Increasingly in demand, gastroenterology, orthopedic, and dermatology specialists can resolve bottlenecks in their appointment calendars and increase revenue dramatically by using more physician assistants and nurse practitioners to help treat patients, according to a new California Healthcare Foundation study.
However, not all states' scope of practice laws may be sufficiently broad to allow the practice. Also, more postgraduate training programs are needed for PAs and NPs to gain proficiency so they don't have to be trained on the job.
The authors wrote that practitioners who use PAs and NPs reported that outcomes were almost always positive and the time they saved allowed physicians to spend more time with more complex patients.
The California Healthcare Foundation study evaluated six practices across the country that now use PAs and NPs to bridge the gap in providing care to their patients. The study, "Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work," was conducted by researchers at the Center for Health Professions at the University of California, San Francisco.
The authors, Catherine Dower and Sharon Christian, interviewed gastroenterologists, dermatologists, and orthopedic specialists who use nurse practitioners and physicians assistants in both hospital and clinic settings in Federal Way, WA; High Point, NC; Salem, OR; Fontana, CA; Gainesville, FL; and Springfield, MO.
The report concluded "these models generally improved access, reduced wait times and proved financially sustainable."
Although third-party payers have varying reimbursement schedules for services provided by NPs and PAs, "when these clinicians independently provide services to patients, Medicare typically reimburses at 85% of the physician reimbursement rates," the researchers wrote.
Outpatient services are billed under Medicare's "incident to" physician care provisions, which pay at 100% of the physician's reimbursement rate as long as the following conditions are met:
- The specialist physician is physically on-site at the time the NP or PA provides the care.
- The specialist physician personally treats and diagnoses patients on their first visit, although the NP or PA provides subsequent care.
- The specialist physician treats and diagnoses patients with new conditions, though NPs and PAs may provide subsequent care.
- The specialist physician remains involved in the patient's care.
Financially, using NPs and PAs brings a good return, the authors wrote. Although rates paid by Medi-Cal, California's Medicaid program, are extremely low, it reimburses PAs and NPs at 100% of the amount payable to a physician for the same service, the study said.
"Practices that participated in the study reported being in good financial positions in large part because of their integration of PAs and NPs," the authors wrote. "Many offices arranged their practice models to comply with Medicare policy allowing them to bill NP and PA services at 100% of the physician rate. Even if they billed some services at 85%, the increased patient volume and the lower salaries of NPs and PAs contributed to solid financing."
One drawback the authors mentioned is that initially, some physicians were unaware of what services NPs and PAs were able to provide. Some "stressed that some physicians were very concerned about the competence of PAs and NPs," and worried that physicians just starting their practices might be uncomfortable incorporating such caregivers "before the practice is financially well established."
However, "A number of medical specialty practices across the U.S. rely in part on NPs and PAs to provide clinical care, including (these) high-demand specialties," the authors concluded. "These practices have successfully improved access to care for patient populations that have been experiencing significant wait times to see specialists."