Transcript Document

Mitchell Wilson, MD
Associate Professor of Medicine
Section Chief of Hospital Medicine
Division of General Medicine and Clinical Epidemiology
Department of Medicine
University of North Carolina School of Medicine
Co-Chair, SHM Non-Physician Provider Committee
Panelists
Scarlett Blue, RNC, MSN, CNA
Ryan Genzink, PA-C
Jeanette Kalupa, MSN, APRN-BC,
APNP
Working With Non Physician
Practitioners: Risks, Benefits,
Alternatives & Indications
Learning Objectives
Examine the potential disadvantages
(risks) and advantages (benefits) of
integrating PAs, NPs, and RN CCCs
into hospitalist programs
Understand how skill mix can add value
to hospitalist programs (alternatives)
Learning Objectives
Determine if PAs, NPs, and RN CCCs
are right for your practice (indications)
by assessing opportunities & barriers
Perform a needs vs. barriers analysis
Define the factors critical to a successful
implementation
Learn how to demonstrate ROI
Session Outline
1. Risks, Benefits, and Alternatives
2. Indications: Are PAs, NPs and RN CCCs
Right For Us?
 Panel Q & A (10 minutes)
3. Implementation: Critical Success Factors
 Panel Q & A (10 minutes)
4. Return on Investment (and billing if we
have time)
 Panel Q & A (10 minutes)
Case Study
Environment
 250 bed suburban community non-teaching
hospital
 Open ICUs but not enough critical care
boarded MDs to staff patients
 Competitor hospitals within a 30 mile radius
 PAs successfully work with surgeons in case
study hospital
 NPs are in some of the PCP’s & cardiologist’s
offices and are well regarded
Case Study
Hospitalist Program Structure
 Hospital employed, 18 months old
 Budgeted now for 8 physician FTE, 6 FTE currently:
• One dissatisfied doctor left one month ago citing excessive
workload & slow recruiting
• 8th position open for 5 months
 24/7 in-house, Code & Rapid Response Team (RRT)
 ED unassigned, many OBS patients
 Schedule
• 7 on/7 off block shift
• Day (7am-7pm): 2 MDs
• Night (7pm-7am): 1 MD
Case Study
Programmatic issues:
 Ave. daily encounters/MD approx. 20,
sometimes more
 ICU with complex cases
 Admissions throughout the day due to ED
unassigned
 Delays in D/C’s & seeing patients, ALOS
increasing, case managers complaining
 Nurses complaining about hospitalist page
reply times
 Satisfaction scores not improving
Case Study
Programmatic issues:
 Turning away patients from PCPs due to
census, acuity & workforce issues
 Cover one hospital, pressure to:
• Admit for more PCPs, specialists, including
surgical co-management
• Consult on more inpatients
• Cover hospitalist patients transferred to an
affiliated Skilled Nursing Facility
 Unable to attend committee meetings and no
QI/QA involvement
Case Study
Culture
 One of the hospitalists worked with a PA/NP
in a practice before joining this one but it
didn’t work out well
 Another of the hospitalists just wants to hire
someone—anyone—to make work life better
so she can get out on-time (PAs will fix this)
 Two of the other hospitalists, including the
founding member, are in favor of trying a
PA/NP and a third used to teach in a
residency program before going private
Case Study
Culture
 The program administrator worries the program will
collapse if another hospitalist leaves
 The CMO fears non-physicians may alienate referring
MDs
 The CNO is not a PA advocate due to some prior
nursing staff occurrences
 A couple of senior members of the medical staff have
never liked that the local practices work with PAs and
NPs
 The bulk of the medical staff are middle-aged or
younger and express no firm objection
Partnering with NPPs in Hospitalist Practices
Identify the
• Disadvantages and Advantages
• Opportunities
• Barriers
Perform a Needs-vs.-Barriers Analysis
Polling Question:
Is this case a “good-to-go” or “just-sayno” to Partnering with NPPs?
