Home Career Midlevels make a rocky entrance into hospital medicine

Midlevels make a rocky entrance into hospital medicine

January 2007

Published in the January 2007 issue of Today’s Hospitalist.

Ali Saleh, MD, had a sense that the nurse practitioner (NP) his program hired last year had significantly lightened the load of the six hospitalists at their Parma, Ohio, hospital. But when the NP was suddenly deployed to Iraq, Dr. Saleh quickly realized just how much his practice had come to depend on the extra help.

Related article: Update 2012; Can midlevels take-up the slack?

“There are a lot of time-consuming things the hospitalist can forego when there’s a midlevel to help out-data-gathering, for example,” says Dr. Saleh, who directs the hospitalist program at the 348-bed Parma Community General Hospital. (The program is a Hospitalists Management Group practice.) The NP freed up physicians to spend more time with patients and made it possible to cut the number of hospitalists staffing the group’s pre-admission testing clinic from two to one.

While Dr. Saleh’s group was able to successfully integrate the NP into their practice, that experience is far from universal. Many other practices are struggling to figure out how to best employ the NP or physician assistant (PA) they bring on board.

Check our latest (2016) articles on all aspects of hospitalist practice management, from productivity metrics to scheduling strategies and paperwork reduction.

Part of the problem is a lack of physician awareness about “what our training or certification involves,” says Zachary Hartsell, PA-C, who supervises the inpatient PA staff at Mayo Clinic-Arizona and has been in hospital medicine for five years. As a result, he adds, “the role of the hospitalist PA has not been well defined.”

Common stumbling blocks include finding the right physician-to-midlevel ratio. Programs are also grappling with what scope of care midlevels should assume and what kind of training and supervision they need.

Growing numbers
While midlevel models may pose challenges, a growing number of hospitalist groups are hazarding that learning curve. For instance, the hospitalist program at the Mayo Clinic Hospital in Phoenix, part of the Mayo Clinic-Arizona system, has more than tripled its midlevel staffing, from two to seven PAs, in the past three years.

According to the most recent Society of Hospital Medicine figures, 16% of hospitalist groups now employ PAs, while 20% have hired NPs. (The mean number of fulltime equivalent providers is .32 and .37, respectively.)

And American Academy of Physician Assistants 2006 survey data show a rising number of PAs in hospital medicine. Approximately 7% of the more than 63,000 practicing PAs-about 37% of whom work in inpatient settings-reported functioning as “hospitalist PAs” in 2006, up from 6% two years earlier.

But even as hospitals expand midlevels’ presence, their role is a work in progress. “They’ve grown in number,” says James Wilkens, MD, chair of hospital medicine at Mayo Clinic, which employs 12 full-time and seven part-time hospitalists, “and what they do for us is still evolving.”

When Mayo first brought in PAs for its non-teaching hospitalist service, the objective was clear: to have them help hospitalists with “peak times,” those afternoon and evening spikes in admissions.

Today, the PAs-under the supervision of a rotating lead hospitalist, who serves as triage officer-work in staggered 12-hour shifts to accommodate peak periods. Handling admissions still makes up 60% of their workload, while discharge preparation takes up another 10% of their time and the rest is spent rounding with hospitalists.

That breakdown may soon change, Dr. Wilkens says, as the program moves to give PAs more continuing-care duties, a modification the PAs themselves asked for. Regardless of their ultimate work duties, Dr. Wilkens says, the PAs significantly reduce hospitalists’ “legwork and paperwork” and are there to stay. The one downside? There aren’t enough PAs.

“Our goal would be to have enough PAs to assign one to each attending,” he says. Mayo may meet that goal with a newly developed post-graduate PA fellowship in hospital medicine, which the program hopes will increase the pool of PAs with hospital medicine training and experience.

Finding the right ratio
Finding the right physician-to-midlevel mix has been a big challenge at the University of Michigan Medical Center in Ann Arbor, where the hospitalist service has tried different configurations in the past five years.

“We originally wanted a one-to-one pairing, with one physician and one PA for each 10 patients,” says Vikas Parekh, MD, assistant director of the hospitalist program, which includes 16 physicians and eight PAs. “But the PAs wanted to manage their own patients, and with 10 complex patients, that simply didn’t work.”

Neither did the next iteration the group tried: having one PA report to two hospitalists. The PAs had trouble coordinating their time between physicians, while individual hospitalists ended up not having a good idea of the PAs’ total workload.

For now, the group has decided to again pair one PA with one hospitalist, but the PA doesn’t cover the physician’s entire patient panel. Instead, PAs are assigned a smaller panel of less-acute patients for whom they’re responsible, with hospitalists providing care oversight for all patients.

