Playing a Primary Role
Six years ago Crystal Page, a certified Physician Assistant, was working in medical billing, thinking about her future in healthcare, and noticing a trend.
“I could see that the doctors around me were always working and it seemed like the PAs had a little more time for their families,” says Page, who had wanted to be a pediatrician when she was in 4th grade. But, after she married while still in college, she decided that the faster track of a PA suited her better than medical school. “PAs have a professional healthcare career just like MDs and Dos, but they always have someone to turn to when they have a question,” she says.
Today, Page is the one-and-only provider at the Buffalo Regional Medical Clinic, a do-it-all primary care clinic serving the 350 residents of Buffalo, South Dakota in the state’s Northwest corner, 85 miles from the nearest hospital. Page’s attending physician makes the 70-mile trek from Belle Fourche to visit the clinic every three months and the two have one-on-one contact once a month. Beyond that, with the exception of the clinic receptionist, Page is largely on her own.
“It is great to be a PA in a small town,” she says. “I think I see greater diversity of illnesses out here. A lot of people in my community are unwilling to travel, even if the weather just looks bad. So we kind of have to stay here and just figure it out.”
Many of the 227 other South Dakota PAs working in primary care – often in the state’s smallest communities – are undoubtedly doing the same thing.
What’s in a Name?
Whether they are called Midlevel Practitioners, Advanced Practice Providers (the term preferred by Sanford), Advanced Practice Clinicians (Regional’s choice), Advanced Practitioners, or simply ‘Midlevels’, there is no doubt that their role – both in primary and specialty care – is growing along with their numbers.
As of December 2013, there were 1651 APPs working in South Dakota – 530 Physician Assistants and 1121 Advanced Practice Nurses, which include Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Clinical Nurse Specialists (CNSs) and Certified Nurse Midwives (CNMs).
“The number of APPs is growing not only because the population is growing, but also because we can’t recruit physicians fast enough,” says Sanford’s Chief Medical Officer Dan Heinemann, MD, president of the South Dakota State Medical Association.
A quick look at the numbers makes it clear why this is. The Association of American Medical Colleges predicts that the country will be 90,000 physicians short by the year 2020. Already, hospital executives are reporting a nationwide vacancy rate for clinical professions of 17.6 percent in 2013 – up from 10.7 percent just four years ago (Source: AMN Healthcare 2013 Clinical Workforce Survey). Physicians were reported to be the most difficult professionals to recruit, followed by nurses, nurse practitioners and physician assistants.
The shortage means that current physicians are often over-extended in terms of patient load. In addition, most are embroiled in trying to meet new guidelines and demands that leave them even less time for patient care. In many clinics, APPs are helping to ease some of the burden by providing follow-up patient care, rounding on hospital patients, assisting in the office or the OR, taking patient phone calls, etc.
“The care of the future is going to be less about individual care and more about populations or group care,” explains Heinemann. “As we transition from taking care of disease to managing populations to maintain their health, there will still be a need to see a sore throat or a sprained ankle or a complex diabetic, but having members of the team who can take care of multiple levels of complexity will be very helpful.”
In many cases, APPs like Page make healthcare possible in places such as Buffalo where it might not otherwise be provided. It is increasingly difficult to recruit physicians to work in communities that have no hospital.
Supporting the Team
For Jerry Schrier, PA-C, healthcare is a second career. The Sioux Falls PA left newspaper journalism after he found himself doing more managing than writing. Now at Avera Medical Group Nephrology, Schrier is one of the145 South Dakota PAs working in a subspecialty area. By seeing complex dialysis patients on a regular basis, Schrier provides his 5 physician colleagues with the freedom to concentrate on more acute problems.
“The physician can only be in one spot at a time,” says Schrier. “But these dialysis patients have complex medical histories and issues that need frequent attention. These patients are labor intensive in terms of their medical needs and our nephrologists are very busy people. I see many of these patients three times a month.”
“What Jerry does for us is invaluable, on many levels,” says Schrier’s colleague, nephrologist Arvin Santos, MD. “We utilize our midlevel the way we might use a resident. That is how we train them and they need to be on that level. Jerry has really become our right arm.”
