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You And Midlevel Providers – A Good Fit?

You And Midlevel Providers A Good Fit

September 16, 2015

Not every doctor is comfortable working with an NP, PA, or nurse midwife. But for those who are, the benefits can be substantial.

Some primary-care doctors swear by midlevel providers; others swear at them. As the Medical Economics Continuing Survey makes clear, the younger the doctor and the fewer years he’s been in practice, the more likely he is to use a nurse practitioner or physician assistant (see article beginning on page 141). Why the reluctance in the part of older doctors? As Dorthy Parker once quipped, “You can’t teach an old dogma new tricks.” Doctors who have been in practice for decades may insist that only a full-fledged physician has the skill to be entrusted with patient care, and that when patients come to a doctor’s office, they expect to see the real McCoy. For a growing number of younger primary care physicians, though, this thinking is outdated – even self-destructive. They realize that having mid-level providers on their staff has these major benefits.

An expanded practice. NPs, PAs, and certified nurse midwives can handle most routine primary-care problems, freeing you to see more patients. In fact, the patient load that many groups and health plans expect a primary-care physician to carry would be onerous, if not impossible, without the help of physician extenders.

Cost-effectiveness. NPs and PAs can perform up to 80 percent of the tasks a physician can, but they generally earn $40,000 to $70,000 a year, or a fraction of what primary care MDs and DOs earn.

Freedom to go beyond the routine. Middle-aged doctors often become bored with their practices. But if you let a midlevel handle the lumps-and-bumps needs of your patients, that frees you to focus on the more complex and interesting cases. Or you can use the extra time to develop expertise in an area of medicine that interests you.

Improve patient access. Some patients may insist on seeing a physician – until they learn that a busy, popular doctor is booked solid for the next three weeks, while the midlevel provider has an opening today. When patients know they’ll receive immediate medical care, that dispels much frustration and anger. As a result, patient satisfaction increases. So does patient loyalty.

On the other hand, midlevel providers present economic and interpersonal challenges. So before you call a headhunter or place a help-wanted ad, you’ll need to answer some tough questions about adding a physician extender to you staff:

Do you have enough patients? If you don’t now, are there enough patients in your area so that your midlevel will be at full speed in six months to a year? (You may want to hire a practice management consultant to help assess this potential.) An NP, PA, or CNM is valuable only if kept profitably busy.

Also, an idle employee is a bored employee. And bored employees can lead to morale problems: A single disgruntled employee can destroy an entire staff’s espirit de corps.

If your productivity isn’t high enough right now to justify adding a midlevel provider, consider building your practice by extending office hours for six months or so. That way, you’ll build a solid patient base for a physician extender.

Can you supervise effectively? Physicians often expect a newly hired NP, PA, or CNM to know by psychic divination how to do her job. Then, when it turns out she doesn’t, the doctors blow a fuse. Being a mind reader isn’t part of a midlevel provider’s job description. Clarify her responsibilities, how you want things done and when she should come to you for help. Clue her in on how to handle difficult patients. These instructions will avoid frustration and disappointment for everyone.

But don’t micromanage her every move. If after a few weeks of working together, you still lack confidence in her basic skills, you have either the wrong person or the wrong temperament for this collaboration.

Can you regard her as a colleague? Even though you’re the boss, an NP, PA, or CNM is a valued teammate, not simply an underling. If you can’t come to terms with this concept, then you’re setting the stage for failure. Invite the extender to call you by your first name in private. This lays the groundwork for an amicable working relationship. Paying a compliment when deserved also helps.

Can you provide the right motivation? The wrong compensation plan will discourage hard work. You’ll run into problems if your practice insists on paying a midlevel a flat salary. This type of pay arrangement is the same energy deflator for physician extenders that it is for physicians. For maximizing productivity, your practice must be flexible enough to pay a base salary plus an incentive.

One of our client practices set up an effective pay plan for its midlevels by modeling it after the group’s physician pay plan. The practice sets salary targets for its primary-care physicians. Seventy percent of the target salary is fixed, and the rest at risk. Doctors can earn as much as 130 percent of their target. So there’s a 60-percent swing in what a physician could earn in a given year, depending on how productive he’s been.

Because midlevel providers’ base salaries are only one-half or less of what physicians earn, they can’t assume a commensurate amount of risk. So the group pays them a base salary of 90 percent of their compensation target, but they can earn as much as 110 percent – a 20 percent swing – if they’re highly productive. While compensation formulas for physicians may vary, those proportions make sense.

Can you evaluate her performance? Physicians are rarely trained to asses staff performance; the vary idea can make them squirm. You’d better be willing to develop this ability. Providing feedback is essential if a midlevel provider is to hone her skills and offer the trouble-free collaboration you need to build your practice. Attend a CME course on employee evaluations. To find one, check with your specialty society or the American College of Physician Executives in Tampa (phone: 813-287-2000; Web site: for one that’s convenient for you.

A midlevel provider should be judged on how she improves three areas: patient access, practice productivity, and patient satisfaction. For the first year, conduct performance reviews about every six weeks. After that, only once or twice a year is necessary.

This article was published by Cejka Search and originally appeared in Medical Economics Magazine. Copyright by Medical Economics Company Inc. at Montvale, NJ 07645. All rights reserved.