Thomas F. Murray, Jr MD

AAOS Now

Published 1/1/2015

Making the Most of PAs and NPs

Physician assistants and nurse practitioners add value, quality

The number of physician assistants (PAs) and nurse practitioners (NPs) working in medical practices has grown substantially. According to a recent survey conducted by Jackson Healthcare, a healthcare staffing firm, nearly one-third of physician respondents say they have increased their use of advanced practice professionals, including PAs. An estimated 10,000 PAs currently practice in orthopaedic surgery, in settings ranging from independent practices to large groups to academic medical centers.

Recently, Thomas F. Murray, Jr MD—a member of the AAOS Practice Management Committee and a sports medicine specialist at the OA Centers for Orthopaedics in Portland, Maine—held a roundtable discussion with two of his fellow committee members and a practicing PA about how PAs and NPs can benefit orthopaedic patients and practices. Participants included the following:

  • Gail S. Chorney, MD, assistant professor, medical director of ambulatory care services, and director of physician practices for the department of orthopaedic surgery at the New York University Hospital for Joint Diseases
  • Anthony V. Petrosini, MD, a sports medicine/arthroscopy specialist at the Orthopaedic Institute of Central Jersey, Spring Lake, N.J.
  • Kemuel Carey, MHS, PA-C, ATC, American Academy of Physician Assistants liaison to the AAOS and a practicing PA at Peninsula Orthopaedic Associates, PA, in Salisbury, Md.

Dr. Murray: How are PAs and NPs used in your practice?

Dr. Chorney: In our practice, PAs and NPs do office hours with the physicians. For new patients, the PA or NP will get the past medical history of the family, the social history, and some idea of what the problem is. They may initiate care by obtaining the proper radiographs or other studies before the doctor sees the patient. They may also stay with the patient afterward to review next steps.

Follow-up or postoperative patients may see the PA or NP as the primary provider, with the physician available. Our PAs and NPs do not have parallel office hours but they may have their own schedule to perform some follow-up procedures such as knee injections.

Dr. Petrosini: Our practice uses PAs in multiple roles. They cover the emergency department (ED) and spine trauma at our hospital on a nightly basis. They also assist on surgical cases, both in the hospital and at our ambulatory surgery centers. Some of them evaluate patients in our office, both with the doctor and on their own. Finally, they are providers in the after-hours urgent care clinic.

Mr. Carey: Our practice employs 16 PAs, 12 of whom are paired with a surgeon for clinic, inpatient rounding, operations, and on-call. Our PAs do not do clerical work such as posting elective surgical cases, taking triage phone calls, placing patients in examination rooms, or interviewing patients.

Paired PAs take inpatient calls as well as first-call 24/7 for a single regional trauma center. They may serve as first-assistants at surgery while on-call. They can perform fracture and joint reductions; splint and stabilize open/closed fractures; and can admit patients to the service of the attending.

In clinic, the PAs run parallel schedules enabling our practice to accommodate patients and triage acuity expeditiously by evaluating new, follow-up, and postop patients. PAs who are not paired with a physician provide daytime hospital coverage for rounds as well as ED coverage; or they might run a day-time urgent care clinic at one of our five offices. The PAs evaluate and manage approximately 20 to 30 patients a day. Our PAs do not do clerical work.

Dr. Murray: Do PAs and NPs function differently in an orthopaedic office than in a primary care
office?

Mr. Carey: Our practice’s NP recently retired. He did everything that the PAs do except for assisting at surgery and taking call, although he was qualified to do that.

Dr. Chorney: In an orthopaedic practice, PAs and NPs function more as true extensions of the orthopaedist, rather than independent practitioners with their own patients, as they might have in a primary care setting.

Dr. Petrosini: We have individualized each PA’s job description. Some PAs have skill sets better suited to evaluating and treating patients in the office; others have superior skills assisting in the OR. All of our PAs must demonstrate a basic competence in terms of reliability, accountability, and interpersonal skills; based on their job descriptions, their individual skill sets can be augmented.

Dr. Murray: Many physicians may be concerned about the cost or overhead for adding a PA or NP. How have PAs and NPs affected your practice’s financial performance?

Dr. Petrosini: Surgical assistant fees can help defray the cost of a PA. The value of office-based PAs depends on how they are used, whether they see their own patients and add to the overall volume of the practice or see patients with a physician to improve flow. An indirect benefit is improving quality of life for our physicians, because our PAs take first call.

Mr. Carey: A PA who functions as a provider and is resourced appropriately will generate significant positive cash flow. However, the quality of life issue mentioned by Dr. Petrosini is also important and must be handled carefully. PAs who work directly with one physician and have little autonomy in decision-making while being expected to perform clerical tasks may become discontented, resulting in a high turnover rate. PAs are trained to practice medicine and become dissatisfied when roles are not par with their training and gained experience.

Even though PAs are reimbursed at 85 percent of the physician fee for treating Medicare patients, this loss of income may be offset by the lower salary for PAs and the freeing of physicians to treat other patients. I encourage practices to provide adequate resources for their PAs and allow for the contribution margins to declare their profitability.

PAs can typically generate the most revenue by seeing patients in clinic. However, a practice should consider the many nonrevenue-generating functions that a PA provides, such as visiting inpatients while the physician is in surgery or the clinic. Another example is a PA first-assisting in the OR. Although the revenue generated in the OR is not typically equivalent to clinic collections, the PA costs less than another surgeon first-assisting on the case, and results in overall practice savings because the first-assist surgeon can be performing surgery in another OR as the primary surgeon or evaluating patients in clinic. The opportunity costs need to be considered with both surgeons and PAs to maximize utilization.

