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/A>Mid-Level Providers in a Changing Healthcare=20 Workforce
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In the wake of healthcare reform, one thing is certain =E2=80=94 by =
2014, 32 million=20
additional Americans are going to have health insurance, and someone =
will need=20
to take care of them.
Who will provide medical care to millions =
of=20
newly-insured people? When Massachusetts made health insurance =
mandatory,=20
physician practices were overwhelmed by the increased demand. Many =
doctors=20
stopped taking new patients, and those who continued to accept new =
patients saw=20
waiting times for appointments lengthen significantly. Visits to =
emergency rooms=20
went up 7 percent, adding unanticipated costs to the program. To avoid =
repeating=20
this pattern nationally, physician practices and hospitals employing =
physicians=20
must proactively add capacity to treat large numbers of new patients.=20
Ideally, every new patient will have access to a primary =
care=20
physician they see on a regular basis to help them maintain good health =
and to=20
prevent unnecessary emergency room visits. But primary care physicians =
are=20
already in short supply. The American Academy of Family Physicians =
predicts a=20
shortfall of 40,000 primary care physicians by 2020. Moreover, the U.S. =
Bureau=20
of Health Professions projects a shortage of 109,600 physicians in all=20
specialties by 2020. Given the long timeframe required to educate new=20
physicians, it seems certain that mid-level providers =E2=80=94 =
physician assistants,=20
nurse practitioners, and others =E2=80=94 will be needed to fill the=20
gap.
Where are mid-level providers practicing=20
today?
Today, roughly 80,000 NPs and 30,000 PAs work in a =
variety of=20
settings around the country. They have traditionally provided care in =
rural and=20
underserved settings, where they work under the supervision of a =
physician who=20
may or may not be located in the same office or community. In these =
settings,=20
mid-level providers diagnose and treat a broad range of routine medical=20
conditions, referring the more complicated cases to the supervising =
physician.=20
In our modern healthcare marketplace, clinics located in pharmacies and =
other=20
retail locations are often staffed with mid-level providers serving in =
this=20
traditional role.
Over the last 30 years, roles of mid-level =
providers=20
have expanded well beyond the primary care environment. Today, mid-level =
providers work in hospitals, emergency departments, inpatient and =
outpatient=20
surgical facilities and in specialty practices such as cardiology and =
oncology,=20
as part of the team that serves patients receiving ongoing treatment. It =
is=20
often a mid-level provider who monitors fragile diabetics, sees cancer =
patients=20
between treatments, sets bones in the ED or closes for the doctor after=20
surgery.
How are mid-level providers=20
paid?
IHStrategies=E2=80=99 proprietary compensation =
database shows that=20
mid-level providers are nearly always paid a base salary based on years =
of=20
experience, with shift differentials, overtime pay, and additional =
payments for=20
taking call. Less than half of organizations in our database report =
using=20
incentive plans that reward individual or team performance. Mid-level =
providers=20
participate in standard, all-employee benefit plans and receive =
additional=20
continuing medical education benefits =E2=80=94 some combination of =
tuition=20
reimbursement, paid time off for exams, expenses for attending medical=20
conferences, professional dues and subscriptions and reimbursement of =
exam or=20
licensure fees.
At the national level, NPs, PAs, and nurse =
midwives are=20
paid fairly comparably, as shown in the table below. =
TOTAL=20
ANNUAL CASH COMPENSATION
| 25th Percentile | 50th Percentile | 75th Percentile | |
| Nurse practitioners |
$79,900 |
$91,500 |
$105,900 |
| Physician assistants |
$77,300 | $88,600 | $102,200 |
| Nurse midwives |
$83,700 |
$92,400 |
$103,300 |
IHStrategies has found = that NPs and=20 PAs in surgical and other select medical sub-specialties are paid 5 = percent to=20 15 percent more than their primary care counterparts. Even so, salaries = for=20 mid-level providers are lower than those of physicians. This suggests = that=20 mid-level providers may represent an option for increasing the capacity = of=20 physician specialty practices without greatly increasing payroll costs.=20
Unlike physicians, most mid-level providers do not have = incentive=20 plans based on productivity today. But as the contributions of mid-level = providers grow in importance to physician practices, we expect=20 productivity-based compensation plans for this group to become more=20 commonplace.
