The Use of Advanced Practice Providers in a Medical Practice: Update 2020

Published on: March 13, 2020

Physicians work with advanced practice providers (APPs) in a variety of medical settings.
Advanced practice providers include physician assistants (PAs), and four classifications of advanced practice registered nurses (APRNs): nurse practitioners (NPs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). As the healthcare industry is experiencing an ever-increasing aging patient population, fewer physicians, is transitioning to value-based reimbursement, APPs are becoming vital to the success of team-based care. In this article we explore the qualifications of APPs, the benefits of employing APPs, as well as the impact they have on the role of physicians.

Advanced Practice Providers Training and Practice

Physician Assistants (PAs):

According to the American Association of Physician Assistants (AAPA): “PAs are educated at the master’s degree level. . . Incoming PA students bring with them an average of more than 3,000 hours of direct patient contact experience, having worked as paramedics, athletic trainers, or medical assistants, for example. PA programs are approximately 27 months (three academic years) and include classroom instruction and more than 2,000 hours of clinical rotations.” This enables them to be certified by the National Commission on Certification of Physician Assistants (NCCPA). All 50 states in the US license PAs.

Their scope of practice includes: (1) taking medical histories, (2) conducting physical exams, (3) diagnosing and treating illness, (4) ordering and interpreting tests, (5) developing treatment plans, (6) prescribing medication, (7) counseling on preventive care, (8) performing procedures, (9) assisting in surgery, (10) making rounds in hospitals and nursing homes, and (11) doing clinical research.

In May 2017, the AAPA passed the Optimal Team Practice (OTP) policy. According to AAPA, “To support OTP, states should eliminate the legal requirement for a specific relationship between a PA, physician or any other health care provider in order for a PA to practice to the full extent of their education, training and experience; create a separate majority-PA board to regulate PAs, or add PAs and physicians who work with PAs to medical or healing arts boards; and, authorize PAs to be eligible for direct payment by all public and private insurers.”

California – On October 9, 2019, Governor Gavin Newsom signed into law SB 697 drafted by Senator Anne Caballero which amended Business & Professions Code 3502 et seq. The bill was to address and revise several aspects of the Physician Assistant Practice Act. The signed bill removed the following requirements:

• The Physician Assistant Board makes recommendations to the Medical Board of California concerning the formulation of guidelines for the consideration and approval of applications by licensed physicians and surgeons to supervise physician assistants;
• The medical record identifies the responsible supervising physician and surgeon; and,
• Written guidelines for adequate supervision be established.

Delegation Agreements will be replaced with Practice Agreements to meet specified requirements and will require a Practice Agreement to establish policies and procedures to identify a physician and surgeon supervising a physician assistant rendering services in a general acute care hospital. Business & Professions Code 3501 (k) defines “practice agreement,” “. . . the writing, developed through collaboration among one or more physicians and surgeons and one or more physician assistants, that defines the medical services the physician assistant is authorized to perform pursuant to Section 3502 and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more physician assistants in the organized health care system. Any reference to a delegation of services agreement relating to physician assistants in any other law shall have the same meaning as a practice agreement.” Delegation Agreements issued before January 1, 2020 will be grandfathered in.

The revised statute also authorizes:

• “. . . a physician assistant to furnish or order a drug or device subject to specified requirements, including that the furnishing or ordering be in accordance with the practice agreement and consistent with the physician assistant’s educational preparation or for which clinical competency has been established and maintained;
• “. . . the physician assistant to furnish or order Schedule II or III controlled substances in accordance with the practice agreement or a patient-specific order approved by the treating or supervising physician and surgeon.”

To date, Alaska, Hawaii and Idaho have not embraced the OTP policy, but state PA chapters are considering it. PAs continued to be supervised in AK, CA, HI and ID where MIEC insures providers. The relationship is defined in a Delegation of Services Agreement or Practice Agreement as adopted via the OTP policy.

Advanced Practice Registered Nurses (APRNs):

APRNs are registered nurses who have had additional training and certification. Nurse practitioners usually complete a master’s degree program. CNMs undergo specialized training in a certificate or master’s program. CNSs complete an advanced training program in one medical specialty, such as oncology, pediatrics, obstetrics or neonatology. CRNAs are required to have specialized training and be certified by a national organization.