Dr. Chorney: We don’t measure profit and loss on nonphysician providers. We track whether the presence of the PA/NP increases the physician’s volume of patients. PAs and NPs can also have an impact with regard to the level of evaluation and management (E&M) coding. If they see the patient first and perform a complete review of systems and complete medical history, that may allow for a higher level of E&M coding.

Thomas F. Murray, Jr MD
Gail S. Chorney, MD
Anthony V. Petrosini, MD
Kemuel Carey, MHS, PA-C, ATC

As an academic medical center, we cannot bill for PAs in the OR. They may be present, but primarily for their own job satisfaction or to assist the OR team in meeting the surgeon’s preferences in draping or postop orders.

Dr. Murray: How has your practice promoted the value of care provided by PAs and NPs, especially if the patient expresses a desire to only see a physician?

Dr. Chorney: In our academic tertiary care practice, this is often an issue. Patients, particularly new patients, will want the physician’s opinion. However, for postop and follow-up care, they’re often happy to see and build a relationship with the PA. We encourage physicians who use a PA or NP for postoperative care to let the patient know upfront so there’s no false expectation. We promote the value of the PA and NP as someone who works closely with the physician, knows what to look for, and can easily access the physician.

Dr. Petrosini: This seems to be a generational issue; more senior patients than younger patients expect to see the physician at every visit. The public is becoming more educated about the value of PAs as members of the care team. Many of our patients are very happy seeing the PA, especially if they need an after-hours visit.

Mr. Carey: We practice in a team-based model, and most patients recognize PAs as providers and extensions of the surgeons. When patients have the option of seeing a PA within days or a physician in a few weeks, they typically will request the earlier appointment. We do have a few patients who only want to be evaluated and treated by physicians, and we honor those requests.

Dr. Murray: How are your practice’s PAs and NPs compensated? Is there a role for quality and productivity incentives?

Mr. Carey: The PAs in our practice receive a year-end bonus based upon practice performance. We do not currently have a productivity incentive, but may consider this option. A 2013 survey of PAs in orthopaedic surgery found that
60 percent of PAs received a bonus, but there was large variability in incentive models.

Dr. Chorney: In our setting, we do not have a productivity bonus for PAs. All our PAs and NPs are on salary, based on a scale determined by the medical center that takes into account their experience.

Dr. Petrosini: Our PAs receive a base salary, as well as additional payments for on-call duties both at the hospital and in our urgent care clinic, which works well. We have not moved to a productivity-type compensation package, but it has been discussed.

Dr. Murray: With the implementation of the Affordable Care Act and the introduction of value-based payment systems, what role will PAs and NPs play in the future of health care?

Dr. Petrosini: I think they will become more useful. Changes in reimbursement will require the most efficient use of physician resources. As we move toward a population management model, PAs—rather than physicians—will be able to provide initial evaluations and follow-up care for most routine situations.

Dr. Chorney: I agree. Adding a PA or NP rather than another physician to a practice may not only be more economical but more efficient. There are only so many hours in a day that physicians can see patients.

Mr. Carey: The influx of newly insured patients seeking healthcare, the demand by aging baby boomers, and the increasing age of the average orthopaedic surgeon are three factors that will require greater involvement by PAs and NPs in providing musculoskeletal care. PAs embrace the team-based approach to the practice of medicine; working with orthopaedic surgeons, we will continue to provide excellent care while meeting the delivery challenges ahead.

Dr. Murray: What advice do you have for orthopaedic surgeons who are considering adding PAs and NPs to their practices?

Dr. Chorney: Know why you want to hire. Do you want your office to become more efficient? Do you want to build your personal productivity? Do you want a better quality of life? Do you want to be more profitable? Make sure you are using other providers in ways that satisfy not only your needs, but theirs as well, and build job satisfaction. If you hire a PA because you don’t like working with electronic medical records and you’re not computer-literate and you turn the PA into a scribe, he or she won’t stay long.

Dr. Petrosini: Agreed. We recommend creating a pro forma that takes into account how the PAs will be used. For example, what percentages of their time will be spent assisting in surgery, seeing patients on their own, and seeing patients with the physician? Once you know that, you can factor in reimbursement and local compensation rates. Certainly PAs with more experience will require higher salaries than new graduates. An understanding of the practice culture is also important; PAs should fit into the practice culture.

Mr. Carey: A defined role is definitely important with a mutual understanding of the responsibilities and resources allocated to the PA. Practices should also review the laws of their state regarding scope of practice for PAs—as well as any practice or hospital bylaws to ensure that the PA can function efficiently in a team-based patient care model. You may need to review contracts with third-party payers to see what’s required to receive reimbursement for services delivered by the PA. Internal billing and collection practices may have to be changed or updated to capture PA or NP productivity.

Hiring a PA shouldn’t be rushed. Take time to find someone who fits the practice both personally and professionally. The value of the PA matures over time, as the physician and the PA develop a mutual, trusting relationship.

Dr. Murray: As orthopaedic care and medicine in general begin to explore the notion of value-based care, providers will need to look for ways to improve their quality of care and services. PAs and NPs can play important roles in fulfilling this value proposition for patients, employers, and payers. Integrating these important providers into a practice’s care team may yield positive results for both the surgeons and their patients.

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