Midlevel Providers in Orthopaedic Surgery: The Patient’s Perspective

Abstract

Background:

Midlevel providers (i.e. physician assistants [PAs] and nurse practitioners [NPs]) are being integrated into systems of care due to the exponentially increasing demand for orthopaedic care. There is a lack of studies which investigate orthopaedic patients’ perspectives regarding midlevel providers.

Methods:

An anonymous questionnaire was administered to 538 first-time patients of four orthopaedic surgeons before their new patient visit. Content included patient perspectives regarding: optimal scope of practice, midlevel provider importance in physician selection, and reimbursement equity with physicians.

Results:

Of 538 consecutive patients, 415 (77%) responded. 57% were female with an average age of 63.9 ± 11.4 years. Most patients (68%) considered the training background of the surgeon’s midlevel provider when initially choosing an orthopaedic surgeon. 34% of all patients perceived PAs to be more highly trained than NPs while 17% perceived the opposite. Patients had specific preferences regarding which services should be surgeon-provided: follow-up for abnormal tests (82%), initial postoperative appointment (81%), new patient visits (81%), and determining the need for advanced diagnostic studies (e.g. MRI) (76%). Patients had specific preferences regarding which services could be midlevel-provided: preoperative teaching (73%), minor in-office procedures (65%), long term postoperative appointments (61%), and prescriptions (61%). Patients lacked a consensus on reimbursement equity for midlevel providers and orthopaedic surgeons, despite most patients (78%) reporting the surgeon provides a higher-quality consultation.

Conclusions:

As health care becomes increasingly consumer-centric and value-driven, a databased utilization of midlevel staff will allow orthopaedic physicians to optimize efficiency and patient satisfaction. Surgeons may consider our results in division of clinical duties among midlevel staff since patients had specific preferences regarding which services should be physician-provided or midlevel-provided. Orthopaedic surgeons may also consider including the midlevel provider in marketing efforts, as most patients considered the midlevel provider’s training background when initially choosing a surgeon and perceived PAs to be more highly trained than NPs. Patients lacked a consensus towards reimbursement equity for orthopaedic surgeons and midlevels, despite reporting that the surgeon provides a higher quality consultation. These findings are important as the midlevel workforce grows in response to the rising demand for orthopaedic care.

Level of Evidence: IV

Introduction

As health care delivery paradigms evolve, midlevel providers (i.e. physician assistants [PAs] and nurse practitioners [NPs]) have become an important consideration in patient care and medical workforce planning. PAs and NPs are being increasingly integrated into orthopaedic systems of care due to the exponentially increasing service demand by the aging population.¹ Hence, the midlevel workforce continues to increase in size. From 2003 to 2014, the number of graduating NP students in the United States increased from 6,611 to nearly 18,500 annually.² The physician assistant workforce also experienced similar increases in size during this period.²

As the midlevel workforce continues to grow, so does the debate surrounding their scope of practice. This controversy centers on whether midlevel providers have adequate experience and training to administer high-quality patient care with minimal or no supervision by a physician.³ Orthopaedic NPs and PAs are also important as health care payment and delivery systems become increasingly consumer-focused and value-driven. In this context, orthopaedic surgeons must consider midlevel providers’ ideal role in optimizing patient satisfaction and clinical outcomes while maintaining efficiency and quality. This debate is ongoing amongst numerous medical specialties in the United States of America.⁴ Regardless of outcome, it will have significant implications for health care payors, providers, and patients.

Although previous studies have examined physician and nurse perspectives on midlevel providers,^5-7 there is a lack of studies on patient perspectives, especially regarding orthopaedic surgery. The objectives of the present study are to identify orthopaedic patient perspectives regarding midlevel provider: 1) optimal scope of clinical practice, 2) impact on care quality, and 3) importance in patients’ initial selection of their orthopaedic surgeon

Materials and Methods

Following Institutional Board Review approval (ORA# 16121907), an anonymous survey was administered to 538 consecutive patients prior to their first clinic appointment with four orthopaedic surgeons. In order to minimize patient bias from evaluation or treatment, all patients who agreed to participation completed the questionnaire prior to their initial clinic visit.

The first section of the survey regarded demographic information (age, gender, health insurance type) and patient perceptions of any differences in training level between NPs and PAs. The second section focused on the optimal scope of clinical practice for orthopaedic midlevel providers. Respondents were presented a clinical service (e.g. “initial postoperative appointment”, “minor in-office procedures”, “long-term postoperative appointments”, etc) with answer options of “Should be provided by orthopaedic physician only” or “Can be provided by either orthopaedic midlevel provider or physician”. The third section examined patient perspectives of midlevel provider: supervision during procedures, reimbursement equity with physicians for the same services, and importance when initially selecting their physician. The final section assessed patient perspectives towards how orthopaedic care quality may be affected by the growing midlevel workforce. Survey contents were generated based on the authors’ experiences and previous similar studies.^5,7 Patient responses were calculated for each item.

Results

Of 538 consecutive patients given the questionnaire, 415 (77%) completed the survey. For participating patients, response rates for each item ranged from 98% to 100%.

