Use Of Nonphysician Providers Research Articles

Patient‐controlled use of nonphysician providers: Appointment scheduling in mixed‐provider settings

The aging population and increasing chronic disease load are rapidly changing the face of primary care delivery, with mid‐level (e.g., nurse) practitioners providing growing proportion of patient care. Potential differences in the quality of care offered by physicians and nurse practitioners may affect patient preferences, thus leading to patient choice behavior. This paper focuses on the problem of appointment scheduling for physician–nurse teams in the presence of patient choice and no‐shows. We propose a novel model that accounts for patient choices in a system with two provider types. Despite the increased structural complexity of the model, we derive sufficient conditions under which the problem is efficiently solvable. To counter the computational challenges arising in the general setting, we propose an easy‐to‐implement heuristic, which is proven to be optimal in the absence of patient no‐shows. Our numerical study shows how the ratio of qualities of care delivered by nurses and physicians affect the profitability of the medical practice, enabling the analysis of the trade‐offs involved in hiring a nurse practitioner. This paper introduces a patient‐controlled approach to incorporating nonphysician providers into physician‐led outpatient care delivery systems and compares it to widely used “ice breaker” and “standalone” modes of using nonphysician providers. Our findings reveal that clinical practices that employ mixed (physicians and nonphysicians) provider pools can significantly improve their financial and operational performance by moving away from the “ice breaker” and “standalone” use of nonphysician providers by delaying the selection of an appropriate care provider till the actual day of care delivery.

Patient-Controlled use of Non-Physician Providers: Appointment Scheduling in Mixed-Provider Settings

The aging population and increasing chronic disease load are rapidly changing the face of primary care delivery, with mid-level (e.g., nurse) practitioners providing growing proportion of patient care. Potential differences in the quality of care offered by physicians and nurse practitioners may affect patient preferences, thus leading to patient choice behavior. This paper focuses on the problem of appointment scheduling for the physician--nurse teams in the presence of patient choice and no-shows. We propose a novel model that accounts for decision-making by patients in a system with two provider types. We prove that the presence of patient choice, in general, breaks down the multimodularity of a medical practice's cost function, creating challenges for the numerical identification of optimal appointment schedules. At the same time, we derive sufficient conditions under which the multimodularity is restored. To counter the computational challenges arising in the general setting, we propose an easy-to-implement heuristic and prove its optimality in the absence of patient no-shows. Our numerical study shows how the ratio of qualities of care delivered by nurses and physicians affects the profitability of the medical practice, enabling the analysis of the trade-offs involved in hiring a nurse practitioner.

Curing Hepatitis C Virus Infection: Best Practices From the U.S. Department of Veterans Affairs

The U.S. Department of Veterans Affairs (VA) is the nation's largest care provider for hepatitis C virus (HCV)-infected patients and is uniquely suited to inform national efforts to eliminate HCV. An extensive array of delivery of services, policy guidance, outreach efforts, and funding has broadened the reach and capacity of the VA to deliver direct-acting antiviral (DAA) HCV therapy, supported by an infrastructure to effectively implement change and informed by extensive population health data analysis. The VA has treated more than 92000 HCV-infected veterans since all-oral DAAs became available in January 2014, with cure rates exceeding 90%; only 51000 veterans in VA care are known to remain potentially eligible for treatment. Key actions advancing the VA's aggressive treatment of HCV infection that are germane to non-VA settings include expansion of treatment capacity through the use of nonphysician providers, video telehealth, and electronic technologies; expansion of integrated care to address psychiatric and substance use comorbidities; and electronic data tools for patient tracking and outreach. A critical component of effective implementation has been building infrastructure through the creation of regional multidisciplinary HCV Innovation Teams, whose system redesign efforts have produced innovative HCV practice models addressing gaps in care while providing more efficient and effective HCV management for the populations they serve. Financing for HCV treatment and infrastructure resources coupled with reduced drug prices has been paramount to the VA's success in curing HCV infection. The VA is poised to share and extend best practices to other health care organizations and providers delivering HCV care, contributing to a concerted effort to reduce the overall burden of HCV infection.

Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis

BackgroundAllowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care.MethodsWe conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options.ResultsSeveral factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers’ knowledge about abortion legislation and services; and health workers’ willingness to provide abortion care. Health workers’ willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers’ and co-workers’ attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies.ConclusionsTo increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.

Redesigning Cancer Care Delivery: Views From Patients and Caregivers.

