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Medical practices are increasingly using nonphysician providers (NPPs) as a solution to the physician shortage and the influx of new patients resulting from the Affordable Care Act. NPPs allow practices to care for more patients and free physicians to perform work that only physicians can do. Particularly worrisome is the projected shortage of primary care physicians as demand for those services increases. NPPs offer one way to accommodate the demand, as they can handle many types of routine primary care visits on their own. As Laura Palmer, FACMPE, an MGMA senior industry analyst notes, “Perhaps the most important thing you can do before you hire an NPP is to thoroughly research what your state allows them to do. An administrator might be concerned that both physicians and patients could be unwilling to accept NPPs as primary care-givers. Have physicians send letters to their patients announcing the NPPs’ hire and collaborative role in the practice.
The necessity for these measures will wane as NPPs become integral players in all aspects of healthcare. Jobs for NPs, nurse anesthetists and nurse midwives are projected to grow 31 percent between 2012 and 2022. The states with the highest employment level for NPs are California, New York, Florida, Texas and Massachusetts. 58 percent of PAs work in health practitioner offices, 23 percent work in hospitals, 7 percent work in outpatient care centers, 4 percent work in government and 3 percent work in educational capacities. New York, California, Texas, Pennsylvania and North Carolina are the states that employ the most PAs.
Getting optimal use out of your NPPs can boost revenue, increase efficiency and free your physicians to focus on other patients.
Not surprisingly, however, NPPs are commanding higher pay as demand for their services rises. The American Academy of Physician Assistants and the American Association of Nurse Practitioners offer salary guidelines for these professionals.
Medical practice leaders should balance NPPs’ revenue contributions against the salaries and benefits they cost the organization.
MGMA’s Cost Survey Report contains a wealth of information about staffing levels for NPPs in both multispecialty and single-specialty practices.
Keep in mind that you need to balance NPPs’ revenue contributions against the salaries and benefits they cost the organization. When deciding whether to hire NPPs on a full-time, part-time or contract basis, review your practice’s expenses and determine whether you can afford the extra cost per FTE physician, understanding that practices with higher revenue tend to have higher staff and costs. Unlike nurses, NPPs can bill insurers directly for their services, providing reimbursement at the physician rate. Alternatively, NPPs can bill Medicare directly after obtaining Medicare credentialing, using their own NPIs. NPPs work under a physician’s direct supervision or in collaboration with physicians. Experienced providers receive the benefit immediately; new graduates have to work a year before becoming eligible for the incentive. Hosylik notes that an excellent working environment also includes a no-tolerance policy for negativity, social events that include all staff and significant others, and monthly meetings with providers and support staff to ensure open communications.
Healthcare organizations use nonphysician providers (NPPs) to extend the therapeutic reach of physicians, increase patient satisfaction and add clinical revenue to the bottom line.
All NPPs can bill insurers for their services, either incident-to4 the care provided by an overseeing physician or as independent practitioners when permitted by their state licensure. Urgent care centers, where walk-in patients can receive ambulatory medical care outside of a hospital emergency room, provide another significant source of NPP employment. Where NPPs are the only practitioners, facilities see significantly lower operating and staff costs, although revenue also drops. Some health systems are partnering with retail clinic operators, thereby boosting retail clinics’ profiles in the public eye.
The nation’s changing healthcare landscape is giving NPPs unprecedented opportunities. The ACA is generating myriad job opportunities for NPPs as millions of previously uninsured Americans gain access to healthcare services.
New models of healthcare delivery, such as the patient-centered medical home (PCMH), call for more clinical roles that NPPs can fill. Both government and private insurers are turning to the PCMH as an outcomes-based, value-driven model where payments can be based on results. Population health forms another key pillar of the PCMH and generates opportunities for NPPs.
Because NPPs spend more time with patients than physicians for routine visits, they can increase the depth of the provider-patient relationship and enhance patient satisfaction. By 2015, the Association of American Medical Colleges forecasts the United States will have 29,800 fewer primary care physicians than it needs.19 This translates into a shortfall of about 135 million ambulatory visits annually (right). Therefore, you might have no need to employ persuasive tactics with patients or colleagues when you hire NPPs.

The MGMA Performance and Practices of Successful Medical Groups: 2010 Report Based on 2009 Data, showed that 61 percent of better-performing practices employ NPPs. For example, in 2012, the median total compensation for an NP in primary care was $94,062; the cost that year to employ a family medicine physician was $207,117. Use this resource to learn best-practices in staffing and compare your employee levels to those of peer organizations. After an initial visit by the physician, NPPs must perform these services under the physician’s direct supervision or while the physician is present in the same office suite to immediately assist.
NPPs may address new problems and see new Medicare patients if the NPP is billing under his or her own NPI. However, failure to comply with any insurer’s NPPs billing rules can put organizations at risk for noncompliance. The American Academy of Physician Assistants has extensive billing resources for members, as does the American Association of Nurse Practitioners.
