Recent research points toward a shortage of physicians over the next 10 years. According to a report prepared for the Association of American Medical Colleges, “physician demand continues to grow faster than supply, leading to a projected total physician shortfall of between 61,700 and 94,700 physicians by 2025.” Projected shortfalls in primary care range between 14,900 and 35,600, while projected shortfalls in non-primary care specialties range between 37,400 and 60,300.1
As more and more physicians reach retirement age and fewer enter the workforce, practices of all specialties will need to consider new methods of providing care. One way that practices can address this issue is by better utilizing clinical care staff to increase a practice’s productivity and to provide more patient-centered care.
Clinical staff can include medical assistants, scribes, medical students, registered nurses and nonphysician providers, such as physician assistants and nurse practitioners. By making sure that all staff are practicing up to their license, practices can better allocate clinical work and provide better care for patients, says Jessica Langley, MS, executive director of education and provider markets, National Healthcareer Association, Leawood, Kan.
Medical assistants
According to the Bureau of Labor Statistics, the employment of medical assistants (MA) is projected to grow by 23% between 2014 and 2024.2 “That’s well above the national average for growth of professions,” says Langley. “It’s really a growing field.”
Langley discussed ways that primary care practices can use medical assistants in her 2016 MGMA Annual Conference session, “Empowering Medical Assistants to Improve Primary Care.”
Langley says that one of the ways a practice can maximize the skills of MAs is to provide post-onboarding training, assessments and certification. By training them yourself, you can be sure of their ability to do the work, she explains.
Utilizing MAs can increase operational efficiency, improve employee and provider satisfaction, and enhance the level of patient care, says Langley. In a primary care setting, MAs can take on the role of health coach or care coordinator, which can take a burden off other clinical staff and provide a better experience for patients.
However, Langley acknowledges that there are several challenges in dealing with MAs, including a lack of standardization in training and scope of practice, a lack of professional acceptance and more resources required to train.
But Langley believes that the benefits of incorporating MAs into primary care outweigh the challenges. Some of the benefits she has seen include:
- Increased professional engagement/teamwork
- Increased practice/operational efficiency
- Increased patient load
- Higher patient engagement
- Reduced ER visits/re-admits
- Reduced no-show rates
- Increased employee and patient satisfaction
- Increased provider satisfaction
- Reduced error and patient injury
“[MAs], when implemented correctly, can really take a burden off of the physicians, allowing them to have a greater level of satisfaction with their work on a daily basis,” says Langley.
High Plains Community Health Center, Lamar, Colo., a rural health center in southeast Colorado, implemented a team-based model that includes training MAs as patient facilitators and incorporating a staff rotation, so that every staff member rotates through various roles in the office.
Since implementing the model in 2001, High Plains has increased provider productivity by 50%, saving nearly $500,000 per year. The practice has a three-to-one ratio of MAs to providers, and many of the MAs are also trained as pharmacy technicians and radiation technicians.
Langley emphasizes that MAs can take on a variety of roles within the practice depending on your practice needs. Just “make sure to check your state regulations,” she says.
Scribes
Medical scribes are another option for improving the workflow in your practice, according to Kyle D. Matthews, CMPE, MGMA Board member, chief executive officer, Phoenix Heart, Glendale, Ariz. Some of the benefits of using scribes? Speed, efficiency, increased patient volume and accuracy, says Matthews. “They’re fast. Well, they make the physician faster.”
Matthews led a session at the MGMA 2016 Annual Conference called, “Improving Medical Practices with APPs, Scribes and Medical Students.”
Scribes can also help increase the patient volume of your practice. “We had a four-month backlog for seeing a cardiologist at our practice,” he says. “We added a scribe and [one of our cardiologists] added four spots a day.”
Matthews points to the patient experience above all else for considering scribes. “Patients are happier when you have a scribe, if you are using them correctly,” he says. If the computer in the exam room faces away from the patient and the doctor is entering information into the computer, the physician is unable to give the patient his or her full attention. By incorporating a scribe, says Matthews, the physician is now focusing on the patient instead of the screen.
There are a couple of different ways to hire scribes. You can contract with a scribe service. “You don’t have to hire [the scribes], they’re not your problem,” says Matthews, and the company can provide a replacement if your usual scribe calls in sick.
