to their patients at
appointments, describing the NPPs as essential members of the
care team; and
■■ Ensure that all interactions that patients witness between NPPs
and other practice staff are professional and collegial.33
The necessity for these measures will wane as NPPs
become integral players in all aspects of healthcare.
Therefore, you may have no need to employ
persuasive tactics with patients or colleagues when
you hire NPPs.
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18
What’s the NPP employment situation?
NPPs face an optimistic employment market. HEALTHeCAREERS, a major U.S. job resource for
healthcare professions, reported for the third quarter of 2013 that eight of the top 10 most in-
demand nonphysician positions include family medicine NP, general PA, psychiatric/mental health
NP, general NP and emergency medicine PA.34 Consider posting your practice’s NPP openings at
HEALTHeCAREERS (healthecareers.com), a leading site for healthcare job recruitment.
U.S. government statistics, too, support the strength of NPP employment opportunities.
For nurse practitioners (as of May 2012):
■■ 105,780 were employed at a mean annual salary of $91,450.
■■ Jobs for NPs, nurse anesthetists and nurse midwives are projected to grow 31 percent between 2012 and 2022.
■■ The states with the highest employment level for NPs are California, New York, Florida, Texas and Massachusetts.
■■ The top-paying states for NPs are Alaska, Hawaii, Oregon, Massachusetts and New Jersey.
■■ Physician offices, hospitals and outpatient care centers make up the majority of employment sites.35
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19
Government statistics for physician assistants state that:
86,700 PAs were employed in the United States at a median annual salary of $90,930.
120,000 positions for PAs are projected for 2022.
58 percent of PAs work in health practitioner offices, 23 percent work in hospitals, 7 percent
work in outpatient care centers, 4 percent work in government and 3 percent work in
educational capacities.
New York, California, Texas, Pennsylvania and North Carolina are the states that employ
the most PAs.
Top-paying states for NPs are Rhode Island, Connecticut, Washington, Oregon and Nevada.36
Clearly, a career as an NPP offers promise.
You can learn more about the job
outlook for physician assistants
and nurse practitioners at:
BLS.gov, PA job outlook
BLS.gov, NP job outlook
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20
2012 median total
compensation for
selected providers
How do I pay NPPs?
$367,117
$207,117
NPPs cost significantly less than physicians to employ.
For example, in 2012, the median total compensation for
$112,689
$94,062
an NP in primary care was $94,062; the cost that year to
employ a family medicine physician was $207,117. Annual
compensation for a surgical PA in 2012 was $112,689 vs.
Primary
care
NP
$367,885 for a general surgeon.37
Not surprisingly, however,
NPPs are commanding
Family
medicine
physician
Surgical
PA
General
surgeon
5 Year Trending — Median Total Compensation
By specialty
higher pay as demand
Certified Registered Nurse Anesthetist
for their services rises.
Nurse Practitioner
350000
From 2008 to 2012,
Nurse Practitioner (Surgical)
300000
400000
250000
their median total
Nurse Practitioner (Primary Care)
compensation increased
2008
2012
200000
150000
Nurse Practitioner (Nonsurgical/Nonprimary
Care)
10 percent to nearly 17
percent, depending on
Physician Assistant (Surgical)
specialty.
Physician Assistant (Primary Care)
38
100000
50000
0
Physician Assistant (Nonsurgical/Nonprimary Care)
0
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$175,000
Source: MGMA Physician Compensation and Production: 2013 Report Based on 2012 Data
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The American Academy of Physician Assistants and the American Association of Nurse
Practitioners offer salary guidelines for these professionals.
Medical groups take a variety of approaches to paying NPPs. An online discussion
among members of the MGMA Financial Management Society on paying nurse practitioners
indicated that some:
Pay NPs an annual salary based on their specialty and their full-time equivalent;
Pay full-time NPs on salary and part-time NPs hourly; or
Provide an annual base salary with a production incentive.39
Medical practice leaders should balance NPPs’ revenue contributions against
the salaries and benefits they cost the organization — more on this below.
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22
What’s appropriate staffing for NPPs
in my practice?
