2017 HSC Section 2 - Practice Management

TABLE I. Utilizations Models for Physician Extenders.

Support

Independent

Model

Scribe

Collaborative

Limited

Partial

Near complete

Billing number used Physician in room Physician in building

Physician

Physician

Physician*

PE No

PE No No

Yes, simultaneous

Yes, second in

No

Yes

Yes

Yes

Yes

*Incident to billing. PE ¼ physician extender.

DISCUSSION We propose a framework of five practice models for the integration of advanced practice providers into an otolaryngology practice (Table I). These models are scribe, collaborative, limited independent, partial inde- pendent, and near complete independent practice. The models encompass the majority of current practice arrangements and are divided primarily based on the autonomy level of the physician extender in a support role or more independent practice. The models are fur- ther defined based on the billing number used and the location of the physician. All five models may be employed in either an academic or private practice set- ting, although certain aspects of each model may dictate what practice type is best. These practice man- agement models may be instituted in isolation or as a continuum of methods to facilitate improved and more cost effective healthcare. Although this manuscript details useful methods for integration of midlevel providers into an outpatient clinic setting, it is recommended that the practice be aware of all applicable laws governing physician extend- ers as these vary by state. In particular, billing practices should be reviewed and Medicare and Medicaid regula- tions should be followed. Practice compliance officers should verify the proper integration of advanced practice providers. The purpose of this manuscript is to supple- ment, not supersede, regulations governed by the state. Scribe The first and most basic model for advanced prac- tice providers is the scribe format. In this model the midlevel provider shadows the physician and completes clerical tasks. The scribe model is especially useful for the orientation of new hires or the transition of advanced practice providers from other subspecialties to the field of otolaryngology. This model allows the physi- cian extender exposure to otolaryngology protocols and physician preferences. By completing clerical tasks par- ticularly during the transition to electronic medical records, the scribe model may promote physician efficiency and increase revenue. In primary care, documentation and patient’s records are found to be ‘‘significantly better kept’’ when assistants such as NPs are involved with patient care. 7 In addition, the midlevel provider may provide assistance with basic in-office procedures. As the knowledge base of the midlevel provider increases they are promoted to greater degrees of responsibility and autonomy.

Collaborative Practice The second support model is one of collaborative practice. Collaborative practice refers to advanced prac- tice providers functioning as a team member working alongside staff physicians. 2 Utilized in this capacity, the midlevel provider gathers important information during the patient care encounter and relays this to the attend- ing physician. The physician processes the information and functions as the manager of a medical team. Ward describes this model as ‘‘first-in-the-room provider’’ to emphasize the order of appearance of the healthcare personnel. 7 Although this description is technically accu- rate, it fails to acknowledge the collaborate effort necessary for successful implementation of this model. To function effectively, the advanced practice provider employed in this model must be able to proficiently obtain, synthesize, verify, and institute complex informa- tion from the patient care encounter. The collaborative practice model uses the physi- cian’s billing number. Although not directly reimbursed for their services, the advanced practice provider helps to generate revenue by increasing the productivity and effi- ciency of the staff physician. The staff physician is able to see a greater number of patients and spend more time performing procedures. In general, a physician extender utilized under this model can promote substantial increase in patient encounters resulting in a net gain to the practice. In primary care, the literature supports increased productivity with use of PAs in a support role. 7 It is important in this scenario to appropriately document that the physician performed all work independently required to support the coding level submitted. Limited Independent Independent practice for midlevel providers refers to conducting patient visits and instituting treatment plans without the direct involvement or presence of a physician. However, independent practice is performed under a given set of predetermined protocols and supervised by attending physicians through a review process. According to the Con- gress Office of Technology Assessment, advanced practice providers can provide independent care equal to that of physicians that is ‘‘within the limits of their expertise.’’ 8 Although the independent models do not directly affect physician productivity, physician extenders may improve practice efficiency by catering to walk-in and overflow patients. The independent models for effective use of phy- sician extenders include limited, partial, and near complete independent practice.

Laryngoscope 121: November 2011

Norris et al.: Physician Extenders in Otolaryngology

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