A key to the positive results was likely the training provided to the studied physical assistants, says an author.

Dec. 16—Integrating more physician assistants (PAs) into a conventional hospitalist practice in a community hospital saved money without sacrificing quality of care, a recent study found.

The study in the October issue of the Journal of Clinical Outcomes Management compared two hospitalist groups practicing in a 384-bed community hospital, Anne Arundel Medical Center in Annapolis, Md. One group staffed at a higher PA-to-physician ratio model, employing three physician and three PAs who rounded with 14 patients a day (nearly 36 percent of all visits), while the other staffed a lower PA-to-physician ratio model of nine hospitalist physicians using two PAs. In that group, the PAs were rounding with nine patients a day (6 percent of all visits).

The study looked at 16,964 adult patients discharged by the hospitalist groups between January 2012 and June 2013 and adjusted for age, acuity, and mortality risk for statistical evaluation.

Timothy Capstack, MD, the study's lead author and medical director of a hospitalist staffing firm, Adfinitas Health, cautioned that while it was a single study at a single location, the results should be replicable in other hospital environments.

The study found no statistically significant differences between the two hospitalist groups in patient mortality, readmissions or length of stay, but learned that the cost of care per patient was $80 less in the expanded PA group, $2,644 versus $2,724.

Hospitalists earn $250,000 annually, compared to $110,000 for PAs, he said.

“So you're getting more bang for your buck,” Capstack said.  “The big win is in the comparative salary department.”

Capstack said that the medical community has debated the roles NPs and PAs should play within hospitalist settings.

“We are not advocating they should practice independently outside of this collaborative role,” said Capstack. “But in a market with not enough physician hospitalists, this model offers another potential way to have hospitalist roles covered in these institutions.”

“The need for hospitalists is expanding and the number of physicians entering the field has not kept pace,” Capstack said.

Capstack said it's important to know that in the study, it wasn't the number of PAs in the two groups that accounted for the difference, but how they were used.

“In our group, the PAs accounted for 36 percent of patient encounters, versus 6 percent in the other group,” he said.  “We're not implying superiority, just non-inferiority. There's an impression in some parts of the medical community that these patients are too sick for PAs and NPs and would prefer physicians alone. We're saying that's not necessarily the case.”

Expanded Roles

Training and education make the expanded roles possible.

“You can’t just go out and hire an NP or PA off the street and have them succeed in this model,” Capstack said in an interview. “The education and collaboration with hospitalists in hospital settings is critical.”

Newly graduated PAs or NPs, or those new to hospital medicine, undergo a rigorous six-month training and collaboration period that includes 10 eight-hour classroom sessions, Capstack said. The specialized training program is modeled from the Society of Hospital Medicine (SHM). Besides the classroom work, new hires are paired with experienced hospitalist physicians and given escalating responsibility of caring for sicker patients in more complex settings. 

Study co-author Joseph Moser, MD, was at Anne Arundel Medical Center during the study period but now serves as CMO for the 120-bed University of Maryland Charles Regional Medical Center.

The group with the extra NPs, Moser said “paid close attention to the training and development of these PAs and developed both the didactic and mentoring programs with them and carefully picked who would participate.”

“The PAs are our front line at Charles Regional, the first contact with patients, and the providers who spend most of the time with patients,” Moser said. “The physicians make rounds as well and provide back up and answer questions. It's an efficient way to utilize each profession because each is working at the top of their skill levels and credentialing. The hospital is gaining the same results at a cost-effective level.”

Moser said patients are briefed about the PAs in advance and told they can see a physician and ask questions.

“One study is rarely the definitive way to decide anything.  We hope to see others do studies to corroborate what we did, Moser said.

Study Reception

Michael Renzi, MD, CMO at the Marlton, N.J.-based revenue cycle management firm, Continuum Health Alliance, said the study confirms that the goal should be staffing to the top of capability, as opposed to staffing to the top of credentials.

 “PAs can be empowered to perform at the same level as physicians in many areas of medicine, including hospitalists,” said Renzi in an interview.

One barrier can be physician acceptance of the expanded roles of advanced practice providers, Renzi acknowledged. 

“Some physicians resist it,” Renzi said. “But they have to be held to the same cost standards as any other business. This model offers a solution so these programs can avoid tremendous financial losses without sacrificing quality."

Patrick Vulgamore, director of practice management and governance at SHM, said more than 50,000 hospitalists work in the nation's hospitals. In 2010, the Medical Group Management Association (MGMA) reported median compensation for hospitalists was $215,000, rising to $252,996 in 2014 and $278,746 this year, Vulgamore said.

“Compensation continues to rise dramatically, showing us demand remains high, outweighing the number of available hospitalists,” Vulgamore said in an interview.

Nearly two-thirds of all hospitalist groups use PAs and NPs in their practices, he said.

“Extending NPs and PAs to do things that traditional physician providers have done engages everybody and allow everyone to practice at the top of their level and lets physicians focus more on challenging patients,” Vulgamore said.

Emilie Thornhill, a PA who chairs SHM's NP/PA Committee, said those providers integrate well into multi-disciplinary hospitalist team settings.

State laws vary in regulating the scope of advance practice providers. For instance, some states do not allow PAs to prescribe drugs, Thornhill said.

The recent study “puts into words what many hospitalist teams are already seeing,” Thornhill said in an interview. “In my group (New Orleans’ Ochsner Medical Center) we've gone from two NP/PAs to 12 and have seen overall good outcomes across the board with high patient satisfaction. Most hospitals will see that adding an NP/PA to their hospitalist practices is immediately cost effective.” 

Mark Taylor is a freelance writer based in Chicago. 

Publication Date: Friday, December 16, 2016