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MD or non-MD? That is the question

August 2013

Published in the August 2013 issue of Today’s Hospitalist

HOSPITAL MEDICINE started with a few internists who decided to focus exclusively on hospital-based care. Over the years, other physicians have been welcomed into the fold: family physicians, pediatricians, and stray specialists like psychiatrists and obstetricians.

But perennial physician shortages now require hospital medicine groups to consider employing nonphysician providers. These hires involve a host of questions “clinical, business, interpersonal “that can be difficult to resolve. Here’s a quick primer on nonphysician practitioners and their financial impact on hospitalist groups.

Who’s who?
Our group presently employs three nurse practitioners (NPs), and we’ve just extended a job offer to a fourth. These providers have worked out famously for us, mainly due to careful recruiting, a broad scope of practice and willing physician collaborators.

Most hospitalists are familiar, at least vaguely, with NPs and physician assistants (PAs). In addition, clinical nurse specialists (CNSs) are a relatively recent entry in the nonphysician mix.

Their backgrounds and roles can get confusing in a hurry.

Scope of practice
Like physicians, a nonphysician practitioner’s scope of practice is determined by education and experience. That scope is further defined by state law, hospital credentialing, and collaborating or supervising physicians.

In our group, we delineate NPs’ scope of practice in a collaborative practice agreement. (Some organizations refer to it as a delegation agreement.) Our health care system requires a written document on initial hiring, with at least annual updates.

he agreement, which outlines the relationship between nonphysician providers and collaborating physicians, has two components: del-
egation of duties and prescriptive authority. The former specifies the activities that fall within that individual practitioner’s scope of practice and include:

  • types of services that can be rendered, such as H&Ps;
  • types of medical conditions that can be treated, with or without physician consultation;
  • ordering, performing and interpreting lab tests;
  • ordering and interpreting ancillary studies, such as X-rays or EKGs;
  • prescribing and managing medications; and
  • performing specific procedures, such as lumbar punctures.

We use a templated collaborative practice agreement, with the sponsoring physician and the NP deciding which boxes to check on the form “and we pretty much check all of them to give each NP the widest scope of practice.
The section on prescriptive authority is an exhaustive list of medication classes that are within providers’ prescribing scope, such as antimicrobials and bronchodilators. The agreement also includes provisions for managing controlled substances.

Roles and responsibilities
Programs need to carefully consider how they intend to use nonphysician practitioners. This can veer away from scope of practice, which deals with state law and clinical qualifications, and can quickly enter the realm of business models and interpersonal relationships.

We consider the NPs in our group to be peers, and they have the same basic scope of practice as their physician partners. They perform H&Ps, new hospital visits and follow-up visits, and discharge exams. All lab tests, ancillary studies and medications are also on the table.

We assume that our NPs “know what they don’t know” and will seek help from group members or specialists as needed. (This is where careful recruiting comes in.)

Other groups may opt for more restricted models. For example, hospitalists could perform initial hospital care services and consults to set up initial treatment plans, then pass patients off to nonphysician providers to manage, unless some huge change in status occurs. This largely hinges on recruiting and finding nonphysician providers satisfied with a more limited role. Group dynamics also play a big role: Do doctors consider non-MDs to be peers or physician extenders?

Nonphysician providers submit charges just like physicians but those charges are reimbursed at a lower rate than for physicians. Depending on how they are used, their reimbursement/salary differential can be a financial boon.

For example, services by nonphysician providers are often reimbursed at 85% of physicians’ rate, but they generally make at least 50% less. National data indicate that NPs earn about $100,000 per year; compare that to $221,000 for hospitalists, per the most recent Today’s Hospitalist salary survey.

If nonphysician providers have a wide-open scope of practice and perform more remunerative services like H&Ps, they can be very healthy for the bottom line. The numbers become less compelling if non-MDs have a more limited role, unless they are also boosting physicians’ billable services.

David Frenz, MD, is a hospitalist for HealthEast Care System and is board certified in both family and addiction medicine. (You can learn more about him and his work at www.davidfrenz.com.) Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.