MGMA’s Cost Survey Report contains a wealth of information about staffing levels for NPPs in
both multispecialty and single-specialty practices. Use this resource to learn best-practices in
staffing and compare your employee levels to those of peer organizations.
Impact of increased numbers of nonphysician
providers on support staff per FTE physician in
physician-owned multispecialty groups
1.19
1.28 1.37
1.56 1.58
1.75
1.29
1.42
1.56
2.60
Zero FTE non-physician providers
.25 or fewer FTE non-physician providers per FTE physician
.26 to .5 FTE non-physician providers per FTE physician
Greater than .5 FTE non-physician providers per FTE physician
1.65
1.00
0.75
0.87
1.01
0.22
Median total
business operating
staff per FTE
physician
Median total
front office support
staff per FTE
physician
Median total
clinical support staff
per FTE
physician
Median total
ancillary support staff
per FTE
physician
©MGMA. All rights reserved.
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23
Keep in mind that you need to balance NPPs’ revenue contributions against the salaries and
benefits they cost the organization. Gans notes that practices may not always reap economies of
scale by employing NPPs. When the ratio of NPPs per full-time-equivalent (FTE) physician increases
above 0.5 FTE in physician-owned multispecialty groups, median FTE clinical support staff per FTE
physician can rise by almost a full-time staff member. This may happen because NPPs must be
properly supported with staff too.40
When deciding whether to hire NPPs on a full-time, part-time or contract basis, review your
practice’s expenses and determine whether you can afford the extra cost per FTE physician,
understanding that practices with higher revenue tend to have higher staff and costs.
©MGMA. All rights reserved.
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24
How does the practice get paid for NPPs’ work?
Unlike nurses, NPPs can bill insurers directly for their services, providing reimbursement at the physician
rate. Federal and private health plans set their own rules for NPP billing.41 Under Medicare, NPPs
can bill “incident to” a physician’s care, using the physician’s National Provider Identifier (NPI).
After an initial visit by the physician, NPPs must perform these services under the physician’s
direct supervision or while the physician is present in the same office suite to immediately assist.
Moreover, “incident to” services must be furnished in the physician’s office or clinic as an integral
part of a Medicare patient’s normal course of treatment.42
Physicians must see new Medicare patients and evaluate
new problems for Medicare patients. NPPs may address new
problems and see new Medicare patients if the NPP is billing
under his or her own NPI. In order to bill subsequent visits with
the NPP as “incident to”, the physician must have continued
active participation and management of the patient’s treatment
with appropriate documentation in the patient’s medical record.
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25
Alternatively, NPPs can bill Medicare directly after obtaining Medicare credentialing,
using their own NPIs. Unless all services fall under the “incident to” definition, NPPs
must complete appropriate Medicare enrollment forms to be paid for providing
care to Medicare beneficiaries. Note that practices credentialing their NPPs through
Medicare receive lower reimbursement than from “incident-to” billing — 85 percent
of the physician fee schedule rate for office visits.43 Laboratory and immunizations are
reimbursed at 100% of the physician fee schedule.
Commercial payers usually require their own credentialing of
NPPs, and also reimburse NPP services at a lower rate than those
provided by physicians. Be sure you understand the requirements
when payers do not cover NPPs and do not enroll them as
credentialed providers. An article by an MGMA authority points
out that “Most payers will cover NPP services, but they may
not enroll them. In this situation, a practice would bill under a
physician’s NPI and follow the billing guidelines in the payer’s
provider manual. Commercial payers will follow state laws and
often require modifiers to correctly identify the provider and
supervising physician providing care.”44
Unless all services fall under the
“incident to” definition, NPPs
must complete appropriate
Medicare enrollment forms to
be paid for providing care to
Medicare beneficiaries.
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26
Many medical practices take both approaches to garner NPP revenue. However, failure to comply
with any insurer’s NPPs billing rules can put organizations at risk for noncompliance.
