Many medical practices aren’t leveraging the full potential of their physician assistants (PAs) and nurse practitioners (NPs) and aren’t capitalizing on reimbursement for their services. As a result, practices may be leaving money on the table and missing opportunities to improve productivity, efficiency and quality of care.

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.

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Is it true that billing under a PA's or an NP's name leaves 15 percent of possible reimbursement on the table?

 "Fifteen percent left on the table" is my favorite myth to dispel. Under the Medicare program, services provided by PAs and NPs are reimbursed at 85 percent of the physician fee schedule, leading many to believe that the discount causes a 15 percent loss. However, the contribution margin (which takes into account the expenses associated with providing a service minus the revenue produced) of the work provided by a PA or an NP is actually higher, even though it is paid at 85 percent of the physician rate because the employment costs is significantly less than that of a physician.

How do you expect PAs and NPs will contribute to value-based healthcare?

I would posit that the PA and NP are already wired for what’s coming down the pike with tracking quality metrics and patient satisfaction. For example, congestive heart failure (CHF) is an area where PAs and NPs have established their role with bundling and performance measures. Post-discharge programs for CHF patients managed and followed closely by PAs and NPs have decreased their readmission rates and lowered the cost of care (Ann Pharmacother 2015;49[11]:1189-96; J Am Geriatr Soc 2004;52[5]:675-84). It works because PAs and NPs can provide continuity of care, are really good at remote monitoring and are capable of interpreting and acting quickly on subtle clinical changes. The goal is to keep them as outpatients, manage them in their homes and avoid readmissions. The patients love it because they know their provider and enjoy the more frequent interactions with the team.

Another example is a program where PAs visited bypass patients in their homes. They were able to adjust diabetes medications and diuretics, address pain, check wounds, … actionable stuff. The program reduced the 30-day total readmission rate by 38 percent compared to patients in the control group (Ann Thorac Surg 2016;102:696-702).

If you’re not thinking about PAs and NPs on the care continuum team, then the whole burden is on the physician, who has way too much for any  one person to do. PAs and NPs should already be in the toolbox because when patients’ care is ongoing, they can have fewer episodes because their symptoms are more likely to be managed before they can get out of hand.