Adding an advanced practice provider to a neurology practice

Abstract

Advanced practice providers (APPs) are qualified medically licensed health care providers, including nurse practitioners (NPs), physician assistants (PAs), nurse anesthetists, certified nurse-midwives, and clinical nurse specialists, who can function either independently or alongside a physician in population-centered care models, disease management integration, care coordination, or in the provision of direct patient care. They also can improve revenue and reduce physician burnout. The use of APPs in the practice of neurology is still in its infancy, and many neurologists are not sure how to integrate an APP in their practice. This article addresses some concerns related to integrating an APP in the inpatient and outpatient settings.

A recent position paper by the American Academy of Neurology states that advanced practice providers (APPs) “will be crucial to improving access and continuity of care” in neurologic practice.¹ APPs are qualified medically licensed health care providers. As medicine becomes more focused on quality and value, new population-centered care models are developing. APPs can play an important role in disease management integration and care coordination, and can provide added value to the entire spectrum of neurologic care. They also can improve revenue and reduce physician burnout.

Training and certification

To meet growing physician shortages, nurse practitioners (NPs) and physician assistants (PAs) were introduced into American medicine in 1965 by 2 divergent pathways.

To become an advanced practice registered nurse (RN) (NP), students must complete a nursing-related 4-year bachelor's degree and become licensed RN by passing the National Council Licensure Examination for Registered Nurses. Then, to be certified as an NP, either a Master of Science in Nursing or a Doctor of Nursing Practice degree is required, with 2–4 additional years of advanced education.² The 2 major national certifying agencies are the American Academy of Nurse Practitioners and American Nurses Credentialing Center. In addition, NP recertification requires 75 continuing education (CE) hours every 5 years within the NP's specific advanced specialty, and a minimum of 1,000 clinical practice hours. There are also requirements for pharmacotherapeutics CEs.^3,4 In 22 states, NPs may work independently of physicians.⁵

Most PA programs are now 3 academic years including more than 2,000 clinical rotations hours.⁶ Advanced curricula can lead to Master Degrees in Physician Assistant Studies, e.g., the program at UT Southwestern⁷; or a Master of Health Science or Medical Science degree. Prior to practice, new graduates must pass the Physician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants. PA recertification requires 100 continuing medical education credits every 2 years and passing the Physician Assistant National Recertifying Exam every 10 years. In all states, PAs must work under a physician's supervision. The extent of supervision varies by state.^8,9

There are no specific neurology or neuroscience boards for NPs or PAs.

Neurology education

APP postgraduate residency/fellowship programs are new. Of the 368 NP and 157 CNS programs nationwide,¹⁰ and 210 accredited PA programs nationwide,¹¹ only 15 offer postgraduate acute/critical care or hospital care residencies as of 2016.¹² Even fewer offer APP neurology postgraduate curricula:

1. Capital Health Neurosciences NP Fellowship in New Jersey¹³

2. UCSD Postgraduate Vascular Neurology NP Fellowship¹⁴

3. Duke Neurology APP Program^15,16

A small minority of APPs in the United States have formal postgraduate neurosciences training, creating tremendous responsibility and opportunity for neurologists when considering APPs for their practice. The applicant's prior clinical experience in addition to formal education should be considered. Practices most successful in employing APPs have defined tutelage programs under the direction of a supervising neurologist, providing a learning environment that stimulates professional growth. The educational process the authors use includes scheduled lectures, shadowing the supervising neurologist for a designated period of time, assigned readings, attending online neurology courses, and learning how to perform and present a comprehensive neurologic history and physical examination. Reviewing and cosigning a proportion of completed charts (mandatory in some states) also helps in assessing APP skills.^17,18 Thus, a period of time for education must be factored into the employment process—at least 6 months in the authors' experience.

While neurology APP programs are developing, nationwide APP jobs are rapidly growing. The US News and World Report Best Jobs for 2016 ranks PAs at 5 and NPs at 6.¹⁹ The decision to employ an APP is highly individualized, depending on the practice’s specific needs and setting.

APPs in outpatient neurology practice

APP functions involve billable direct patient care activities and nonbillable activites.^20,21 Billable activities are clinical patient services above what medical assistants, office assistants, or licensed practical nurses/RNs are licensed to do. Based on state law, community needs, and physician preference, APPs can see new or established patients. This reduces the neurologist's wait time for new patient consultations. A practice analysis to determine the daily number of patient visits the APP will see, using evaluation and management (E&M) Current Procedural Terminology codes, could be used as preliminary assessment to estimate profitability. Other billable E&M activities include patient education and family counseling, and medical services such as administration of botulinum toxin (e.g., in headache medicine), IV infusions, and other injection procedures. There is also a movement toward integration of APPs into stroke telemedicine teams.²² Conversely, certain procedures should only be performed by physicians, e.g., neurophysiology studies (e.g., EMG), spinal nerve blocks, facet injections, and similar interventions.