Disadvantages
(Risks)
NPPs in Hospital Medicine
Substituting for Residents:
Disadvantages of PAs and NPs
More expensive than residents
Loss of Medicare DME & IME
Conflict with CMS cost reports
Academic pay scales generally lower
than community competition
Role conflict: X vs Y
Redundancy?
Integrated Hospitalist Teams:
Disadvantages of PAs and NPs
 Stakeholder perceptions
•
•
•
•
•
PCPs
Referring physicians
Hospitalist group members
Hospital staff (Admin, Nursing, Ancillary)
Patients & family
 Laws & Bylaws
 Physician supervision
• Especially for new grads
 Employment models & billing
Integrated Hospitalist Teams:
Disadvantages of PAs and NPs
 Will cost upwards of $80,000+ (plus benefits,
recruitment, admin overhead, CME)
 Medical liability for physician?
 ??Decreased “face time”??
 Potential redundancy
 Competition?
Advantages
(Benefits)
NPPs in Hospital Medicine
Substituting for Residents:
Advantages of PAs and NPs
 Greater consistency of ability
 More clinical experience
 Diminished supervision
 Better “systems” managers
 Enhanced efficiency
 Stronger staff affiliations
 Higher visibility and availability
 Improved continuity of care
Silver et. al., Cawley et. al., Frick et.
al., Jones et. al.
Substituting for Residents:
Advantages of PAs and NPs
Sometimes the one “constant”
Not subject to RRC duty hour
restrictions!
Can still serve as educators to
residents, nurses, and/or PAs & NPs in
training
This is their career
Integrated Hospitalist Teams:
Advantages of PAs and NPs
 Cost less than M.D. F.T.E.
 Manage the care of patients not requiring
direct physician care time
 Allows physician to:
• Focus on more difficult and complex cases
• Provide access to services (program structure,
new business)
• Participate in quality, safety & other hospital
initiatives
• Still avail for PA/NP supervision & consultation
• Share on-call time, cross-coverage
• Colleague close at hand
Integrated Hospitalist Teams:
Advantages of PAs and NPs
Surge capacity
Provide high-quality care
Facilitate and coordinate care
processes
Enhance efficiency
Augment practice productivity
Serve most specialties
Integrated Hospitalist Teams:
Advantages of PAs and NPs
Perform procedures
Spend more time with patients,
especially w.r.t. education, prevention,
health maintenance
Interface with ancillary services and
consultants & improves communication
Increase hospital staff satisfaction
Write prescriptions
May lessen the liability risk
Integrated Hospitalist Teams:
Advantages of PAs and NPs
Services reimbursed by Medicare,
Insurers
Makes a TEAM out of you and me!
Value-Added
(Alternatives)
NPPs in Hospital Medicine
The Driver for Partnering
“Skill mix enables programs to deploy
resources (physician and nonphysician) in a way that matches skill
set with skill need to optimize program
performance and efficiency.”
--M.J. Wilson, M.D.
Cost Effective Model
Allows program to increase volume at
less direct cost – PA and NP salaries &
benefits less than that of the physician
Helps balance revenue versus expense
with regard to:
• Program mission
• Payor mix
• Patient population
Cost Effective Model
 Promote uniformity & consistency of practice
through the use of practice guidelines
 Integrated teams maintain outcomes
• Studies show reduced LOS, improved communication and
collaboration, and improved hospital profit without altering
readmissions or mortality
 More hospitalist positions than physicians
which makes the PA and NP model a viable
alternative to work force shortage issues
Cost Effective Model
Billing options allow for shared or
independent visits
The same way that hospitalists add
value* so too do PAs & NPs in
hospitalist practices
*SHM special supplement "How Hospitalists Add Value"
Why
Integrate
PAs, NPs, and RN CCCs
into
They
Hospitalist Practices?
Because
Add Value!
How Do NPPs Add Value?
