Practice Management Curriculum

Effectively Integrating Non-physician Practitioners in Oncology

Practice

After this session, you will be able to:

• Describe the types of non-physician practitioners in oncology practices;

• Identify important elements of state scope of practice and the specifics in your state;

• Discuss a variety of practice models for non-physician practitioners in oncology practices;

• Know the rules for billing for non-physician practitioner services; and

• Understand the value of non-physician practitioners and how to successfully integrate them into your practice.

Who are Non-physician Practitioners?

• Non-physician practitioner (NPP) is the Medicare term

• Also known as physician extenders, mid-level providers

• In oncology, typically refers to nurse practitioner or physician assistant; sometimes clinical nurse specialist

Benefits of Using NPPs

• Increase new patient capacity and overall patient volume at less expense than adding a new physician– NPP can see follow up patients creating time for physician to see consultations and new patients

Impact of NPPs on Physician Productivity

New patients / FTE medical oncologist

Barr, T, Towle, E, Jordan, W: The 2007 National Practice Benchmark: Results of a National Survey of Oncology Practices. Journal of Oncology Practice 4:178-183, 2008

More Benefits

• Generate practice revenue when physicians are out of the practice– Chemotherapy and other services can be rendered incident to an NPP

– Do careful financial analysis when billing services using the NPP provider #

• Payment is at 85% of the physician fee schedule rate

• Serve as clinical resource for nurses, other staff and patients when physician not available

Enhance Patient Satisfaction

• Reduce patient wait times– NPPs frequently add flexibility to the appointment schedule

– Patients can get appointments sooner and help decrease wait time in lobby

• Increase time spent with patients• See urgent problems in a timely manner

Patient Satisfaction

• More than 60 percent of group practices (all specialties) now employ NPs and PAs, and most enjoy gains in patient satisfaction, productivity, and income as a result.

• Studies show that more than 90 percent of patients who see NPs or PAs are satisfied with their care, and observe that these providers have good listening and counseling skills.

Duke University, Summer 2002

Physician Satisfaction

• 2006 Survey of Clinical Oncologists, Forecasting the Supply of and Demand for Oncologists

• 56% of respondents work with NPs and/or PAs– 30% work with NPs/PAs in “traditional scope of practice roles”: patient education and counseling, pain and symptom management, manage patients during visits

– 26% work with NPs/Pas for “more advanced procedures”: assisting with NP consults, ordering routine chemotherapy, performing invasive procedures

Physician agreement with statements regarding use of

NPs/PAsTraditional Role

Advanced Role

Increases the efficiency of my practice

70% 92%

Allows me to spend more time on complex cases

73% 87%

Contributes to my professional satisfaction

66% 85%

Improves overall patient care

69% 88%

Oncology Workforce

• ASCO workforce study predicts a “state of acute shortage” of oncologists by 2020– Number of oncologists is projected to increase by 20% BUT need for oncology services will increase by 48% resulting in overall shortage

– Increased use of NPPs is one strategy

Erikson C, Salsberg E, Forte G, et al: Future supply and demand for oncologists. Journal of Oncology Practice 3:79-86, 2007

NP and PA Growth

• Dramatic growth in number of PAs and NPs between 1999 and 2005– 55% growth in number of PAs– 61% growth in number of NPs

• American Academy of Physician Assistants (AAPA) projects continued PA workforce growth of 49% between 2005 and 2014

• Continued growth of NP workforce less certain

Nurse Practitioner

• Registered Nurse with advanced education and clinical training in a health care specialty area– Medicare requires Master’s degree in nursing

• Practice under the rules and regulations of the Nurse Practice Act of the state in which they work

• Practice independently and/or in collaboration with other health care professionals

• Prescriptive authority is specific to each state

Nurse Practitioner

• Services may include– Diagnosing, treating, evaluating and managing acute and chronic illness and disease

– Ordering, conducting, supervising and interpreting diagnostic tests

– Prescription of pharmacologic agents and non-pharmacologic therapies

– Counseling and educating patients on health behaviors, self-care skills and treatment options

Nurse Practitioner

• Credentialed through a variety of organizations including American Nurses Credential Center, American Academy of Nurse Practitioners, Oncology Nursing Certification Corporation– Re-certification required every 5 – 6 yrs– Continuing education requirements

• Many practices provide financial support for certification and continuing education

Physician Assistant

• Health care professional licensed to practice medicine with physician supervision– Increasing number of states are requiring Master’s Degree; not required by Medicare

• Specific duties vary with training, experience and state law

• Scope of practice corresponds to the supervising physician’s practice– Licensure and regulation generally governed by Board of Medicine

Physician Assistant

• Services may include– Diagnosing and treating illnesses– Conducting physical examinations– Ordering and interpreting tests– Counseling on preventative health care– Assisting in surgery– Writing prescriptions (in 49 states)

Physician Assistant

• Certification is through the National Commission on Certification of Physician Assistants (NCCPA)– Designated PA-C (Physician assistant-certified)

– Initial certification, renewal every 6 years

– Continuing education requirement

NP or PA?