Nurse Practitioner (NP):

According to the American Association of Nurse Practitioners: “All NPs must complete a master’s or doctoral degree program and have advanced clinical training beyond their initial professional registered nurse (RN) preparation. Didactic and clinical courses prepare nurses with specialized knowledge and clinical competency to practice in primary care, acute care and long-term health care settings.”

“NPs are licensed in all states and the District of Columbia, and they practice under the rules and regulations of the state in which they are licensed. They provide high-quality care in rural, urban and suburban communities and in many types of settings, including clinics, hospitals, emergency rooms, urgent care sites, private physician or NP practices, nursing homes, schools, colleges and public health departments.”

Depending upon state laws and regulations, NPs practice autonomously and in collaboration with physicians and other health care professionals. They provide a full range of primary, acute and specialty health care services, outlined in their Scope of Practice for those NPs who work in collaborative relationship, including:

• Ordering, performing and interpreting diagnostic tests such as lab work and x-rays;
• Diagnosing and treating acute and chronic conditions such as diabetes, high blood pressure, infections and injuries;
• Prescribing medications and other treatments;
• Counseling; and,
• Educating patients on disease prevention and positive health and lifestyle choices.

The states of Alaska, Hawaii, and Idaho allow APRNs to practice independently, however, they must establish collaborative networks with physicians; California requires a collaborative relationship with a physician to be in place as defined in a APRN’s Scope of Practice.

Certified Nurse-Midwife (CNM):

Certified Nurse-Midwives are described by the American College of Nurse-Midwives®, as educated in both nursing and midwifery: “They earn graduate degrees, complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME), and pass a national certification examination administered by the American Midwifery Certification Board (AMCB) to receive the professional designation of CNM.”

“[Their] services include the independent provision of primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods; admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling.”

CNMs are licenses in all 50 US states and the District of Columbia.

Clinical Nurse Specialist (CNS):

The training for CNSs is like other Advanced Practice Registered Nurses. According to the National Association of Clinical Nurse Specialists, they specialize in:

• Population (e.g., pediatrics, geriatrics, women’s health);
• Setting (e.g., critical care or emergency room);
• Disease or medical subspecialty (e.g., diabetes or oncology);
• Type of care (e.g., psychiatric or rehabilitation); and/or
• Type of problem (e.g., pain, wounds, stress).

Current certification examinations based on population include: Adult/Gerontology, pediatrics, and neonatal.

Certified Registered Nurse Anesthetist:

The American Association of Nurse Anesthetists description of CRNAs training includes: “The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry; anatomy, physiology, and pathophysiology; professional aspects of nurse anesthesia practice; basic and advanced principles of anesthesia practice including physics, equipment, technology and pain management; research; and clinical correlation conferences . . . In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.”

The National Board of Certification and Recertification for Nurse Anesthetists (NBCR) administers the national certification examination that each graduate of a nurse anesthesia educational program must pass before he or she can be certified as a CRNA.

The AANA website advises, “CRNAs administer anesthesia and anesthesia-related care in four general categories: (1) preanesthetic preparation and evaluation; (2) anesthesia induction, maintenance and emergence; (3) postanesthesia care; and (4) perianesthetic and clinical support functions.”

For a comprehensive list of the CRNAs Scope of Process and Standards of Practice, click here and expand the clinical practice section.

Information about state laws and regulations as they apply to Advanced Practice Providers can be reviewed in the state-specific APP articles listed below:

• Alaska
• California
• Hawaii
• Idaho

Why Collaborate with Advanced Practice Providers? 

 There are definite benefits for APPs and physicians to work together. By forming a well-defined, highly collaborative relationship, physicians and APPs can successfully treat an expanding Medicare-eligible baby boomer patient population. By working in partnership with APPs, physicians can:  

• Increase productivity.  