The Mantra of Hospitalists
The purpose of admitting patients to the
hospital is to discharge them
Discharge planning begins at the moment
of admission
The average length of stay for most patients
should not exceed three (3) days
.
Procedures
ICU
RRT
Codes
The conundrum of
competing
Family conferences
congruent
contemporaneous
care processes
Consults
Quality Improvement
projects
The Competition for provider time…
delays the continuum of care that
culminates in the patient’s (un)timely
discharge.
Competition for Provider Time:
The Ivory Tower Structure
Academia
Residency
Review Committee
Residents
Interns
Duty Hours
Restrictions
Students
Competition for Provider Time:
A non-housestaff Solution
Integrating PAs, NPs and RN CCCs in Acute Care
The integrated model of medical practice, in
which the patient care team is led by the
medical manager (MD or DO), assisted by the
patient care manager (PA or NP), and clinically
coordinated by the CCC (RN) is one solution to
the competition for care processes in the
management of inpatients.
Competition for Provider Time:
A non-housestaff Solution
Integrating PAs, NPs and RN CCCs in Acute Care
 Physician (medical manager) makes key medical
decisions & follows medical progress
 PA/NP (patient care manager) implements decisions
(dependent & independent), monitors care
 Nurse CCC coordinates the clinical care processes
culminating in discharge
Physician Assistants,
Nurse Practitioners,
and RN CCCs
Pitching the Value-Added Proposition
The Health Care Value
Cascade
Value = Quality
/
Cost
Health Care = Clinical quality x Satisfaction
Quality
Clinical Quality = structure, process, outcomes
Wachter, "Hospital Medicine" p.33,
Donabedian , "JAMA" 1988
PAs, NPs, and RN CCCs
Pitching the Value-Added Proposition
Some Elements of Value:
Structure:
Denotes the attributes of the setting
“How is care organized”
Process: Denotes action in giving & receiving care
“What is done”
Outcome: Denotes the effects of care on health
“What Happened”
PAs, NPs, and RN CCCs
Pitching the Value-Added Proposition
Evidence: Studies, Experience
Structure
Processes
Outcomes
Value =
ClinQual x Satisfaction
Cost
Procedures
Quality Improvement
projects
Family conferences
Dr Wilson
Procedures
Family conferences
Quality
Improvement
projects
Consults
Physician Assistants and Nurse Practitioners
Pitching the Value-Added Proposition
“As these two major national advisory groups
(Institute of Medicine and Pew Health
Professions Commission) and other policy
analysts have concluded, it is the integration
of care using a team of providers, not the
fragmentation of care through the proliferation
of independent providers, that will be the
model of high-quality and cost-effective
health care in the future.”
Crane, S., "Physician Executive"
1995
Indications:
Are PAs, NPs, and RN CCCs
Right for Us?
NPPs in Hospital Medicine
Opportunities
NPPs in Hospital Medicine
Opportunities: Programmatic
 Hospitalist Resources
• Recruiting
• Retention
• Satisfaction
 Growth
• Supply-Demand mismatch
• Access to care
• New business & market share
 Structure
• In-house vs. call
• Single hospital vs. multi-site
• Admitter vs. Rounder
Opportunities: Programmatic
 Program Performance*
•
•
•
•
Throughput
Hospital Cost & Utilization
Customer Satisfaction
Quality, Safety and Stewardship
 Hospital specific needs
• Code Team
• RRT
• Lines
• Restraints
• ED Unassigned
• ICU
*SHM white paper: “Measuring Hospitalist Performance"
Opportunities: Environment
 Are PAs & NPs already practicing:
•
•
•
•
Referring physician offices
Autonomously in clinics
Sub-specialist's practices
Hospital based
 If so:
•
•
•
•
Is their work widely known?
How are they regarded generally?
What is their reputation specifically?
What do they do?
Opportunities: Environment
 Are there PA & NP programs nearby?