Coding specialist Laurie Desjardins, CPC, PCS, delineates the pitfalls of NPP “incident-to” billing,
noting that “Nurses, medical assistants or other trained personnel may also perform incident-to
services such as immunizations, injections or brief evaluation and management (E&M) services
such as those associated with blood pressure checks” using CPT* code 99211.45 “Remember, a
physician, physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife or clinical
psychologist may provide direct supervision for ancillary personnel.” CPT 99211 is the only E&M
code that does not mandate the presence of a physician in
the exam room, so it’s mainly applied to visits with ancillary
personnel for doctor-requested measurements, education and
follow-up. The code should not be used, Desjardins cautions,
in place of one that is more accurate or appropriate.46
Be sure to check with the Centers for Medicare & Medicaid Services
(CMS) Web site, as well as with your group’s commercial payers
to stay in compliance with NPP billing rules.
*Current procedural terminology
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Payers will have their own web
links and/or live representatives
for this purpose. The American
Academy of Physician Assistants
has extensive billing resources for
members, as does the American
Association of Nurse Practitioners.
©MGMA. All rights reserved.
27
How do we recruit and retain
NPPs in our practice?
Once you’ve decided to add NPPs to your
organization’s staff, you need to hire the best and
keep them. Deborah Hosilyk, PAHM, an MGMA
member and administrator, Advancements in
Dermatology, Edina, Minn., described her group’s
proven tactics to hire and retain NPPs.
“Keep in mind,” Hosylik says, “that it’s not the
number of responses you get but the quality of the
applicants. You can train new graduates and those
with experience in other areas of medicine, but they
won’t succeed without a passion for your group’s
specialty.”48
To find candidates:
Post ads on the websites of local NP and
PA associations and allied health schools;
Purchase mailing lists from these
associations and advertise your openings
via direct mail;
Ask your staff, pharmaceutical
representatives and other vendors
to spread the word and provide
recommendations.47
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28
Keeping good NPPs involves building a workplace and culture
attractive to all employees. In addition to offering NPPs a competitive
salary with good benefits, Hosylik recommends:
Providing an allowance for continuing medical education —
with time off;
Paying for NPP licenses, malpractice coverage, association
memberships, etc.;
Giving NPPs some autonomy and responsibility for clinical
operations or staff; and
Using an incentive plan to motivate production.
Experienced providers receive the benefit immediately; new
graduates have to work a year before becoming eligible for the
incentive. Hosylik’s practice pays NPPs a small percentage of net
collections that each generates monthly — which increases the
number of patients seen per day.
©MGMA. All rights reserved.
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29
Hosylik notes that an excellent working
environment also includes a no-tolerance
Questions to include in NPP interviews48
policy for negativity, social events
What experience do you have with our specialty,
personally or professionally?
that include all staff and significant
others, and monthly meetings with
providers and support staff to ensure
Has your clinical judgment ever been questioned? If so, by
whom and why? What was the outcome?
open communications. In addition,
What are your clinical strengths? Would others agree?
sharing financial and performance data
is an important piece to share with
nonphysician providers as well.
She recommends asking NPP candidates
certain questions to determine their
suitability for employment in your practice
(right).
How would your patients describe you? What would they
say you do best?
What would your patients say you could do better?
How many patients can you see a day? How many do you
prefer to see a day?
Have you ever been reported to the medical board? Do
you have any claims against you now or in the past?
Have you had any malpractice suits?
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30
Looking to the future
The nation’s changing healthcare landscape is giving NPPs unprecedented opportunities.
The ACA, the U.S. physician shortage and new models of healthcare delivery are reshaping
the way Americans deliver, receive and regard healthcare.
Affordable Care Act and shortage of primary care physicians
The ACA is generating myriad job
Because many newly insured individuals
opportunities for NPPs as millions of
seek primary care, NPPs can help cover
previously uninsured Americans gain
for a serious U.S. shortfall in general-
access to healthcare services. NPPs
medicine physicians: a gap estimated
offer a skilled alternative to physicians
from 9,000-45,000 for practitioners
for healthcare organizations seeking to
of general internal medicine, family
treat more patients, balance provider
medicine, geriatric and general
workloads and sustain their clinical
pediatrics.49
viability while combating administrative,
regulatory and financial pressures.
