American College of Physicians: Internal Medicine — Doctors for Adults ®


How to integrate a midlevel into your practice team

Copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

A few years ago, patients waited as long as a week to see Gerald K. Brantley, MD. Though he is part of a multspecialty group in central Georgia, he works alone in his office in Perry. He had become so swamped that he simply called in prescriptions for some patients, seeing them only if their troubles continued.

Now that he has a nurse practitioner, however, most patients come in the day they call. "It's been a blessing to have her," Dr. Brantley said. "It makes my life much more bearable here in the office."

Experts and physicians agree that hiring a midlevel provider—a nurse practitioner (NP) or physician assistant (PA)—can be an effective way to boost revenue, improve patient access or give physicians more time to see patients with complex conditions. With median salaries of $57,000 for NPs and $60,000 for primary care PAs, midlevels offer an economical alternative to hiring a new internist—who you'll pay about $145,000.

Too often, however, physicians fail to make the best use of their midlevels. They either give their new clinical staff too little responsibility and autonomy, or they expect them to do too much. Here are some tips to help you integrate midlevels into your practice and make them a valued part of the team.


Midlevels can perform many of an internist's functions: routine histories and physicals, follow-up visits and patient education. Midlevels order tests, interpret labs and X-rays, and sometimes perform procedures.

Some physicians prefer midlevels see only certain patients. LeeRoy Meyer, ACP-ASIM Member, an internist at University Medical Associates in Omaha, Neb., sends patients with joint problems to a PA who happens to be a marathon runner interested in orthopedics. "He's better at it than I am," Dr. Meyer said.

Experts suggest that before hiring anyone, first decide what you want them to contribute to the team. You might, for example, want someone to help increase volume and generate revenue. On the other hand, you might need midlevels to take charge of patient education, freeing up your time to handle more volume or more complex cases.

Whatever you need, communicate your expectations to job candidates. "The most prevalent reason for bad experiences with midlevels is unmet expectations," said Gary Matthews, president of Physicians HealthCare Advisors, a practice management and advisory firm in Atlanta. "A midlevel might think he or she was hired for patient education while the physician expects revenue generation."


Each state determines exactly how much autonomy you can delegate to a midlevel. State regulations specify to what extent they can prescribe drugs, whether you have to be on site or simply available by phone, and whether--and how often--you must review a midlevel's charts.

Though NPs can prescribe drugs in all states, restrictions on controlled substances vary from state to state. In a few states, a physician signature is necessary, said Jan Towers, PhD, a family nurse practitioner and director of health policy with the American Academy of Nurse Practitioners. Physician assistants have some level of prescriptive authority in 47 states, but the degree of authority also varies.

Within those limits, though, midlevels can function fairly autonomously and see patients, take call and even run the office alone.

Sooji Lee-Rugh, MD, an internist at Advent Health Group in Arlington, Va., hired a PA in the summer of 2000 to help handle growing volume in a practice with two part-time physicians. She also covered Dr. Lee-Rugh's maternity leave this past summer, working half-days alone in the office four days a week and all day on Wednesdays. (Dr. Lee-Rugh's partner was available by beeper at all times.)

Before she went on leave, Dr. Lee-Rugh alternated with her new PA, seeing chronic-disease patients every other visit. She said she wanted to keep up with her patients' conditions and progress more than monitor the PA.

Midlevels can also assist in the hospital. Becky Wittenburg, an NP and advance practice nurse, for example, makes rounds for Albuquerque-based New Mexico Heart Institute physicians who are busy or travelling to satellite offices. She performs emergency room admission histories and physicals, and she orders diagnostic tests.

In some practices, midlevels take call. Physician assistant Luisa Carreiro, who works at a two-physician internal medicine practice in Washington, takes call one weekend a month from nursing homes and patients phoning in after-hours. Physicians still take hospital calls.

When taking call, Ms. Carreiro said she decides whether to call in prescriptions, send urgent patients to the emergency room or arrange follow-up office appointments. A physician is always available to back her up quickly if she has questions, and she can arrange admission to a hospital under the physician's name if necessary.

"Just taking the calls one weekend a month definitely helps," said Marc R. Shepard, ACP-ASIM Member, one of the practice's internists.


Some physicians hold regular meetings with their NPs or PAs to monitor their performance. Others catch them on the fly, during chart reviews or only when there's a problem.

