Hospital based NP's.

Advanced Practice Columnist / Guide · May 10, 2007

From what I've been hearing from NP colleagues, a lot of the changes in terms of introducing hospital-based mid-level providers came from the hospital administration themselves. In one example I know of, a group of NP's and PA's in an academic institution are in charge of IM patients who are under private practice docs. They admit patients from the ER and manage day-to-day patient issues until discharge. This group claims that since they started, length of stay has improved, patient transition from ER to floor had been made much smoother, and discharges have never been delayed because the attending hasn't rounded or prescriptions have not been written for. Diagnostic tests have been expedited as well. They are even starting to train this group to place PICC lines with US guidance as there has been a backlog with Interventional Radiology as far as PICC placements. I guess regardless of who bills for what, the improved hospital experience for patients and the decreased length of stay has been well worth it for this hospital. It is however, bad business for these private practice docs because mid-levels have basically taken over much of their work. Although one can also infer that on a positive note, that this will free the docs of the scut-work required in managing in-patients allowing them to focus more on their clinic patients.

In another setting I am aware of, a group of 14 private-practice cardiologists in a well-known cardiac hospital have hired 3 NP's who carry the service beeper and respond to consults (ER, floors, ICU's) and admissions. The cardiologists are basically busy in the cath lab or in the clinic so this allows timely coordination of their service in terms of consults being seen right away, patients being admitted and out of the ER in a timely manner, and discharges being carried without delay - very similar to the scenario I pointed above.

core0 · May 10, 2007

from what i've been hearing from np colleagues, a lot of the changes in terms of introducing hospital-based mid-level providers came from the hospital administration themselves. in one example i know of, a group of np's and pa's in an academic institution are in charge of im patients who are under private practice docs. they admit patients from the er and manage day-to-day patient issues until discharge. this group claims that since they started, length of stay has improved, patient transition from er to floor had been made much smoother, and discharges have never been delayed because the attending hasn't rounded or prescriptions have not been written for. diagnostic tests have been expedited as well. they are even starting to train this group to place picc lines with us guidance as there has been a backlog with interventional radiology as far as picc placements. i guess regardless of who bills for what, the improved hospital experience for patients and the decreased length of stay has been well worth it for this hospital. it is however, bad business for these private practice docs because mid-levels have basically taken over much of their work. although one can also infer that on a positive note, that this will free the docs of the scut-work required in managing in-patients allowing them to focus more on their clinic patients.
i can see this in an academic institution but these are in private practice. we have two spinal surgery np's (different hospitals). they are both employed by the hospital. most of their role seems to be educational, what traditionally has been the role of the cns. it may just be that they hired np's into this role. i guess if you could decrease los enough it would pay for itself, but that has a lot of variables.
in another setting i am aware of, a group of 14 private-practice cardiologists in a well-known cardiac hospital have hired 3 np's who carry the service beeper and respond to consults (er, floors, icu's) and admissions. the cardiologists are basically busy in the cath lab or in the clinic so this allows timely coordination of their service in terms of consults being seen right away, patients being admitted and out of the er in a timely manner, and discharges being carried without delay - very similar to the scenario i pointed above.

this is how our cardiologists work. the issue with np's as hospital employees is two-fold. one is the hospital providing something of value for the physician. if they are this would be a stark violation. i would think that as long as they do not bill for the np services they would be ok (not sure about this though). also if providing the np was tied to a certain number of admissions then this would be a stark violation. the other point is that if the physicians were smart they would hire these np's and collect on the billing. while this doesn't work in surgery, it would definitely work in medicine.

david carpenter, pa-c

Advanced Practice Columnist / Guide · May 10, 2007

This is how our cardiologists work. The issue with NP's as hospital employees is two-fold. One is the hospital providing something of value for the physician. If they are this would be a Stark violation. I would think that as long as they do not bill for the NP services they would be OK (not sure about this though). Also if providing the NP was tied to a certain number of admissions then this would be a Stark violation. The other point is that if the physicians were smart they would hire these NP's and collect on the billing. While this doesn't work in surgery, it would definitely work in medicine.
David Carpenter, PA-C

Again, I didn't ask the details on how the billing is done by this cardiology group. What I know is that the NP's are employed by the private practice group and that Medicare requires that if an NP completes a consult, the billing should be under the NP's name regardless of whether the physician was involved in the process. The NP's are credentialed by the hospitals where the group sees patients in. Word is, they are asking to hire more NP's.