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31
Patient-centered medical home
Although groups may choose to hire
New models of healthcare delivery, such as the patient-centered
nonclinical staff for care coordination,
medical home (PCMH), call for more clinical roles that NPPs
NPPs are well suited for this
can fill. The PCMH is primary care that is “patient-centered,
responsibility. In addition, they increase
comprehensive, team-based, coordinated, accessible, and focused
patients’ access to care by offering
on quality and safety.”50
clinical alternatives to physicians,
Both government and private insurers are turning to the PCMH
serve as key members of the patient’s
as an outcomes-based, value-driven model where payments can
healthcare team and overall managers
be based on results. Insurers increasingly expect practices to
of PCMH principles and goals.
coordinate patients’ care with other providers and facilities to avoid
duplicating services, ensure appropriateness of care and reduce
error.
Population health forms another key pillar of the PCMH and generates opportunities for
NPPs. Forty-five percent of healthcare leaders polled by the HealthLeaders 2013 Media
Population Health Survey say they plan to improve access to NPPs as part of an investment
in population health management.51
Careful consideration of NPPs’ clinical abilities, expenses, revenue generation and
appropriateness for your facility should give you a deeper appreciation of these
versatile professionals.
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32
Sources
1.
Klein K. Has Obamacare really signed up 10 million people? The
Washington Post. January 6, 2014. www.washingtonpost.com/
blogs/wonkblog/wp/2014/01/06/has-obamacare-reallysigned-up-10-million-people/. Accessed Feb. 26, 2014.
2. Bureau of Labor Statistics, U.S. Department of Labor, Occupational
Outlook Handbook, 2014-15 Edition, on the Internet at http://
www.bls.gov/ooh/healthcare. Accessed Feb. 24, 2014.
3. Gans, DN. Why nonphysican providers? On the edge. MGMA
Connexion. Nov 2005, 5(10):25-27.
4. Center for Medicare & Medicaid Services, Medicare
Learning Network (MLN) Matters. http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/SE0441.pdf. Accessed Feb.
26, 2014.
5. Dunn C. The basics of nonphysician providers (NPPs). Medical
Group Management Association blog, July 30, 2010. www.
mgma.com/blog/the-basics-of-nonphysician-providers(NPPs).]
6.Ibid.
7.Ibid.
8. Gans, DN. Why nonphysican providers? On the edge. MGMA
Connexion. Nov. 2005, 5(10):25-27.
10. Grider R. 2013 year in review. Still lots of eyes on the walk-in
space. The ConvUrgentCare Report. Merchant Medicine. Jan. 1,
2014. Vol. 7, No. 1.
11. Urgent Care Center. http://www.urgentcarecenter.org/press.
html. Accessed Feb. 26, 2014.
12. American Academy of Urgent Care Medicine. What is urgent
care? http://aaucm.org/about/urgentcare/default.aspx.
Accessed Feb. 7, 2014.
13. Grider R.
14. Greene J. In reform era, retail clinics become part of the
healthcare delivery system. Crain’s Detroit Business, Dec.
9, 2013. Reprinted online in Modern Healthcare. www.
modernhealthcare.com/article/20131209/INFO/312099991/
in-reform-era-retail-clinics-become-part-of-the-healthcaredelivery. Accessed Feb. 11, 2014.
15.Ibid.
16. Robeznieks A. CoxHealth recruits docs, launches retail clinics
to prepare for newly insured. Vital signs – the healthcare
business blog. Jan. 17, 2104. Modern Healthcare. www.
modernhealthcare.com/article/20140117/BLOG/301179999/
coxhealth-recruits-docs-launches-retail-clinics-to-prepare-fornewly. Accessed Feb. 11, 2014.
9. O’Hare S. Mid-level providers in a changing healthcare
workforce. Becker’s Hospital Review. Aug. 17, 2010. www.
beckershospitalreview.com/compensation-issues/mid-levelproviders-in-a-changing-healthcare-workforce.html. Accessed
Jan. 30, 2014.
©MGMA. All rights reserved.
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33
Sources (cont’d)
17. Physician assistants the engine driving retail health clinics. July
29, 2013. http://blog.healthjobsnationwide.com/physicianassistants-the-engine-driving-retail-health-clinics. Accessed
Feb. 11, 2014.
