The Roles of Nonphysician Practitioners in Retina

If you are considering a new provider, you might consider a nurse practitioner or physician assistant.

PAUL M. LARSON, MBA, MMSc, COMT, COE, CPC, CPMA

Are you concerned about your ability to handle future patient volumes? The most obvious solution — hiring another physician — might not be the smartest choice. Other options are available, and they can make strong financial sense and help you continue to provide high-quality care.

Perhaps the strongest idea is to hire a physician assistant (PA) or nurse practitioner (NP); there are practices that have made such hires and succeeded with regard to both cost and quality parameters. In this article, we’ll explore general population and provider trends, describe the legal and regulatory framework you need to be aware of, and then look at a few other relevant issues.

DO YOU NEED TO INCREASE STAFF?

First, let’s look at projections for population and provider volumes in the near future because these are critical to know. Although your area’s particular needs might vary, the US data are very clear: there won’t be a sufficient number of eyecare providers as the population grows. The Department of Health and Human Services (HHS) has forecasted a need for 28% more ophthalmologists by 2020; Figures 1 and 2 clearly demonstrate the trend lines.

Figure 1. Population growth over age 65
SOURCE: US CENSUS BUREAU

Figure 2. Required vs. Projected Eye Care Provider Volume
SOURCE: US DEPARTMENT OF HEALTH AND HUMAN SERVICES

Second, the Patient Protection and Affordable Care Act (PPACA) has dramatically increased the number of insured patients across all age categories (including those older than 50, a key retina demographic). While the actual enrollment numbers may be in dispute, it is clear there will be more people insured.^1,2

Add to these issues the diseases being seen in greater percentages of the population (eg, diabetes), and the need for more frequent care for certain diseases due to changes in practice patterns (eg, exudative age-related macular degeneration and anti-VEGF drugs), and the problem becomes even more acute for retinal physicians.

While you may be able to increase productivity and efficiency a small amount, for most retina practices, there is a point at which neither of these factors can grow without affecting your health and that of your staff. You can take a negative view and say, “We are at the maximum already; more isn’t an option.” Or you can look at the data objectively, evaluate them, and then decide how to proceed.

You may have already investigated and feel that perhaps another doctor isn’t right for you at this moment; perhaps there isn’t quite enough volume yet to warrant that. It’s also possible that a provider is either too difficult to find in your area or too expensive to hire. It may be time to consider a PA or NP. In the regulatory world, PAs and NPs as referred to most commonly as physician-extenders (aka, nonphysician practitioners, or NPPs).

WHAT CAN THEY DO?

You’re interested, so what comes next? It’s important to know where the scope-of-practice lines are drawn. It’s also critical to make full use of the skill sets that NPPs bring to a practice. It’s clear they are not technicians; your staff must be aware of this fact as well. NPs are usually regulated by state nursing boards, while PAs are likely to fall under the medical board.

Both types of NPPs are used to collaborative care. If you look at the raw numbers, there were more than 70,000 PAs and 106,000 NPs in the 2010 US census data³; the numbers are likely even larger now.

In looking only at PAs, it’s important to note that each state may have its own specific scope-of-practice regulations. Most states follow the “Six Key Elements” of the Ideal State PA Practice Acts, which allow the supervising physician to determine the exact duties and limitations of the PAs who work under them.⁴

Recent graduates from the approximately 180 current PA training programs, on average, possess a Master’s degree, have spent more than 3,500 hours in direct patient contact, and have had a program length of 27 months. Unfortunately, while general eye care is covered in the curricula, actual eyecare rotations are sparse; they are generally an elective, if offered at all.

Nurse practitioners are not likely scope-of-practice constrained, although you should check that against possibly relevant state nursing laws. The state board of nursing is the most likely organization to ask.

At Corcoran Consulting Group, we believe practices might consider PA or NP use in the following clinic and ASC/HOPD areas:

• Preoperative history and physical (H&P);

• Triage and walk-in care;

• Surgical assistance; and

• Minor surgery (in the case of retina, a key area could be performance of intravitreal injections).