Cancer is a leading cause of death in the United States. Although treatments have improved, patients and caregivers continue to report significant gaps in their care. The objective of this study was to examine the views of patients and caregivers on their experiences with current cancer care delivery and identify key strategies to improve the delivery of care. Semistructured interviews were conducted with 75 patients and 45 caregivers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis. Participants reported multiple gaps in care delivery, including barriers in health communication with health care providers, lack of elucidation of care goals, lack of care coordination, and challenges in accessing care. Participants identified that greater use of nonphysician providers and alternative formats, such as telephone-based care and home and community-based care, would narrow these gaps. Understanding patients' and caregivers' experiences with gaps in cancer care delivery can inform cancer care delivery redesign efforts and lead to targeted interventions that result in patient-centered and family-oriented care.

Expanding capacity for hepatitis C treatment in the United States: team-based care and use of nonphysician providers.

Hepatitis C treatment is rapidly evolving with significant improvements in patient outcomes. With an estimated prevalence of over 3 million persons living with chronic hepatitis C in the United States, it is anticipated that there will be an increase in the number of persons seeking care and treatment for chronic hepatitis C infection. Current systems of care may be overburdened with people seeking care for chronic hepatitis C virus (HCV). Interprofessional models of care have been shown to be feasible and effective in treating different populations affected by chronic HCV. Use of interprofessional teams, integrated models of care, and greater use of nonphysician providers offer a potential solution for expanding capacity to comprehensive HCV treatment and care in the United States.

The Use of Nonphysician Providers in Adult Intensive Care Units

In the United States there are not currently enough critical care-trained practitioners to provide care to all critically ill patients. With calls for "high-intensity" staffing and 24-hour coverage of our intensive care units, the board-certified intensivists we do have are being stretched ever more thin. Nonphysician providers (physician assistants and nurse practitioners) are being used with increasing frequency in critical care settings to provide care to critically ill patients. In this review, we explore the impact of introducing nonphysician providers into the adult intensive care unit.

Impact of Nonphysician Staffing on Outcomes in a Medical ICU

As the number of ICU beds and demand for intensivists increase, alternative solutions are needed to provide coverage for critically ill patients. The impact of different staffing models on the outcomes of patients in the medical ICU (MICU) remains unknown. In our study, we compare outcomes of nonphysician provider-based teams to those of medical house staff-based teams in the MICU. We conducted a retrospective review of 590 daytime (7:00 am-7:00 pm) admissions to two MICUs at one hospital. In one MICU staffed by nurse practitioners and physician assistants (MICU-NP/PA) there were nonphysicians (nurse practitioners and physicians assistants) during the day (7:00 am-7:00 pm) with attending physician coverage overnight. In the other MICU, there were medicine residents (MICU-RES) (24 h/d). The outcomes investigated were hospital mortality, length of stay (LOS) (ICU, hospital), and posthospital discharge destination. Three hundred two patients were admitted to the MICU-NP/PA and 288 to the MICU-RES. Mortality probability model III (MPM(0)-III) predicted mortality was similar (P = .14). There was no significant difference in hospital mortality (32.1% for MICU-NP/PA vs 32.3% for MICU-RES, P = .96), MICU LOS (4.22 ± 2.51 days for MICU-NP/PA vs 4.44 ± 3.10 days for MICU-RES, P = .59), or hospital LOS (14.01 ± 2.92 days for MICU-NP/PA vs 13.74 ± 2.94 days for MICU-RES, P = .86). Discharge to a skilled care facility (vs home) was similar (37.1% for MICU-NP/PA vs 32.5% for MICU-RES, P = .34). After multivariate adjustment, MICU staffing type was not associated with hospital mortality (P = .26), MICU LOS (P = .29), hospital LOS (P = .19), or posthospital discharge destination (P = .90). Staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU.