 Competition
• Nearby hospitals
• Nearby hospitalists
 Location & Size
• Urban
• Rural and/or Critical Access
• Less than 100 beds
 ICU: Open or closed
 Teaching hospital
Opportunities: Culture
Hospitalist
• Worked successfully with PAs & NPs
before?
• Advocates & Champions
• Patriarch or Monarch—positive outlook
• Musketeers versus Mercenaries
– all for one and one for all
– every hospitalist for themselves
Opportunities: Culture
Hospitalist (cont.)
• Non physician group members
• Clinician Educators, teacher-types
• Mentor structure in place
Hospital
• Nursing and NPs
• Change oriented
Opportunities
 If you have seen one hospital medicine
program you have seen one hospital
medicine program – view this as an
OPPORTUNITY to customize and tailor your
collaborative PA and NP model to your
practice
 Proactive “planning mode” (instead of
reactive “crisis mode”)
Opportunities
 Don’t reinvent the wheel – SHM experts are
available to help
I was seldom able to see an opportunity
until it had ceased to be one.
--Mark Twain's Autobiography
Barriers to Success
NPPs in Hospital Medicine
The greatest barrier to someone
achieving their potential is their denial of
it.
--Simon Travaglia
Barriers: Programmatic
 Hospitalist Resources
•
•
•
•
•
Different employers: Physician & PA/NP
Payroll rules
Human Resources
Low attrition
Hiring the wrong person
 Growth
•
•
•
•
•
Unmotivated workforce
Lack of incentives
Restricted Access
Limitations on new business & market share
Flat line
Barriers: Programmatic
 Structure
• Lack of supervision
• Poor role definition and/or lack of understanding
the role
• Lack of preparedness
• Lack of administrative & practice infrastructure &
support
 Program Performance
• Productivity tracking and/or incentive structure:
– Doesn’t credit physician for the 15% shared-visit effort
– doesn’t include PA & NP effort
Barriers: Programmatic
 Program Performance (cont.)
• No system in place to track
– PA & NP performance measures and
outcomes
– patient satisfaction with PAs & NPs
• Failure to credential PAs & NPs with
payors
• Billing system not ready to accommodate
PA & NP charges
Barriers: Environment
Are PAs & NPs new or novel?
If PAs & NPs are already practicing:
•
•
•
•
Is their work widely known?
How are they regarded generally?
What is their reputation specifically?
What do they do?
Barriers: Environment
Unrealistic expectations
• Hospital: “The hospitalists will fix our
problems”
• Hospitalists: “The PA/NP will fix our
problems”
Perception that the driver (for
integration) is increasing pressure to
offset program cost
Barriers: Environment
Perception that integration will alienate
referral groups
Lack of environmental awareness
• Perception
• Reality
Laws & Bylaws
Changes in hospital leadership
Barriers: Culture
Hospitalist
• Worked unsuccessfully with PAs & NPs
before
• Naysayers
• No Advocate or Champion
• Patriarch or Monarch—ambivalent or
worse
• Mercenaries versus Musketeers
– every hospitalist for themselves
– all for one and one for all
Barriers: Culture
Hospitalist
• Unwillingness to:
– Teach
– Mentor
– Oversee & Review
• Unwillingness to change the culture
• Polarized group
Barriers: Culture
 General Attitude
• Fear of competition
• Only doctors can do the job
• Diminishes physician importance
 Bad Attitude
• Not just no but “heck no”
 Reactive “crisis mode” (instead of proactive
“planning mode”)
 A bad attitude is like a flat tire—you can’t get
anywhere unless you change it!
Should We
Integrate
NPPs
Into
Our
NPPs
Hospitalist Practice?
Are
right for you?
Are NPPs right for your practice?
 Environment is everything & culture is critical
 Not a “one size fits all” model
 Do your homework—data informs decisions
•
•
•
•
Advantages
Disadvantages
Opportunities
Barriers
Practice Site
Needs
vs
Barriers to
Implementation
Are NPPs right for your practice?
