Integrating NP/PAs into Endocrine Practice

Transcription

1 Integrating NP/PAs into Endocrine Practice Reid Litchfield, MD, FACE Board of Directors, American Association of Clinical Endocrinologists Desert Endocrinology, Las Vegas/Henderson, NV Ji Chun (CJ), PA C, MPAS, BC ADM President, American Society of Endocrine Physician Assistants OptumCare Medical Group, Orange County, CA

2 Disclosures No disclosures related to the content of this presentation Dr Litchfield Speaker s Bureau Novo Nordisk Abbvie Janssen Abbott Diabetes Care Consultant Abbott Diabetes Care Ji Hyun Chun (CJ) Speaker s Bureau AstraZeneca Abbvie Abbott Nutrition Advisory Board Novo Nordisk Intarcia Merck Abbott Mannkind

3 Objectives Acknowledge the commonalities and differences in NP and PA's training and scope of practice. Review the roles of NP/PA and the collaborating endocrinologist for successful team based practice. Delineate the benefit/risk of incorporating NP/PAs into your endocrine practice.

4 Who are we? Physician Assistant Nationally certified and state licensed to practice medicine on healthcare teams with physicians and other providers Advanced Practice Registered Nurse Prepared by education and certification to assess, diagnose, and manage patient problems, order tests, and prescribe medicine. Nurse Practitioners Clinical Nurse Specialists Certified Nurse Midwives Certified Registered Nurse Anesthetists Aapa.org / ncsbn.org

5 What Do We Do? NPP utilization in the future of US healthcare: An MGMA Research & Analysis report. Mar 2014

6 Training N P P A Birth 1965 at Uni. of CO 1967 at Duke Uni. Base Nursing model Medical model Degree Minimum Master s *Doctorate (DNP) recommended by AACN Majority Master s *some Bachelor s remaining obligated to be Master s by 2020 Length months Average 27 months Hours Didactic: 500 hrs Clinical: avg 720 hrs (1,000 hrs for DNP) Didactic: 1,000 hrs Clinical: 2,000 hrs DNP: Doctor of Nursing Practice AACN: American Association of Colleges of Nursing Adapted from nursepractitionerschools.com / beaphysicianassistant.com / acponline.org

7 Certification / Licensure Certification Licensure Recertification N P Exam by ANCC or AANP State board of nursing or board of medical examiners Every 5yrs Retake exam or 1,000 hrs clinical practice CEU P A Exam by NCCPA State medical board 100 CME hrs q2yrs and Retake exam q10yrs ANCC: American Nurses Credentialing Center AANP: American Academy of Nurse Practitioners NCCPA: National Commission of Certification of Physician Assistants Adapted from nursepractitionerschools.com / beaphysicianassistant.com / acponline.org

8 Scope of Practice Varies significantly by each state N P P A Autonomy Independent in 24 Dependent states (including D.C.) Rx In all states *restrictions exist and vary by state Scope of practice minimum set by state and modified by each practice Adapted from aanp.org / aapa.org / npcentral.net

9 NPs by state bartonassociates.com/locum tenens resources/nurse practitioner scope of practice laws/ aanp.org/legislation regulation/state legislation/state practice environment

10 PAs by state bartonassociates.com/locum tenens resources/pa scope of practice laws/ aapa.org/advocacy central/state advocacy/state laws and regulations/

11 Why hire NP/PA? Expand (get more pies) Increase patient volume Improve efficiency Lessen the workload (sharing the pie) Improve patient satisfaction With less cost Without compromising quality Horrocks et al. BMJ 2002 / Cawley and Hooker. AM J Manag Care 2013 / Newhouse et al. Nursing Economics 2011

12 Quality of Care Comparable DM care by NP/PAs compared to physician colleagues Yang et al. Midlevel Providers and A1c Outcomes. The American Journal of Medicine, Vol 131, No 3, March 2018

13 Cost Salary Median $100K, varies depending on specialty, state, experience and other employment conditions N P P A www1.salary.com/nurse Practitioner Salary.html www1.salary.com/physician Assistant Medical Salary.html

14 Cost Benefits (i.e., health, CME, retirement) Licensing fees, Malpractice insurance Additional overhead fees (i.e., support staff, office space, EMR) supervision time Bureau of Labor Statistics bls.gov

15 Supervision Requirements Varies by states (be sure to check!) Collaborative agreement required? How many NP/PAs can you supervise? Chart and/or prescription review Requires physical presence? For NP: aanp.org/legislation regulation/state legislation/state practiceenvironment For PA: aapa.org/advocacy central/state advocacy/state laws andregulations/

16 Supervision Requirements

17 Revenue NP/PA rendered services are paid at % (more on this later) NP/PA can manage similar patient load as physician colleagues High Return on Investment: $1 in return for every $0.30 paid Medical Group Management Association (MGMA) Physician Compensation and Production Survey

18 Billing Medicare Direct billing (under NP/PA s NPI): 85% of physician fee Incident to billing (under physician NPI): 100% NP/PA must be an employee of the physician Initial visit (for that condition) must be performed by physician Direct supervision: A physician in the group is in the same building/suite at the time of the service cms.gov/regulations and Guidance/Guidance/Manuals/downloads/clm104c12.pdf aapa.org/wp content/uploads/2017/01/third_party_payment_2017_final.pdf medscape.com/viewarticle/422935_6

