Mitchell Wilson, MD Associate Professor of Medicine Section Chief of Hospital Medicine Division of General Medicine and Clinical Epidemiology Department

Mitchell Wilson, MDMitchell Wilson, MDAssociate Professor of Medicine

Section Chief of Hospital MedicineDivision of General Medicine and Clinical Epidemiology

Department of MedicineUniversity of North Carolina School of Medicine

Co-Chair, SHM Non-Physician Provider Committee

PanelistsPanelists

Scarlett Blue, RNC, MSN, CNA

Ryan Genzink, PA-C

Jeanette Kalupa, MSN, APRN-BC, APNP

Working With Non Physician Working With Non Physician Practitioners: Risks, Benefits, Practitioners: Risks, Benefits,

Alternatives & IndicationsAlternatives & Indications

Learning ObjectivesLearning 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 valuevalue to hospitalist programs (alternatives)

Learning ObjectivesLearning Objectives

Determine if PAs, NPs, and RN CCCs are right for your practice (indications) by assessing opportunities & barriers

Perform a needs vs. barriers analysisDefine the factors critical to a

successful implementationLearn how to demonstrate ROI

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


4. Return on Investment (and billing if we have time)


Session OutlineSession Outline

Case StudyCase 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


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


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


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


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


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 PracticesPartnering with NPPs in Hospitalist Practices

Identify the• Disadvantages and Advantages• Opportunities• Barriers

Perform a Needs-vs.-Barriers AnalysisPolling Question:Polling Question:

Is this case a “good-to-gogood-to-go” or “just-say-just-say-nono” to Partnering with NPPs?

Disadvantages(Risks)

NPPs in Hospital Medicine

Substituting for Residents: Substituting for Residents: Disadvantages of PAs and NPsDisadvantages of PAs and NPs

More expensive than residentsLoss of Medicare DME & IMEConflict with CMS cost reportsAcademic pay scales generally lower

than community competitionRole conflict: X vs YRedundancy?

Integrated Hospitalist Teams: Integrated Hospitalist Teams: Disadvantages of PAs and NPsDisadvantages 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: Integrated Hospitalist Teams: Disadvantages of PAs and NPsDisadvantages 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)


Silver et. al., Cawley et. al., Frick et. al., Jones et. al.

Substituting for Residents: Substituting for Residents: Advantages of PAs and NPsAdvantages 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

Substituting for Residents: Substituting for Residents: Advantages of PAs and NPsAdvantages 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: Integrated Hospitalist Teams: Advantages of PAs and NPsAdvantages 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


Surge capacityProvide high-quality careFacilitate and coordinate care

processesEnhance efficiencyAugment practice productivityServe most specialties


Perform proceduresSpend more time with patients,

especially w.r.t. education, prevention, health maintenance

Interface with ancillary services and consultants & improves communication

Increase hospital staff satisfactionWrite prescriptionsMay lessen the liability risk


Services reimbursed by Medicare, Insurers

Makes a TEAM out of you and me!

Value-Added(Alternatives)


The Driver for PartneringThe Driver for Partnering

“Skill mix enables programs to deploy resources (physician and non-physician) in a way that matches skill set with skill need to optimize program performance and efficiency.”

--M.J. Wilson, M.D.

Cost Effective ModelCost 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


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


Billing options allow for shared or independent visits

The same way that hospitalists add hospitalists add value*value* so too do PAs & NPs in hospitalist practices

*SHM special supplement "How Hospitalists Add Value"*SHM special supplement "How Hospitalists Add Value"

WhyWhyIntegrate

PAs, NPs, and RN CCCs

into

Hospitalist Practices?

BecauseBecauseThey

Add Value!

How Do NPPs Add Value?How Do NPPs Add Value?

The The MantraMantra of Hospitalists of Hospitalists

The purpose of admitting patients to the hospital is to discharge them

Discharge planning begins at the moment

of admissionThe average length of stay for most patients should not exceed three (3)

days.

The conundrum ofThe conundrum of

competingcompeting

congruentcongruent

contemporaneouscontemporaneous

care processescare processesOvernight hand-

offs

Admiss

ion

s

Follow up visits

Consults

Procedures

Family conferences

Quality Improvement projects

ICURRT

Codes Dis

charg

e

s

The The CompetitionCompetition for provider time… for provider time…

delaysdelays the continuum of care that culminates in the patient’s (un)timely

dischargedischarge.