The PAs also take on much of the paperwork, including daily notes, discharge summary drafts, and coordination of studies and consultant evaluations. And because the hospitalists rotate off every week, PAs bring continuity to patients with longer lengths of stay.

“We encourage them to be active in developing the management plan, but they still need a fair amount of MD input,” says Dr. Parekh. “We hope this arrangement-it’s almost akin to the intern-attending relationship-will work better, but honestly, it’s still a learning process.” Despite those challenges, the group has doubled its number of PAs in the last six months in response to the growing need for services.

Integrating a patchwork of experience
A program at University of California, San Francisco (UCSF) is also experiencing a steep learning curve in how best to utilize midlevel skills, according to Niraj Sehgal, MD. Dr. Sehgal directs the non-resident hospitalist service at UCSF Medical Center at Mount Zion, a 24-bed unit operated by five hospitalists and two NPs.

Because hospitalists often have limited experience with NPs’ and PAs’ training and skill sets, “we’re still struggling with how to direct, train and mentor them, not to mention allow for their professional growth,” he points out.

While physicians tend to equate NPs with residents or “junior attendings,” he says, one of the biggest challenges is defining midlevels’ scope of care-which can vary considerably.

“You have many NPs who learned specific skills and then functioned autonomously,” he says, citing NPs’ role in ambulatory care where they become primary providers in defined clinical situations, such as managing outpatient diabetes. “We need to develop similar strategies that apply to the very heterogeneous inpatient population.”

Even NPs with acute care experience tend to concentrate on very specific-and varied-areas, he adds: handling admissions or discharges in one setting, caring for low-acuity patients in another, and managing patients with defined clinical protocols in a third.

“The job descriptions vary tremendously,” he says, one more reason why many programs find it hard to “develop a roadmap” for NPs’ scope, autonomy and professional growth. While he would like to see the issue studied as far as cost effectiveness and staffing models, he’s heard anecdotally that some hospitalist programs are reconsidering their midlevel model or looking for other ways to offload non-clinical duties.

“We’re discovering,” says Dr. Sehgal, “that not every service will benefit from physician extenders, particularly if the staffing model and expectations aren’t carefully thought out.” Mayo’s Dr. Wilkens concurs that integrating midlevels’ varied skill sets into a practice can be a challenge.

Three of Mayo’s PAs had related inpatient experience when they were hired, while five did not. Training for the experienced PAs lasted about eight weeks, he says, compared to up to six months for those who were new graduates.

Success stories
Still other programs have had great success with midlevel staffing. One is Hospitalists of West Michigan (HOWM), a program based in Grand Rapids that serves two hospitals in the Spectrum Health seven-hospital system.

Over seven years, the program has grown to include 25 PAs and 11 hospitalists who work in four discrete teams. What’s the PA-physician ratio that HOWM finds works best? Two-to-one, with one PA rounding with a hospitalist during the day, while another day-time PA handles admissions and consults.

Today, PAs do much of the same work as hospitalists, says HOWM president Khan Nedd, MD. They handle most admission histories and physicals, collaborate on consults, and provide night-time coverage for off-site physicians.

“Hiring a PA simply to push paper and [compile] discharge summaries is a waste of resources,” Dr. Nedd explains. The program also encourages PAs to sharpen their skills by giving them financial incentives to participate in a journal club with the physicians and to become active on hospital committees.

Ryan Genzink, PA-C, who joined the group in 2000, agrees. Limiting the role of PAs to scribes, he says, will limit their understanding of treatment plans-and, ultimately, the quality of care.

At the same time, Mr. Genzink says the key to his expanded role is the education the group provides. “Our physicians train us to do everything they do in a given situation,” he says. That training, he explains, is similar to a resident’s, with PAs starting with a certain group of patients and receiving continuous input from the hospitalists on how those patients should be managed.

Dr. Nedd points to another big benefit of the group’s training program: helping midlevels move beyond a task mentality.

“One barrier is getting PAs to think in terms of systems or big-picture issues,” he says. “They’re certainly capable of that, but so much in medicine-and what PAs learn-is protocol driven.” When the hospitals’ ED departments implemented a throughput initiative, for example, they inadvertently caused a bottleneck in hospitalist admissions, with patients arriving on the floor without orders.

The PAs have been asked to help resolve the problem, interacting with individuals outside the hospitalist service-which is new turf for them.

The need for flexibility
Hospitalist programs that have found success with midlevels point to another key strategy: constantly re-assessing midlevels’ roles and workload.

