Midlevel Providers: Worthwhile Hires

Planning and Proper Supervision are Key

By Joanne Tetrault
Joanne Tetrault is a writer for Physicians Practice

Like most business endeavors related to your practice — whether it’s buying an electronic medical record or streamlining your scheduling process — planning is essential when it comes time to add a midlevel provider (MLP) to your staff.

The term midlevel provider generally applies to nurse practitioners and physician assistants; others may include nurse midwives, nurse anesthetists and clinical nurse specialists. They are excellent resources for easing physicians’ packed schedules and improving access to your practice — thus generating greater patient satisfaction.

According to William Smits, M.D., medical director of The Asthma and Allergy Center in Fort Wayne, Ind., adding two nurse practitioners to his staff “easily allowed me to double [the size of] my practice.” Smits’ patient panel is about 15,000-patients strong.

And because they require less capital outlay than hiring a new physician, MLPs are a good option for physicians who “know they can use help and are not ready to bring on a physician provider,” said Smits.

When given the appropriate role in the practice, MLPs become more than simply “physician extenders,” but valuable additions who have distinct skill sets.

For example, nurses tend to “have very good relationship skills,” said practice administrator Emily Brower of Urban Medical Group in Jamaica Plains, Mass. “And when a patient is chronically ill ... those relationship skills really have an opportunity to shine through.” Once patients experience those relationship-based interactions (that physicians often simply don’t have time to provide), they often come to expect — even demand — them.

So while it’s true that unburdening overworked physicians with additional, talented care providers is a good thing, keep in mind that adding an MLP to the mix takes some forethought. Be certain you know ahead of time the role your MLP will play and that you both have similar expectations.

Define roles
“I’ve seen practices say, ‘Let’s hire a nurse practitioner (NP),’ without being clear about why they need one, or what the NP’s role will be,” said Debi Croes of Croes-Oliva Group, a medical practice consultancy in Burlington, Mass. Croes believes this is a mistake.

First, it is important to understand the qualifications and abilities of your MLP. Nurse practitioners are registered nurses who have an advanced degree, usually a master’s degree. Physician assistants (PAs) are licensed to provide care under the supervision of a physician.

According to the Web site, www.physicianrecruiter.com, “the difference between nurse practitioners and physician assistants is a gray area ... often described in terms of supervision — PAs are licensed to practice with the supervision of a physician, while NPs seek a collaborative relationship with physicians.”

When it comes to clinical responsibilities, MLPs’ prescribing authority varies by state. Your state medical board is also a good resource to help you determine the scope of practice for the type of MLP you plan to hire.

In Indiana, where Smits practices, for example, NPs have prescribing authority, which was an important consideration for him.

Read the fine print
There are also some legal, contractual, and administrative issues to consider before hiring an MLP. “It’s very important to not only speak to your lawyer — or at least your medical society’s legal advice line — but also speak to your malpractice carrier,” said Croes.

To minimize risk, “Be sure to add the MLP onto your corporate malpractice policy,” said Joan Roediger, J.D., a health care attorney practicing in Philadelphia.

Also, review your payer contracts to determine whether they require MLPs to be credentialed for billing purposes.

Finally, be sure to analyze the numbers and types of patients your practice sees before hiring an MLP and have an agreed-upon plan for which cases are appropriate for a non-physician and which are not.

“I’m a great advocate of [midlevel providers] because there’s a lot of work they can do to free me up for the physician-only work,” said Smits. For example, they can take a history, check vital signs and make sure all lab work is assembled. In Smits’ office, the two MLPs handle well-patient visits or return visits that don’t require significant changes to the treatment plan, “and leave more difficult management problems [to the physician],” Smits added.

Create good rapport
Interoffice relationships can suffer when the supervisory role of the physician is unclear or inconsistent, or when MLPs feel they are “second class citizens.” To avoid this, the supervising physician should meet regularly with the MLP to review and evaluate his or her work.

“We do case reviews on a monthly basis,” said Smits. “I review 5 percent of their charts, which is required by law in our state.” He asks his MLPs to “choose the more challenging ones” and he gives them feedback.

After a training period that lasts from three months to a year under Smits’ supervision, he said he gives his MLPs “lots of autonomy once I feel comfortable they are doing everything they need to.” He admits that it can be difficult for some physicians to let go of part of their workload, but in the end, it is worthwhile.

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