Competition for Provider Time:Competition for Provider Time:

The The Ivory TowerIvory Tower Structure Structure

Academia ResidentsInterns Students

Residency Review CommitteeResidency Review Committee

Duty Hours RestrictionsDuty Hours Restrictions

Integrating PAs, NPs and RN CCCs in Acute CareIntegrating 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 managermedical manager (MD or DO), assisted by the patient care managerpatient care manager (PA or NP), and clinically coordinated by the CCCCCC (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 CareIntegrating PAs, NPs and RN CCCs in Acute Care

Physician Physician (medical manager) makes key medical decisions & follows medical progress

PA/NPPA/NP (patient care manager) implements decisions (dependent & independent), monitors care

Nurse CCCNurse CCC coordinates the clinical care processes culminating in discharge

Competition for Provider Time:A non-housestaff Solution

Physician Assistants,Nurse Practitioners,

and RN CCCs

Pitching the Value-AddedValue-Added Proposition

Wachter, "Hospital Medicine" p.33, Donabedian , "JAMA" 1988

Value = Value = QualityQuality // Cost Cost

The Health Care ValueThe Health Care ValueCascadeCascade

Health CareHealth Care == Clinical qualityClinical quality xx SatisfactionSatisfactionQualityQuality

Clinical Quality = structurestructure, process, outcomes

PAs, NPs, and RN CCCsPAs, NPs, and RN CCCsPitching the Value-Added PropositionPitching the Value-Added Proposition

Some Elements of Value:

Structure: Denotes the attributes of the setting

Process: Denotes action in giving & receiving care

Outcome: Denotes the effects of care on health

““How is care organized”How is care organized”

““What is done”What is done”

““What Happened”What Happened”

Value = ClinQual x Satisfaction

Cost

Evidence: Studies, Experience

StructureStructure

Processes

Outcomes

PAs, NPs, and RN CCCsPAs, NPs, and RN CCCsPitching the Value-Added PropositionPitching the Value-Added Proposition

Overnight hand-

offs

Admiss

ion

s

Follow up visits

Procedures

Family conferences

Dr Dr WilsonWilson


Disch

arge

s

Overnight hand-

offs

Admiss

ion

s

Disch

arges

Follow up visits

Consults

Procedures

Family conferences


Crane, S., "Physician Executive" 1995

Physician Assistants and Nurse PractitionersPhysician Assistants and Nurse Practitioners

Pitching the Value-Added PropositionPitching 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 it is the integration of care using a of care using a team of providersteam of providers, not the , not the fragmentation of care through the proliferation fragmentation of care through the proliferation of independent providers, that will be the of independent providers, that will be the model of high-quality and cost-effective model of high-quality and cost-effective health carehealth care in the future.” in the future.”


Indications:Are PAs, NPs, and RN CCCs

Right for Us?


Opportunities

Opportunities: ProgrammaticOpportunities: 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: ProgrammaticOpportunities: 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"*SHM white paper: “Measuring Hospitalist Performance"

Opportunities: EnvironmentOpportunities: 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: EnvironmentOpportunities: 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: CultureOpportunities: 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: CultureOpportunities: Culture

Hospitalist (cont.)• Non physician group members• Clinician Educators, teacher-types• Mentor structure in place

Hospital• Nursing and NPs• Change oriented

OpportunitiesOpportunities

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”)

OpportunitiesOpportunities

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 SuccessBarriers to Success


The greatest barrier to someone achieving their potential is their denial of it.

--Simon Travaglia

Barriers: ProgrammaticBarriers: 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


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


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: EnvironmentBarriers: 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?


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


Perception that integration will alienate referral groups

Lack of environmental awareness• Perception• Reality

Laws & BylawsChanges in hospital leadership

Barriers: CultureBarriers: 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


Hospitalist• Unwillingness to:

– Teach– Mentor– Oversee & Review

• Unwillingness to change the culture• Polarized group


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!

Integrate

NPPs

Into Our

Hospitalist Practice?

AreAreNPPs

right for you?