Figure 1 contains demographic data of respondents. There was a majority of female participants (57% female versus 43% male). Most patients had private health insurance (54%) and a mean age of 63.9 ± 11.4 years (mean ± standard deviation). Over half of the patients (53%) perceived a difference in PA and NP training levels, with 34% of total patients perceiving PAs as more highly trained and 19% of total patients perceiving NPs to be more highly trained.

Figure 1.

Respondent demographics and perceptions of training differences between nurse practitioners (NPs) and physician assistants (PAs).

Figure 2 lists patients’ general views towards midlevel providers. Most patients responded that the surgeon’s midlevel provider is an important consideration when: 1) initially choosing an orthopaedic surgeon (67%), and 2) referring their orthopaedic surgeon to family or friends (71%). 77% of respondents perceived that the orthopaedic surgeon offers a higher-quality consultation and exam than a midlevel for the same clinic visit type. Most patients A (84%) reported that the orthopaedic surgeon should remain in the operating room while the midlevel provider assists with operative exposure and closure. Patient responses varied regarding whether orthopaedic surgeons and midlevel providers should receive equal reimbursement for providing the same type of clinical service.

Figure 2.

Orthopaedic patient perspectives regarding midlevel providers. Participants were surveyed regarding their level of agreement or disagreement with each statement, with the choices being “strongly agree”, “somewhat agree”, “neutral”, “somewhat disagree”, or “strongly disagree”. Responses were then combined under the “Agree”, “Neutral”, or “Disagree” categories, respectively.

Figure 3 refers to midlevel providers’ scope of practice, with specific consideration on whether patients prefer certain clinical services be provided by the orthopaedic physician only or either the orthopaedic physician or midlevel provider. Patients preferred that some services be provided by the orthopaedic physician only, including: follow-up regarding abnormal test results or imaging (82% of patients), the first follow-up appointment after surgery (81%), and the initial clinic appointment (new patient visit) (81%). Patients also reported that certain services could be provided by either the orthopaedic physician or midlevel provider, such as: preoperative teaching (73%), minor in-office procedures (65%), long term postoperative appointments (61%), and prescriptions (61%).

Figure 3.

Midlevel providers’ scope of practice in orthopaedic surgery. Survey participants were asked “In an orthopaedic clinic, who should provide…?” with each respective clinical service subsequently listed. Response options were “Should be provided by orthopaedic physician only” or “Can be provided by either orthopaedic midlevel provider or orthopaedic physician.”

Figure 4 pertains to the potential impact of midlevel providers on orthopaedic care quality. Most patients reported that utilization of midlevel providers can improve timeliness of care (66% of patients), efficiency and cost-effectiveness (61%), and health care costs (60%). Patient perceptions varied regarding midlevel providers’ impact on patient outcomes and effectiveness.

Discussion

An understanding of orthopaedic patient perspectives towards midlevel providers is growing in importance. Our findings are relevant as the midlevel workforce grows in response to the rising demand for orthopaedic care. First, midlevel provider training backgrounds and credentials are important considerations to patients when initially selecting an orthopaedic surgeon, as is their experience with the midlevel when recommending their orthopaedic surgeon to family and friends (Figure 2). However, responses varied regarding perceived training levels and expertise of NPs versus PAs (Figure 1). Second, patients had distinct preferences regarding clinical services that should be physician-provided and those that could be provided by either the orthopaedic physician or midlevel provider (Figure 3). Third, patients reported that the orthopaedic physician could provide a higher quality consultation and exam than the midlevel provider. However, there was no consensus regarding reimbursement equity for physicians and midlevel providers performing the same services (Figure 2). These results are useful as orthopaedic surgeons seek to balance quality, efficiency, and patient satisfaction in the setting of an increasingly consumer-focused and value-driven healthcare system.

Previous studies have investigated factors considered by patients when selecting a new orthopaedic physician.^8-10 Although all studies found the physician’s credentials and training background to be among patients’ most important criteria, none examined the training background of the midlevel provider as a selection criterion. Our patients considered the midlevel provider when initially selecting their orthopaedic surgeon (Figure 2), but perspectives were varied regarding perceived training differences between PAs and NPs (Figure 1). Over half of patients (54%) perceived one to be more highly trained, with 34% of all patients perceiving PAs to be more highly trained and 19% of all patients perceiving NPs to be more highly trained. The training of PAs and NPs differs in duration and extent, as does their process for credentialing and licensure. Both usually require a prerequisite bachelor’s degree. PA-C (physician assistant-certified) licensure by the National Commission on Certification of Physician Assistants (NCCPA) requires completion of an accredited PA-C master’s program, which are usually 3 years in duration. CNP (certified nurse practitioner) licensure by the American Academy of Nurse Practitioners (AANP) typically requires clinical experience as a registered nurse (RN) and subsequent completion of a doctoral or master’s nursing program. Several program types exist (e.g. Adult Nurse Practitioner [ANP-BC], Master’s of Science in Nursing [MSN], etc), and all are considered an Advanced Practice Nurse (APRN). These programs are 2 years or more in duration. Maintenance of PA-C certification includes a mandatory recertification examination every 10 years, while maintenance of NP certification occurs in 5-year cycles but does not necessarily require a recertification examination. Guidelines regarding midlevel providers’ scope of clinical practice and physician supervision are established by each state’s medical board.^11,12

