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DISCUSSION
We propose a framework of five practice models for
the integration of advanced practice providers into an
otolaryngology practice (Table I). These models are
scribe, collaborative, limited independent, partial inde-
pendent, and near complete independent practice. The
models encompass the majority of current practice
arrangements and are divided primarily based on the
autonomy level of the physician extender in a support
role or more independent practice. The models are fur-
ther defined based on the billing number used and the
location of the physician. All five models may be
employed in either an academic or private practice set-
ting, although certain aspects of each model may
dictate what practice type is best. These practice man-
agement models may be instituted in isolation or as a
continuum of methods to facilitate improved and more
cost effective healthcare.
Although this manuscript details useful methods
for integration of midlevel providers into an outpatient
clinic setting, it is recommended that the practice be
aware of all applicable laws governing physician extend-
ers as these vary by state. In particular, billing practices
should be reviewed and Medicare and Medicaid regula-
tions should be followed. Practice compliance officers
should verify the proper integration of advanced practice
providers. The purpose of this manuscript is to supple-
ment, not supersede, regulations governed by the state.
Scribe
The first and most basic model for advanced prac-
tice providers is the scribe format. In this model the
midlevel provider shadows the physician and completes
clerical tasks. The scribe model is especially useful for
the orientation of new hires or the transition of
advanced practice providers from other subspecialties to
the field of otolaryngology. This model allows the physi-
cian extender exposure to otolaryngology protocols and
physician preferences. By completing clerical tasks par-
ticularly during the transition to electronic medical
records, the scribe model may promote physician efficiency
and increase revenue. In primary care, documentation
and patient’s records are found to be ‘‘significantly better
kept’’ when assistants such as NPs are involved with
patient care.
7
In addition, the midlevel provider may
provide assistance with basic in-office procedures. As the
knowledge base of the midlevel provider increases they
are promoted to greater degrees of responsibility and
autonomy.
Collaborative Practice
The second support model is one of collaborative
practice. Collaborative practice refers to advanced prac-
tice providers functioning as a team member working
alongside staff physicians.
2
Utilized in this capacity, the
midlevel provider gathers important information during
the patient care encounter and relays this to the attend-
ing physician. The physician processes the information
and functions as the manager of a medical team. Ward
describes this model as ‘‘first-in-the-room provider’’ to
emphasize the order of appearance of the healthcare
personnel.
7
Although this description is technically accu-
rate, it fails to acknowledge the collaborate effort
necessary for successful implementation of this model.
To function effectively, the advanced practice provider
employed in this model must be able to proficiently
obtain, synthesize, verify, and institute complex informa-
tion from the patient care encounter.
The collaborative practice model uses the physi-
cian’s billing number. Although not directly reimbursed
for their services, the advanced practice provider helps to
generate revenue by increasing the productivity and effi-
ciency of the staff physician. The staff physician is able to
see a greater number of patients and spend more time
performing procedures. In general, a physician extender
utilized under this model can promote substantial
increase in patient encounters resulting in a net gain to
the practice. In primary care, the literature supports
increased productivity with use of PAs in a support role.
7
It is important in this scenario to appropriately document
that the physician performed all work independently
required to support the coding level submitted.
Limited Independent
Independent practice for midlevel providers refers to
conducting patient visits and instituting treatment plans
without the direct involvement or presence of a physician.
However, independent practice is performed under a given
set of predetermined protocols and supervised by attending
physicians through a review process. According to the Con-
gress Office of Technology Assessment, advanced practice
providers can provide independent care equal to that of
physicians that is ‘‘within the limits of their expertise.’’
8
Although the independent models do not directly affect
physician productivity, physician extenders may improve
practice efficiency by catering to walk-in and overflow
patients. The independent models for effective use of phy-
sician extenders include limited, partial, and near
complete independent practice.
TABLE I.
Utilizations Models for Physician Extenders.
Support
Independent
Model
Scribe
Collaborative
Limited
Partial
Near complete
Billing number used
Physician
Physician
Physician*
PE
PE
Physician in room
Yes, simultaneous
Yes, second in
No
No
No
Physician in building
Yes
Yes
Yes
Yes
No
*Incident to billing.
PE
¼
physician extender.
Laryngoscope 121: November 2011
Norris et al.: Physician Extenders in Otolaryngology
140