You should also consider training your own scribes, says Matthews. Although this takes more time and resources, you can be confident that they are going to do their jobs the way you want them to. But make sure the people that you decide to train have the right temperament for the job, he says.
Is it worth training them? “If you are going to depend on scribes for your workflow, I would go with an external company,” says Matthews. “When they walk in the door day one, they have a basic understanding of what’s going on. If you hire or train, it’s going to take time to get them up to speed.”
How you pay for scribes depends on the situation. If just one physician is using a scribe, it may make more sense for the physician to pay for the scribe out of his or her reimbursement, which means a reduced management responsibility for the medical practice. However, if you include the cost of the scribes as part of the practice overhead, the practice could potentially use the scribe in other roles when the physician is out of the office.
Regardless, Matthews emphasizes the increased liability the practice will face when more people are interacting with the patient. “You now have an extra person in the mix that could get something wrong,” says Matthews.
According to a recent MGMA Stat poll, only 35% of respondents said they currently use scribes — either external or employed — in their practice. Ken Hertz, FACMPE, principal consultant, MGMA Health Care Consulting Group, says that generally using a scribe increases physician job satisfaction and improves productivity. “Research suggests that with a scribe, a physician can likely see five to eight more patients per day, generating approximately $105,000 in additional annual revenue – significantly more than the cost of the scribe plus benefits,” says Hertz. He suggests that practices take a serious look.
While scribes may help with productivity, it might not work out for every physician. “Not every scribe is going to fit every provider,” says Matthews.
Medical students
Matthews also recommends working with local medical schools and allowing medical students to work with physicians in the practice setting. Not only can medical students help the physician be more productive, they also allow for the physician to stay in touch with the profession and get involved in the community. “It’s a way for physicians to give back,” says Matthews. And physicians can learn from the students as well.
“If they are slowing down the provider then they’re probably not being managed right,” says Matthews. “Medical students can actually speed up your provider if it’s done in a coordinated way. They should be able to go into the exam room and really get some of the easiest stuff out of the way so that when the provider comes in they can work through the main things and not have to worry about some of the small things.”
If you decide to allow medical students into your practice, it is important to manage the access that medical students have, including HIPAA, information technology, OSHA, other protocols, as well as their schedules, says Matthews. They need to have training on all policies and guidelines. “You have to say, ‘Look, these people when they are in our office, they are acting as an agent of the practice,’” says Matthews.
Registered nurses
Jack Needleman, PhD, professor and chair, Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, points to registered nurses (RNs) as another member of the clinical staff that can “help take the burden off of doctors.” Needleman discussed the recent recommendations of the Josiah Macy Jr, Foundation on using RNs to transform primary care at a panel at the University of Colorado College of Nursing, Aurora, Colo.
One of the biggest hurdles according to Needleman is making sure practices are using RNs up to their license, rather than as MAs. “RNs can take the lead on managing patient care, which can help reduce the cost of care,” says Needleman.
For Thomas Sinksy, MD, internal medicine, Medical Associates Clinic, Dubuque, Iowa, RNs play a vital role in his clinical care team. The primary care clinic has three nurses per one physician. RNs gather information on patients, update records, go over preventive care, chronic illness management and medication reconciliation. “Then I, as the doctor, go back into the exam room with the RN and the RN presents the patient — similar to the way a resident doctor would present a patient to an attending physician — and we are able to have a three-way discussion as I do a physical exam and talk about a treatment plan,” explains Sinsky.
After Sinsky leaves the room, the RN stays with the patient to answer any questions the patient has and to help implement the treatment plan, while the doctor moves on to the next patient, who has been similarly prepared by an RN.
Malia Davis, ANP, director of nursing services and clinical team development, Clinica Family Health, Lafayette, Colo., has a similar setup at her clinic. The “co-visits,” as she calls them, allow patients to have a 45-minute visit, while only taking five to seven minutes of the provider’s time.
Financially, Sinsky says “co-visits” run by RNs make sense. “We see more patients and we are able to do more complex visits and preventive visits,” he explains.