Needs Versus Barriers Analysis
Barriers
to
Implementation
Practice Site
Needs
High
Low
High
HH
HL
Low
LH
LL
Case Study: Needs vs. Barriers
 Difficult & complex cases
 Access to service (PCPs, comanagement)
 Timeliness of care
 Surge capacity
 Interface issues with case
managers, staff nurses and
ancillary care
 Hospital & Patient satisfaction
 Committee & QI/QA
involvement
 Recruiting, Retention, &
hospitalist satisfaction
 Supply-Demand mismatch
 New business (including multisite)
 24/7 in-house
Rounder is admitter structure
 Program performance
 Code/RRT
 ED Unassigned & OBS cases
 PAs & NPs known entities in
environment, well regarded
 Nearby competitor hospitals,
suburban
 Open ICU
 Advocates
•
•
•
•
Founder
Two hospitalists
Teacher-type
+/-Program administrator
 Medical Staff express no firm
opposition
Case Study: Needs vs Barriers
 No role definition as of yet
 Lack of preparedness
• Programmatic
• Environmental
 One hospitalist unsuccessful
in past
 Possible supervision issue
with 1-2 hospitalists
 “The PA/NP will fix things”
attitude
 Integration will alienate
referring physicians (CMO)
 Bias against PAs (CNO)
 Two senior medical staff
members not in favor
Are NPPs right for your practice?
Needs Versus Barriers Analysis
Barriers
to
Implementation
High
Practice Site
Needs
Low
High
HHCase StudyHL
Low
LH
LL
Barriers are merely opportunities waiting
to be born.
--M. J. Wilson, M.D.
Panel Discussion
Implementation
How can NPPs be Integrated Into the
Hospitalist Practice
Plan & Execute: Stakeholder Buy-in
 Do your homework, then lay the groundwork
• Become an expert in PA and NP practice
• Teach others what you’ve learned
 Identify and survey all stakeholders, conduct
focus groups in high barrier environments
•
•
•
•
•
•
Hospital Administration
PCPs
Referring Providers
Hospitalist Team
Patient care staff
Patients
Plan & Execute: Stakeholder Buy-in
 Use the information you receive in structuring
PA and NP assignments & responsibilities
 Provide feedback to stakeholders by letting
them know:
• That you were listening
• What you did with their information
 Communicate, Communicate, Communicate
• Tell them what you are going to tell them, then tell
them, and then tell them what you told them
Plan & Execute: Stakeholder Buy-in
Mitch, I can’t emphasize enough that if you are
adding a first mid-level, there must be buy-in
and support from the community and the
group with very clear expectations.
The group has to want this and then back the
mid-level up when his/her role is questioned
or challenged.
--Lorraine Britting, MS, ANP
SHM Non-Physician Provider Committee
Plan & Execute: Skill Mix
 Go with what your environment knows
• Do PAs or NPs predominate?
• In what setting?
 Define the duties, then match the roles
• Structure the advertising, interview, and hire
process to assure best practice fit
– High acuity/ICU care = experienced PA or ACNP
– Elderly population/MMM = experienced PA or GNP or
ACNP, +/- ANP (depending on experience)
– OBS/CDU = PA or ANP, +/-FNP (depending on
experience) or ACNP
Plan & Execute: Skill Mix
 Define the duties, then match the roles,
(cont.)