At Brigham and Women’s Hospital in Boston, for instance, PAs were originally hired in 2005 to help the hospitalist service deal with resident work-hour restrictions. Most of the PAs had prior inpatient experience.

Because reducing the number of night-time admissions was so critical, the PAs took mostly “holdover” admissions, says Christopher Roy, MD, medical director of the Physician Assistant Clinical Education (PACE) service, which includes three Brigham hospitalist attendings. Because they are working with the close supervision of an attending hospitalist, PAs are able to take very complex patients.

“Our PAs take care of very sick patients, not just the simpler admissions,” Dr. Roy says.

As the service evolved, however, it became clear that staffing was inadequate, given the high turnover and complexity of patients on the service. That led the group to hire one more PA, bringing the hospitalist-to-PA ratio to one-to-

“The census is now slightly lighter on the housestaff service,” Dr. Roy says, “and it’s enabled us to address our concerns about PAs’ professional growth. We didn’t want them to feel like second-class citizens.”

The PAs are also increasingly taking non-clinical leadership roles, working on quality assurance and patient satisfaction initiatives. That has likewise helped with retention.

“When you have experienced PAs like ours,” Dr. Roy explains, “you want to keep them.”

Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.


Other hurdles to clear: regulation and reimbursement

The fact that physician assistants (PAs) and nurse practitioners (NPs) are relatively unknown quantities in hospital medicine may be limiting their use. But so does the fact that PA and NP regulation varies from state to state, as do payers’ policies regarding billing for midlevel services.

In most states, NPs and PAs are governed by state medical boards. According to Michael Ruhlen, MD, chair of the non-physician provider committee of the Society of Hospital Medicine and physician liaison to the Toledo Hospital/Toledo Children’s Hospital PA program in Toledo, Ohio, the involvement of state medical boards means that midlevels’ scope of practice, especially in prescribing, can vary a great deal.

“There are pockets where the [hospitalist-midlevel team] model works wonderfully,” says Dr. Ruhlen, “but I don’t think we’ll see universal adoption of this until there is much greater standardization among state medical boards.”

Revenue and billing
Payment issues pose other problems. Per Medicare rules, NPs and PAs can bill out at only 85% of the physician rate if they bill under their own provider number. That’s led some hospitalist programs to assume they’ll make less revenue if they hire midlevels, which isn’t usually the case, says Michael Powe, director of health systems and reimbursement for the American Academy of Physician Assistants.

With a 2006 mean of $84,396, PA salaries amount to a little more than half of a typical hospitalist’s. Groups that achieve significant efficiencies can increase their census or reduce their hospitalist staffing-and see a bottom-line improvement.

“Often what the PA does is a billable service-and an opportunity for the hospitalist to perform another billable service or visit,” Mr. Powe says, “so it’s cost effective financially.”

Most groups, however, bill via the Medicare shared-visit rule, in which joint services are billed under the physician’s billing number at 100% of the allowed rate. Hospitalist supervision of the midlevel is required, as is patient “face-to-face time” with a physician. Procedures and consultations are currently excluded from shared-visit billing.

Joint billing is how Hospitalists of West Michigan in Grand Rapids, which employs two day-time PAs per hospitalist, operates.

“We’re still able to bill aggressively, because a lot of our patients are very sick people, and we’re not afraid to bill what’s appropriate,” said group president Khan Nedd, MD. “That makes the PA-to-physician ratio cost effective.”

Getting payers and physicians on board
Another issue: Some commercial payers have been slow to embrace NPs and PAs who bill on their own.

Even in states where state and federal authorities allow midlevels to bill for services, says Dr. Ruhlen, “many payers either don’t recognize the [CPT code] modifiers that indicate midlevel services or don’t include midlevels in their provider panels.”

That kind of market variation is one reason Hospitalists Management Group (HMG) of Canton, Ohio, a national hospitalist practice group, doesn’t allow midlevels to bill independently. The company, which operates 18 programs and employs 140 hospitalists and 15 midlevels, has another reason to shy away from midlevel billing, says HMG president and CEO Stephen Houff, MD: the expectations of referring physicians.

“The office-based physicians and specialists who ask us to see their patients want the services that a physician can provide,” says Dr. Houff. “That’s in our collaborative agreements with referrers and our midlevels.”

The attitudes of referring physicians, he adds, can vary as much as those of commercial payers.

“There are markets in which midlevels are very well accepted,” Dr. Houff points out. “But using an NP or PA in a market where the culture is aligned in a different direction can create conflict, so be aware of the politics.”