• Education and training– PA: Bachelor’s Degree or Master’s Degree; educated in the medical model designed to complement physician training

– NP: Master’s Degree required in most states; nursing model

• Supervision or collaboration– PA: All states require some level of supervision; most (not all) allow electronic communication

– NP: Some states allow independent practice; 28 states require collaborative practice agreement with a physician

NP or PA?

• State Scope of Practice– PA: generally licensed/regulated by Board of Medicine

– NP: generally licensed/regulated by Board of Nursing

– State scope of practice varies widely from state to state for both NPs and PAs

• Prescriptive Authority– Like scope of practice, wide variation between NPs and PAs, and from state to state

NP or PA?

• Payer issues– Most - but not all - payers recognize both NPs and PAs; you must know your payer market

• Practice model – Physician experience, preference– Acceptance by staff

• Community norm– Acceptance by patients, referring physicians

– Job description, duties, goals

NP or PA?

• Background– Many NPs interested in oncology have an oncology nursing background

– May have been an OCN-certified RN, then received advanced training as a nurse practitioner

– Look for the AOCN certification

Your State

• State specific information on scope of practice, licensure and prescriptive authority is included in your meeting materials

How common are NPPs?

• 2006 Survey of Clinical Oncologists (from Forecasting the Supply of and Demand for Oncologists, 2007)

– 56% of respondents reported that they work with NPPs

• Onmark Office-based Oncology Business Benchmarking Survey, 2007 report– 49% of respondents work with NPPs– Average of 0.5 NPP / FTE physician

• Oncology Metrics’ National Practice Benchmark, 2008 report– 62% of respondents work with NPPs– Average of .46 NPP / FTE physician

Practice Models

• Practice models vary– Work with all physicians

• See all patients as determined by practice

– Work one-on-one with a single physician– Team with small group of physicians

• In many practices, NPPs see patients independently

– Physicians are available but do not participate in every visit

– NPPs have a separate patient schedule

Practice Models

• Focus on patient education– In some practices, NPPs do a pre-chemotherapy evaluation that replaces the nursing chemo class or teaching visit

– A billable event when performed by NPP and appropriately documented

– Introduces the NPP early in the care cycle as the resource for chemotherapy side effects, problems

Practice Models

• Disease specific models– Breast center– Bone marrow transplant

• Clinical Research– Function as sub-investigator to the PI

• Sign off on data discrepancies, adverse events; flag lab abnormalities; sign chemo orders; perform physical exams – all under the direction of the PI

• Improved efficiency for PI, less costly for the practice

Practice Models

• Inpatient hospital services– Daily hospital rounds, prep work for consultations

• A tool to improve physician efficiency in the hospital

– Hospital privileges vary dramatically

• Satellite office coverage– Financial modeling is important

• Infusion suite coverage – For large infusion suites, NPP is immediately available as resource to nurses, patients

Practice Models

• Palliative care focus• Resource for psychological and social issues

• Pain management• Survivorship clinics

Procedures

• Many NPPs perform procedures– Bone marrow biopsy and aspirate, lumbar puncture, intrathecal chemotherapy

• Must follow state scope of practice• Training and supervision are important

Consultations

• According to Medicare guidelines, NPPs can perform consultations if allowed by state scope of practice

• Be cautious– Referring physicians may object– If a physician never provides a direct professional service (E/M) to the patient, NPP services cannot be billed as incident to

Call Coverage: PAs

• 2007 survey by American Academy of Physician Assistants (AAPA)– 23% of PAs take some call (down from 32% in 2005 survey)

– 6.4% indicate they receive some compensation for on-call services (down from 16% in 2005 survey)