18. Auerbach DI, et al. Nurse-managed health centers and patientcentered medical homes could mitigate expected primary care
physician shortage. Health Aff, Nov 2013;32(11):1933-41.
19. A new day for NPPs. MGMA Connexion. Jan. 2011. 11(1):37-37.
20. Palmer L. Know your state laws governing NPPs before you
incorporate them in your practice. MGMA e-Source, March 12,
2013. www.mgma.com/practice-resources/publications/esource/2013/know-your-state-laws-governing-npps-beforeyou-incorporate-them-in-your-practice.
21.Ibid.
28. What is a PA? American Academy of Physician Assistants.
www.aapa.org/the_pa_profession/what_is_a_pa.aspx.
Accessed Feb. 1, 2014.
29. Schwartz SK. Understanding scope of practice. Physicians
Practice, April 10, 2010. www.physicianspractice.com/articles/
understanding-scope-practice. Accessed Jan. 30, 2014.
30. American Association of Nurse Practitioners. States
categorized by type. www.aanp.org/component/content/
article/66-legislation-regulation/state-practice-environment/
1380-state-practice-by-type. Accessed Feb. 4, 2014.
31. American Academy of Physician Assistants. PA prescribing
authority by state. www.aapa.org/uploadedFiles/content/The_
PA_Profession/Federal_and_State_Affairs/Resource_Items/
Rx%20Chart%207-13.pdf. Accessed Feb. 4, 2014.
23.Ibid.
32. Elements of successfully integrating a mid-level provider
into practice. J Oncol Pract doi: 10.1200/JOP.1.3.93JOP
September 2005, vol. 1 no. 3 93-94; http://jop.ascopubs.org/
content/1/3/93.full.
24. Dunn C.
33.Ibid.
25.Ibid.
34. HealtheCareers Network. Q3 2013 Healthcare Jobs Snapshot.
26.Ibid.
35. Bureau of Labor Statistics, U.S. Department of Labor, Occupa­
tional Outlook Handbook, 2014-15 Edition, Nurse Practitioners,
on the Internet at www.bls.gov/ooh/healthcare/nurseanesthetists-nurse-midwives-and-nurse-practitioners.htm
and www.bls.gov/ooh/healthcare/nurse-practitioners.htm.
Accessed Feb. 07, 2014.
22. Hyden M. 4 ways to optimize your nonphysician providers.
MGMA In Practice blog. Oct. 7, 2011.
27. Sinclair S. The evolving role of midlevel providers. Sideshow
presentation, slide 13. The Cleveland Clinic. May 12, 2011.
www.clevelandclinicmeded.com/live/courses/2011/quality11/
osyllabus/12/Lunch/1245Sinclair,LunchAndPanel.pdf.
Accessed Jan. 30, 2014.
36.Ibid.
37.Ibid.
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34
Sources (cont’d)
38.Ibid.
39. Shriver D. How do you compensate nurse practitioners? Party
Line. MGMA Connexion, Feb. 2012; 12(2):13.
40. Gans D. What changes with more nonphysician providers?
MGMA Connexion Aug. 2010, pp.21-22.
41. Wiberg C. Understand payer requirements for billing
nonphysician providers. MGMA Connection. April 2, 2013.
Accessed Feb. 5, 2014.
42.Ibid.
43.Ibid.
44.Ibid.
45. Desjardins L. Avoiding the pitfalls of Medicare’s ‘incident-to’
rules. MGMA Connexion Nov/Dec 2008.
46.Ibid.
47. Hosylik D. How you can find — and keep — nonphysician
providers. MGMA Connexion, Aug. 2009:27-28.
48.Ibid.
49. Chen PW. Where have all the primary care doctors gone?
New York Times. Dec. 20, 2012. http://well.blogs.nytimes.
com/2012/12/20/where-have-all-the-primary-care-doctorsgone/. Accessed Jan. 30, 2012.
50. Patient-Centered Primary Care Collaborative. Defining the
medical home. www.pcpcc.org/about/medical-home.
Accessed Feb. 1, 2014.
51. 2013 HealthLeaders Media Population Health Survey, Oct. 2013.
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