Nonphysician providers
An increasing number of medical practices are incorporating nurse practitioners and physician assistants into their workflow as well, according to MGMA’s recent research and analysis report, and NPP integration may help to alleviate the projected primary care physician shortage if they are effectively integrated, according to the National Center for Health Workforce Analysis.
During her MGMA 2016 Annual Conference session, “Improving Quality and Lowering Costs with Advanced Practitioners,” Trish Anen, RN, MBA, NEA-BC, executive sponsor/co-founder, Center for Advancing Provider Practices, vice president, Advisory Services, Illinois Health and Hospital Association, Chicago, discussed the growing value of NPPs. Some of the benefits include improving patient experience, managing population health, reducing the cost of care and creating a satisfying practice environment.
Matthews agrees that there are definitely benefits to incorporating NPPs into a practice, especially when it comes to providing a team approach to care and increasing patient volume. “NPPs can help cover same-day and follow-up appointments, as well as provide additional services,” says Matthews.
“We’re at the tipping point now. We’re seeing nurse practitioners as one of the truly essential factors in being able to achieve the Triple Aim – kind of the secret sauce,” says Anen.
In many states, what NPPs are allowed to do is increasing – 21 states now allow nurse practitioners full practice. “We’re seeing more and more of a push toward that,” says Matthews.
“Many practices have nurse practitioners but many don’t know how to use them,” says Anen. If a practice is considering incorporating more NPPs or increasing their scope, Anen says there are few strategic considerations administrators should address:
- Consider credentialing, vetting and other processes.
- Define your models of care, who is doing what and why. (If you don’t define this, NPs end up doing RN work, which they are overqualified for.)
- Outline your workforce plan as well as retention and engagement policies.
- Consider team-based compensation, to ensure that your compensation is aligned so that everyone is working together, as opposed to “you’re stealing my RVUs.”
At Catholic Health Initiatives (CHI), Michelle L. Edwards, DNP, APRN, FNP, ACNP, FAANP, system vice president, advanced practice, Englewood, Colo., says they used NPPs to move toward a patient-centered primary care model. Rather than focus on volume, they moved toward a value-driven philosophy that focused on a team-based approach and made sure to utilize all clinical staff at top of license.
Most prominently, this allowed the practices to see significantly more patients. Before the transition, they had very few NPPs and the panel size per physician was roughly 2,500. After the transition their ratio was roughly 3 NPs to 1 physician, which allowed for a team panel size of at least 7,000 patients, says Edwards. This patient-centered model also allowed the practices to expand hours and open up access for patients.
Using NPPs is particularly useful in dealing with new patients. “We are definitely seeing more of that,” says Anen. “If the patient can’t see the physician for three months, they’re going to go somewhere else. The key is to make sure to introduce the patient to the entire team.”
Edwards agrees. “It’s about introducing the team to the patient and all of the members that make up the team so that it’s not a surprise to the patient,” she says. “This has been helpful when we’ve had bottlenecks in specialty clinics. NPPs are able to evaluate the patient’s needs before they see the specialists.”
When utilizing NPPs, it is also important to make sure you are billing correctly. Submitting NPP claims under the NPP’s own national provider identifier (NPI) is reimbursed at 85% of the fee schedule. To receive 100% of the fee schedule, the NPP can bill incident-to; however, the supervising physician must be in the office suite and readily available if assistance is needed and stay involved in the treatment plan.
Some practices that don’t currently use NPPs may be concerned that NPPs are not worth it financially; however, MGMA data shows that practices that utilize NPPs tend to perform better financially than practices that do not.
Conclusion
Regardless of your practice’s current setup, it may be worthwhile to re-evaluate the roles your clinical staff play in caring for patients. The primary question you should be asking according to Anen: “What is it that we really need so that everyone is working to top of credential?”
One tool that Langley recommends is the Primary Care Team Guide, created by the MacColl Center for Health Care Innovation at Group Health Research Institute,which includes a practice assessment and tools for better utilizing your clinical staff.
Using clinical staff can help your practice to see more patients without overworking your providers, which is beneficial both to patients and to your practice.
Notes:
1. Dall T, West T, Chakrabarti R, Iacobucci W. “The complexities of physician supply and demand: Projections from 2014 to 2025.” HIS Inc. Prepared for the Association of American Medical Colleges, Washington, D.C., 2016.
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