For example, in Colorado, NPs can evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments and prescribe medications under the authority of the state’s board of nursing.
In addition, sharing financial and performance data is an important piece to share with nonphysician providers as well. Roles for these skilled individuals are expanding as the number of physicians shrinks (especially in primary care), the population of seniors expands and the Patient Protection and Affordable Care Act (ACA) makes healthcare accessible to more than 10 million more Americans1. Today, midlevel providers work in hospitals, emergency departments, inpatient and outpatient surgical facilities and in specialty practices such as cardiology and oncology, as part of the team that serves patients receiving ongoing treatment. Urgent care centers continue to proliferate, with 9,000 across the nation at the start of 2013.10,11 As employers of NPPs, urgent care centers offer flexible schedules and competitive pay.
These facilities, catering to walk-in patients with nonemergent conditions, are almost exclusively staffed by NPPs and offer inexpensive, convenient care for many routine medical situations. This may be because of fewer ancillaries, fewer procedures and shorter office visits than typically seen in the office with physicians. NPPs offer a skilled alternative to physicians for healthcare organizations seeking to treat more patients, balance provider workloads and sustain their clinical viability while combating administrative, regulatory and financial pressures. Insurers increasingly expect practices to coordinate patients’ care with other providers and facilities to avoid duplicating services, ensure appropriateness of care and reduce error. Seems either no one is talking about louis daguerre at this moment on GOOGLE-PLUS or the GOOGLE-PLUS service is congested. Most recently in the 2013 report, ambulatory encounters for nurse practitioners increased to 2,242 while primary care physician assistant encounters decreased to 2,763. When the ratio of NPPs per full-time-equivalent (FTE) physician increases above 0.5 FTE in physician-owned multispecialty groups, median FTE clinical support staff per FTE physician can rise by almost a full-time staff member. She recommends asking NPP candidates certain questions to determine their suitability for employment in your practice. Urgent care centers focus on primary acute medical problems at the lower end of the severity spectrum12 and share characteristics of emergency and primary-care facilities.
According to the ConvUrgentCare Report, the country had 1,603 retail clinics at the end of 2013 compared with 1,417 at the end of 2012. Health system patients can visit the MinuteClinics as they would any other approved provider.
Because many newly insured individuals seek primary care, NPPs can help cover for a serious U.S.
Nurse-managed health centers and patient centered medical homes could mitigate expected primary care physician shortage.
David Gans, MSHA, FACMPE, senior fellow, MGMA Industry Affairs, notes that “In primary care practices, they can provide 80 percent or more of services with equal or better patient satisfaction at a lower cost than a physician.
Commercial payers usually require their own credentialing of NPPs, and also reimburse NPP services at a lower rate than those provided by physicians.
Be sure you understand the requirements when payers do not cover NPPs and do not enroll them as credentialed providers. An article by an MGMA authority points out that “Most payers will cover NPP services, but they may not enroll them. THESE VERY SAME ENFORCEMENT AGENCIES, WHO HAVE SWORN TO PROTECT AND SERVE, OUR COUNTRY, AND CITIZENS ,ARE BUT SOME, OF THE CORRUPT,GREEDY TRAITORS .ENGAGED IN THE TYRANNY AND TORTURE. The school district has moved to a biometric identification program, saying students will no longer have to use an ID card to buy lunch.A  BIOMETRICS TO TRACK YOUR KIDS!!!!!i»?i»?A TARGETED INDIVIDUALS, THE GREEDY CRIMINALS ARE NOW CONDONING THEIR TECH! Paul Weindling, history of medicine professor at Oxford Brookes University, describes his search for the lost victims of Nazi experiments. The chairman of the board at ESL a€” then proprietor of the desert wasteland in Nevada known as a€?Area 51a€? a€” was William Perry, who would be appointed secretary of defense several years later. EUCACH.ORG PanelIn a 2-hour wide-ranging Panel with Alfred Lambremont Webre on the Transhumanist Agenda, Magnus Olsson, Dr. Henning Witte, and Melanie Vritschan, three experts from the European Coalition Against Covert Harassment, revealed recent technological advances in human robotization and nano implant technologies, and an acceleration of what Melanie Vritschan characterized as a a€?global enslavement programa€?.Shift from electromagnetic to scalar wavesThese technologies have now shifted from electromagnetic wave to scalar waves and use super quantum computers in the quantum cloud to control a€?pipesa€? a reference to the brains of humans that have been taken over via DNA, via implants that can be breathed can breach the blood-brain barrier and then controlled via scalar waved on a super-grid. Eventually, such 'subvocal speech' systems could be used in spacesuits, in noisy places like airport towers to capture air-traffic controller commands, or even in traditional voice-recognition programs to increase accuracy, according to NASA scientists."What is analyzed is silent, or sub auditory, speech, such as when a person silently reads or talks to himself," said Chuck Jorgensen, a scientist whose team is developing silent, subvocal speech recognition at NASA Ames Research Center in California's Silicon Valley.
