The Case for Shifting More Services to Midlevel Providers

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With reimbursements shrinking and patient volume expected to rise under the reform law, our healthcare system comes up against a stark reality. There are not enough physicians to go around, and the federal government certainly is in no mood to expand physician supply by funding more GME training slots.

As we move to new methods of reimbursement, such as bundled payments and accountable care organizations, we have an opportunity to rethink what physicians do and honestly assess what tasks could be handled by other professionals who have sufficient training to do it. I'm thinking of nurse practitioners, physician assistants and nurse anesthetists.

People disagree on what exactly to call these professionals. This is due to longstanding debates about their scope of practice and the amount of physician supervision they need. I still hear them called "physician extenders," suggesting they're nothing more than an appendage of physicians. The American Academy of Nurse Practitioners, on the other hand, wants to call them "independently licensed providers," which I find a bit murky. Aren't physicians also "independently licensed providers"?  

I prefer the term "midlevel providers." Since each state has a different definition of what these professionals are allowed to do, "midlevel providers" is about as specific as you can get, denoting a level of expertise somewhere between physicians and registered nurses.

How midlevels could help
It has been estimated that midlevels, who have about 2-3 years of postgraduate training, could perform as much as 80 percent of what physicians do. Several scientific studies show quality outcomes for midlevels and physicians are the same across many tasks. Usually working under physician supervision, midlevels can perform a history and physical and preliminary diagnosis, turning the patient over to a physician when needed. In Wisconsin, midlevels are even allowed to prescribe some drugs, though this is still not allowed in many states.

Midlevels work across all specialties. Giving them many of the tasks physicians traditionally do could greatly improve productivity, and that is what the American economy is all about. Productivity is the engine of our prosperity, and no sector of our economy needs improved productivity more than healthcare. Our services are approaching 17 percent of GNP, an unsustainable level. We need to get it down to 15 percent, an enormous feat given evolving demographics. It would involve a basic reassessment of how we use our healthcare workforce.

The healthcare system sorely needs this extra pool of providers. The Association of American Medical Colleges forecasts the nation will be short 62,900 physicians in five years due to aging of baby-boomer patients, retirements of many baby-boomer physicians and expansion of coverage under the Patient Protection and Affordable Care Act. The healthcare reform law has authorized $167.3 million to build the supply of primary care physicians, but the AAMC said this won't be enough. While medical schools have been increasing class sizes, graduates will still vie for federally funded residency positions that have been capped at 100,000 slots since 1997.

There are about 240,000 midlevels in the United States, compared with 700,000 physicians, but numbers of midlevels are expected to rise relatively rapidly. Physician assistants, for example, are projected to be the second-fastest growing health profession, after home health aides, in the coming decade, and 8,000 new nurse practitioners are being added to the workforce every year.

Meeting physician pushback

Midlevels still encounter resistance from organized medicine, which plays out in states' scope-of-practice laws and insurers' reimbursement decisions. Patients, however, seem to have accepted this class of providers. Despite some initial mistrust, studies show patients warm up to them. That makes sense. The midlevel can spend more time with patients and thus develop a firmer relationship than a physician can. In the end, patients don't care whether the person treating them has gone to medical school or not. Basically they want someone who will listen to them and has sufficient training to deal with their condition.

Even physician resistance seems milder. The AMA recently denounced a new Institute of Medicine report recommending the same reimbursements for midlevels and physicians for the same work and calling for uniform scope of practice standards across the country. "Increasing the responsibility of nurses is not the answer to the physician shortage," said AMA Trustee Rebecca Patchin, MD, noting physicians have much longer training than midlevels. But Dr. Patchin, a former nurse, did endorse a "physician-led team approach" using these caregivers, and that's a good start.

In fact, the horse has already left the barn. Physicians' practices are now routinely using midlevels for many higher-level tasks than what nurses do. Even some leaders in academic medicine, once a holdout against the trend, strongly endorse shifting more tasks over to midlevels. In a recent interview, Edward Miller, MD, dean of the Johns Hopkins School of Medicine, said U.S. healthcare does not need more physicians and should rely more on midlevels and ancillary staff.

Dr. Miller predicted the floodgates will open for non-physician providers as soon as we shift from fee-for-service reimbursements to new systems of bundled payments, including ACOs and capitated rates. "The payment system, I feel, is the culprit of much of this," Dr. Miller told the Johns Hopkins University Gazette. "I only get paid if I touch as you as a physician. But if I get a premium per month to take care of you, maybe I don't need to see you every time. Maybe my nurse practitioner sees you."

What needs to be done

For midlevels to flourish, we need uniform scope of practice standards across all states and guaranteed reimbursements by all payors. While Medicare generally reimburses midlevels at 85 percent of the rate for physicians, some insurers still won't pay independent midlevels. These payors either don't recognize the CPT code modifiers for midlevel services or don't include midlevels in their provider panels. The answer is to work directly with employers who are interested in using midlevels to keep their costs down. Self-insured employers can create protocols specifying which tasks should be performed by midlevels instead of physicians.

As supervisors, physicians have a key role in deciding what midlevels can do. When determining tasks for midlevels, physicians should ask themselves, "Could you teach someone else to do this particular task?" If so, it may not need to done by a physician.
In shifting more work to midlevels, we need to guard against burnout. Establishing eight-minute office visits, for example, would make providers feel rushed and patients dissatisfied, and it would eliminate a key advantage of midlevels — to spend more time with the patient and establish a rapport.

The bottom line is that we are not using our healthcare workforce to its full capacity. Scope of practice restrictions, payor policies and physicians' attitudes are reducing the productivity of midlevels at a time when we need it more than ever.

Stephen F. Ronstrom has more than 25 years of hospital leadership experience, having served for the past  12 years as an executive in the Hospital Sisters Health System. He is currently president and CEO of the Hospital Sisters' Western Wisconsin division, which includes 344-bed Sacred Heart Hospital in Eau Claire, Wis. Learn more about Hospital Sisters Health System.


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