2017 HSC Section 2 - Practice Management
complexity of the patients requires specialty manage- ment. According to Kennedy, utilization of advanced practice providers within the collaborative practice model has the ‘‘potential to deliver an exceptionally high level of care for chronic disorders.’’ 2 It is reported that NPs may excel in assisting in the management of chronic diseases as they are ‘‘trained specifically for health promo- tion and education.’’ 16 Although the support models are the least profitable, they may still increase revenue through improving physician productivity. The need to pro- vide efficient management of chronic disease will increase as the use of episodic bundling payments becomes more widespread posthealthcare reform implementation. FUTURE DIRECTIONS The integration of advanced practice providers into clinical practice continues to be in evolution. The role of a midlevel provider depends on the need of the physician and group with which they are employed. 8 In addition, the healthcare reform bill may create more demand for specialty care through a greater number of insured patients. Combined with a predicted shortage of otolar- yngologist, the increase in insured individuals has the potential to overwhelm the current otolaryngology work force. 2 State law currently dictates the amount and type of physician supervision given to advanced practice pro- viders. 12 However, with respect to the current physician shortage, the level of physician supervision may be modified to help offset escalating healthcare demands. There has been increased usage of midlevel pro- viders in many medical specialties and is related to shortage of physicians, expansion of practice parameters, and increase in the number of practitioners being trained. 6 For example, dermatology practices that utilize midlevel providers increased 43% from 2002 to 2007. 6 Academic practices, in particular, are most likely to employ advanced practice providers compared with other practice venues. 6 Academic and tertiary referral centers may employ more advanced practice providers due to increased resources required for training and supervi- sion. 6 The collaborative practice model is ideal for management of complex patients treated at tertiary aca- demic centers. 2 There are trends for greater level of autonomy and additional postgraduate training. Residency programs are available for advanced care practitioners who desire additional training in subspecialized areas; however, no current programs are available in otolaryngology. 8,17 Although postgraduate training is not necessary for advanced practice providers to work in an otolaryngol- ogy clinic, a comfort level must be obtained before the physician extender transitions to partial or near com- plete independent practice. 2 We propose that a stepwise progression through these effective use models may function as a framework for informal ‘‘postgraduate training’’ of physician extenders in otolaryngology. Most information related to the cost effectiveness of advanced practice providers relates to their use in pri- mary care. A report from the American Academy of NPs found that NPs have the potential to ‘‘decrease cost per
patient visit by as much as one-third’’ especially when practicing in an autonomous capacity. 18 A review of 206 physician providers revealed lower overall labor costs per visit when advanced practice providers were used to greater extent. 18 Research supports that quality of care and outcomes are similar between physician extenders and physicians while providing savings of 25% in spe- cialty areas. 19 However, a recent economic analysis revealed that as NPs gain greater autonomy and pre- scriptive authority, their salaries will increase and cause a reflexive decrease in physician salaries. 20 This analysis likely relates to the primary care scenario where there are competing interests between NPs and physicians. CONCLUSIONS There are an increasing number of advanced prac- tice providers in healthcare and in subspecialty fields such as otolaryngology. As the presence of midlevel pro- viders increases, physicians should be aware of the practice management models available for incorporation of these practitioners in an outpatient setting. We pres- ent a framework of five utilization models to discuss the incorporation of midlevel providers into an outpatient otolaryngology clinic. These models may be of benefit to physician practices by increasing revenue and efficiency while also improving patient care and education. Improvements in patient satisfaction are also important as future changes to healthcare delivery may hinge reimbursement on level of patient satisfaction. In sum- mary, the addition of an advanced practice provider to an otolaryngology practice may be beneficial for all involved while helping to offset an increasing healthcare provider shortage. BIBLIOGRAPHY 1. Hooker RS. The extension of rheumatology services with physician assis- tants and nurse practitioners. Best Pract Res Clin Rheumatol 2008;22: 523–533. 2. Reger C, Kennedy D. Changing practice models in otolaryngology—head and neck surgery: the role of collaborative practice. Otolaryngol Head Neck Surg 2009;141:670–673. 3. American Academy of Physician Assistants. 2008 Annual Census Report. Available at: http://www.aapa.org/images/stories/Specialty_Practice/ Otorhinolaryngology08C.pdf. Accessed April 15, 2010. 4. America Academy of Nurse Practitioners. 2008 Annual Report. Available at: http://www.aanp.org/NR/rdonlyres/97CD0283–59DF-4964–819B- 61E58864B4F8/0/08AnnualReport.pdf. Accessed April 15, 2010. 5. Association of American Medical Colleges. 2006 Physician Specialty Data. Available at: https://services.aamc.org/publications/showfile.cfm?file ¼ version67.pdf&prd_id ¼ 160&prv_id ¼ 190&pdf_id ¼ 67. Accessed April 22, 2010. 6. Resneck JS Jr, Kimball AB. Who else is providing care in dermatology practices? Trends in the use of nonphysician clinicians. J Am Acad Der- matol 2008;58:211–216. 7. Laurant M, Harmsen M, Wollersheim H, et al. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev 2009;66(6 Suppl):36S–89S. 8. Ward WT, Eberson CP, Otis SA, et al. Pediatric orthopaedic practice manage- ment: the role of midlevel providers. J Pediatr Orthop 2008;28:795–798. 9. Ho P, Pesicka D, Schafer A, et al. Physician assistants: trialing a new sur- gical health professional in Australia. ANZ J Surg 2010;80:430–437. 10. American Academy of Physician Assistants. Incident-to-billing. Available at: http://www.aapa.org/advocacy-and-practice-resources/reimbursement/ medicare/889-incident-to-billing. Accessed August 28, 2010. 11. Center for Medicare and Medicaid services. Medicare carrier manual: part 3—claims process. Available at: http://www.cms.hhs.gov/transmittals/ downloads/R1764B3.pdf. Accessed August 28, 2010. 12. American Academy of Physician Assistants. Physician Assistants In Oto- laryngology. August 2006. Available at: http://www.aapa.org/images/sto- ries/IssueBriefs/Specialty%20Practice/PAs%20in%20Otolaryngology%20- %202010.pdf. Accessed August 28, 2010.
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