Rising Stars: The Growing Demand for Advanced Practitioners...Shore Capital Partners, LLC 6...

© 2012 Crain Communications Inc

Rising Stars: The Growing Demand forAdvanced PractitionersModerator: Subadhra Sriram, Editorial Director,

Staffing Industry AnalystsPanelists:

Jeff Bowling, CEO, The Delta Companies Ryan Kelley, Partner, Shore Capital Partners LLC Cynthia Kinnas, President, Randstad Healthcare

Grace Paranzino, Chief Clinical Officer, Healthcare Product,Centers of Excellence, Kelly Services

Concurrent Session: Strategy & Opportunities Track

Tuesday, Oct. 16 | 3:30 pm | Ironwood 8

© 2012 Crain Communications Inc

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Concurrent Session: Strategy & Opportunities Track

Rising Stars: The Growing Demand forAdvanced Practitioners

The Growing Demand for Advanced Practitioners

Ryan Kelley, Partner

Confidential & Proprietary

Shore Capital Partners, LLC 4

• Shore Capital believes the healthcare staffing market is attractive for several reasons:1. Highly fragmented industry with many small & relatively unsophisticated players2. Limited sales & marketing infrastructure at many companies3. Niche clinical & non-clinical areas of healthcare continue to experience low unemployment (1 - 3%)4. Healthcare jobs are often highly “portable” across geographic boundaries5. Changing regulatory & structural environment creates tailwinds (EMR meaningful use, ICD-10, etc.)6. Staffing firms can benefit from key macro themes without taking direct reimbursement or technology risk

(e.g. aging population, healthcare reform, shortage of labor, increased technology utilization)

(1) Staffing Industry Analysts.

% of Firms with Executives by Company Age(1) HC Skews Toward Attractive “Contract” Market(1)

Permanent5%

Contract95%

Healthcare Staffing Interest

Shore Capital Partners, LLC 5

• The healthcare labor market experiences extremely low unemployment across a wide range of niche sub-specialty areas as shown below

• Demand for healthcare labor continues to expand rapidly as shown by employment growth in various niche sectors of healthcare

(1) Staffing Industry Analysts and the Bureau of Labor Statistics.(2) AMN Healthcare reports.

Supply: Unemployment as of May 2012(1)

8.2%

4.3%

3.2% 3.0% 2.9%2.2% 2.0%

1.0% 0.8% 0.7%

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

General Unemployment Figures

Demand: Employment Growth (2008 – 2018P)(2)

39%

30%26%

23%

14%

0%

10%

20%

30%

40%

50%

PhysicianAssistants

PhysicalTherapists

Physicians &Surgeons

RegisteredNurses

Pharmacists

Healthcare Staffing Supply & Demand Trends

Shore Capital Partners, LLC 6

Education Requirements(2)

• Bachelors Degree (Must take Biology & Chemistry Courses)

• Masters Program Accredited by The AAPA (2 years)

• Bachelor of Science in Nursing

• Registered Nurse license

• Graduate Degree In Advanced-Practice Nursing (2-3 years) by an accredited program

Labor ForceTrends(2)(3)

(1) Galegroup.(2) BLS.(3) NCES.

NP & PASynopsis(1)

• Work without direct supervision of a physician

• Generally responsible for:− Practice management / Documentation− Patient examination and treatment− Ordering / interpreting ancillaries

• Allowed to prescribe in all states

• Diagnose health conditions under directionof physician

• Generally responsible for: − Medical documentation− Patient examination and treatment− Ordering / interpreting ancillaries

• Allowed to prescribe in 48 states

Nurse Practitioner (NP) Physician Assistant (PA)

Nurse Practitioner & Physician Assistant Overview

182,000229,320

0

125,000

250,000

Total Employed(2010)

Proj. Employed(2020)

83,600108,300

0

125,000

250,000

Total Employed(2010)

Proj. Employed(2020)

