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Healthcare Practice Strategies - Spring 2016 - A Matter of Leverage - How Mid-levels Can Transform Your Practice

Apr 20, 2016

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The role of mid-level providers — nurse practitioners, physician’s assistants and other advanced clinical providers — is expanding in our ever-evolving healthcare system.

Thanks to the Affordable Care Act and an aging population, more Americans are seeking health care. At the same time, payment models are increasingly rewarding quality over quantity. Practices most likely to succeed in this era of accountable care have figured out ways to leverage mid-level providers to not just handle increased patient volume, but also provide better outcomes.

Improving Productivity and Access

In the primary care setting in particular, overburdened physicians are utilizing mid-levels to bolster productivity and patient access while also providing the patient education and follow up that help prevent complications and re-admissions. Here’s how it typically plays out: 

Main Street Family Practice brings a nurse practitioner onboard who can treat upward of 80 percent of the patients seen each day. The remaining 20 percent of higher acuity cases are referred to one of the practice’s physicians. Medicare and private insurers reimburse the new nurse practitioner at anywhere from 80 percent to 100 percent of what Main Street’s physician providers receive.  

With a mid-level handling the typical colds and sprains, the physicians are free to concentrate on more complex, higher-reimbursing cases. At the same time, the physicians are able to spend more time with patients, even while supervising the work of nurse practitioners. 

It’s not just general and family practice physicians who are benefitting from using mid-levels. Specialty practices are incorporating physician assistants and nurse practitioners into the mix to reduce wait times for specialty services. In particular, specialties such as pediatric, women’s health, psych/mental health and gerontology are leading the pack. 

Three Ways It Could Work

Of course, you’ll need to take into consideration the scope of practice laws for mid-levels in your state (many states are currently considering expanding the scope of practice for nurse practitioners). In general, there appear to be three key roles that mid-levels are well-suited to play.   

  1. Handle acute care visits — A PA or NP can be utilized to improve same-day patient access and extend practice hours for acute care visits. This is perhaps the easiest way to quickly incorporate a new mid-level. 
  2. Become a member of an integrated care team — A mid-level can function as an extension of the primary care physician on a care team. He or she would handle lower-acuity visits and provide chronic and preventive care as well as treatment of acute problems. Physician productivity can be expected to benefit from this approach. 
  3. Operate as a fully paneled provider — A nurse practitioner could also be given full responsibility for an entire patient population. Depending on state laws, this approach may allow for the largest degree of patient panel expansion at a lower cost than hiring an additional physician. 

Of course, patients would need to be educated about the capabilities of mid-level providers to ensure they are comfortable seeing one as their main primary care provider.  

Do the Math

Mid-level providers are able to perform about 80 percent of a primary care physician's work while collecting about 70 percent as much in revenue. In 2015, the mean full-time base salary for mid-level providers was $97,083. This means mid-levels can bring in more revenue in proportion to their compensation than most internists and family physicians.  

In fact, for every $1 in compensation, the typical PA brings in $3 in gross earnings for the practice, according to the Medical Group Management Association. By contrast, internists typically gross slightly more than twice their compensation.  

Integrate Them Properly

Educate your office staff and billers on the laws and specifications of any non-physician providers so they fully understand the mid-level’s role, capabilities and impact on practice workflow and patient service. Likewise, take the time to introduce mid-levels to patients as colleagues. Make sure patients understand that you will always be available should they desire to “see the doctor.”  

Finally, remember that successful practices treat mid-levels as healthcare providers, not employees. Their pay is incentive-based (i.e., a competitive base salary with financial incentives around volume, quality outcomes, cost containment, etc.). 

The competition for mid-levels will certainly heat up under healthcare reform as busy waiting rooms and an emphasis on primary care increase demand for these “extenders.” With that in mind, physicians are well-advised to make sure they are offering the right combination of salary, benefits and work-life balance to retain existing NPs and PAs — or recruit new ones. 


Are You Ready for a Mid-level?

Your practice might be ready for a mid-level if:  

  • The practice has grown to the point that same-day appointment slots have all but disappeared and new patients are being turned away. 
  • You’re seeing more patients than you’d prefer or finding that your established patients need more care than you can comfortably provide. 
  • You’re a mid-career doctor looking to reinvigorate your professional life by focusing on more challenging cases or developing expertise in an area that interests you.

In any of these cases, you may be willing to exchange a short-term drop in income for a less-harried patient load.

 Healthcare Practice Strategies - Spring 2016

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