 A working example: A two-physician oncology practice interviewed in the on-line publication ASCO Daily News discussed how they and their patients benefit from working with APPs. As APPs are becoming more common in oncology as a specialty, if used to their full competencies and capabilities, they can greatly enhance a healthcare team. Nurse practitioners and physician assistants in the interviewed practice, “. . . provide nearly all survivorship care in the office. They oversee most patients on maintenance chemotherapy as well as those on active induction or adjuvant chemotherapy. They take calls throughout the week, write prescriptions and orders, run the palliative care team, and, [according to the practice owner], ‘are seeing patients that physicians would have seen 20 years ago. They are hugely valuable.’ ” (August 14, 2019; https://dailynews.ascopubs.org/do/10.5555/ADN.19.190382/full/). 

• Provide greater access to care and high-quality outcomes. 

January 2019 data from the AANP, seven out of ten nurse practitioners provide patient care in general medicine, adult/geriatric, pediatrics and women’s health. They average three patients per hour.  

One 2011 study from the Journal of Oncology Practice found that APPs who work with more than one physician can increase productivity by up to 19%. 

The AAPA is of the position, PAs extend the care that physicians provide and increase access to care because they have been educated in the collaborative approach to healthcare. Studies have consistently shown that PAs provide high-quality of case and by incorporating PAs into office or hospital practice can improve outcomes. Studies have also shown that patients are satisfied with medical care provided by PAs. (https://www.aapa.org/career-central/employer-resources/employing-a-pa/) 

• Produce protective documentation. 

Liability specialists who conduct office surveys find that nurse practitioners and physician assistants tend to keep detailed and complete medical records. Most APPs have had the importance of documentation stressed in their training and know their performance reviews are based, in part, on the supervising physician’s review of medical records. 

• Help physicians and APPs increase their quality of life and personal wellness. 

By assessing the patient volume between practice physicians and APPs, the patient load can be divided more equally. As the previously cited oncologist opined, “It’s helped tremendously with my overall quality of life,” because he has more time to be with his family.  

Physicians can help avoid APP burnout by allowing them to practice at their competency level and not use them as “extenders.” Rather by challenging them to capacity, APP work satisfaction is enhanced and could produce superior patient care. 

Advanced Practice Providers Claims Data

Unfortunately, current data about the frequency and severity of APP claims is not readily available. In February 2014, MPL Associates (MPLA) published in the DSP Blackboard the article, “A Look into Advanced Practice Provider Medical Professional Liability Claims in the Data Sharing Project,” in which the organization reported on APP claims data between 2003 and 2012. MPLA Datasharing Project (DSP) formerly captured APP data pertaining to “Associated Personnel” in which the APP is endorsed under a physician’s policy or a specific specialty if the APP has his/her own coverage. Of the approximate 96,000 reported closed medical professional liability claims, APPS were named in 0.45%, “. . . while primary care physicians made up 21% of those total claims under the non-surgical specialties.”

From DSP Blackboard, February 2014:

Improperly performed procedures were the top chief medical factor for APPs (Table 1). With a 29% paid-to-closed ratio totaling over $10 million in total indemnity, it also reflects the largest payment of $3 million. The second chief medical factor was diagnostic errors with a 27% payment ratio and the highest average indemnity of $330,344. Although small in the number of claims, medication errors had the highest paid-to-closed ratio at 35%.

Table 1. Top Five Chief Medical Factors for Advanced Practice Providers 

CHIEF MEDICAL FACTOR APP ONLY	CLOSED CLAIMS	PAID CLAIMS	% PAID-TO-CLOSED	TOTAL INDEMNITY	AVG INDEMNITY	LARGEST PAYMENT
Improper performance	117	34	29.1	$10,561,794	$310,641	$3,000,000
Errors in diagnosis	99	27	27.3	$8,919,281	$330,344	$1,000,000
No medical misadventure	36	6	16.7	$1,144,530	$190,755	$900,000
Medication errors	34	12	35.3	$2,424,883	$202,074	$1,000,000
Failure to supervise or monitor case	25	7	28.0	$903,044	$129,006	$200,000

Among the claims that resulted in an indemnity payment, the top five outcomes are listed in Table 2 for APPs. Although broken tooth led in the number of closed claims reported, acute myocardial infarction and burn to the face, head, or neck equally had the largest number of paid claims (6) with relatively high paid-to-closed ratios. Malunion of fracture ranked third in the list of top outcomes and had a 100% payment ratio, totaling over $719,000 in indemnity. 