Schrier says his relationship is slightly different with each of the five doctors he works with and, while he sometimes has to remind himself which doctor prefers which kind of support, he has no doubt about his value in the clinic.
“All of this is being driven by patient care,” says Schrier. “As healthcare changes, there are more and more requirements being put on MDs, which is taking time away from caring for their patients. This opens a whole market for PAs and NPs to fill. If you have a patient with a complicated medical history and they can be seen more often, that is a good thing. It’s all about frequency.”
The frequency of visits made possible by having a PA on staff is not just good for patients; It’s also good for business. With Schrier on board to see dialysis patients multiple times a month, the clinic can meet the four-times-per-month level required by Medicare for maximum billing.
“Dialysis patients are chronically ill and on life-sustaining therapy,” says Dr. Santos. “You need to see them quite frequently because of how sick they are, but our practice is so busy that it is practically impossible for us to see them four times a month. Medicare allows us, as physicians, to see the patients at least once a month if a midlevel sees them the other three times. From a revenue standpoint, the difference between one visit and four visits is almost half of the maximum billing.”
While busy doctors like Santos welcome the help of an APP – even calling him or her their “right hand” – not everyone is happy about the increasingly central role of midlevel providers in patient care. And, although Dr. Santos says relationships between physicians and midlevels are generally good, tensions do sometimes arise, especially in cases where the non-physician provider has more experience than the physician with whom he or she is working.
“For instance, nurses who become NPs tend to be very smart, very driven. Most have done specialty work,” says Santos. “They might say, ‘That’s not how we did things in the ICU.’ And that can rub a younger, more headstrong physician the wrong way. But I’d say that, 95% of the time, we all do really well together.”
“Some physicians are very adamant that they don’t want their patients treated by someone with less medical education than a physician. That’s one extreme,” says Larry Sellers, MD, an Internal Medicine physician at Mercy Medical Center in Sioux City, Iowa. Sellers and his partner have a part-time PA on whom they both rely.
“On the other end of the spectrum are physicians who want to hire as many midlevels as the law will allow because they can double or triple the amount of revenue going through their office.”
“Most of us are somewhere in the middle,” he says.
Ultimately, both Sellers and Santos say that the keys to successful and patient-benefitting working relationships are mutual respect and trust. “If the trust isn’t there, the relationship is not going to work,” says Santos. “My PA was a medic in Iran,” says Dr. Sellers, as an expression of the trust he puts in his own PA. “He saw a lot more trauma than I have ever seen in my life. So he is my go-to guy for that kind of thing.”
“There is always going to be some contention,” concedes Dr. Heinemann. “Some APPs say ‘We can replace primary care physicians’ which can make physicians bristle.” But Heinemann says, in his experience, relationships between midlevels and physicians tend to be even better in the Plains states than they are elsewhere in the country, largely because of the needs in rural communities.
“Physicians from the Midwest who know how critical APPs are to providing care, especially in the rural communities, sometimes shake our heads with some of our ‘big city’ colleagues who say ‘Why are you letting them do that? They shouldn’t be doing that!’
Don’t tell that to a resourceful and independent PA like Crystal Page or to the residents of Buffalo who depend on her services. “Healthcare is just not growing as quickly as the population,” observes Page. “We are growing and we are aging and someone is going to have to pick up the slack.” As ICD-10 threatens to slow down productivity in medical offices across the country, Page says she would not be surprised to see more people seeking care from midlevel providers in smaller clinics like hers, which may be able to offer perks like sooner appointments.
“The reality is that healthcare is going to be delivered, more and more, by non-physicians,” says Dr. Sellers. “As a profession, we can either stay committed to the belief that they are not as well-educated and can’t sort through the nuances and complexities at the same level as physicians. Or we can face reality and realize that they are critical to providing healthcare opportunities to our patients.”
“We know that their role is going to expand. We just don’t know exactly how,” agrees Heinemann. “I believe that APPs have a significant role to play in the future of team-based healthcare and physicians need to be open to working with them. There is no question that our patients are better served when we work together.”