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The use of mid-level providers is an important strategy for practice efficiency, and the benefits of their use were described in the last issue of the Journal of Oncology Practice (July 2005). In brief, mid-level providers—primarily nurse practitioners and physician assistants—help to enhance the quality of care, increase patient satisfaction, lower costs, and increase revenue.
The decision to add a mid-level provider to an oncology practice requires careful consideration of several factors. First, the oncologist should research state regulations and reimbursement rules. Prescribing authority for mid-level providers varies across the United States, with some states allowing these providers to write prescriptions for all medications, including controlled substances, and others requiring a physician signature on prescriptions. In addition, not all states allow mid-level providers to order tests or to bill independently for their services. Lastly, some states require that a physician be onsite with a mid-level provider at all times, while other states allow that the physician be available by phone. These requirements also differ between physician assistants and nurse practitioners, and the state regulations may influence which specialty a practice decides to hire.
Once the decision has been made to bring on a mid-level provider, the oncologist must determine how that person will function within the practice. The issue of roles within a practice is one of the biggest problems with integrating mid-level providers, says Rebecca Hawkins, MSN, ANP, AOCN, of St. Mary Medical Center, Walla Walla, Washington, who worked as a clinical nurse specialist/nurse practitioner in an oncology practice for 13 years. “Physicians need to consider where gaps in care are and how the mid-level provider can help fill the gap,” she says. She adds, “Many physicians expect the mid-level provider to know what to do. There's a lot of frustration because the physician expects the mid-level to hit the ground running, while he or she is waiting for the physician to take the lead. Roles and responsibilities need to be articulated.”
Not all mid-level providers will function the same way within a practice. For example, Hawkins says that the oncologist she worked with preferred to see all new patients, and she saw patients for routine follow-up. In contrast, Steven Foltz, MS, PA-C, of St. Luke's Hospital, Duluth, Minnesota, sees all new patients in the oncology practice where he has worked for 5 years. Foltz conducts a history and physical examination for each new patient before the oncologist meets with the patient to discuss treatment. In addition to his responsibilities in the office, Foltz also participates in hospital rounds. Other mid-level providers only do hospital rounds, whereas some remain in the office or outpatient clinic. “It's all about what works best for the physician and the practice,” Hawkins says.
Education and experience are important considerations when hiring a mid-level provider. “Some physician assistant or nurse practitioner programs provide an oncology focus, but they're a luxury, not a necessity,” says Hawkins. She explains, “Mid-level providers in an oncology setting spend a great deal of time managing medical problems, so a general background is valuable.”
Extensive training or orientation within the practice is essential for a mid-level provider to be successful. When Foltz began at St. Luke's, Ron Kirschling, MD, was operating a solo practice. Because of this, Foltz says his training and orientation were not “formal.” However, in the beginning, he saw every patient with Kirschling, who took the time to explain the logic behind his decisions and actions. “You need a good teacher,” Foltz notes. In addition, Foltz read and researched as much as he could and enrolled in a self-study program in hematology/oncology at the University of Wisconsin.
One barrier to successfully integrating mid-level providers is a physician's resistance to delegating responsibilities. “It takes physicians who are willing to let go,” says Hawkins. “A physician has to want a collaborative practice and needs to understand that a mid-level provider will actually allow for seeing more patients, not fewer.” Foltz adds that delegating usually increases over time. “As the physician becomes more confident in the skills of the mid-level provider, he or she can delegate more. As my skills improved and Dr. Kirschling's confidence grew, he became to depend on me more and more,” he says. Many oncologists' only previous experience collaborating with other providers comes from their experience as faculty members in training programs, in which the faculty must duplicate, for billing purposes, the activities already performed by the medical student or resident. This experience translates to mid-level provider use in the introductory period but is not an efficient model as time progresses.
Another important point is how the mid-level provider is introduced to patients as well as colleagues. “When I joined the oncology practice, the physician sent a letter of introduction to patients, and I shadowed him in my first weeks so that I could meet all the patients,” says Hawkins. Foltz adds that a patient's acceptance of his role was particularly good if he met the patient on the first visit. “It's important to establish the relationship from the very beginning,” he says.
Highlighting the collaborative nature necessary for optimum integration, Hawkins notes that she was introduced to the oncologist's colleagues as a partner. “I also introduced myself to the laboratory staff and other departments and participated in tumor boards. You need to make formal connections.”
Hawkins admits that some physicians aren't comfortable with the model and it may not work for everyone. But the benefits, both she and Foltz think, make it a sound decision. “It can be successful,” says Hawkins, “if you have good forethought, planning, and excellent communication.”
For a mid-level provider to be integrated successfully into an oncology practice, oncologists must be willing to
American Academy of Physician Assistants (AAPA)
Membership numbers more than 33,500 physician assistants in all practice settings.
Association of Physician Assistants in Oncology (APAO)
Affiliated with AAPA; members practicing in clinical and research settings in oncology.
American Academy of Nurse Practitioners (AANP)
Represents more than 80,000 nurse practitioners in all settings.
Oncology Nursing Society (ONS)
Membership includes more than 30,000 registered nurses, including advanced practice nurses, working in oncology settings.
Many medical schools have nurse practitioner and physician assistant training programs. Program directors are also good sources of information on program graduates or may direct you to their program's placement office.