Services delivered by PAs and NPs—specifically, those that a physician would otherwise have to provide—have been covered by Medicare Part B since 1998, but only recently have many practices and hospitals begun to scrutinize the value and productivity of these clinician team members.
“As organizations began employing larger numbers of these providers, they started asking how much revenue are they generating and how are they contributing,” says Tricia Marriott, PA-C, MPAS, MJ, CHC, senior director of regulatory and professional advocacy at the American Academy of PAs and senior advisor for the Center for Healthcare Leadership and Management. The “foundational concept,” says Marriott, is that PAs and NPs should be functioning as providers, doing work that typically would be provided by physicians. "Getting this right is the recipe for success—increasing patient access, creating workflow efficiences and developing more revenue opportunities for the practice," she says.
A PA herself, Marriott has worked in a variety of settings over the past 31 years. She talked with Cardiovascular Business about strategies for deploying PAs and NPs in cardiovascular service lines (CVSLs).
Should CVSL leaders be concerned that they are underutilizing their PAs and NPs?
In general, yes, but there are some practices that are doing it well and have been for a long time. There’s a lot of variability across the country, often depending on how much experience the physicians and/or the clinical operations teams have working with PAs and NPs. It tends to expand organically, where people hire one, it works out well, so they hire another. Of course, we'd like it to be mindful and intentional, as part of a larger overall strategy for a successful practice.
Practices need to step back and ask questions: Why are we hiring PAs and NPs? What’s the need or the problem we’re trying to solve? And what role will we ask them to provide? If their presence isn’t making the practice more productive—if they’re doing the work of a scribe or a medical secretary, for example, rather than providing professional services—then there are opportunities that aren’t being captured and misappropriation of resources at great expense to the practice.
What types of opportunities?
If you need more providers, if more patients need to be seen in the office or if you have a three-week wait time for new patients to be seen, then you have an opportunity to bring in a PA or an NP so that you can offer office hours when the cardiologist is, for example, in the cath lab. A three-week wait means you’re losing patients to other practices because consumers don’t want to wait. The goal is to offload or share physician work that a PA or an NP could also do well.
Are there misconceptions behind PA/NP underutilization?
It’s a myth that, when a PA or an NP sees a patient, the physician also needs to see a patient, be on site or even sign the chart in most instances. The rules are such that in all states PAs and NPS can evaluate patients, diagnose and treat, order and interpret diagnostic studies, and prescribe medications.
When it comes to optimal integration of PAs and NPs, I tend to fall back to, first, what are the rules? And, second, what are people comfortable with? You don’t just plug and play with a PA or an NP. There has to be a conversation about what they’re going to do. If the physicians aren’t comfortable with the PA or NP seeing certain types of patients, then you don’t start there. Maybe you start with them seeing follow-ups, but eventually, as comfort and confidence increase, the possibilities are endless.
In cardiology, PAs and NPs can do consults for acute myocardial infarctions in the ER while the interventional cardiologists are in the cath lab with other patients, which means the patients can be seen more expeditiously, the workflow and patient throughput are improved and the physician might be able to perform more procedures. The same applies to electrophysiologists, who can stay in the EP lab while the PA or NP is doing workups, which are pretty straightforward. PAs and NPs are also serving on cardiovascular procedural teams, providing care in critical care settings and performing post-procedural global work.
In other words, PAs and NPs can do the majority of the thinking work and interventions, but it gets escalated or elevated to the cardiologist as needed.