Nonphysician Providers in Oncology

To the Editor: The May 2007 issue of Journal of Oncology Practice (JOP) contains two brief references to the use of nonphysician providers in oncology. Both deserve additional comment. Dr James Cohen, in his Letter to the Editor regarding the findings of the workforce study published in JOP in March, writes that the use of physician-extenders will be detrimental to the role of the physician-patient relationship.1 The growing body of data regarding the use of physician-extenders in the workforce suggests, in fact, that physician-extenders improve patient satisfaction, and professional satisfaction without adversely impacting the professional relationship between the patient and the physician.2 Dr Peter Paul Yu, writing for the ASCO Clinical Practice Committee discusses the potential role the nurse practitioner (NP) may play in the oncology workforce by examining what is currently understood about the background and training of the NP in oncology.3 Absent from the discussion is a similar consideration of requirements for physician assistant (PA) education. PA education is structured in the medical model. There are more than 130 accredited PA training programs. PAs must pass a national certifying examination in order to use the title Physician Assistant-Certified. Certified PAs must take a recertification examination every 6 years, in addition to earning 100 hours of continuing medical education credits every 2 years. Specialty certification is not required of PAs wishing to practice in subspecialties. There is currently one postgraduate residency program for PAs interested in additional oncology training. PAs work in the complete spectrum of oncology care, including medical oncology, surgical oncology, and radiation oncology, in the treatment of both pediatric and adult patients. To represent completely the spectrum of nonphysician providers in oncology care, PAs should be included in the ASCO Clinical Practice Committee discussion regarding nonphysician provider education and training.

A Comparison of Intensive Care Unit Physician Staffing Costs at the 3 Mayo Clinic Sites

To determine the provider cost of administering intensive care unit (ICU) services, comparing 3 different staffing models for ICU coverage, and to compare the costs of using house staff vs nonphysician providers (NPPs). Data were collected on total staff composition and number of beds In ICUs from January 1, 2004, through December 31, 2004, at the 3 Mayo Clinic sites: Rochester, Minn; Jacksonville, Fla; and Scottsdale, Ariz. Institutional or national average staff salaries were used to determine total staffing costs per ICU bed per year at each site. Medicare medical education reimbursements were also taken into account. Costs per ICU bed for physician staffing were $18,630 in Rochester, $37,515 in Jacksonville, and $38,010 in Scottsdale. When NPPs were substituted for house staff, the costs per bed were $72,466 in Rochester, $61,291 in Jacksonville, and $49,909 in Scottsdale. Incremental costs per ICU bed using NPPs were $53,836 in Rochester, $23,776 in Jacksonville, and $11,899 in Scottsdale. Use of residents and fellows in ICU staffing at a major tertiary health center is more cost-efficient than use of NPPs. This finding could have Implications for the cost of physician services in nonteaching community hospitals and the methods by which care is provided.

Pathology resident attitudes and opinions about pathologists' assistants.

Changes in health care economics and organization have resulted in increased use of nonphysician providers in most health care settings. Attitudinal acceptance of nonphysician providers is important in the current health care environment. To obtain descriptive information regarding pathology resident attitudes and opinions about pathologists' assistants in anatomic pathology practice and to assess the implications of resident attitudes and opinions for pathology practice and training. A self-administered, mailed, voluntary, anonymous questionnaire was distributed to a cross-sectional sample of pathology residents in the United States (2531 pathology residents registered as resident members of one of the national pathology professional organizations). The questionnaire contained (1) items relating to resident demographics and program characteristics, (2) Likert-scale response items containing positive and negative statements about pathologists' assistants, (3) a multiple-choice item related to pathologists' assistants scope of practice, and (4) an open-ended item inviting additional comments. Both quantitative and qualitative analysis of responses was performed. The overall response rate was 19.4% (n = 490); 50% of the respondents were women, and 77% reported use of pathologists' assistants in their program. Most respondents were 25 to 35 years old and in postgraduate years 3 through 5 of their training, and most were located in the Midwestern United States. The majority of residents expressed overall positive attitudes and opinions about pathologists' assistants and felt that pathologists' assistants enhanced resident training by optimizing resident workload. A minority (10%-20%) of residents expressed negative attitudes or opinions about pathologists' assistants. Additionally, some residents reported a lack of knowledge about pathologists' assistants' training or roles. Increased resident education and open discussion concerning pathologists' assistants may be beneficial for optimizing resident attitudes about and training experiences with pathologists' assistants.

The attitudes of rural Minnesota family physicians toward nurse practitioners and physician assistants.

Increased use of nurse practitioners and physician assistants has been promoted as a possible solution to the shortage of primary care providers in rural locations. If the use of nonphysician providers is to be optimized in these areas, awareness and acceptance of their capabilities by rural family physicians is essential. This study surveyed the attitudes of rural Minnesota family physicians toward the use of physician assistants and nurse practitioners. Forty-six percent of the 600 rural family physicians surveyed responded to the questionnaire. Approximately 90 percent of responding physicians indicated a high degree of confidence in the abilities of nonphysician providers in the areas of preventive and routine care; some concern was expressed about the proficiency of nonphysician providers taking call, covering the emergency room, and doing hospital rounds--activities that involve a broader base of clinical knowledge and diagnostic skills. Other concerns were an increased workload for physicians due to their assumed supervisory roles, an increase in complexity of cases seen by physicians, increased physician liability, job competition between nonphysician providers and physicians, and the lack of educational opportunities and supervisory guidelines for physicians regarding collaborative relationships. Appropriate roles for family physicians, nurse practitioners and physician assistants are not well-defined in the minds of respondents, and it appears future acceptance and practice patterns will depend on how these roles are established and accepted.

