APPs in Otolaryngology Can Help Fill Gaps in Patient Care

CHICAGO–Kristi Gidley, PA-C, a physician assistant, administrative director, and supervisor of advanced-practice providers (APPs) in the department of otolaryngology at the University of Alabama in Birmingham, introduced a session on APPs at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Society. She began with a basic description of certified nurse practitioners (NPs) and physician assistants (PAs), both of whom can be APPs.

NPs often choose a specialty area and complete 500 didactic hours, plus 700 to 800 clinical hours, before they become certified in that specialty (otolaryngology nurses are, certified by the National Certifying Board of Otorhinolaryngology and Head–Neck Nurses). PAs also take board exams, but they are certified by the National Commission on Certification of Physician Assistants. In addition, they are licensed through the state medical boards and must earn continuing medical education credits as well as take an exam to recertify every six to ten years, requirements that mirror those expected of medical doctors.

Healthcare has seen an overall increase in demand for APPs, partly due to expanded coverage under the Affordable Care Act and the increasing numbers of aging baby boomers. This upsurge in patient demand is coupled with an under-supplied healthcare system, and experts estimate that by 2025, the demand for physicians will dramatically exceed supply. While the otolaryngology workforce increased in number through 2001, it remained stable from 2001 to 2006 and began a decline in 2006. The result is that one in five counties has seen a decline in the ratio of otolaryngologists to population. Despite the reduced number of physicians, consumers continue to expect and demand high quality and timely care. APPs can help fill this gap.

NPs often choose a specialty area and complete 500 didactic hours, plus 700 to 800 clinical hours, before they become certified in that specialty.

Role of APPs

The APP scope of practice varies across states but includes prescriptive authority as well as the ability to perform many routine procedures. With training, APPs may also be able to perform more advanced procedures. APPs can thus bill for any code and can perform whatever procedures their training, experience, and the physician allow. Marie Gilbert, PA-C, works at Northeast ENT and Allergy in Dover, N.H. She explained that while the supervision requirements for APPs can vary from state to state, the physician is generally not required to be on site with the PA, as long as they are reachable by phone. In addition, PAs must have their own National Provider Identifier number to bill for services. PA services are not always billed under the physician.

Gilbert provided some specific examples of how APPs can directly contribute to a practice. Once a patient has seen a physician for a problem and the plan of care has been made, the PA or NP can conduct the recheck of that problem under that plan of care as long as a physician is physically present within the office. APPs can also see new patients, perform some procedures, and order workups, among other services (see “What Can APPs Do,” below).

Business Plans

Most practices thinking about hiring an APP must first look to their business plans in order to justify the hiring of an APP. Such a business case provides justification for a proposed business change and typically outlines the allocation of capital and resources required to implement it. APPs improve revenue streams, specifically with regard to evaluation and management visits, postoperative care, and procedures, so hiring an APP usually translates into a cost savings for the practice.

Wendy Stern, MD, an otolaryngologist at Southcoast Physicians Group in North Dartmouth, Mass., spoke specifically about building the business case to hire an APP. “Just over half of us are in private practice,” said Dr. Stern, describing the results of the American Academy of Otolaryngology–Head and Neck Surgery socioeconomic survey. Whether a physician is in private practice or practices in a larger setting, the first questions to ask are: What do I need, and what do I want? The answers to these questions could be improved patient access or improved quality of care. According to Dr. Stern, “Every business plan has to look at quality because that is going to affect the bottom line.”

Many physicians feel challenged to deliver the access and quality that an increasing number of patients now demand. APPs can help the practice meet that challenge because they not only improve access, but they can also improve quality as documented by outcomes and patient satisfaction. APPs can provide more face time for the patient, decrease wait time, and improve the efficiency of clinic flow. They also make it easier for patients to access early follow-up clinics and discharge visits.

Next Steps

The APP workforce grew nearly 35% over the last five years, and this growth is expected to continue. While the number of APPs is growing, so is the demand to hire them. Gilbert said that a good way to identify and recruit a qualified APP is for a physician to invest time as a lecturer or preceptor at a local PA or NP program. APPs can also be found through the American Academy of Physician Assistants job finder (aapa.org) or the Society of Physician Assistants in Otorhinolaryngology–Head and Neck Surgery (entpa.org). Both NPs and PAs can also be found at Healthcareers.com.

The bottom line, said Gilbert, is that, “You as a group of physicians need to choose: What are your priorities?” It may be that hiring an APP is one of them.

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Dr. Pullen is a freelance medical writer based in Illinois.