We numbered the columns and rows, and we could identify each letter with a pair of single-digit numbers," Jorgensen said.

People in noisy conditions could use the system when privacy is needed, such as during telephone conversations on buses or trains, according to scientists."An expanded muscle-control system could help injured astronauts control machines.
If an astronaut is suffering from muscle weakness due to a long stint in microgravity, the astronaut could send signals to software that would assist with landings on Mars or the Earth, for example," Jorgensen explained. These are processed to remove noise, and then we process them to see useful parts of the signals to show one word from another," Jorgensen said.After the signals are amplified, computer software 'reads' the signals to recognize each word and sound. Our Research and Development Division has been in contact with the Federal Bureau of Prisons, the California Department of Corrections, the Texas Department of Public Safety, and the Massachusetts Department of Correction to run limited trials of the 2020 neural chip implant. We have established representatives of our interests in both management and institutional level positions within these departments. Federal regulations do not yet permit testing of implants on prisoners, but we have entered nto contractual agreements with privatized health care professionals and specified correctional personnel to do limited testing of our products.
We need, however, to expand our testing to research how effective the 2020 neural chip implant performs in those identified as the most aggressive in our society. In California, several prisoners were identified as members of the security threat group, EME, or Mexican Mafia. They were brought to the health services unit at Pelican Bay and tranquilized with advanced sedatives developed by our Cambridge,Massachussetts laboratories. The results of implants on 8 prisoners yielded the following results: a€?Implants served as surveillance monitoring device for threat group activity. However, during that period substantial data was gathered by our research and development team which suggests that the implants exceed expected results.
One of the major concerns of Security and the R & D team was that the test subject would discover the chemial imbalance during the initial adjustment period and the test would have to be scurbbed. However, due to advanced technological developments in the sedatives administered, the 48 hour adjustment period can be attributed t prescription medication given to the test subjects after the implant procedure. One of the concerns raised by R & D was the cause of the bleeding and how to eliminate that problem. Unexplained bleeding might cause the subject to inquire further about his "routine" visit to the infirmary or health care facility. Security officials now know several strategies employed by the EME that facilitate the transmission of illegal drugs and weapons into their correctional facilities. One intelligence officier remarked that while they cannot use the informaiton that have in a court of law that they now know who to watch and what outside "connections" they have. The prison at Soledad is now considering transferring three subjects to Vacaville wher we have ongoing implant reserach.
Our technicians have promised that they can do three 2020 neural chip implants in less than an hour. Soledad officials hope to collect information from the trio to bring a 14 month investigation into drug trafficking by correctional officers to a close. Essentially, the implants make the unsuspecting prisoner a walking-talking recorder of every event he comes into contact with. There are only five intelligence officers and the Commisoner of Corrections who actually know the full scope of the implant testing. In Massachusetts, the Department of Corrections has already entered into high level discussion about releasing certain offenders to the community with the 2020 neural chip implants. Our people are not altogether against the idea, however, attorneys for Intelli-Connection have advised against implant technology outside strick control settings. While we have a strong lobby in the Congress and various state legislatures favoring our product, we must proceed with the utmost caution on uncontrolled use of the 2020 neural chip. If the chip were discovered in use not authorized by law and the procedure traced to us we could not endure for long the resulting publicity and liability payments.
Massachusetts officials have developed an intelligence branch from their Fugitive Task Force Squad that would do limited test runs under tight controls with the pre-release subjects. Correctons officials have dubbed these poetnetial test subjects "the insurance group." (the name derives from the concept that the 2020 implant insures compliance with the law and allows officials to detect misconduct or violations without question) A retired police detective from Charlestown, Massachusetts, now with the intelligence unit has asked us to consider using the 2020 neural chip on hard core felons suspected of bank and armored car robbery. He stated, "Charlestown would never be the same, we'd finally know what was happening before they knew what was happening." We will continue to explore community uses of the 2020 chip, but our company rep will be attached to all law enforcement operations with an extraction crrew that can be on-site in 2 hours from anywhere at anytime. We have an Intelli-Connection discussion group who is meeting with the Director of Security at Florence, Colorado's federal super maximum security unit. The initial discussions with the Director have been promising and we hope to have an R & D unit at this important facilitly within the next six months.
Napolitano insisted that the department was not planning on engaging in any form of ideological profiling.
I will tell him face-to-face that we honor veterans at DHS and employ thousands across the department, up to and including the Deputy Secretary," Ms. Steve Buyer of Indiana, the ranking Republican on the House Committee on Veterans' Affairs, called it "inconceivable" that the Obama administration would categorize veterans as a potential threat.

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