2017 HSC Section 2 - Practice Management

The first independent model for effective use of advanced practice providers is limited independent prac- tice. This model is based on ‘‘incident to’’ billing, which is a type of physician extender billing practice for select patients. Incident to billing is a Medicare provision that allows midlevel providers to perform independent care but bill at 100% reimbursement if certain criteria are met. 9,10 Stipulations for incident to billing include that the patient must be an established patient within the scope of the physician’s practice. Billing utilizes the physician’s billing number and the physician must be on site. 9 The ideal patients for limited independent practice and incident to billing include follow-up patients and routine postoperative patients. The low acuity and established nature of ‘‘incident to’’ patients promotes a gentle transition between collabora- tive and independent practice for physician extenders. The model of limited independent practice differs from the other independent practice models because it utilizes the physician’s billing number for higher reimbursement rates. However, only select patients meet criteria for this model thereby limiting the scope of practice. Partial Independent In partial independent model utilization, the physi- cian extender conducts patient encounters by himself or herself with the physician available in the office. The partial independent model promotes autonomy of the advanced practice provider while allowing the capacity for the physician to provide assistance on complex patients. This model is advantageous because it allows for increase in patient encounters without the addition of another otolaryngology physician. Ideal patients include walk-in, follow-up, routine postoperative, and low acuity new patients. Reimbursement rates for patient encoun- ters are less than physician reimbursement due to utilization of the midlevel provider billing number. How- ever, lower reimbursement rates are offset by the lower salary rates of physician extenders. Although the partial independent model is ideal for the busy practice, the prac- tice must have available office space and the staffing capacity for increased patient load. Near Complete Independent The final model is near complete independent prac- tice. In this setting, the advanced practice provider will practice with the supervising physician off site. The phy- sician extender will function under a predetermined set of guidelines and practice protocols. Periodic chart reviews are often performed by the physician but the degree of required supervision is regulated by the state. 2 Although the supervising physician is out of the office, he or she is available for questions or situations that fall outside of the practice parameters. This model is advan- tageous, especially in solo or small group practice, because it allows utilization of office space while the physician is offsite or in the operating room. Again, reimbursement is based on the physician extender bill- ing number but provides the best utilization of resources by preventing unused office space.

Application and Advantages of Utilization Models Midlevel providers are useful adjuncts for practi- tioners who are unable to meet the clinical demand of the community they serve. Busy solo or small private practices may benefit from physician extenders employed under the independent model of practice. Advanced prac- tice providers in this setting may improve practice efficiency and increase revenue by managing walk-in appointments, low acuity or postoperative patients, and situations where the physician is called to an emergency during clinic hours. 11 A midlevel provider in this situation may function through limited, partial, or near complete independent practice, depending on the patient, acuity of the situation, or location of the physician. It is important to consider that the same advanced practice provider has the flexibility to function within all of the model practice patterns described during the same day or over time as a practice grows and its needs change. The addition of a midlevel provider is more econom- ical than adding another physician partner. Reimbursement for advanced practice providers may vary based on contractual agreements with private insur- ance; however, is generally at 85% of the fee schedule amount for physicians. 10,12 Although reimbursement rates are moderately reduced compared to physician rates, the compensation rate of midlevel providers com- pared to physicians is dramatically different. 13 Dierick- van Daele et al. 13 found that ‘‘direct costs plus productiv- ity costs were significantly lower for nurse practitioner consultations’’ compared with consultations of general practitioners. According to a national survey, the average base salary for advanced practice providers is $80,000 plus addition costs of 25% to 30% for benefits and over- head. 12 The annual salary for PAs in otolaryngology practices is $86,856 versus $90,019 annually for all other PAs. 3 Furthermore, adding a midlevel provider may be easier than finding an otolaryngologist available for hire particularly in rural settings and as the demand for healthcare services continues to exceed the number of specialists trained. A final benefit for utilization of midlevel providers is one of improvement in patient care. Patient satisfac- tion, patient education, and management of chronic diseases are improved by creating a multidisciplinary team approach to patient care through the addition of advanced practice providers in the collaborative practice model. 2,14 Patient education may be improved in areas such as tobacco cessation or nutrition, especially for patients with head and neck cancer. In a systematic review of the recent primary care literature, patient education was found to be significantly improved when NPs participate in patient care. 7 Patient satisfaction is determined in part by time spent in the patient encounter. Rashid’s integrative review found that advanced practice nurses had unhurried consul- tations with a tendency to reinforce messages making the patient the focus of their attention. 15 Midlevel providers may increase the amount of time spent with patients while optimizing physician efficiency. 14 The benefit of improvement in patient care may be best utilized in an academic setting or where the

Laryngoscope 121: November 2011

Norris et al.: Physician Extenders in Otolaryngology

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