• Start out with the best of the best—the microscope
will be on full power
• Hire and pay for experience
– Invest in your start-up—you get what you pay for
– Especially important for high barrier environments and
where immediate success is critical
• Recruit local talent whenever possible
– Even if new to hospitalist role
– A known and trusted provider new to the role may enable
early acceptance more than an unknown who knows how
to do the job
Plan & Execute: Structure Services
 Tailor supervision and assignments to
experience and skill set:
• Evaluate individual physician characteristics and
partner physician and PAs/NPs based on best fit
• Tailor physician supervision to the experience and
skills of the PA and NP
• Capitalize on PA and NP past experiences and
strengths
 Use a mentoring process
Plan & Execute: Structure Services
 Make team assignments: Less experienced
PA/NP
 Worked successfully with PA/NP before
 Teacher-types
 Advocates and Champions
 Musketeers
 Patriarch, Monarch—positive outlook
 Worked unsuccessfully
 Naysayers
 Mercenary
 Patriarch, Monarch—ambivalent or worse
 Unwilling to teach
Plan & Execute: Structure Services
 Make team assignments: More experienced
PA/NP
 Worked successfully with PA/NP before
 Patriarch, Monarch—positive outlook
 Advocates and Champions
 Musketeers
 Teacher-types
 Worked unsuccessfully
 Naysayers
 Mercenary
 Patriarch, Monarch—ambivalent or worse
 Unwilling to teach
Plan & Execute: Structure Services
 Make work assignments:
• Less experience
– Protocol, pathway, guideline driven DRGs
– Low acuity (chest pain, mild pulmonary, GU)
– Direct supervision, more shared-visits
• More experience
– Protocol, pathway, guideline driven DRGs to start,
transition quickly to non-pathway DRGs
– Higher acuity
– Indirect supervision, fewer shared-visits
Plan & Execute: Structure Services
 Make work assignments (cont.):
• All experience levels
– Touch-base “card-flip” daily—late morning & afternoon
• Referring Physicians
– Preferentially assign by buy-in versus opt-out
 Stagger the on-service start dates
• On-service/off-service rotation dates differ for
physicians & PAs/NPs
• Overlap allows for more continuity of care &
slightly eases the first day on
Plan & Execute: Structure Services
 Check-out process for PAs/NPs going off—
coming on service
• Mirror physician process if possible
 Stagger the new-hire start dates
 Start out slow and gradually increase patient
load and assignments
Plan & Execute: Leadership Pearls
 Debrief with:
• PAs/NPs often (daily, qod, biweekly, etc.) during
start-up
• Hospitalists per above
• Meet with both groups together at least once
during each rotation
• Nurses & nurse administration
• Key Stakeholders
 Actively engage feedback
 Actively resolve turbulence
Plan & Execute: Leadership Pearls
 Rewards for:
• Buy-in
• Enablers of success
• Teams making it work
 Consequences for:
•
•
•
•
Opt-out
Obstruction
Subversion
Sabotage
 Move towards a single-tiered schedule
Plan & Execute: Leadership Pearls
 Stick to the play book
• Assignments to create “go-do” not “go-for”
• Encourage flexibility and interdependence
• Develop dynamic, cross-functional teamwork
 Don’t allow a second-class citizen culture to
emerge
• Equal voice, equal vote at team meetings and
practice related activities
• Reserve agenda space and discussion time for
PA/NP issues
 Create early wins and publicize to
stakeholders
Plan & Execute: Leadership Pearls
 Make sure you have baseline data – performance
measures
 Track outcomes and performance measures from
pre-PA and NP structure to post- PA and NP
implementation
 Work with hospital administration & program
management
•
•
•
•
Determine what is most important to funding source
Stratify needs by priority & importance
Align goals
Develop services to achieve greatest gains for the effort
 Capitalize on “real time service” delivery
Plan & Execute: Leadership Pearls
 Know the rules:





• State regulations, registration, certification
• Institutional bylaws and privileges
• Documentation, billing, and reimbursement
Don’t be afraid to “drop back and punt”
Keep working it until you get it “right”
Remember there is no “I” in TEAM!
Provide a career path and incentives
Keep the key stakeholders in mind when:
• Sharing your results
• Developing your marketing plan
Critical Success Factors
 Delineations of duties: What the PA, NP, and
RN CCC can and cannot do
 Hire for fit (not for fill)
 Key stake-holder buy-in
 Hospitalist Advocates & Champions
 Hospitalist group culture of equality
 Preparedness in planning and execution
 Marketing
Critical Failure Factors
The opposite of success factors!
