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How you use midlevel providers in your practice depends on your unique patient population, your practice’s preferences, and your state’s laws, says Darrell Schryver, DPA, principal with the Healthcare Consulting Group of the Medical Group Management Association (MGMA) in Englewood, CO. Each state has different regulations about what midlevel providers can do and the amount of supervision they require, and each practice should decide what would work best for it, Schryver adds.
"There is no set protocol for using midlevel providers. Each group has to establish its own protocols and clearly define which patients must see the physician and who can initially be screened by a physician assistant or nurse practitioner," Schryver says. For instance, at Dean Medical Center, a multispecialty group practice in Madison, WI, primary care physician assistants handle everything from well-care examinations to acute illnesses and injuries to chronic disease management, says Lou Falligant, PA-C, a physician assistant with more than 25 years of experience.
At Dean Medical Center, physician assistants in cardiovascular surgery and general surgery are strictly hospital-based. They assist during surgery and manage postoperative patients. Dean’s orthopedic physician assistants work predominantly in the hospital setting, assisting with surgery and postoperative care. In addition, 25% of their practice is in the clinic, where they see surgical follow-ups and outpatients and conduct simple consults. The practice’s neurology physician assistants see a subset of clients, including patients with seizures, multiple sclerosis, and headache. These PAs have a strong educational role.
The physician assistants at East Albany (GA) Medical Center perform the majority of the routine health screenings, women’s health checks, and other procedures, leaving physicians free to take care of the more complicated, sicker patients. The clinic has 10 physician assistants and 18 physicians. For instance, by the time a physician has finished hospital rounds, the physician assistants already have made a dent in the day’s patient load. They also assist in the hospital but typically do not make rounds. "We are more effective working with the outpatients," Malcolm says.
At East Albany Medical Center, almost all the clinics are directed by a physician assistant, freeing the physicians to spend more time on clinical care than on managerial duties. Falligant’s duties at Dean Medical Center include a combination of administrative and clinical roles. He works in family practice, seeing patients on a fill-in basis for physician assistants who are gone for the day. Most of his time is spent in administration, performing work similar to that of a medical director. "I do troubleshooting, such as dealing with staffing problems or personality conflicts, all the things a medical director would be involved in," Falligant says.
He recruits and conducts orientation of new physician assistants and handles practice management projects. "I monitor patient counts and productivity and compile the data so people can see where they stand in relation to their peers," Falligant says.
Allina Medical Center in Forest Lake, MN, gives its physician assistants the ability to choose what procedures they are comfortable handling, says physician assistant Beverly Kimball, PA-C. For instance, one of Kimball’s physician assistant colleagues prefers not to do certain procedures with male patients, so schedulers make sure men don’t get put on her schedule. Kimball works on the same schedule as the physicians and has 15-, 30-, and 45-minute slots for patients. She reserves 45 minutes for an adult physical as opposed to the 30-minute slot physicians typically use.
At Bristol Street Pediatrics in Elkhart, IN, nurse practitioners see patients with simple illnesses who are at least six months old. After six months, nurse practitioners perform every other physical examination for the child. "It’s been really well-received by our patients. A lot of them would rather see a nurse practitioner than a doctor," says Anne Meden-Cutler, administrator. The nurse practitioner visits are scheduled with 10 minutes more time than physician visits.
When parents call the office, the calls either go to the front desk or to the telephone nurse who screens the calls. If the children are over six months old and have a simple illness, they are offered an appointment with a nurse practitioner. If they are younger than six months, the call goes to the telephone nurse, and a visit is scheduled with a physician. If patients don’t feel comfortable with a nurse practitioner, they can see the doctor.
Well-children examinations are often scheduled two months in advance with physicians. The nurse practitioner can usually see a patient for a well-child exam in one or two weeks.<