HISTORY AND PHYSICAL

Importantly, Medicare regulations allow for NPPs to be reimbursed for claims filed for “preoperative consultations … for new or established patients by any physician or qualified NPP at the request of the surgeon, as long as all of the requirements … are met and the service is medically necessary and not routine screening.”⁵

Note that, if the visit is solely for “clearance,” absent other health concerns, Medicare considers it routine screening,⁶ and it is likely not covered for payment. Don’t lose sight that, from a revenue aspect, although the low-level exam from the NPP might not be paid, the more valuable surgeon’s time is now freed up to perform other exams and surgeries.

The medical chart for the NPP visit should show that the reason for the preoperative exam is to reassess chronic systemic conditions (eg, diabetes, hypertension, other) in light of planned surgery.

Billing — if it is a covered service — is normally a low-to-moderate established E/M code (eg, CPT 99212 or 99213) under the NPP’s national provider identifier (NPI) and the group tax identification number (TIN).

CLINICAL AND SURGICAL DUTIES

Some offices already have NPPs who directly assist surgeons. While not always billable, the time savings alone for other providers might be the major consideration when deciding to utilize a PA or NP in surgery.

The specialties who use PAs most often are orthopedics and emergency medicine; each uses more than 10,000 PAs.⁴ Medicare allows a large number of PA services to be covered, including minor surgery, physical examinations, and “other activities that involve an independent evaluation …”⁷

NPs are common in many primary care and specialty situations. NP coverage guidelines under Medicare are governed by a different section of the Medicare manual but are generally similar and can, in some ways, be less constrained.⁷

“Clinical duties” can encompass a wide variety of services and might vary significantly by the practice subspecialty; if not restricted by a state scope of practice (rare), the possibilities are numerous.

In retina, NPPs might perform exams, administer injections, perform triage, or assess emergency situations before the retina physician does, as well as take calls. A multispecialty ophthalmology group could use the same NP or PA in different ways if the NPP salary for a single provider is a concern.

REIMBURSEMENT CONSIDERATIONS

Medicare pays based on 85% of the physician fee schedule when the NPP is providing services such as H&P and working independently (other payers generally follow this guidance, but be sure to check).

If the NPP performs duties under the direct supervision of a physician, the services might be considered “incident to” the physician’s services and paid based on 100% of the physician fee schedule. While outside the scope of this article, the general points to be considered for “incident-to” billing for a PA service are listed in Box 1 (previous page).

Bear in mind that using an NPP frees your other providers, allowing them to perform other high-revenue activities. However, “incident-to” billing has received an extraordinary level of payer scrutiny within and outside of Medicare, so it is especially prudent to be compliant.

SALARY AND OTHER CONSIDERATIONS

In May 2014, the median annual PA salary was approximately $97,000; NP salaries were somewhat higher.⁸ Practices might utilize NPPs on a full- or part-time basis. Credentialing is another important consideration; practices must be proactive in much the same manner as they are with new physicians. Be sure to plan ahead so that there are no issues.

How would you go about attracting an NPP? Your state or local PA or NP organization is an excellent first start. Consider providing exposure to PA or NP students if a training program is nearby. Have your providers consider speaking to the program either as a recruiting consideration or as an eye- or retina-specific classroom module. As mentioned above, initial, part-time use of PAs or NPs for history and physical use is one way to start; when you feel the person is a good fit, you can discuss expansion of the role and time.

Consider any time lag while you wait for credentialing as a training opportunity for the NPP. These are smart people with generally good people skills, so they can absorb complex information quickly. Be sure the individual has a valid license and NPI number and that you perform all due diligence; NPPs are in direct patient contact. Consider how they will be covered for medical malpractice. Box 2 provides a short list of considerations from a hiring and on-boarding perspective.

CONCLUSION

The number of patients we care for will rise; their conditions are more complex and more schedule-intensive. The number of retinal physicians needed to provide necessary care is not growing at the rate needed.⁹ Other provider types, such as PAs and NPs, should be considered to make up the anticipated shortfall. They are smart and motivated, and they are good team players who can perform a wide variety of retina services. RP

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