2017 HSC Section 2 - Practice Management

164 / 240

complexity of the patients requires specialty manage-
ment. According to Kennedy, utilization of advanced
practice providers within the collaborative practice
model has the ‘‘potential to deliver an exceptionally high
level of care for chronic disorders.’’2 It is reported that
NPs may excel in assisting in the management of chronic
diseases as they are ‘‘trained specifically for health promo-
tion and education.’’16 Although the support models are
the least profitable, they may still increase revenue
through improving physician productivity. The need to pro-
vide efficient management of chronic disease will increase
as the use of episodic bundling payments becomes more
widespread posthealthcare reform implementation.
FUTURE DIRECTIONS
The integration of advanced practice providers into
clinical practice continues to be in evolution. The role of
a midlevel provider depends on the need of the physician
and group with which they are employed. 8 In addition,
the healthcare reform bill may create more demand for
specialty care through a greater number of insured
patients. Combined with a predicted shortage of otolar-
yngologist, the increase in insured individuals has the
potential to overwhelm the current otolaryngology work
force. 2 State law currently dictates the amount and type
of physician supervision given to advanced practice pro-
viders. 12 However, with respect to the current physician
shortage, the level of physician supervision may be
modified to help offset escalating healthcare demands.
There has been increased usage of midlevel pro-
viders in many medical specialties and is related to
shortage of physicians, expansion of practice parameters,
and increase in the number of practitioners being
trained. 6 For example, dermatology practices that utilize
midlevel providers increased 43% from 2002 to 2007.6
Academic practices, in particular, are most likely to
employ advanced practice providers compared with other
practice venues.6 Academic and tertiary referral centers
may employ more advanced practice providers due to
increased resources required for training and supervi-
sion.6 The collaborative practice model is ideal for
management of complex patients treated at tertiary aca-
demic centers.2
There are trends for greater level of autonomy and
additional postgraduate training. Residency programs
are available for advanced care practitioners who desire
additional training in subspecialized areas; however, no
current programs are available in otolaryngology.8,17
Although postgraduate training is not necessary for
advanced practice providers to work in an otolaryngol-
ogy clinic, a comfort level must be obtained before the
physician extender transitions to partial or near com-
plete independent practice. 2 We propose that a stepwise
progression through these effective use models may
function as a framework for informal ‘‘postgraduate
training’’ of physician extenders in otolaryngology.
Most information related to the cost effectiveness of
advanced practice providers relates to their use in pri-
mary care. A report from the American Academy of NPs
found that NPs have the potential to ‘‘decrease cost per
patient visit by as much as one-third’’ especially when
practicing in an autonomous capacity.18 A review of 206
physician providers revealed lower overall labor costs
per visit when advanced practice providers were used to
greater extent.18 Research supports that quality of care
and outcomes are similar between physician extenders
and physicians while providing savings of 25% in spe-
cialty areas.19 However, a recent economic analysis
revealed that as NPs gain greater autonomy and pre-
scriptive authority, their salaries will increase and cause
a reflexive decrease in physician salaries.20 This analysis
likely relates to the primary care scenario where there
are competing interests between NPs and physicians.
CONCLUSIONS
There are an increasing number of advanced prac-
tice providers in healthcare and in subspecialty fields
such as otolaryngology. As the presence of midlevel pro-
viders increases, physicians should be aware of the
practice management models available for incorporation
of these practitioners in an outpatient setting. We pres-
ent a framework of five utilization models to discuss the
incorporation of midlevel providers into an outpatient
otolaryngology clinic. These models may be of benefit to
physician practices by increasing revenue and efficiency
while also improving patient care and education.
Improvements in patient satisfaction are also important
as future changes to healthcare delivery may hinge
reimbursement on level of patient satisfaction. In sum-
mary, the addition of an advanced practice provider to
an otolaryngology practice may be beneficial for all
involved while helping to offset an increasing healthcare
provider shortage.
BIBLIOGRAPHY
1. Hooker RS. The extension of rheumatology services with physician assis-
tants and nurse practitioners. Best Pract Res Clin Rheumatol 2008;22:
523–533.
2. Reger C, Kennedy D. Changing practice models in otolaryngology—head
and neck surgery: the role of collaborative practice. Otolaryngol Head
Neck Surg 2009;141:670–673.
3. American Academy of Physician Assistants. 2008 Annual Census Report.
Available at:
Otorhinolaryngology08C.pdf. Accessed April 15, 2010.
4. America Academy of Nurse Practitioners. 2008 Annual Report. Available
at: 59DF-4964–819B-
61E58864B4F8/0/08AnnualReport.pdf. Accessed April 15, 2010.
5. Association of American Medical Colleges. 2006 Physician Specialty Data.
Available at: ¼
version67.pdf&prd_id¼ 160&prv_id¼190&pdf_id¼67. Accessed April 22,
2010.
6. Resneck JS Jr, Kimball AB. Who else is providing care in dermatology
practices? Trends in the use of nonphysician clinicians. J Am Acad Der-
matol 2008;58:211–216.
7. Laurant M, Harmsen M, Wollersheim H, et al. The impact of nonphysician
clinicians: do they improve the quality and cost-effectiveness of health
care services? Med Care Res Rev 2009;66(6 Suppl):36S–89S.
8. Ward WT, Eberson CP, Otis SA, et al. Pediatric orthopaedic practice manage-
ment: the role of midlevel providers. J Pediatr Orthop 2008;28:795–798.
9. Ho P, Pesicka D, Schafer A, et al. Physician assistants: trialing a new sur-
gical health professional in Australia. ANZ J Surg 2010;80:430–437.
10. American Academy of Physician Assistants. Incident-to-billing. Available
at:
medicare/889-incident-to-billing. Accessed August 28, 2010.
11. Center for Medicare and Medicaid services. Medicare carrier manual: part
3—claims process. Available at:
downloads/R1764B3.pdf. Accessed August 28, 2010.
12. American Academy of Physician Assistants. Physician Assistants In Oto-
laryngology. August 2006. Available at:
ries/IssueBriefs/Specialty%20Practice/PAs%20in%20Otolaryngology%20-
%202010.pdf. Accessed August 28, 2010.
Laryngoscope 121: November 2011 Norris et al.: Physician Extenders in Otolaryngology
142