Hospitals Finding a Place for Midlevel Healthcare Providers

By Debra Wood, RN, contributor

May 19, 2011 - With an aging population, limitations on medical residents’ hours and physician shortages, midlevel providers are delivering care not only in the outpatient setting but also in the hospital. And the trends can be seen in both temporary and permanent employment.

“We’ve seen a need for hospitalist nurse practitioners and physician assistants,” said Heather Speed-Laureno, senior territory sales manager for Staff Care, an AMN Healthcare company that specializes in locum tenens staffing services. “People are trying to keep the cost down. [Midlevel providers] can still see as many patients and depending on the state, they can operate almost independently.”

Kirsten Tracer, regional vice president of the medical/surgical division of Staff Care, added the company has experienced a strong demand for emergency department midlevel providers to keep up with volume increases as more people seek care in that setting, as well as health systems bringing in midlevels to help staff system-owned practices.

Tracer agreed with Speed-Laureno that cost considerations can be a factor in placement requests: “Midlevels doing locums are cheaper than bringing in another physician, and they can prevent physician burnout,” she said. Staff Care matches temporary physicians, dentists, CRNAs, nurse practitioners and physician assistants with all types of medical facilities.

Nurse practitioners and physician assistants have been providing care for nearly 50 years in the United States. That need for midlevel providers arose from a physician manpower shortage, something that continues today and is projected to increase. Consequently, hospitals, as well as physician practices, are hiring greater numbers of midlevel providers.

“The trend is, in part, the evolution of the nurse practitioner role,” said Tay Kopanos, NP, director of health policy, state government affairs for the American Academy of Nurse Practitioners (AANP), based in Arlington, Va.

Of the more than 135,000 nurse practitioners practicing in the country, 5.3 percent have specialized in acute care, according to a 2009-2010 survey by the AANP. In addition, nurses educated in adult care in other specialties may be practicing in the hospital setting. Kopanos reported “an up-tick in the number of graduate programs offering an acute-care nurse practitioner tract.”

A greater percentage of physician assistants (PAs) are hospital based. Forty percent of the 75,000 clinically practicing PAs in the United States work in the hospital setting, according to a 2010 issue brief from the American Academy of Physician Assistants (AAPA) in Alexandria, Va.

Tricia Marriott, PA-C, MPAS, director of reimbursement advocacy for the AAPA, said the first surge in hospitals’ hiring of PAs followed the Accreditation Council for Graduate Medical Education’s regulation that limited residents’ work hours starting in 2003.

“PAs are well suited to fill that void--to provide the care at the bedside, in the OR, in the ER,” Marriott said. “It’s driven by many things, including evidence that PAs clearly have improved quality data in hospital units and decreased length of stay.”

Marriott anticipates a second surge in PA demand as the Accreditation Council for Graduate Medical Education further reduces resident hours, scheduled to start July 1, 2011.

Ronnen Isakov, a director at SS&G Healthcare, an Ohio-based financial and operational healthcare consulting and management firm, confirmed the trend toward hospitals hiring more midlevel providers for both primary and subspecialty care, especially in rural markets where it is difficult to hire physicians.

“Financially, the outlay for midlevel is not as high as for a physician,” said Isakov, adding that hospitals also are partnering with retail clinics, which depend on midlevel providers to treat minor illnesses. “Midlevels take care of day-to-day patient needs.”

Isakov added that with the deployment of electronic medical records, physicians can oversee midlevels more easily and review patient records remotely. Insurers, he said, typically, reimburse for midlevel providers at 75 percent to 85 percent of what they pay for a physician visit, making it economically beneficial to employ PAs and NPs.

Physicians delegate certain care to PAs, within their scope of practice, which frees up physicians for more complex cases. The PAs are accessible to answer nurses’ questions, complete histories and physicals, assist in surgery, respond to emergencies, write discharge summaries, and provide other care. PAs may bill for their services.

Nurse practitioners may practice independently in 15 states and the District of Columbia. They can diagnose, interpret tests, and treat and manage patient care. Twenty-three states allow independent practice for NPs with the exception of prescribing medications. Those NPs must have collaborative agreements with physicians, as do nurse practitioners in the remaining states.

“The trend is toward modernizing regulations to provide patients access to the full scope of services,” Kopanos said. “We have four decades of research and evaluation of nurse practitioner practice that consistently has supported that nurse practitioners provide high quality, safe care.”, which compiles advertisements from company websites and job boards, listed more than 1,300 job openings for nurse practitioner hospitalists on May 10, 2011, with salaries ranging from more than $60,000 to more than $180,000 annually, and more than 900 physician assistant hospital positions available, with salaries ranging from more than $30,000 to more than $160,000.

The anticipated influx of patients seeking care after full implementation of the Affordable Care Act will likely increase the need for midlevel providers.

“The healthcare workforce has not expanded and more and more patients are being covered,” Marriott said. “Many physicians will need a hand, and PAs provide physician services.”

Kopanos agreed, adding, “We are going to need every healthcare provider, every specialty, every discipline and at every level of care as we move forward in the future. In part it is related to the implementation of the Affordable Care Act, but additionally, it is spurred by our aging population and the need to have more effective, safe, quality, affordable health care. We will need everyone. Nurse practitioners are part of the solution.”


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