Practice Economics

NPs, PAs Vital to Hospital Medicine


Yes, it’s time for another “year ahead” type column where the writer attempts to provide clarity on future events. What does “Hospital Medicine 2016” hold for us? I hope by the time Hospital Medicine 2017 rolls around, everyone will have forgotten the wrong predictions and only remember those that reveal my exceptional clairvoyance and prescient knowledge.

NP and PA Practice in Hospital Medicine Will Continue to Grow

Well, it doesn’t take a crystal ball or tarot cards to predict this. One only has to look at the data. The 2012 State of Hospital Medicine report revealed that 51.7% of hospital medicine groups (HMGs) employed nurse practitioners (NPs) and/or physician assistants (PAs) in their practice. Two short years later, the survey showed 83% of HMGs reported having NPs and/or PAs in their groups. That is an astounding amount of growth in a short period of time, which brings me to my next prediction.

Tracy Cardin

Tracy Cardin

HMGs Will Have to Continue to Figure Out How to Hire and Deploy NPs and PAs in Sensible Ways

I know that statement is very controversial. Not. But the true work of utilizing NP and PA providers in hospitalist practice is not in the hiring; it’s how to use these providers in thoughtful, sensible, and cost-effective ways.

A group leader really needs to know and understand the drivers behind the need for these hires as well as understand the financial landscape in the hiring. Are you hiring an NP/PA because you want to reduce your provider workforce cost? Are you hiring to target quality outcomes in a specific patient population? Are you hiring to staff your observation unit, freeing up your physicians for higher-acuity work? Are you hiring to treat and improve physician burnout? Or is this the only carbon-based life form you can attract to the outer boroughs of your northern clime in the deepest, darkest days of January?

All these may or may not be good reasons, but understanding those variables will help you get the right person for the right reason and will help you evaluate the return on investment and the impact on practice.

Diversity Prevents Disease

Much like the potato monoculture of McDonald’s french fries increasing the risk of potato diseases, monoculture in your hospitalist group may breed burnout and bad attitudes. Diversity of experience, perspective, and skill set may inoculate your group, keeping the dreaded crispy coated from complaining about schedule, workload, or acuity or, worse yet, simply leaving.

I don’t have data to support this, but I have heard anecdotally from more than one HMG leader that the addition of NP/PA providers to physician teams has improved physician satisfaction. SHM obviously agrees with this philosophy, as they value and support the value of a “big tent” philosophy. This big tent includes all types of people who contribute to the culture of this organization, making it stronger, more nimble and innovative, and definitely more fun.

Diversity in providers can only have a positive impact on your organization’s culture.

Whatever the Reason You Hire Them, Get Ready for Change

Be prepared for evolution. You may have initially hired an NP or PA simply to do admissions or to see all of your orthopedic co-management patients. But over time, your practice is going to morph and evolve, hopefully, in positive ways. Bring your NP/PA colleagues along for the ride; pull up a chair to the table. They may be able to provide new direction, support, or service lines to your practice in ways you hadn’t considered.

NP/PA providers’ abilities and ambitions will change over time as well. Make sure that change goes both ways. You may find that their influence and impact on your organization’s productivity and growth go beyond their industry. Consider utilizing NP/PA providers in novel ways; maybe they have great onboarding skills, are fabulous at scheduling, or can look at a spreadsheet without going cross-eyed or bald.

Change is growth. And growth is good. Unless you would rather die.

HM Needs to Develop Innovative Care Models; NPs/PAs Provide a Platform for Innovation

Inpatient medicine is changing in a rapid and unpredictable way. Some of the necessity of that work is driven by financial incentives and quality indicators, but necessity is the biggest driver of all. People, patients, and providers are getting old (thank God it’s not just me). There simply are not enough physicians to care for our rapidly aging population, or if there are, they are all employed in sunny Southern California. How we respond to this threat or opportunity is one of our most important charges. We own the inpatient kingdom. We need to lead with benevolence and thoughtfulness. We need to really look ahead and identify new ways to manage the complexity of a system whose complexity continues to mutate like some avian virus. I can’t see a future without a crucial role played by my NP/PA brethren. Can we begin this conversation with the long view in mind and really begin to own this in a true and responsible way?

Thanks for your attention, and remember, in 2017 you will have forgotten all the ways, if any, that I was wrong. TH

Ms. Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago and is chair of SHM’s NP/PA Committee. She is a newly elected SHM board member.

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