By William J. Mazzocco
The recent passage of the Balanced Budget Act of 1997 carried with it some very sweeping health care regulatory changes. One of the most significant deals with that group of non-physician advanced practice providers collectively referred to as mid-level practitioners. This designation usually includes nurse practitioners, physician assistants, clinical nurse specialists and nurse midwives.
The main components of the legislation deal with the expansion of Medicare reimbursement to advance practice nurses, (prior to this only PAs were reimbursable in most situations), and a relaxation of the physician supervisory component. This reimbursement would be standardized at 85 percent of the customary physician fee irrespective of practice setting, i.e., hospital, SNF, or operating room. The degree of physician supervision would be ceded back to the respective state legislatures. This meant that it would be possible in most states for the mid-level to see Medicare patients without the necessity of the physician being in the office. Most states recognize supervision by means of standard telecommunication equipment as a viable alternative to on-site supervision.
Despite earlier favorable legislation, (The Omnibus Budget Reconciliation Act of 1986) and this new legislation, not all practices have been able to capitalize on the increased revenue potential by using these practitioners. Quite frankly, some practices have been quite disappointed in the work performance and revenue generated by this group. Some of these concerns can be attributed to individual failures and the newness of the concept. Obviously, something was missing from the equation. Studies had shown that these practitioners could provide quality care at an affordable price but individual practices were having difficulty reproducing these results. What was the problem?
The answer was as simple as it was multifaceted. The reason that the practices were not seeing increased reimbursement was because, in many cases, these practitioners were simply not being used. A significant reason for this under-utilization was that the physician, the practice, and many times the mid-level themselves were not aware of how to utilize this unique employee. The physicians were often ignorant of the training provided as well as the laws that governed their usage. Putting it succinctly, the physicians did not know how much confidence to place in this new provider. The degree of utilization has been shown to be directly related to the confidence level of the physician supervisor.
How can one correct this knowledge deficit? One corrects it the same way one corrects any deficit: you educate all the parties concerned. The physician, the practice and the mid-level must take the time to learn about the concept. One of the first tasks would be to orient the mid-level to the practice. Unfortunately, most receive virtually no instruction beyond, “park you car here.” The physicians themselves are also at fault. Many know more about the specifications of their car than they do about the laws that regulate this valuable employee.
While the various representative professional organizations, i.e., the American Academy of Physician Assistants and the American Academy of Nurse Practitioners, will strongly advocate that they are safe, competent health care providers, the fact is that most of these practitioners receive no formal residency training. There are some notable exceptions, but overall they receive didactic training augmented by rotating clerkships. These are much like the medical school curriculum, only shorter. I raise this issue, not to criticize, but to explain the misconception often held by potential physician employers that these practitioners are a “finished product.” I like to use the analogy of a graduate medical student. He or she has completed schooling but would hardly be able to run an office or function as a legitimate first assistant in the operating room. Yet every day graduate mid-levels with less training are being asked to do exactly that!
If you are going to hire a mid-level and expect to get the most out of him or her, you are going to have to take the time to correct both your knowledge deficits. This is best done using an objective organized orientation which includes a skills and knowledge assessment program. If you need a pair of trained hands in the operating room and want to use them to do more than hold a retractor, then you are going to have to train them. Once mid-levels have had the opportunity for additional training and experience they have been shown to be interchangeable with residents acting as house staff. The key words here are “additional training” and “experience.” The practice can let the practitioner gain this experience in a haphazard manner or it can utilize an organized program. It is plain to see which would be more efficient in terms of time, effort and final result.
Here are some recommendations to help build a strong foundation:
Evaluate the financial health of your practice. If money is tight and you’re not busy, don’t hire a mid-level at this time. There will be too much pressure on both parties.
Write a detailed job description for the position. You have to be able to communicate your needs to your new employee. If you cannot do this neither you or your employee will ever be satisfied.
Contact the various representative professional groups and obtain information packets on the various mid-level types to help make your decision, but remember they are lobbying organizations. To inject a component of objectivity I usually recommend that the practice check the local regulations and review actual course descriptions from some representative colleges catalogs. These practitioners may be grouped together but their basic educational requirements may vary from state to state and profession to profession.
Check with your state medical board to see which practitioner has the most flexibility under state law, for example, prescription writing.
Take the time to read the state regulations that govern mid-levels. They are usually succinct and easy to understand. If you have a question, contact your attorney or the state medical board for clarification.
Design or have a consultant design an orientation program that is specific to your practice situation. This will become your objective yardstick to assess the knowledge and experience of your employee. Even experienced mid-levels can benefit from this practice, especially if they are moving into a different specialty.
Educate your office staff and billers on the laws and specifications of this employee and establish a clear chain of command.
View the mid-level like a newly graduated medical student and not a finished product. The orientation checklists are much like the residency patient lists you were exposed to while in training. Your practice will be their “residency”.
Take the time to introduce the mid-levels to your patients as a colleague. Emphasize that you will always honor a patient request to see only the doctor.
Build a solid foundation by instituting a detailed orientation and integration program. If this is too difficult or time consuming, you can have a consultant construct one for you. You must have a sound foundation before you can attempt any expanded or innovative practice techniques. Remember, there must be no communication filters between you and the mid-level.
All of these techniques are useless if the individual chosen is inadequate. Take your time and find the person you want, not just who is available. The physician must take an active role in the interviewing process. It is clear that no employee can be a greater source of revenue or expose the practice to increased liability if not properly supervised. Open lines of communications are a must. As their employer, you are ultimately responsible for their actions despite the fact that they are required to carry their own malpractice insurance.
To summarize: structure the practice for success by ensuring that the mid-level, the practice and the physician have taken the time to prepare a solid foundation. Know exactly how and where you want to use the mid-level. Take an active role in the recruitment and training so that he or she can perform the tasks assigned. Remember, the practitioner will only become what you allow him or her to become! Finally, the mid-level concept can work extremely well, but only in those practices willing to make the commitment to orient, educate, and integrate mid-levels into the practice. If you are not ready to make that commitment, you should be prepared for a lower level of service and/or consider not hiring a mid-level at this time.
William J. Mazzocco is president and chief consultant for Medical Administrative Support Services in Altoona, Pennsylvania.