• Poor role delineation
• Wrong person/wrong seat on the bus*
(poor fit)
• Lack of mentoring tailored to experience
• Pervasive opt-out
• Billing & performance monitoring absent
Taking on “too much, too fast”
Michael Collins, "From Good to
Great"
Panel Discussion
Demonstrating ROI
The Bottom Line
Demonstrating ROI
M ed icare
E&M Code
D escrip tio n
M ed icare
A llo w ab le
# of
P A /N P
A llo w ab le/M D
P A /N P % 85%
E n co u n ters
P A /N P
# of
P A /N P
P A /N P
C o llectio n R ate C o llectio n R ate E n co u n ters C o llectio n R ate C o llectio n R ate
30%
46%
30%
46%
A d m it
99221 low
99222 interm ed
99223 com plex
$82.49
$113.41
$166.87
$70.12
$96.40
$141.84
99231 low
99232 interm ed
99233 com plex
$34.33
$61.49
$88.16
$29.18
$52.27
$74.94
10
$31,952.65
$48,994.06
7
$26,313.95
$40,348.05
99238 l.t. 30
99239 g.t. 30
$62.52
$89.90
$53.14
$76.42
5
$29,095.25
$44,612.71
3
$20,537.82
$31,491.32
$58.90
$96.86
$136.23
$50.07
$82.33
$115.80
$62.41
$53.05
$118.00
$155.73
$193.80
$100.30
$132.37
$164.73
$61,047.89
$93,606.77
$46,851.77
$71,839.37
F /U
DC
OBS
99218 low
99219 interm ed
99220 com plex
OBS
99217 D /C
O B S S am e D ate
99234 low
99235 interm ed
99236 com plex
T o tal
P ro d u ctivity
Demonstrating ROI
H igh (15) Productivity
H igh C ollection
H igh (15) Productivity
Low C ollection
Increm ental N et R evenue
Increm ental N et R evenue
$93,606.77
PA /N P
$61,047.89
$107,647.78
MD
$70,205.07
Average (10) Productivity
H igh C ollection
Average (10) Productivity
Low C ollection
Increm ental N et R evenue
Increm ental N et R evenue
$71,839.37
PA /N P
$46,851.77
$82,615.27
MD
$53,879.53
46%
30%
C ollections
Demonstrating ROI
Value of a PA/NP
Increase in Patients/Day
Increase in Net Professional
Revenue/Patient Day (46% Collection
Rate)
PA/NP Cost ($80K/yr, 26% fringe)
PA/NP Net Incremental Cost
15
10
$93,606.77
$71,839.37
$201,600.00
$201,600.00
($107,993.23)
($129,760.63)
Demonstrating ROI
Value of a PA/NP
Increase in Patients/Day
Increase in Net Professional
Revenue/Patient Day (46% Collection
Rate)
15
10
$93,606.77
$71,839.37
$201,600.00
$201,600.00
PA/NP Net Incremental Cost
($107,993.23)
($129,760.63)
MD Net Incremental Cost ($157.5K/yr, 26%)
($289,252.22)
($314,284.72)
PA/NP Cost ($80K/yr, 26% fringe)
Demonstrating ROI
Value of a PA/NP
Increase in Patients/Day
Increase in Net Professional
Revenue/Patient Day (46% Collection
Rate)
15
10
$93,606.77
$71,839.37
$201,600.00
$201,600.00
PA/NP Net Incremental Cost
($107,993.23)
($129,760.63)
MD Net Incremental Cost ($157.5K/yr, 26%)
($289,252.22)
($314,284.72)
Net Incremental Increase in Loss MD vs PA
($181,258.98)
($184,524.09)
PA/NP Cost ($80K/yr, 26% fringe)
Billing Medicare:
Hospital Settings
Shared Visits
Remember the “3 Sames and a Some”
rule:
Same employer
Same patient
Same day
Some face-to-face time with the patient
On-line Resources
www.aapa.org
www.aanp.org
www.nurse.org/acnp
Panel Discussion