Average Wage (2012): $91K

Average Wage (2012): $93K

Shore Capital Partners, LLC 7

NP / PA Specialty Areas• NPs and PAs are increasingly in-demand as a cost-effective solution to the shortage of

primary care physicians‒ NPs are primarily focused on the delivery of primary care (85% of specialty areas are related to primary care)‒ PAs more focused on hospital / surgical specialties; often act as “chief of staff” directly under a physician

• Trend towards mid-levels delivering care vs. augmenting care in order to reduce cost and expedite treatment

Nurse Practitioner Specialties(1) Physician Assistant Specialties(2)

Primary Care Specialty Other Specialty

48%

19%

9% 9% 6% 3% 3% 2% 1%0%

20%

40%

60%

31%

10%

1%

23%19%

11%3% 2%

0%

20%

40%

60%

Primary Care: 85%Primary Care: 42%

(1) AANP.(2) AAPA.

Shore Capital Partners, LLC 8

Physician Substitutability / Conclusions

• Kaiser Permanente analyzed the physician substitutability of PAs and NPs‒ 83% of tasks in a primary care practice can be safely performed by a PA or NP‒ PAs and NPs also found to be effective substitutes for physician residents in U.S. medical education

• Other factors in physician substitution by PAs and NPs:‒ Overall Delegation………………………………………83%‒ Supervision Duties……………………………………...10%‒ Compensation / Production Ratio……………………..39%‒ Societal Cost to Educate (vs. a physician)…………...20%‒ Average # of outpatients seen per day……………….21.7

• Conclusions:‒ U.S. has experience with over 200,000 non-physician clinicians over the past 40 years‒ PA and NP care quality has proved to be similar (if not indistinguishable) from physician-delivered care‒ PA and NP substitution capabilities span multiple practice settings and clinical sub-specialties‒ Substantial economic benefits to practices that effectively integrate PAs and NPs

Sources: • J.C., McNally, M. Schweitzer, S.O., Blomquist, R.M., & Berger, B.D. (1980).• New health professions after a decade and a half: Delegation, productivity and costs in primary care. Journal

of Health Politics, Policy & Law; 5(3):470–497.• Hooker RS. Physician Assistant, (2000).

Grace K. Paranzino, EdD, RN CHES, FAAOHNChief Clinical OfficerKelly Services, Inc.®

Recruitment Challenges and Strategies

Challenge: NP Demand is High..

Nurse Practitioners – 10 year forecast demand

And PA Demand is Higher

PHYSICIANS ASSISTANTS – 10 year forecast demand

Healthcare Workers Are Engaged, Yet Looking

Globally, more than 4,200 healthcare professionals responded to the 2012 Kelly Global Workforce Index.

63%MORE THAN 6 IN 10

Intend to look for a job with another organization within the next year.

Most cited factors that would cause healthcare professionals to leave their organization:

• Lack of opportunities for advancement (20%)• Poor management (20%)• Poor salary/benefits (19%)• Inadequate work/life balance (9%)

The majority of healthcare professionals feel engaged with their current employer. 66%

52%EVEN WHEN THEY’RE

HAPPY WITH THEIR JOBS…

… of Healthcare workers actively look for better job opportunities or evaluate the external job market.

The majority of healthcare professionals believe that

changing employers is the best way to develop new

skills and grow in their career (another 19% are unsure).

54%49%

NEARLY HALF…

… do not feel that their current employer is realizing the full benefits of their potential.

Define/derive meaning from their work by their ability to

excel/develop in their field. 73%

Become An ‘Employer Of Choice’

• Define Target / “Ideal Candidate”– Help the best talent find your organization– Align core values to what is important to

them

• Capitalize on Technology: – Use CRM tools / functionality to maintain

connection to communities– Strong ATS functionality is a must– Gamification for ‘day in the life’ or training

opportunities– Candidate Experience is KEY!

• Adopt A Recruitment 3.0 philosophy– Focus on the “best talent”– Everyone is a potential candidate

or brand ambassador– Not every candidate is active– Two-way “real” communication with

potential candidates

Increase Community via ...

