Advanced Practice Clinicians: About More Than Savings

Advanced practice clinicians are sometimes casually thought of as a cheaper alternative to physicians by healthcare administrators. In actuality, there are many compelling reasons to bring these clinicians into a practice; economics is not the whole picture.

Many high-performing practices have found that advanced practice clinicians (APCs), including nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMWs), provide a cost-effective approach to care that can qualitatively expand a group’s services, and efficiently provide needed services.

APCs are both easier to find than physicians, and have increasingly independent practice capabilities. There are more PAs and NPs joining the labor force each year than the number of physicians (MDs and DOs). In addition, more and more states are loosening practice restrictions on PAs and NPs, increasing the appeal as well as demand for that level of practitioner.

Clinical Practice

APCs are more restricted in their clinical practice than physicians, and that limitation can make them more adaptable to the administrative responsibilities of clinical service. They can take on supervisory roles in patient care management, and act as an effective bridge between practice staff (including clinical practice staff) and physicians. While physicians are still largely perceived as “the rain makers” in a clinical practice, APCs can help a practice provide better access, decision-making, and referral services, and go a long way to improving patient quality and satisfaction.

The intended clinical practice role for APCs in a given practice or department needs to be thoughtfully determined before a decision to recruit. Is the goal to develop an NP’s independent primary care practice, or is the NP to handle sick and follow-up visits for a panel of patients shared with one or more physicians? Will the NP or PA be used to increase reimbursable visits, or to handle non-reimbursable, yet required, clinical duties?

Some physicians have trouble accepting APCs into the club of practitioners; that will likely cause friction with the APCs. Teams require oversight, and a clinical practice team typically needs a physician manager that is willing and able to assume responsibility for the team—including the APCs.

APCs also fit well into a practice context that allows for a proscribed, albeit limited, level of clinical service where there is established physician back up, such as through call arrangements. Hence APCs are a very effective resource for hospitalist staffing needs.

Recruiting

In recruiting APCs, it is important that those involved in the process not characterize them in any way as “an extender” to a physician. Such a view will be received with hostility in the PA, NP and CNMW communities and will likely lead to limited success in recruiting. Avoid labels like “physician extenders” and “mid-levels,” which emphasize something lacking rather than characterizing an employee’s contribution. Contribution to clinical practice, recruitment opportunities and efficiency are much more positive, quantifiable and accurate hiring criteria.

Like any recruiting effort, it’s all about fit. That means sorting through the APC’s practice and job expectations with the physicians and giving them buy-in to the recruiting process and the kind of service they would like to achieve.

Cost-effectiveness

In primary care, the median benchmark compensation for physicians is approximately twice that of PAs and NPs. That is not the complete picture, however. Depending on the duties, a new APC may not need new staff support like a physician. Offsetting that, they might also generate fewer reimbursable visits. Some APCs take more time with patients or have non-billable clinical support. All of these variations mean that the P&L of an APC may only have a slight bottom line advantage compared to a physician.

The more appropriate consideration is whether the group as a whole, including physicians, has a lower level of cost for a given level of service, and can maximize the quality, volume, and coverage of the group.