The changing supply of renal physicians

In 1993, there were 4,355 active, postresident physicians in the United States who, according to the American Medical Association (AMA) Physician Masterfile, had their primary specialty in either adult nephrology or pediatric nephrology. These renal physicians constituted 0.8% of the active postresident physician population, and there were 1.67 renal physicians for every 100,000 people in the United States. The population of renal physicians has grown at a significantly greater rate than the physician population as a whole. The number of renal physicians increased more than 10-fold between 1970 and 1993, and it increased by 19% between 1990 and 1993. In recent years, the growth of the renal physician population has been bolstered by the large number of new international medical graduates (IMGs) entering the United States, who have entered nephrology at a much higher rate than entering US medical graduates (USMGs). The future growth of the renal physician population will be determined by a wide variety of factors, including future trends in specialty selection and whether policies are implemented to reshape the physician workforce. The projection analysis of the future supply of adult nephrologists considers three different scenarios. First, if the production of new nephrologists remains at status quo, the supply of adult nephrologists will increase 101% between 1993 and 2010. However, it is possible that the number of entrants into the adult nephrologist population will increase because of the large influx of IMGs in US residency programs in recent years. If new IMGs continue to enter adult nephrology at their current rates and if this heightened level of entry is sustained, the supply of adult nephrologists will increase 134% between 1993 and 2010. Finally, if proposals are implemented to reduce the number of first-year residency positions to 110% of the number of new graduates of US medical schools and to raise the proportion of new physicians entering primary care to 50%, the supply of adult nephrologists will increase 62% between 1993 and 2010. The demand for nephrologists' services is likely to grow in the near future. The prevalence rate of end-stage renal disease (ESRD) more than doubled between 1984 and 1993, and a continuation of this trend will expand the need for more nephrologists. The long-term growth of the ESRD population will also be sustained, to some extent, by the aging of the US population, because the prevalence of ESRD is relatively high in the older age categories. However, long-term increases in the demand for nephrologists may be restricted by the growth of managed care, the use of nonphysician providers, and the implementation of other cost-cutting measures that impact the delivery of services to the ESRD population.

The use of nonphysician providers in managed care settings.

The use of nonphysician providers in managed care settings.

Clinical staffing in staff- and group-model HMOs.

Analysts frequently have used health maintenance organization (HMO) staffing patterns as a yardstick for estimating national clinical workforce requirements. Based on a nationwide survey of fifty-four staff- and group-model HMOs, the largest sample yet used in an analysis of this type, this DataWatch examines physician-to-member ratios, the use of nonphysician providers, and HMOs' methods of estimating clinical staffing needs. Overall physician staffing ratios and primary care physician staffing ratios closely resemble those reported in previous studies, but they exhibit wide variability and are strongly correlated with HMO size. Although caution should be exercised when using HMO staffing ratios in projections of physician workforce requirements, the ratios described here support projections of a specialty physician surplus.

Task force 1: The underserved

The ACC has affirmed its commitment to universal access to health care. Underserved populations exist in urban and rural centers. Common to each is a paucity of personnel trained in cardiovascular care and a lack of access to preventive and highly technologic services. These factors contribute to a poor health outcome (75). Part of the rural problem can be corrected by the transfer of information to local providers by the use of new information systems. Included would be real-time electronic consultation, on-site subspecialty visits and the appropriate use of nonphysician providers (15). The urban problem requires changes in priorities and responsibilities of the academic health centers toward the communities they serve. Curricula changes of cardiovascular specialists, internists, generalists and nonphysician health care personnel must include diversity in training, physician training of ethnically matched providers in addition to technical excellence and research into methods of patient education and motivation for a healthier life-style (51). Reimbursement must appropriately reward those caring for underserved patients and those providing evaluation and management services (43,52).

