For years, advanced practice nurses (APNs) have acted as hidden providers, generating revenues for physician employers following “incident-to” billing guidelines. Historically, it may have been a logical business practice and even mandatory at a time when physicians were required to countersign orders by nurse practitioners (NPs) or be physically present when NPs saw patients. However, these conditions of practice are no longer the case in the majority of states where APNs have the legal right to practice independent of a physician.
Today, using APNs as independent providers can create new opportunities for physician offices. These clinicians enable long-term and tertiary care facilities to grow revenue, lower costs, and improve patient outcomes.
Enhanced profitability
Incorporating NPs as independent providers can initially boost revenue by increasing the number of patients that can be seen in a practice. Whether viewed as a fortunate or unfortunate state of affairs, our current healthcare system is based on how many patients we see every day, how much time we spend with each patient, and what the per visit cost is for a practice. Using NPs as independent providers releases their physician counterparts from being physically present when the patient is seen, thus allowing physicians to enhance their productivity.
Although incident-to billing reimburses physicians 100% of the allowable amount, it requires that the physician be present in the office, see the patient at his or her first visit, and then continue to see the patient on an ongoing basis. Independently credentialed NPs can free a physician from this obligation, significantly increasing the total number of patients seen. For example, a study conducted in a large HMO setting found that adding an NP to the practice could virtually double the typical panel of patients seen by a physician. The projected increase in revenue was $1.28 per member per month, or approximately $1.65 million per 100,000 enrollees per year.1
The benefits yielded from this aren't only an increase in the number of patients seen during clinic hours, but an increase in available time to allow the physician to address serious acute illnesses or expand services to other sites. For instance, since incident-to billing only allows for office visits, having NPs as independent providers can add home visits to the services a clinic can offer and increase the profitability of having NPs in your practice.2
Physicians who've worked with NPs are likely to agree that hiring an NP would attract new patients to a practice and increase a physician's time for activities other than patient care.3 It's essential to the future of healthcare delivery that physicians and NPs work together as a team, as their efforts are complementary, not competitive. Collaborative practice models can enhance both the quality and cost-effectiveness of healthcare.3
It's also true for hospitals where NPs can independently see the patient and bill, and seek collaboration with specialists as indicated. At a time when an aging population with chronic illnesses can overwhelm a hospital staff, NPs can provide relief for hospitals already short of internal medicine specialists at a significantly reduced cost to the facility.
Patient satisfaction
In addition to new patient visits, it's also important to ensure patient return visits, especially now that many health plans allow individuals to move freely between approved providers. Retention of patients is often associated with their satisfaction with a given practice and quality of care. If their concerns are addressed and patient care is a priority, chances are they'll be back next time they need treatment. Research has shown that NPs appear to have better communication, counseling, and interviewing skills than physicians, and that malpractice premiums and rates support patient satisfaction with NP care. Additionally, NPs score higher on patient satisfaction surveys, not only for care provided but for interpersonal skills.4
Research has also detailed that having an NP as part of a care team attracts new patients that report a higher degree of satisfaction with services, and that an NP's patient is more compliant than a physician's patient in keeping appointments. Nonetheless, physicians have argued against employing NPs because of reduced reimbursement rates. Independent NP providers traditionally receive only 85% of the reimbursement rate of physicians versus 100% for incident-to billing. However, this 15% difference becomes almost irrelevant considering the cost savings realized by employing an NP as an independent provider.
By employing NPs in the independent role, healthcare offices and facilities can improve health promotion and risk-reduction activities, which are sought by HMOs and comprise the basis for the emerging paradigm of health promotion/risk reduction in healthcare. Moreover, investigators have found that NPs often provide higher quality care in many areas including the amount or depth of discussion regarding child healthcare, preventive health, and wellness; amount of advice, therapeutic listening, and support offered to patients; completeness of history and follow-up on history findings; completeness of physical examination and interviewing skills; and patient knowledge of the management plan given to them by the provider.5
Reach your potential
Because NPs come from a nursing background, they don't always advocate for themselves well. Their tendency is generally to “look for a job” instead of seeking a position where they fully use their skills. NPs practicing as physician “substitutes” risk professional survival.6 Therefore, it's incumbent upon NPs to discuss the legal scope of practice, the contributions they've made to healthcare systems, and what their actions mean to improved quality of life and patient outcomes.
Many NP curriculums don't include negotiations for positions or emphasize the business of healthcare. In addition, medical curriculums don't always include information on complementary providers and their scope of practice. Future education models should focus at least some attention on these issues to enhance mutual understanding among professions and show the multitude of ways healthcare providers can work together.
Fulfill your goals
Hiring an independent NP provider is an advantageous way to grow a practice in a cost-effective manner. If your facility's goals revolve around increased revenue, improved patient outcomes, increased patient satisfaction, recognition of services rendered, and compensation for services performed, including an independently credentialed NP as a practice partner might be the answer.
REFERENCES
1. Burl J, Bonner A, Rao M. Demonstration of the cost-effectiveness of a nurse practitioner/physician team in primary care teams.
HMO Practice. 1994;8(4):156–157.
2. Self D. Nurse practitioners are beneficial resource for house calls, nursing home visits. 2006.
Available at:
http://www.geri.com/geriatrics/article/articleDetail.jsp?id=385588. Accessed May 1, 2007.
3. Aquilino M, Damiano P, Willard J, et al. Primary care physician perceptions of the nurse practitioner in the 1990s.
Arch Fam Med. 1999;8:224–227.
4. Office of Technology Assessment.
Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives: A Policy Analysis. Washington, DC: US Government Printing Office. 1986.
5. Prescott PA, Driscoll L. Evaluating nurse practitioner performance.
Nurse Pract. 1980;1(1):28–32.
6. Brush B, Capezuti E. Professional autonomy: essential for nurse practitioner survival in the 21st century.
J Am Acad Nurse Pract. 1997;9(6):265–270.