19 Billing Medicaid, Commercial Does not necessarily follow Medicare rules Vary by each state and plan (need to check!) At full or reduced rate Admission to provider panel and directly bill Decline to admit to provider panel but allow to provide services for patients on a physician s panel. Decline to admit NP/PA to provider panel and permitting only those on provider panels to see patients cms.gov/regulations and Guidance/Guidance/Manuals/downloads/clm104c12.pdf aapa.org/wp content/uploads/2017/01/third_party_payment_2017_final.pdf medscape.com/viewarticle/422935_6

20 Recruitment From the scratch New grad No endocrine experience Experienced

21 Recruitment Job postings Each professions state and national organizations *ASEPA offers free job posting at endocrine pa.com Local NP/PA schools Recruiter Industry reps Word of mouth

22 Training In office Shadowing Journal club Q/A, etc Web Medscape NACE PCE etc conference / meetings AACE Endocrine Society ADA MEDS Academic institutions Pharma programs etc

23 A Decade of Lessons Learned In Endocrine Practice with PAs & NPs W. Reid Litchfield, MD, FACE, ECNU

24 Essential Ingredients Trusting Supervising Physician Not every physician is suited to work with PA/NP Ability to delegate Ability to surrender control Capable NP/PA Intellect This is not rocket science it s harder Chronic Care Practice Model Nobody dies, nobody gets better.

25 Preparing Your Practice for Endocrine PA/NP

26 What s In A Name? Be deliberate in how you refer to NP/PA with patients My PA/NP or The PA/NP My Partner/Colleague The way you refer to the NP/PA matters

27 Office Staff Considerations Require appropriate deference of support staff to PA/NP Front Office Medical Assistant plays a big role in Making MD/DO/PA/NP look good Creating patient confidence Public Relations Consistency in Team Care Narrative All members of the team specialize in treating endocrine patients The PA/NP have been trained by the doctor and they work together as a team

28 Office Staff Considerations Do not undermine staff confidence Vocal criticisms of the PA/NP Body Language Appropriate praise of PA/NP in front of support staff If physician has confidence in the PA/NP, staff confidence with follow

29 Patient Considerations Have staff be clear in who follow up appointment is scheduled with You ll be seeing Dr. Litchfield s partner... on your next visit Your follow up appointment is with... When as patient is surprised that follow up appointment is with someone they are not expecting to see they feel bind sided

30 Patient Considerations Maintain patient choice for future follow up care The doctor wants you back in 6 weeks but his schedule is full, so he s asked that I schedule your follow up visit with his partner... You can schedule follow up with the doctor on your next visit if you d like. Periodic Follow Up Visits with Physician Reinforcement of team care model Meaningful access to physician for refractory problems

31 Education

32 Education: The Supervising Physician It takes 2 3 years of Fellowship to become minimally competent to practice endocrinology Don t expect your PA/NP to be an expert in 3 months Be accessible Budget sufficient time in your schedule for meaningful Training Supervision Problem Solving Encourage Professional Development/Education

33 Education: The PA/NP You have primary responsibility for your own competence Initial Education Continuing Education Reading Around Cases Advanced Endocrine Education Source Material First Things First Become a Specialist

34 Supervision

35 Supervising Physician Can you realistically expect to supervise non physician provider with no interruption of your schedule? Not at first Probably not even later Reviewing their work Chart review Patient review on f/u visits Structured Expansion of NP/PA Clinical Responsibilities Scope of Practice Thyroid ultrasound Procedures

36 Asking For Help Formal Collaboration Patient Safety First Document Collaboration Pop In Patient Confidence Booster NP/PA Affirmation Informal Collaboration Supervising/non supervising Physician Other NP/PA in the practice CDE, pharmacists, etc

37 Image Management

38 Image Management: Supervising Physician Do not undermine staff confidence Vocal criticisms of the PA/NP Body Language Appropriate praise of PA/NP in front of support staff If physician has confidence in the PA/NP, staff confidence with follow Appropriate expressions of confidence to patients Reaffirm medical therapy prescribed by NP/PA

39 Image Management: Supervising Physician Appropriate expressions of confidence to patients Reaffirm medical therapy prescribed by NP/PA Building Patient Confidence in PA/NP Formal Collaborations Pop Ins Subsequent Face To Face/Telephone Encounters

40 Image Management: The NP/PA Don t fake competence that you don t have Erosion of trust Don t telegraph your insecurity Front Office & Medical Assistants Patients Work Ethic Medicine is not a 9 to 5 Do your share Be Awesome Take Pride In Your Work

41 Image Management: The NP/PA Communication It s not what you say, it s how you say it. Stay Positive Documentation A major part of determining your perception In the practice In the community Take Pride In Your Work

42 Time Management

43 The Schedule Gradual Ramp Up Limited ability to control Same Day Cancellations No Shows Extreme stressor for PA/NP Problems Exceed Available Time Do your best in time you have Continue efforts next visit Finding Balance

44 Documentation & Coding Time is Money Adequate Coding Billable Time Documentation Over documentation vs Under documentation Timely Note Completion

45 Patient Case Presentation Thumbnail Sketch Concise patient case presentation Pertinent positives/negatives Physical Findings Lab Results Tentative Plan of Action Areas of concern or uncertainty Never complete the plan before you see the patient

46 Survival Skills

47 Survival Skills: The Supervising Physician Be Patient Be Fair Keep Perspective Endocrine care is changing Team based care is here to stay Economic viability of endocrinology requires NP/PA collaboration PA/NP care as an extension of your care We vs. Me Don t Compromise Patient Care

48 Survival Skills: The PA/NP Be Competent Be Teachable Be Loyal Be A Team Player Office Drama Don t cause it Don t participate in it

49 W. Reid Litchfield, MD, FACE 2415 W. Horizon Ridge Parkway Henderson, NV (702)