Table 2. Top Five Outcomes by Paid Claims for Advanced Practice Providers

OUTCOMES BY PAID CLAIMS APP ONLY	CLOSED CLAIMS	PAID CLAIMS	% PAID-TO-CLOSED	TOTAL INDEMNITY	AVG INDEMNITY	LARGEST PAYMENT
Myocardial infarction, acute	8	6	75.0	$1,931,667	$321,945	$1,000,000
Face, head or neck burn of	7	6	85.7	$615,500	$102,583	$402,500
Malunion of fracture	4	4	100.0	$719,900	$179,975	$504,000
Broken tooth	11	4	36.4	$12,726	$3,182	$6,000
Encephalopathy, not further defined	8	4	50.0	$1,187,500	$296,875	$500,000

Preventing APP liabilities 

Some of the leading reasons APPs are named as defendants in litigation include: they rendered a service beyond their capabilities; took an inadequate history; failed to consult with their supervising or collaborating physician when indicated and, as a result, failed to diagnose a condition; neglected to refer a patient; failed to follow established protocols; and improperly ordered or monitored medications. The liability risks for physicians who employ APPs can be minimized by developing and implementing reasonable protocols, guidelines, and policies for the hiring, supervising and reviewing of APPs. 

Of note: Based upon MIEC’s claims history and patient safety risk management experience, we strongly recommend that policyholders who employ and work with APPs develop and maintain a cohesive team and healthy physician-patient relationship with their patients. It is beneficial to the relationship if patients know their physician is part of an active team. The relationship is tested, and liability potentially increases when your patients feel abandoned after suffering an unexpected outcome such as an adverse medication reaction, an intraoperative complication that leaves them disabled or in chronic pain, a hospital readmission, and more. You avoid patient perception of abandonment when you address the issues. Your APP should certainly be part of the team treating the patient to recovery; however, we believe patient satisfaction is promoted and liability risk decreases if you as the treating physician meet first with your injured patient. 

Claims experience also reveals that surgeons reduce their risk and preserve their patients’ confidence and trust when the treating surgeons, rather than their PAs, see patients for the first post-operative visits. This gives the physicians an opportunity to evaluate the patients. More importantly it communicates to patients care and concern, allows them to ask any questions they may have as to outcome of the operation, recovery, and more. 

MIEC Recommendations 

1. Check an applicant’s credentials carefully before hiring; verify an APP’s credentials and prior experience as thoroughly as you would that of a physician. Ensure that their specialty mirrors yours so that you can supervise them.
   
2. Review state laws on licensure, scope of practice, and supervision of APPs.
   
3. As part of the APPs orientation to your practice, ensure that the APP is committed to your practice mission, culture and standards. Consider assigning a mentor to the APP and establish a probationary period of 30-day and 90-day performance reviews, together with on-going feedback about their performance after they are hired to ensure competence and promote the team model.
   
4. Introduce your APP to your new patients to solidify his/her role as a valuable member of the team. Explain a bit about their education and why their abilities complement your practice. Demonstrate your confidence in them as part of the introductory conversation.
   
5. Ensure that you develop a written practice agreement or Delegation of Services Agreement as defined by state statute for your PA, as well as a Scope of Practice to work with APRNs. To be successful, challenge you APPs to practice within their competency and training.
   
6. When building a healthcare team, behave like a team. Establish an “open door” policy with APPs to discuss their questions or concerns about treatment of patients. Hold huddles to ensure that everyone is on the same page about the recommended treatment plan. “Advertise” your team. Some ideas: Talk about them to patients; introduce your APPs on your website; hang pictures of your team in the reception area of your office; and develop team-work messaging throughout your office. 
   
7. Establish criteria for ongoing, periodic review of the APP’s documentation as mandated by the laws in your state. If your state laws are silent about periodic records review requirements, do not be reluctant to establish a criteria anyway.
   
8. Ask patients for feedback about their level of satisfaction with treatment by APPs.
   
9. Inform MIEC if you employ APPs; unlike some unlicensed office staff who may not have to be named on your policy, coverage of APPs requires an Underwriter’s approval; if the APP is not an employee, require that he or she has liability insurance with limits equal to your own.
   
10. If the APP is expected to see your hospitalized patients, get approval from the hospital or ask the APP to apply for privileges from the hospital’s medical staff.