Changing Roles of Mid-Level=20 Providers
There is no question that hospitals and physician=20 practices will need to change the way they deliver care as the = healthcare=20 environment continues to evolve. The aging of our population, looming = shortages=20 of physicians and nurses, and increasing access to health insurance all = point to=20 needing to care for more patients with fewer providers. According to the = American Hospital Association, hospitals will need to redesign work = processes=20 and introduce new technologies to increase efficiency, effectiveness and = employee satisfaction; retain existing workers, including those able to = retire;=20 and attract a new generation of workers if they are going to have an = adequate=20 workforce in the coming years. Physician practices will face the same=20 challenges.
The introduction of accountable care = organizations and=20 the anticipated shift in reimbursement from fee-for-service to payments = for=20 episodes of care will demand greater efficiency and a renewed emphasis = on=20 outcomes. The concept of the =E2=80=9Cmedical home=E2=80=9D will require = a team approach and=20 greater coordination between health professionals who deliver care in a = seamless=20 manner.
There are compelling reasons to consider expanding the = roles of=20 NPs and PAs in both hospitals and physician practices. The timeframe for = educating mid-level providers is much shorter than the timeframe for = educating=20 physicians, making it easier to increase their presence in the workplace = quickly. Organizations can recruit mid-level providers directly from the = medical=20 schools and nursing schools that train them, or can identify good = candidates=20 from their own staffs and offer them the additional training they need = to step=20 into the role.
Mid-level providers are cost-effective in = primary=20 care settings, where they can relieve physicians of the necessity of = providing=20 routine care. This approach enriches the work experience for physicians, = enhancing retention. Mid-level providers are also cost-effective in = specialty=20 practice settings, providing much of the medical care patients need = while=20 allowing physicians to focus more attention on the complex issues that = make the=20 best use of their knowledge and experience.
Including NPs = and PAs=20 on the clinical staff can enhance scheduling flexibility and make it = easier to=20 offer part-time jobs without compromising quality of care. This may help = attract=20 and retain physicians beyond normal retirement age and women physicians = who are=20 reluctant to commit to full-time schedules.
As NPs and PAs = take on=20 expanded roles similar to those of physicians, we expect incentive plans = to=20 become a standard component of pay, although awards will be more modest = in size=20 than those of physicians. Like physicians, we expect mid-level providers = to=20 receive incentive awards for productivity, patient satisfaction, = adherence to=20 quality standards and achievement of other organizational goals. The = design of=20 compensation programs for mid-level providers will also influence the = design of=20 programs for the physicians who supervise them.
Looking=20 Ahead
In the near future, the medical community will be = expected to=20 serve more patients with fewer physicians. This reality will require a = redesign=20 in the way medical care is delivered, and mid-level providers will = likely play a=20 bigger role than they do today. As your organization plans for these = changes,=20 consider these questions:
=E2=80=A2 Where will = your=20 organization get enough providers to see an influx of new patients?=20
=E2=80=A2 Will mid-level providers be part = of the solution=20 to physician shortages in your organization?
=E2=80=A2 = What=20 strategies will you adopt to recruit and retain the mid-level providers = you=20 need?
=E2=80=A2 How will your compensation package = for mid-level=20 providers help your organization stand out in a tight labor=20 market?
=E2=80=A2 If you think of NPs and PAs as = part of your=20 physician staff, instead of your nursing staff, should you pay them = differently=20 than you do today? Should you add incentive pay or other benefits?=20
=E2=80=A2 How will your organization compensate = physicians for=20 supervising mid-level providers?
=E2=80=A2 = What is the=20 appropriate relationship between physician pay and mid-level provider=20 pay?
The way your hospital or health system answers these = questions may=20 determine how successful you are in meeting the demands of a new = healthcare=20 marketplace.
Integrated Healthcare Strategies provides = not-for-profit=20 healthcare organizations with direct access to a comprehensive array of=20 healthcare-specific services, delivered by professionals from the = industry who=20 understand the rigors of running a healthcare organization =E2=80=93 = from the lunchroom=20 to the Board Room. Integrated Healthcare Strategies specializes in the = areas of=20 physician strategy and compensation, employee compensation, executive=20 compensation, human capital solutions, labor relations, leadership = transition=20 planning, executive search, employee surveys, performance management and = board=20 governance solutions. For more information, please visit
To receive the latest hospital =
and=20
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