Efficient APPs also assume additional important, albeit nonbillable responsibilities, by supporting and coordinating key patient care elements, such as management of referral agreements, maintenance of tracking systems, and referral feedback loops. APPs are also equipped to assist within the evolving health care environment as specialists in the transition to population health management, by acting as the link in integrating care with the primary care physician in patient-centered medical homes, or coordinating care with other physicians in patient-centered medical neighborhoods. Whether APPs will affect utilization of downstream services (such as imaging or admission) is unknown; however, this is an important aspect to examine in the evolving health care environment.

APPs in hospital neurology practice

As neurology transforms into a model where physicians are primarily either outpatient or inpatient, neurohospitalists, neurointensivists, and neurology-trained APPs are playing a dominant role in larger urban and teaching hospitals,²³ but also in community hospitals. In a recent cross-sectional survey involving critical care programs in highly respected academic medical centers, two-thirds reported that patient care was positively affected by the use of APPs.¹⁵ An APP, working in tandem with a neurohospitalist, performs E&M services, assists in hospital admissions, rounds on patients daily, reviews neuroimaging and laboratory results, and performs certain inpatient procedures, such as lumbar puncture, arterial line placement, central line placement, endotracheal intubation, ventilator management, and intracranial pressure monitoring. The privileging of what hospital procedures APPs can perform is specific to state laws and to the health care system itself. APPs also help bridge the gap between inpatient and outpatient follow-up, provide family and patient education, and collaborate with other consultants, which is an essential part of discharge planning and prevention of unnecessary hospital readmissions.

In both inpatient and outpatient settings, many APPs are also involved in research and student education.

Billing and compensation of APPs

This is a brief discussion of billing and compensation. Future articles further elaborating this topic will follow.

Before hiring an APP, neurologists should become familiar with the Medicare Benefit Policy Manual, chapter 15, pages 142–147, which describe covered services that can be performed by APPs, including rules and regulations for employing APPs.²⁴

For outpatient care, “incident to a physician's professional services means that the services or supplies are furnished as an integral, although incidental part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness.” Outpatient services billed under “incident to” are reimbursed by Medicare and some commercial payers at 100% of the physician fee schedule,^25-27 while outpatient services billed under an APP's own National Provider Identification number (NPI) are generally reimbursed at 80%–85% of the physician fee schedule. Specific Medicare criteria must be met, however, for “incident to” billing.

To qualify as incident to, a service must be:

1. Part of the patient's normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment;

2. Commonly furnished in a physician's office or clinic;

3. An expense to the physician's practice;

4. Directly supervised by any physician from the practice; and

5. The APP must be paid by the physician's practice

At home services can also be billed as incident to under specific circumstances.

For hospital APPs, if the physician and the APP see the patient on the same day, APP billing is under the physician's NPI at 100% of the physician fee schedule. If not, then APP billing is under the APP's NPI at 85% of the physician fee schedule. For commercial payers, most require APP hospital billing to go under the physician's NPI.

As for compensation, APPs are typically compensated on a straight salary basis with a bonus option. APP employment also requires investments in overhead, including benefits. Fair market values for APP salaries within a specific region are available from several sources:

1. Department of Labor, Bureau of Labor Statistics: Occupational Employment and Wages^28,29

2. American Academy of PAs: Salary Report³⁰

3. American Medical Group Association: Advanced Practice Clinician Compensation and Pay Practices Survey³¹

CONCLUSION

As neurologists grapple with adaptation of present-day government rules and regulations, including different payment alternative models, in certain neurology practices new partnerships are developing between neurologists and APPs. The decision as to whether there is an advantage to integrating an APP into a practice is highly individualized.

AUTHOR CONTRIBUTIONS

S.B. Black: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data, statistical analysis, study supervision. S.B. Pearlman: drafting/revising the manuscript. C.K. Khoury: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data, study supervision.

STUDY FUNDING

No targeted funding reported.

DISCLOSURES

S.B. Black and S.B. Pearlman report no disclosures. C.K. Khoury has received publishing royalties from Uptodate.com. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.