Hospitals Finding New Ways to Integrate PAs and NPs

Marcia Frellick

March 07, 2019

NATIONAL HARBOR, Maryland — Although the number of hospitals using nurse practitioners (NPs) and physician assistants (PAs) has increased over the last couple of years, many hospitals continue to underuse them, according to the most recent Society of Hospital Medicine State of Hospital Medicine report.

The 2018 report showed that 76.8% of hospitals are using NPs and PAs, up from the 68.4% cited in the 2016 report. However, numbers vary by region — from 79.0% to 88.0% in the East, Midwest, and South, to only 44% in the West.

And although 90% of hospitals reported that the work of NPs and PAs was billed independently, as shared services, or as a combination of the two, 10% of hospitals reported that NPs and PAs "don't generally provide billable services," said Tricia Marriott, PA-C, MPAS, MJ in health law, regional director of PA and advanced practice registered nurse providers at Trinity Health of New England.

When NPs and PAs are not providing billable services, that is a "completely inappropriate use use of a provider," said Marriott, who will speak about return on investment for NPs and PAs at the upcoming Society of Hospital Medicine 2019 Annual Meeting.

"They are being used as helpers, and they are very expensive helpers," she told Medscape Medical News.

Expensive Helpers

The helper arrangement is a very old model, developed before 1998, when Medicare first recognized the work of NPs and PAs, she explained.

If NPs and PAs are doing something that would otherwise not be done by a physician, "then you need to offload that to someone else," she said. For example, NPs and PAs should also not be doing data entry.

"A scribe is $0.57 a minute and a PA is $1.35 a minute," she reported. "Instead of using your PA to do order entry or data entry, a scribe is the way to go. If the only reason you're bringing in a PA or NP is because you're struggling with a computer, that's not a solution."

Another mistake hospitals make is assuming that all NPs and PAs have the same skills. Experience is critical when determining where each provider will work best. Just hiring more of them is an inefficient use of funds if there is no strategic plan for each role, said Marriott.

In some ways, the pendulum might have swung too far from the days when NPs and PAs had to defend their existence. Now, they are not always receiving the time and training they need to become proficient in their assigned roles.

"We're suffering from our successes, in that hospitals don't realize that not every NP or PA is the same," said Marriot. "There's a level of effort that has to go into understanding each others' ways."

And time for collaboration with care teams needs to be built into the workflow, she added.

Growth Areas for NPs and PAs

Telemedicine is one area where NPs and Pas can effectively contribute to hospital medicine, according to Tracy Cardin, ACNP, vice president of advanced practice providers at Sound Physicians in Tacoma, Washington.

When NPs and PAs are paired with telemedicine teams, they can field questions when a patient's primary physician is not available, she said.

"The majority of cross-cover does not require an in-person evaluation," she told Medscape Medical News. Some hospitals use telemedicine so that providers in a central location can answer questions from several hospitals and ease staffing issues.

NPs and PAs can provide backup for the telemedicine team if an onsite evaluation is needed, facilitate admissions, and handle more urgent care. In turn, the remote telemedicine team can back up NPs and PAs when they are working alone, for instance, and need a consultation.

Another growth area for NPs and PAs is behavioral health, Cardin explained, because more hospitals are establishing freestanding behavioral health programs. And some are starting to augment psychiatric services with the medical services of advanced practice providers.

Consults for Surgeons

In hospitals with high surgical volumes, partnerships between advanced practice providers and physicians have been working well, she reported. NPs and PAs — who often have an expert understanding of the most recent guidelines and protocols — can consult on the management of a patient's diabetes, high blood pressure, hyperlipidemia, or chronic pain, for instance, instead of physicians.

"I've found that to be a very satisfying role for NPs and PAs," said Cardin.

Whatever the specifics, the best models are collaborative, she said.

"Change is part of hospital medicine and it's a team sport," she explained. "I cannot do my job without my very-well-respected physician partners and I hope they view the partnership with NPs and PAs in a similar way. The best of all worlds is when we solve patient and system problems together."

Marriott has disclosed no relevant financial relationships. Cardin is secretary for the Society of Hospital Medicine's board of directors.

Society of Hospital Medicine (HM) 2019 Annual Meeting. To be presented March 26 and March 27, 2019.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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