The most appropriate medium, for yourtarget candidates:• Social Media

– Drive participation in the top sites for your targets– Include automated job distribution and

enhance cross posting to other social properties & targeted niche communities

– “Social availability”

• Mobile– Its 2012, almost 40% of your candidates are applying and

viewing your content via their smart phone

• Talent Communities– Help nurture talent in demand

The New Reality

In The Past..• People need companies

• Machines, capital and geography are the competitive advantage

• Better talent makes some difference

• Jobs are scarce

• Employers are loyal, and jobs are secure

• Recruiting is like purchasing

Current State..• Companies need people

• Talented people are the competitive advantage

• Training talent makes a huge difference and helps employees find value in their employer

• Talented people are scarce

• People are mobile, and their commitment is short-term

• Recruiting is marketing & sales

Compliance Issues and Challenges

APRN Advanced Practitioners

APRN Definition:• Completed accredited graduate level education program in one

of four roles of CRNA, CNM, CNS, CNP• Passed national certification that measures APRN role and

population-based competencies• Acquired advanced clinical knowledge and skills to provide direct

care to patients (Defining factor for all APRNs is that significant component of education and practice focuses on the direct care of individuals)

– Certified Registered Nurse Anesthetists (CRNAs)– Certified Nurse-Midwives (CNMs)– Clinical Nurse Specialists (CNSs)– Certified Nurse Practitioners (CNPs)

Collaboration/Supervisory Language in State Practice Acts for NPs

Source: ©American Academy of Nurse Practitioners, 2011

Plenary Authority (No Physician Relationship Required)

Collaboration with Physician

General Supervision/Delegation by Physician

Collaboration or Supervision for Prescribing Only

Collaboration for Prescribing Schedule II Drugs Only

Other

+++

+++

States that Do Not Require NP Collaborative Agreements

Source: aanp.org

AK

WA

ORMT

AZ NM

WI

MO

ME

NH

DC

PA Regulation

Each state must define the regulatory agency responsible for implementation of the law governing physician assistants. These include:

• The State Board of Medical Examiners• The Department of Health or boards that are selected or created

to regulate PA practice– A number of states have created separate PA licensing boards

• A Supervision Agreement/Delegation of Services Agreement is required in every state

• State regulation is based on 3 concepts: – Licensure, delegation, and supervision

PAs Are Generally Regulated by the State Medical Board

• PA needs a license

• Uniform licensure criteria: graduation from an accreditedphysician assistant (PA) programand passage of the NCCPA exam

• Most states allow limited practice for new grads awaiting exam

• In most states, physicians must notify the board of their intention to supervise the PA

The NCCPA

• All PAs are required to pass the Physician Assistant National Certification Examination administered by the National Commission on Certification of Physician Assistants – acts as a de facto licensing exam

• To maintain national certification (that “-C”) PAs must earn 100 hours of CME every 2 years and pass a recertification exam every 6 years

• Over 90% of PAs maintain current certification

PA Practice is Based on Physician Delegation

What do state laws allow physicians to delegate?

• Generally any task for which the PA is trained that is within the physician’s scope of practice

• A handful of states require submission of a job description to the state board for approval

• A few states have specific restrictions –these are being repealed

Physician-delegated Prescriptive Authority

• All states allow physicians to delegate prescriptive authority to PAs

• Laws becoming more uniform• 48 states authorize physicians to

delegate controlled medication prescribing to PAs (states in which physicians may not yet delegate controlled Rx to PAs are FL and KY)

• Medication orders and prescriptions are different

What Does Supervision Require?

• Generally, state law defines supervision as “the ability of the physician to exercise direction over the actions of the PA”

• Physician not required to be on-site (except in very specific circumstances)

• Physician must be available via telecommunication

• Supervision by multiple or alternate physicians allowed

• Some states require co-signature of some charts

During the hiring process, request the following from the PA

• A copy of current state license(with license #, DEA # if applicable, and expiration dates).

• Conduct Primary Source Verification of the state license.• A copy of current certification from the National Commission on

Certification of Physician Assistants (NCCPA). – PAs will get a certificate each time they recertify. This will have the NCCPA #,

issue date, and expiration date.