Gridlock on the Oregon Trail

Gridlock, partisan politics, empty wallets, and the blame game are usually associated with life inside the D.C. Beltway, but they have surfaced recently in the state of Oregon and brought efforts to implement the controversial Oregon Health Plan (OHP) to a virtual standstill. In a 19 March 1993 decision greeted with much enthusiasm by state political leaders, the medical community, and health care activists, the Clinton administration approved a Medicaid waiver to permit implementation of the OHP. The core of the plan restricts access of Medicaid patients to some health services in order to provide a basic package of benefits for some 120,000 Oregonians currently without health care insurance. The Bush administration had denied the Medicaid waiver in August 1992 because of concerns that quality of life assessments were embedded in a prioritized list of 688 health services, and that the priorities thereby might result in discrimination against the disabled and violate the Americans with Disabilities Act. A revised version, submitted in December 1992, attempted to eliminate the quality of life methods and guaranteed funding for 568 of the 688 services, including such previously excluded conditions as low birthweight babies, cirrhosis of the liver, and chronic bronchitis. After persistent lobbying by the Oregon congressional delegation and Gov. Barbara Roberts, the approval of the waiver was announced by Donna E. Shalala, secretary of health and human services. Shalala's approval, which was subject to twenty-nine conditions (primarily technical and reporting issues), allows the OHP to proceed for a five-year experimental period, beginning in January 1994. Under the OHP the income level for Medicaid eligibility would be raised from its current 50 percent of the federal poverty index to 100 percent ($14,343 for a family of four in 1992), and expand the total number of Medicaid recipients in the state from 240,000 to 360,000. The waiver approval also triggers a state version of a pay or program, in which employers will be mandated to provide health insurance for employees or be subject to a new payroll tax. Employers who play must offer health plans substantially similar to the Medicaid priority list and bear at least 75 percent of the cost for employees and 50 percent of the cost for their dependents. Among the more substantive conditions of federal approval, Shalala requested that the state submit within 60 days (18 May) another priority ranking to ensure that persons with disabilities are not potential subjects of discrimination. For example, the OHP will not be permitted to consider functional limitations (such as inability to walk) or impairments that persist after treatment as a measure of a treatment's effectiveness. The state was also asked to consider whether infertility (currently excluded from coverage) should be covered as a disability. And Oregon was also required not to rescind its guarantee of funding up to the level of the 568 services without prior approval from HHS. Oregon's political leaders were unanimous in asserting that Oregon was blazing a new path for the nation to follow as it takes up reform proposals at the national level to be issued by Hillary Rodham Clinton's task force. Rep. Ron Wyden (D-Ore.), a principal advocate of the OHP before the Clinton administration, remarked: Any good national health bill has to contain features of the Oregon plan, . . . universal coverage, preventive health care, cost containment through managed care, extensive use of nonphysician providers, and an emphasis on what's medically effective for our citizens (Washington Post, 20 March 1993). However, since the granting of the waiver, the OHP has looked like it would be an exemplar only of the obstacles that any national proposal might face. A major problem with implementation that has emerged is financial. The costs of the OHP over the five-year period are estimated at $6. …

The determinants of utilization of nonphysician providers in rural community and migrant health centers.

The use of nonphysician providers, such as nurse practitioners, physician assistants, and certified nurse midwives, in rural areas is critically important due to the continued primary care access problems. This study examines the major factors influencing the use of nonphysician providers in rural community and migrant health centers based on a 1991 national survey of the centers. This study demonstrates that the employment of nonphysician providers in rural community and migrant health centers is significantly influenced by both supply and demand factors. Among supply factors, there is a significant and positive relationship between the number of total staff and the number of nonphysician providers employed. There is a significant but inverse relationship between the number of physicians and the number of nonphysician providers employed, indicating nonphysician providers primarily serve as substitutes for physicians in rural community and migrant health centers. The supply of nonphysician providers, as measured by the number of affiliated training programs, is significantly related to the employment of nonphysician providers. The demand variable, geographic location, and the centers' staffing policies are also significant determinants of the use of nonphysician providers.

Predicting the Need for Primary Care Specialists

Because of a need to project the requirements for the training of primary care practitioners in the state of New Mexico, we reviewed available means of determining health manpower needs. Combining several of these methods, we constructed a three-tiered model, taking into account different patterns of care-seeking in areas of various population densities. These methods may be applicable in other states like New Mexico where densely populated cities contrast with sparsely settled rural areas. All such methods, however, are confounded by the state of balance of many factors, including immigration and emigration of physicians, use of nonphysician providers, and patient movement across boundaries for care. This report contributes to the growing literature on health manpower needs by recognizing and attempting to account for differences between urban and rural patterns of care-seeking.