Call Coverage: PAs2007 AAPA Physician Assistant Census Report for

Oncology PAs http://www.aapa.org/research/SpecialtyReports07/Onc

ology07C.pdf

Medical Oncology

Count Percent

Respondents 366 100.0%

Do not take call

269 73.5%

Take some call

83 22.7%

Always on call

13 3.6%

Call Coverage: NPs

• 2007 National Salary Survey of Nurse Practitioners by Advance for Nurse Practitioners– 25% of respondents report call duty as part of their job

• 38% of that group report specific additional compensation

• NPPs (both PAs and NPs) should always have physician back-up available when taking call

Hiring a Non-physician Practitioner

• Understand state requirements and regulations

• Develop a job description– Involve physicians and nurses in the process

• Advertise both locally and nationally– Use national association websites and journals

– Contact local NP/PA training programs; consider a student internship

Hiring a Non-physician Practitioner

• Offer a competitive salary and benefits• Take your time

– Expect it to take as long as a physician search

• Look at your own practice – is there an OCN nurse that might go back to school to become a nurse practitioner?

• Plan your training process – it’s hard to find an NPP with oncology training

Compensation

• Salary is always local; check local resources first– State or regional Medical Group Management Association (MGMA) chapters

– Local PA or NP society, ONS chapter– Hospitals or other practices or in your area

Compensation

• Other resources– MGMA Compensation and Production Survey

• www.mgma.com

– 2007 American Academy of Physician Assistants, Physician Assistant Census Report for Oncology

• http://www.aapa.org/research/SpecialtyReports07/Oncology07C.pdf

– Advance for Nurse Practitioners 2007 Salary Survey Results

• http://nurse-practitioners.advanceweb.com/Article/2007-Salary-Survey-Results-A-Decade-of-Growth-3.aspx

Integrating NPPs into Practice:

Physician Role• When developing the job description

– Discuss how each physician feels they will work with the NPP and try to come to consensus

– Determine the practice model before NPP starts

• Will the NPP see patients for all physicians or only specific physicians?

• Will they be assigned to a specific function or disease – breast center, clinical research?

Physician Role

• Be prepared to invest time in education– Plan and schedule specific training with physicians, other NPPs, possibly nurses

• Job shadows• Round with physicians• Didactic sessions

– Develop a curriculum or training plan– Consider local chemotherapy course as introduction if needed

– Mentor– Evaluate and provide feedback regularly

Integrating NPPs into Practice: Nurses

• Discuss the plan to add an NPP with nurses early in process– More flexibility in patient scheduling, continuity of care, reimbursement issues, etc.

• Ask for nursing input into development of job description

• Involve nurses in orientation and training process, especially for NPPs with limited oncology experience

Integrating NPPs into Practice: Patients

• Physician introduction whenever possible

• Always inform patients when they will see the NPP– Describe NPPs as part of the “patient care team” with the physician and nurse

• Include NPP information in written materials about practice and on practice website

• NPP credentials should be visible

Integrating NPPs into Practice: Staff

• Physicians and administration will set the tone for the staff – The NPP is a provider

• A confident and respectful staff attitude is important in instilling confidence for patients

Integrating NPPs into Practice: Referring Physicians

• Include NPP names on signage, marquees, letterhead, practice website

• Personally introduce NPPs to key referring physicians; invite NPP participation in tumor board meetings

• Physician should discuss NPP involvement in cases with referring physicians

Billing Issues: Medicare

• Medicare will pay for services furnished by physician assistants, nurse practitioners and clinical nurse specialists in the same manner as if the services were furnished by physicians

• Services must be within scope of practice of the NPP under state law

• NPPs must accept assignment on all claims• Services may be billed incident to a physician or using the NPP provider number

Incident to is a Medicare Term

• In a non-institutional setting (other than a hospital or skilled nursing facility), Medicare pays for services furnished incident to a physician’s or other practitioner’s services

• Services and supplies must– Be an integral, although incidental, part of the physician’s professional service;

– Be commonly furnished in physician’s offices or clinics;

– Be furnished under the physician’s direct supervision;

– Represent an expense incurred by the physician

Direct Supervision

• Physician must be present in the office suite – but incident to does not require direct involvement of physician in every service

• Services can be considered incident to when physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of course of treatment

• Supervising physician can be another physician from the group practice

So what does this mean?

• NPP services can be rendered incident to a physician service– NPP can provide complete service; service is billed and paid as though it was provided by the physician

– Physician must demonstrate active involvement in the patients case but does not have to see the patient at every NPP visit

It Also Means...

