February 2007 | Back to Table of Contents

Pulse

Nursing the Bottom Line

Hospitals and clinics find that hiring advanced practice nurses and physician assistants makes economic sense.

Loie Lenarz, M.D., remembers the year her clinic hired its first nurse practitioner. It was 1989, and Lagoon Family Health Care needed another provider to keep up with growing patient demand. Family physicians were scarce, so Lenarz and her colleagues decided instead to hire a nurse practitioner. “We knew there was work she could do and do extremely well as an independent provider within our group,” says Lenarz, who is now chief clinical officer for Fairview Health Services. She also knew the nurse’s salary would be a fraction of that of a physician. “From an economic standpoint, hiring her made sense.”

Walk into any hospital or clinic in the Twin Cities today and you’ll find advanced practice registered nurses (certified nurse practitioners, nurse anesthetists, nurse midwives, and clinical nurse specialists) as well as physician assistants doing work that was once only done by physicians. Their presence is the sum of the shortage of practitioners in certain medical specialties, the growing complexity of medical care and the demands it places on physicians, and the need to control costs. “Without them, the clinics, the hospitals, and the community would be in a world of hurt,” says Lenarz, who adds that she can’t think of any large group practice or health system that doesn’t use these providers.

Dr. Nurse Minnesota hospitals and clinics will soon see a new type of health care professional on the floors—the doctor of nursing practice (D.N.P.). The University of Minnesota School of Nursing began offering a D.N.P. degree program in January. “The D.N.P., like the D.D.S. and the M.D., is really the highest preparation for practice in the field,” says Sandra Edwardson, Ph.D., a professor of nursing at and the former dean of the University of Minnesota School of Nursing. Although it’s yet unclear where nurses who complete the doctorate will fall on the salary scale, they will primarily work in clinical settings, as opposed to research or academic environments, and will be schooled in evidence-based practice, health economics, informatics, and health policy.—K.K.

Although physician assistants and advanced practice registered nurses have long provided primary care in rural areas that have trouble recruiting and retaining physicians, they’re now being used in a variety of specialty settings and in ways that they weren’t 20 years ago.

At HealthEast’s St. Paul-area hospitals, for example, physician assistants work alongside physicians in the emergency department and nurse practitioners help staff the adult and neonatal intensive care units. Fairview now uses them to assist hospitalists, in cardiology, and, increasingly, in behavioral health. Mayo Clinic recently created a Preoperative Evaluation Center that is staffed by two physician assistants along with physicians and anesthesiologists. And at HealthPartners, nurse practitioners assist with quality initiatives such as improving the care of diabetic patients.

Pat Courneya, M.D., associate medical director for HealthPartners health plan, was practicing at North Suburban Family Physicians in the mid 1990s when the practice brought on its first nurse practitioner. He has since seen these providers assume more and more responsibility, especially as patient care has become more complicated and physicians are required to take part in time-consuming quality-improvement initiatives and outcomes reporting. “Initially, they did much more urgent care and straightforward things—treating colds and sore throats. Now, they are important team members in managing chronic care patients,” he says.

Fairview considers physician assistants and nurse practitioners “authorized practitioners” who are responsible for their own panels of patients. “What has changed is that increasingly we see them as independent practitioners in their own right,” Lenarz says.

Pluses and Minuses
Lenarz explains that that view grew out of an understanding that some of the care provided in hospitals and clinics doesn’t necessarily have to be given by a physician. “Why should someone who spent 20 years in training be doing things that take a lot of time and could be handled just as well or better by someone who has a narrower area of expertise?” says Bob Beck, M.D., vice president of medical affairs and chief medical officer for HealthEast Care System. Especially if there’s a less expensive provider who can do the work (see “What Do They Make?”).

“The reality is that there is a salary difference and that does make it attractive for a practice to consider hiring nurse practitioners and physician assistants,” Lenarz says. In addition, their malpractice insurance costs less, too. According to the MMIC Group, which provides professional liability insurance to physicians, hospitals, and clinics in the Upper Midwest, the minimum annual premium for a physician assistant or nurse practitioner is $1,200 versus $3,800 for a family physician.

Reimbursement from insurers, however, is often the same, regardless of who delivers the care. HealthPartners, for example, pays the same amount for a vaginal delivery, regardless of whether it is attended to by a physician or a nurse midwife. However, it pays 40 percent to 50 percent more when anesthesia is provided by an anesthesiologist rather than a nurse anesthetist. Blue Cross and Blue Shield of Minnesota reimburses for services provided by physicians, advanced practice nurses, and physician assistants at the same rate. Medica pays 85 percent of the maximum allowed for a physician doing the same procedure.

What Do They Make? Annual salaries of providers in Minneapolis and St. Paul Provider Median Salary Anesthesiologist - $292,116 Certified nurse anesthetist - $139,531 Ob/gyn physician - $237,747 Certified nurse midwife - $88,532 Family physician - $167,564 Physician assistant - $ 83,075 Source: Salary.com; HR reported data as of December 2006

The ledger doesn’t just show pluses, however. Lenarz points out that there are costs that go along with using such providers. For example, nurse practitioners and physician assistants don’t take call duty or provide hospital care. So the physicians in a medical group will have the added burden of call and hospital work associated with their patients. “They’ll have the added revenue, but it adds to the physician load,” she says.

Medical groups also have to take into account the fact that physicians need to provide oversight for physician assistants. In Minnesota, both physician assistants and advanced practice nurses (who have either master’s or doctoral degrees and have earned certification) can diagnose and treat many common conditions, order diagnostic tests, and prescribe medications. Physician assistants do so under the supervision of and advanced practice nurses in collaboration with a physician.

No Turning Back
As hospitals and clinics continue to search for ways to put a lid on costs and make up for a shortage of certain types of physicians (Lenarz says the skills of general internal medicine physicians, for example, are in demand), they’ll no doubt continue to look to physician assistants and advanced practice nurses to fill the void. “I would be very surprised if this wasn’t a continuing trend,” she says. “I would guess that we will see their scope of practice expand.”

Last fall, federal lawmakers introduced a bill that would have allowed physician assistants to order home health, hospice, and skilled nursing care for Medicare beneficiaries.

Courneya says the use of these nurses and physician assistants is a good deal for patients as well as for hospitals and clinics. “Some of our patients see themselves as having a primary care relationship not just with their physician but with their nurse practitioner,” he says. And that gives physicians time to focus on the bigger picture and the sicker patients. “I know I would be swamped without them,” he says of the nurse practitioners he works with.—Kim Kiser