Dr. Shepard, for example, said he gets a question from Ms. Carreiro about once per half-day session. He goes over Ms. Carreiro's charts after each session, asking questions as necessary.

Dr. Lee-Rugh doesn't hold scheduled meetings with her practice's new PA, but they often speak during daily chart reviews, discuss cases throughout the day and write their progress notes in the same area of the office.

Typically, physicians say they build a rapport with their midlevels, trusting them to call for assistance when necessary. "After a while, you pick up their style," Ms. Carreiro said.

In fact, Dr. Shepard says he rarely disagrees with Ms. Carreiro's decisions. He said he only ocassionally substitutes a medication, for example, or disagrees with a decision to refer. "I think she usually makes great decisions," he explained.


Most midlevels function as employees, not partners. Some practices, however, offer incentives or bonuses based on productivity. Elizabeth Woodcock, an Atlanta-based practice management consultant, suggested that your midlevel compensation plan mirror the plan physicians use, albeit with different targets.

If you're interested in basing compensation on productivity, you might use ambulatory encounters, charges or work RVUs as targets. You can rely on industry benchmarks when available or establish internal benchmarks based on experience.

Start small and initially base no more than 10% of the midlevel's salary on incentives. If you base more than 30% of pay on incentives, Ms. Woodcock said, you might have more difficulty recruiting. She also suggested incorporating patient satisfaction or quality indicators into performance targets.

Be sure that the compensation plan matches the job description. If you want midelvels to spend time educating diabetes patients or performing well-woman physicals, it would be unfair to base incentives on high productivity targets.


Medicare will pay 85% of the normal physician fee when midlevels bill under their own provider number. Under certain conditions, a midlevel can bill "incident to" a physician's number, and you'll receive 100% reimbursement. To do so, the physician must be in the same suite when the midlevel sees the patient and must have seen that patient on the initial visit, said Carolyn Buppert, an NP and attorney who specializes in reimbursement issues.

Though Ms. Buppert believes the initial visit rule applies only to new patients, she said regulators have interpreted the rule to mean that physicians must first see even an established patient if he or she has a new condition. "If you want to be really sure," she explained, "go by the stricter interpretation until the government clarifies, which it has not."

Some private insurers have adopted a similar rule; others allow physicians to bill under their own name for all services performed by an NP or PA. Rules vary by state for Medicaid patients.

"If practices want to be absolutely sure, they have to ask each insurer," Ms. Buppert said.

Working with staff

If they're doing work similar to a physician, midlevels will need similar resources. A midlevel will probably work out of two exam rooms. A productive midlevel will need his or her own nurse or medical assistant, though in some cases two midlevels can share, Ms. Woodcock said.

Mr. Matthews suggested a practice orient the rest of the clinical and administrative staff. Let them know what a midlevel can do and what will be expected of the midlevel, such as which patients should be assigned to him or her.

You might have to rewrite job descriptions for other clinical staff. Nurses and medical assistants might now answer directly to the midlevel, and some responsibilities may shift. To avoid confusion and territorial disputes, let everyone know up front—and in writing—who will be escorting patients, giving injections, taking histories and performing physicals, Mr. Matthews said.

Patient reactions

Don't foget to talk to patients about your new staff. Place literature in the waiting area that explains what a midlevel does. Send letters to patients introducing the new provider. Consider holding an after-hours open house for patients, as you would for a new partner. Revise your practice brochure to include your new staff.

Your appointment clerks should tell patients whether they will be seeing a nurse practitioner or physician assistant. Midlevels, too, should educate patients—and in some cases continue educating them when they forget. It's not unusual for patients to use the word "doctor" even if they've seen the midlevel before.

In fact, Mr. Matthews said he believes that when a midlevel is first introduced into a practice and during all new patient visits, the physician should speak to patients to help them accept the midlevel. "Just pop your head in the door," he said. "It takes 10 seconds."

When Dr. Brantley first hired an NP in 1997, he believed the NP would see a patient and he would come in afterwards. But over time, his patients grew accustomed to seeing a nurse practitioner, and he no longer sees every patient. "My patients developed a trust in that NP," he said.

Other physicians, too, say that most patients quickly come around. "I think initially they hesitate, they'd rather see the physician," Dr. Lee-Rugh said. "But once they meet her and talk to her and realize she's competent, they have no problem."

Bryan Walpert is a freelance writer in Denver.


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