• Services can be rendered incident to an NPP if physician is not available or present in suite– If allowed within state scope of practice

• Chemotherapy (and other services) can be provided incident to the NPP– NPP must be present in the office suite and immediately available to provide assistance if required

If the services is not incident to

• For Medicare patients, bill under NPP’s ID number– Physician fee schedule services (E/M, drug administration) are paid at 85% of the physician fee schedule amount

– No change in drug payment– Careful financial analysis is important

Billing Issues: Other Payers

• May or may not recognize non-physician practitioners– Most payers do

• May recognize NPs and not PAs or vice versa

• Some require individual provider numbers; others require that you bill under the physician name/number

Billing Issues: Other Payers

• Credential as required by each individual payer

• Identify billing issues and comply with individual payer requirements

• Educate payers as needed– Emphasize importance to patient care process

– Use other payer policies as examples if needed

Billing Issues: Other Payers

• Research policies for each of your major payers– Some may not have written policies– At minimum, get policy verbally and confirm in writing, then follow their requirements

• Suggest payers follow Medicare’s lead– Allow coverage for services as though provided by physician

– Pay “incident to” or using NPP provider number

One More Consideration: Productivity Tracking

• Most practices track physician productivity for compensation and/or work load assignments

• Important to discuss and decide how to track NPP services– Are NPP services tracked collectively or by individual provider?

– Are incident to services attributed to the patient’s attending physician? Or the supervising physician in clinic?

– What about services billed under the NPP’s provider number?

The Benefits

• Easier to hire and less expensive than adding a medical oncologist

• Increase physician and practice productivity

• High patient and physician satisfaction

• Valuable members of the oncology practice care team

ASCOResources

ASCO in ACTION• Bi-weekly e-newsletter via ASCO Express

• Updates on legislative and regulatory issues

• Updates on CMS initiatives

• Links to important resources, tools, and legislation

• Available online

Alerts & Breaking News

• Alerts and breaking news on issues affecting oncology

• Sent to ASCO members

• Available on ASCO website

• For Practice Managers and Executives• Highlights key issues • Resources for you, your practice, your staff, and your patients• To subscribe, email practice@asco.org

Journal of Oncology Practice http://jop.ascopubs.org

• Regular features include– Original Research– Practice of Research– Business of the Business– Ethics Vignettes– Practical Tips– Strategies for Career Success

• Manuscripts and letters to the editor may be sent to jopsubmissions@asco.org

Practical Tips for the Oncology Practice

• Detailed information about coding, billing, Medicare coverage guidelines

• Includes excerpts from Medicare coverage manuals

• Order at www.asco.org/practicaltips

EElectronilectroni

cc HHealth ealth

RRecordsecords

• ASCO Electronic Health Record Initiatives at:– www.asco.org/ehr

• Social networking site– ASCOConnections.org

• EHR Lab at 2011 ASCO Annual Meeting

Why are we talking about Health Information

Technology?• Patients• Payers• Practice

Clinical Tools & Guidelines

• Executive summaries

• Flow sheets• Patient guides

www.asco.org/guidelines

Coding & Reimbursement Assistance

• http://www.asco.org/billingcoding

• ASCO member benefit, provided free of charge to ASCO members and their staff

• Available to non-members for a nominal fee per inquiry

ASCO University• Three online modules

– Oncology Billing and Coding Primer

– Coding & Billing Case Applications

– Medicare Case Applications

• Excellent resource for your staff

• Includes Certificate of Completion

Practice Management Curriculum

– Communicating Cancer Care Costs– Adapting to Medicare Changes– Generating Practice Efficiencies– Health Information Technology in Practice

– Effectively Integrating Non-physician Practitioners in Oncology Practice

– Practice Check-up: Assessing the Financial Health of Your Practice

Contact Us

• ASCO’s Cancer Policy & Clinical Affairs Department– 571-483-1670– Practice@asco.org or – publicpolicy@asco.org

Medicare

• www.cms.hhs.gov • Information for Medicare fee-for-service NPPs who provide services to Medicare beneficiaries– http://www.cms.hhs.gov/MLNProducts/70_APNPA.asp

– Includes links to manuals, CMS transmittals, MLN articles, enrollment procedures

Other Organizations

• American Academy of Physician Assistants– www.aapa.org

• Oncology Nursing Society– http://www.ons.org/publications/positions/AdvancePractice.shtml

• American Academy of Nurse Practitioners– www.aanp.org