This topic is probably not high on the list of items to worry about when entering into a new employment agreement, but I have seen it cause endless hassles and irritation to new physicians after starting a new position.
Recent Developments in “Midlevel” Providers
I will first note that NPs and PAs don’t favor being called “midlevel” providers. So, I tend to call them practitioners or non-physician providers (NPPs). Most physician-owned practices and hospital based groups have been hiring physician assistants and nurse practitioners for two primary reasons:
- hiring a physician is a long, difficult, competitive process,
- it is much less expensive to hire NPPs.
The number of PAs is projected to grow by about 40% in the next 4 years. But the number of jobs posted is growing by about 50% per year! The growth in NP positions is growing at a slightly lower rate.
As I recruited and deployed NPPs for my previous employer, I observed the following questions arising:
- will an NPP need direct supervision, and if so, for how long?
- what kind of ongoing supervision and review will they need?
- who will perform chart reviews for quality improvement purposes?
- if the NPP will need a period of training (either due to being a new graduate, or because she is switching to a different specialty area), who will provide the training and for how long?
- is it appropriate to have a newly trained physician supervising and training a new NPP (most new physicians will need a period of time to become more efficient themselves)?
- how should our physicians be compensated for the additional time and energy needed to train and/or supervise an NPP?
Even in an era where NPs are being allowed to practice independently in some states, most hospital systems and physician groups will want the additional quality achieved by having their NPPs collaborate with a physician. And working with an NPP has the following impact on collaborating physicians:
- they must be available for consultation directly or via text or telephone any time the NPP is working;
- their liability may be increased because they are legally responsible for actions of their NPP(s) and will be named in a lawsuit involving their NPP(s);
- when training a new NPP, the physician’s productivity will definitely be reduced, thereby possibly affecting any compensation that depends on personally performed wRVUs;
- there is a psychological drain involved in collaborating with other practitioners in this manner, magnified when multiple collaborative agreements are in place.
In an effort to increase productivity, it is not uncommon to ask a physician to supervise multiple NPPs. In some cases, state law restricts the number of NPs and/or PAs that are allowed to be supervised. But the higher the number of supervisory relationships, the more psychological, temporal and interpersonal resources that will need to be expended.
I have seen several models of compensation used for physicians collaborating with NPPs. If the collaborating physician directly benefits from the collaboration, then the existing compensation formula will not need to be changed. For example, if a surgical specialist receives compensation based on wRVUs and is likely to be able to personally see more patients and perform more surgery, then there is no need to adjust the basic compensation formula. This is similar to the situation in a private practice wherein the physician owners benefit directly by increasing the volume of patients at a lower expense than hiring a new physician, even taking into account the additional salary of the NPP.
Similarly, if a physician is paid a salary that does not change even if patient volumes are reduced when training or supervising an NPP then no adjustment will be needed.
However, if wRVUs go down, or if additional time will need to be devoted to training and supervising an NPP, then additional compensation will be required. The supervision becomes an administrative function that should be compensated.
Some groups use a model in which supervisory duties are assigned a dollar amount per year, such as $5,000 per year. Then the group pays the physician that amount for each collaborating agreement in place, and caps the number that will be allowed.
A unique challenge can arise when a PA or NP is placed in a remote urgent care clinic as a way to promote outreach to under-served communities. In order to supervise such an NPP, if patients of all ages are being seen, then the collaborating physician should have the same skills and/or privileges. This may, in fact, be a requirement of insurance payers, hospital medical staff or the physician’s liability insurance carrier. In that situation, you would need a Family Physician or Emergency Medicine physician to provide collaboration. But some systems do not have enough of those specialists to cover the rapidly expanding volume of NPPs (i.e., the system is deploying many NPPs in a network of outlying clinics). The system may then use a combination of general internists and pediatricians to provide collaboration. This leads to further complexities in designing a plan to divvy up budgeted supervision dollars.
Taking into consideration the issues discussed above, a compensation plan might be tiered in the following way:
|Collaboration and Training||$$||$$$|
Under this plan, it is understood that in addition to the supervision, the responsible physician will be performing a formal review of a certain number or percentage of each NPP’s charts for quality of documentation and care, and use of approved protocols. And the collaborating physician is paid more for supervision and training a new NPP.
As an NPP moves from novice to experienced, or from remote to direct (on site) supervision, the amount of compensation for the collaboration would be decreased to the appropriate level. Each $ above could represent a payment to the supervising physician of $2,000 to $5,000 per NPP per year. This is just a guideline, since I have not seen any surveys that list the typical payments being made to collaborating physicians.