Patients were notably neutral (37%) regarding reimbursement equity for orthopaedic physician and midlevel provision of the same clinical services (Figure 2). Interestingly, the percentage of patients (38%) opposing reimbursement equity (presumably favoring higher reimbursement for orthopaedic physicians than midlevel providers for a given clinical service) is inconsistent with the percentage (77%) who reported that the orthopaedic physician provides a higher quality consultation and exam (Figure 2). Our findings also suggest patients do not believe that increasing the orthopaedic midlevel workforce will have an effect on patient safety or outcomes, but may improve cost-efficiency and timeliness of care (Figure 4). Previous studies on primary care patients demonstrated lower diagnosis and management expenditures for NP patients compared to patients assigned to a primary care physician (PCP), with similar satisfaction scores.^13,14 Studies have also considered whether increasing the midlevel workforce size while offering equal reimbursement as physicians would negate the current savings from their current disproportionately lower reimbursement.⁷ Additional studies regarding the economics and division of the workforce between physicians and midlevel providers are necessary as society seeks potential cost savings by expanding midlevel providers’ scope of clinical practice.

Patient preferences were notable regarding which services should be provided by an orthopaedic physician only and which could be provided by either the midlevel provider or orthopaedic physician (Figure 3). Patients strongly preferred physician-only provision of: follow-up regarding abnormal test results or images (82%), the first postoperative appointment (81%), the initial clinic visit (81%), and ordering advanced diagnostic studies (e.g. MRI) (76%). Conversely, patients were most amenable to midlevel providers offering: preoperative teaching (73%), minor in-office procedures (e.g. pain injections) (65%), long-term postoperative appointments (months/years) (61%), and prescriptions (61%). Most patients (84%) responded that the orthopaedic surgeon should remain in the operating room while the midlevel provider assists with operative exposure and closure (Figure 2). Additional studies are needed regarding patient preferences on disclosure regarding each team member’s role in the operating room, especially which operative steps are performed without the surgeon present. We are unaware of other studies regarding orthopaedic patient preferences towards clinical service provision by the orthopaedic surgeon or midlevel provider. A study of primary care patients found appointment availability to be most important in patients’ willingness to receive care from a midlevel provider.¹⁵ Another 2012 review of midlevel provider independent procedure billing of Medicare found that NPs and PAs independently billed for over 4 million procedures, with radiographs and joint injections being among the most common.¹⁶ Although our results suggest patients are amenable to receiving these clinical services from a midlevel provider, other authors have expressed concerns regarding these independent billings for diagnostic radiographs in the context of the inherent liability and difficulty in their interpretation.¹⁶ Patients also strongly preferred to see the surgeon at the first postoperative visit (81%), which is often provided by a midlevel provider since it is within the “global period” for billing purposes. Further studies regarding patient perspectives towards the global billing period and provision of clinical services may also be useful.

Midlevel providers’ scope of clinical practice is also interesting in the context of orthopaedic care, as medical groups and hospitals often advertise orthopaedic clinics which may be primarily staffed by orthopaedic “providers” with variable training backgrounds (orthopaedic surgeon, family practice physician, doctorate of nursing practice, orthopaedic nurse practitioner, etc). While our patients sought care from orthopaedic surgeons, the general public may be unaware of differences in provider qualifications. One 2008 study from the American Medical Association found 40% percent of the general public incorrectly believed a doctor of nursing was a medical doctor.¹⁷ Legislation which mandates all provider types clarify their qualifications and degree may be beneficial to orthopaedic patients in considering their provider’s recommendations. Regardless, our results highlight those services which patients are most amenable to receiving from the midlevel, thereby allowing the orthopaedic surgeon to focus on clinical services that patients prefer to receive from the physician only.

Our study had potential limitations. First, survey patients were from one private practice in an urban setting. Therefore, the study findings may not represent all orthopaedic practice types and geographic regions. Second, although study participants were patients of four orthopaedic surgeons, all responses were obtained prior to the initial clinical visit in order to minimize bias from assessment, treatment, or the clinic visit. Third, obtaining additional demographic data with which to stratify our results may have allowed determination of patient characteristics which drive preferences regarding physician and midlevel involvement in their orthopaedic care. However, this is outside the scope of our investigation, which was to assess patients’ perspectives of midlevel providers in their orthopaedic care. Future studies could acquire data from academic and private orthopaedic practices in various locations for greater generalizability.

Conclusion

As health care becomes consumer-centric and value-driven, understanding patient perspectives on midlevel providers will allow orthopaedic surgeons to optimize quality, patient satisfaction, and efficiency. Our study suggests that the midlevel provider influences patients’ selection of an orthopaedic surgeon and referrals of family and friends. Patients preferred that certain clinical services be provided by the orthopaedic surgeon only, but were amenable to others being provided by either the orthopaedic physician or midlevel provider. Patients lacked a consensus towards reimbursement equity for physicians and midlevels providing the same clinical service. These findings are important as the midlevel workforce grows in response to the rising demand for orthopaedic care.