• Letters of reference from previous employers and colleagues —particularly peer recommendations and physician evaluations regarding the performance of specific responsibilities (i.e., surgical skills or other special skills)

• Documentation of CME records or additional training the PA has received, e.g., current ACLS, BLS, PALS, or other Certificates

• A copy of any recent hospital privileges. If the PA has a log documenting specific procedures, request a copy.

Customer Considerations

• Inquire of the local hospital(s) about their policies regarding PA practice.

• Have PAs worked in the hospital before? • Have they been privileged? If so, what are the procedures for

privileging? How long will it take? • Are there any physician co-signature requirements? • Are competency measures used for any procedures the physician

may want to delegate to the PA? • What are the admission policies of the hospital?

What are the policies on initial consultation in the hospital?

The Growing Demand for Advanced Practitioners

Cynthia KinnasPresident

Randstad Healthcare

Differences between Contract/Travel RN’s and Contract/Travel AP’s (i.e.: NP’s, PA’s)

• Smaller pool of AP’s that travel as a career• AP’s typically do more contract work in their local

area• NP’s can move between specialties/settings more

easily + gravitate toward “whole patient” care settings (i.e.: Family NP)

• PA’s tend to gravitate toward the procedural specialties

• AP’s usually have a higher level of education than RN’s, and tend to take a more formal and career focused approach toward contract work

Working with AP’s vs. RN’s

• AP’s expect a higher level of professionalism and accuracy from their recruiters

• AP’s tend to be less tolerant of “process” (application/credentialing) than RN’s

• Benefits package offered to traveling AP’s is more extensive and lucrative

Differences in Licensure/Certifications NP vs. RN

• NP’s can be nationally certified by a certifying body (usually the ANCC or AANP). This is similar to sitting for the boards as an RN except it is on a national vs. state level and is not necessarily required to be able to practice as an NP.

• There are no “Compact States” for NP’s; they have to apply for a new advanced practice license in each state they are going to work. Each state has different criteria for licensure, so you have to be diligent in keeping up to date with these requirements (for example, some states will require the national certification for licensure, and others will not)

• NP’s must be very knowledgeable of the specific laws (they vary) of each state in which they will work so they do not inadvertently prescribe or practice out of compliance while on contract. Do not rely on the client to be aware of this or to monitor it!

– Supervising MD requirements

– Prescriptive authority laws

– DEA license application

Educating Clients

• Some clients are brand new to hiring AP’s and may not realize the intricacies of hiring this type of professional.

• Account Managers must know which questions to ask to determine what type of AP they need as well as what is allowable based on the practice laws of the state.

• Be careful to ensure the client has the appropriate supervision in place for the AP according to the laws of the state.

Target Markets

• AP’s typically work in a wider variety of settings than RN’s

• PA’s work in hospital as well as outpatient settings.

• NP’s typically shift from hospitals towards clinics, outpatient centers, Physician offices, etc.

• Demand for NP’s is higher in smaller, non-teaching hospitals as teaching hospitals use residents or PA’s for typical NP duties

Private MD/DO Practice or NP Practice

Other

In-Patient Hospital and ER

Hospital Outpatient Clinic

Community or Rural Health Center

Extended Care/Long Term Care Facility

Main Practice Settings

Source: Data taken from 2009-10 AANP National NP Sample Survey

31.8%

3%

9%

12.1%

14.4%

15.2%

The Growing Demand for Advanced Practitioners

Jeff BowlingCEO

The Delta Companies

Physician Assistant’s & Nurse Practitioners• Supply & Demand

– Demographics– Geographies– Supporting Healthcare Trends– Patiently Waiting

• Procurement of Candidates– Sources– Tendencies– Loyalty

• Dealing with Candidates– Personalities

• Tax Treatment – 1099 v. W2– State Driven– Triggers– NALTO Stance

• TDC’s view of this space

© 2012 Crain Communications Inc

Give Us Immediate Feedback

A B C D F294440 294441 294442 294443 294444

Please grade your satisfaction with this session on a scale from A (highest) to F (lowest) by texting your grade to #22333.

Concurrent Session: Strategy & Opportunities Track

Rising Stars: The Growing Demand forAdvanced Practitioners