Should WeShould We

Are NPPs right for your practice?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 SiteNeeds

vsBarriers to

Implementation


Needs Versus Barriers Analysis

High Low

HighHigh HHH HHL

LowLow LLH LLL

Barriersto

Implementation

Practice SitePractice SiteNeedsNeeds

Case Study: Case Study: NeedsNeeds vs. Barriers vs. Barriers

Difficult & complex cases Access to service (PCPs, co-

management) 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 multi-

site) 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 Case Study: Needs vs BarriersBarriers

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


Needs Versus Barriers Analysis

High Low

HighHigh HHH HHL

LowLow LLH LLL

Barriersto

Implementation

Practice SitePractice SiteNeedsNeeds


Barriers are merely opportunities waiting to be born.

--M. J. Wilson, M.D.

Panel DiscussionPanel Discussion

ImplementationImplementation

How can NPPs be Integrated Into the How can NPPs be Integrated Into the Hospitalist PracticeHospitalist Practice

Plan & Execute: Stakeholder Buy-inPlan & 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


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


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, ANPSHM Non-Physician Provider Committee

Plan & Execute: Skill MixPlan & 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 MixPlan & 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 ServicesPlan & 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


Make team assignments: Less experienced PA/NPWorked successfully with PA/NP beforeTeacher-typesAdvocates and ChampionsMusketeersPatriarch, Monarch—positive outlook Worked unsuccessfully Naysayers Mercenary Patriarch, Monarch—ambivalent or worse Unwilling to teach


Make team assignments: More experienced PA/NPWorked successfully with PA/NP beforePatriarch, Monarch—positive outlookAdvocates and ChampionsMusketeersTeacher-types Worked unsuccessfully Naysayers Mercenary Patriarch, Monarch—ambivalent or worse Unwilling to teach


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


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


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 Plan & Execute: Leadership PearlsPearls

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


Rewards for:• Buy-in• Enablers of success• Teams making it work

Consequences for:• Opt-out• Obstruction• Subversion• Sabotage

Move towards a single-tiered schedule


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


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


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 FactorsCritical 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

Michael Collins, "From Good to Great"

Critical Failure FactorsCritical 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”


The Bottom LineThe Bottom Line

Demonstrating ROIDemonstrating ROI

E&M Code DescriptionMedicare

Allowable/MD

Medicare Allowable

PA/NP % 85%# of

EncountersPA/NP

Collection RatePA/NP

Collection Rate# of

EncountersPA/NP

Collection RatePA/NP

Collection Rate

30% 46% 30% 46%Admit

99221 low $82.49 $70.1299222 intermed $113.41 $96.4099223 complex $166.87 $141.84

F/U99231 low $34.33 $29.18 10 $31,952.65 $48,994.06 7 $26,313.95 $40,348.0599232 intermed $61.49 $52.2799233 complex $88.16 $74.94

DC99238 l.t. 30 $62.52 $53.14 5 $29,095.25 $44,612.71 3 $20,537.82 $31,491.3299239 g.t. 30 $89.90 $76.42

OBS99218 low $58.90 $50.0799219 intermed $96.86 $82.3399220 complex $136.23 $115.80

OBS99217 D/C $62.41 $53.05

OBS Same Date99234 low $118.00 $100.3099235 intermed $155.73 $132.3799236 complex $193.80 $164.73

Total $61,047.89 $93,606.77 $46,851.77 $71,839.37



High (15) Productivity High (15) ProductivityHigh Collection Low Collection

Incremental Net Revenue Incremental Net Revenue$93,606.77 PA/NP $61,047.89

$107,647.78 MD $70,205.07

Average (10) Productivity Average (10) ProductivityHigh Collection Low Collection

Incremental Net Revenue Incremental Net Revenue$71,839.37 PA/NP $46,851.77$82,615.27 MD $53,879.53

46% 30%

Collections

P

rod

uct

ivit

y

Demonstrating ROIDemonstrating ROIValue of a PA/NP

Increase in Patients/Day 15 10

Increase in Net Professional Revenue/Patient Day (46% Collection Rate) $93,606.77 $71,839.37

PA/NP Cost ($80K/yr, 26% fringe) $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)






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)

Billing Medicare:Billing Medicare:

Hospital SettingsHospital Settings

Shared VisitsShared Visits

Remember the “33 SamesSames and a SomeSome” rule:

SameSame employerSameSame patientSameSame daySomeSome face-to-face time with the patient

On-line ResourcesOn-line Resources

www.aapa.orgwww.aanp.orgwww.nurse.org/acnp

http://www.aanp.org/


Documents

Mitchell Wilson, MD Associate Professor of Medicine Section Chief of Hospital Medicine Division of General Medicine and Clinical Epidemiology Department