Experts Bust Myths About Working With NPs and PAs

Marcia Frellick

April 17, 2018

ORLANDO — As nurse practitioners (NPs) and physician assistants (PAs) become integral players in hospital teams, the working relationships between these advanced practice providers (APPs) and physicians become a pressing issue.

Medicare recognized the services of APPs about 20 years ago, but their roles are still not fully understood, and some hospital policies haven't caught up.

Common myths about these relationships were debunked during a special track here at the Society of Hospital Medicine 2018 Annual Meeting.

Myth: APPs can't see new Medicare patients

"They absolutely can, and there doesn't need to be a physician in the office or onsite," said Tricia Marriott, PA, regional director for NPs and PAs at Trinity Health of New England's five hospitals. "A physician does not have to see every patient unless you've put some nonsense in your bylaws."

Myth: When APPs see new patients, practices lose money because Medicare only reimburses at 85%

If these providers are properly deployed, practices won't lose that 15% because the cost of employing PAs and NPs is significantly lower than the cost of employing physicians, Marriott explained.

In fact, "78% of the better-performing practices are utilizing what they call nonphysician providers," according to a 2016 rising trend report produced by the Medical Group Management Association.

Myth: When patients see APPs instead of physicians, it damages "the brand"

"Patients really want to be seen," Marriott pointed out. In the emergency department, "the patient wants to get off the gurney."

Access and convenience consistently rank much higher than preference for a physician in surveys such as the one conducted by the Advisory Board consulting group, she noted.

Being open to an adjustment in thought processes on this might get at what the consumer really wants, she added.

Myth: Practicing at the top of a license means that APPs are trained in all aspects the license covers

"I'm licensed to drive a car, but you don't want me in the Daytona 500," said Marriott, who has 32 years of experience as a PA, most of it in orthopedics and emergency medicine.

Although she has substantial experience caring for someone with a disarticulated limb, she had to get training to treat frozen shoulder.

That's important for hiring. "You're going to have to craft things specific to what people come to the table with," she pointed out.

Myth: The law says that physicians have to sign off on every APP note

In 1998, an act of Congress allowed Medicare to recognize APP services as physician services.

Before that, "hospital bylaws specifically restricted NP and PA licenses," said Noam Shabani, lead PA in the hospital medicine unit at Massachusetts General Hospital in Boston. "Physicians had to cosign every single note and see patients every single day."

"Although the law has changed, the bylaws of the hospitals haven't, so we're still seeing examples of this," he reported.

Myth: Working with APPs is like working with residents

Lines are not as clearly defined for physician relationships with APPs as they are with residents and, because the relationship is much newer, there is little training surrounding it, said Sarah Apgar, MD, assistant clinical professor in the division of hospital medicine at University of California, San Francisco.

Teaching can be involved in the relationships between physicians and APPs, but the primary goal is a collaborative relationship that serves the patient, not a supervisory hierarchy.

Apgar said she has been working with the interprofessional education committee at her institution, and that kind of academic focus plus enhanced curricula in medical schools are starting to address team relationships and better define roles.

Myth: APPs shouldn't lead clinical teams

"Anyone can step into the role of leader, potentially, depending on their knowledge base," Apgar said.

In fact, sometimes an APP with the necessary leadership skills — who might have spent the most time with the patient — is the most appropriate team leader, she pointed out.

The quality of the working relationships and the health of care teams are integral to the wellbeing of their patients. Efforts to improve relationships by establishing a stronger team approach with well-defined roles is in everyone's best interest, Apgar said.

Positive professional relationships can also help prevent burnout and restore the joy of practice. This can translate into fewer medical errors, less turnover, more professional engagement and, ultimately, better clinical outcomes.

Marriott, Shabani, and Apgar have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2018 Annual Meeting. Presented April 12, 2018.

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