When hiring midlevels, proceed with caution

The very first thing a service needs to do before hiring midlevels is sit down to determine its goals and scope, then figure out the best way to staff for those goals.

The process of integrating midlevels into a hospitalist service is like peeling an onion—it's multi-layered, and it will make you cry. At least, that's how Adam Singer, ACP Member, chairman/ CEO of IPC The Hospitalist Company, describes it.

“There are layers and layers of issues to think about, from federal and state law, to training, to hospital bylaws,” said Dr. Singer, whose company has 150 practices, 35 of which use midlevels. “You can't just hire (a midlevel) because you're growing, and expect it to automatically work.”

Jane Ballard RN Ryan Genzink physician assistant and Carlos Merritt ACP Member of Hospitalists of West Michigan
Jane Ballard, RN, Ryan Genzink, physician assistant, and Carlos Merritt, ACP Member, of Hospitalists of West Michigan.

Dr. Singer isn't trying to be discouraging, he said. In fact, he thinks midlevels are necessary, because there aren't enough physicians to fill hospitalist slots. But employers need to know what they are getting into, he said—and other experts agreed, including those whose hospitals have successfully used midlevels for years.

“What happens in most hospitals is that they are growing and they need to add doctors, but it's hard to find additional MDs and pay for them, “ said John Nelson, FACP, a principal at hospitalist practice management consulting firm Nelson/Flores Associates. “They see the heart surgeons and orthopods adding NPs and think ‘we should do that, too—it's cost-effective, it casts a wider net for recruitment.’ And it is a great idea, but you just need to analyze and manage it carefully.”

Plenty of hospitals have tried it: 27% of hospital medicine groups staff nurse practitioners (NPs), and 21% staff physician assistants (PAs), according to the Society of Hospital Medicine's 2007-2008 Bi-Annual Survey on the State of the Hospital Medicine Movement. The question is, should you?

Making the decision

The very first thing a service needs to do before hiring midlevels is sit down to determine its goals and scope, then figure out the best way to staff for those goals, experts said. In some cases, it may make sense to use only hospitalists in the service, because their broader skill set is needed for a given patient population. In other cases, it may make sense to use a team approach—to split patient populations between midlevels and hospitalists, with the hospitalists acting as supervisors.

The latter model works well for the cancer service at the University of San Francisco Medical Center, where, instead of housestaff caring for patients, it is done by a team of hospitalists and midlevels, said Niraj Sehgal, ACP Member, medical director of UCSF Medical Center at Mt. Zion. But it didn't work as well on the non-housestaff medicine service at Mt. Zion, where the patients, having been triaged and admitted from another hospital's emergency department, are more heterogeneous. In fact, Mt. Zion's four-and-a-half-year-old hospitalist program no longer uses midlevel providers.

“The midlevels we hired at Mt. Zion didn't necessarily have a full grasp of the larger medical service and the type of patients we had coming over, so they frequently needed to consult with the hospitalists,” Dr. Sehgal said. “Over time, it just became easier to hire hospitalists to do everything directly. This was in part related to the unique aspects of our service structure and operations.”

A similar thing happened at the University of Michigan Health System at Ann Arbor (UMHS), where there is a very diverse patient population. The hospital started using midlevels with its resident-based hospitalist service in 2000, then moved them to the nonresident service in 2004. It is now in the process of closing down the midlevel component.

“With our patients, no single diagnosis is more than 5% of our patient population; they tend to be pretty ill and complex,” said Vikas Parekh, ACP Member, associate director of the UMHS hospitalist program. “It's not even easy for the faculty to care for the patients, and we found that with the midlevels, it was challenging to get them to a level where they could take care of enough patients to justify the investment.”

On the plus side, midlevels are probably easier to find, and thus hire, than hospitalists, Dr. Singer said. They are also, obviously, less expensive. Midlevels bill at 15% less than hospitalists, but the pay gap between them and hospitalists is usually quite a bit more than 15%, Dr. Singer said.

One should make sure the savings to a hospitalist service are worth other tradeoffs, however. UCSF's Mt. Zion had to kill its midlevel hospitalist program partly because the midlevels weren't being paid enough less than hospitalists to compensate for their smaller skill set, Dr. Sehgal said. The finances didn't pan out at UMHS, either.

“We had originally calculated that we would be able to gain an extra five or six patients a day per new midlevel, which would pay for the cost of hiring that person. But it worked out where we were only seeing one or two extra patients a day,” said Robert Chang, ACP Member, who used to oversee the PA component of the hospitalist program.

Dr. Nelson agrees that hospitalist practices need to crunch numbers carefully when adding a midlevel.

“If a heart surgeon adds an NP, and the NP can make the surgeon 15% more productive, then the NP probably pays for (himself),” Dr. Nelson said. “But the salary difference between an NP and a hospitalist isn't as vast as with a surgeon, so an NP might have to make a hospitalist about 50% more productive to pay for (himself).”

The team approach

Although there are many ways to integrate a midlevel into a hospitalist service, the most popular, experts said, is to have the midlevel do most of the patient care duties of a hospitalist with physician supervision and perhaps a smaller or less complex patient load.

At the two hospitals served by Hospitalists of West Michigan, midlevels work on a team with a physician and a nurse. They alternate monthly between rounding and admitting teams, which keeps their skills in both areas sharp, said Khan Nedd, MD, HOWM president. Teams always meet at the beginning and end of the day to talk about schedules and patient issues that have arisen; they sometimes meet at mid-day, as well.

“We intentionally built in a lot of communication so there is accountability, and so the patients' needs are met,” said Dr. Nedd, whose two hospitals have 25 midlevels and 13 hospitalists.

With his or her designated patients, the midlevel on the rounding team does initial rounding, labs and information gathering, and makes clinical decisions along the way. Nurses handle family interactions and discharges, among other things. The hospitalist checks in on every patient at least once, but doesn't repeat the intensive visits that have already been done by the midlevel, Dr. Nedd said.

“Inpatient care requires building a relationship with patients where you do multiple visits,” Dr. Nedd said. “With a physician on his or her own, there are a lot of gaps, but with a team you are obviously able to see more patients, and see them more often.”

The Mayo Clinic started using midlevels with hospitalists in perioperative medicine in 2000. Specifically, a team of one hospitalist and two midlevels would act as general medicine consultants for orthopedics when that division needed help with a medically complex patient, said Joanne Heathman, RN, a certified nurse practitioner who supervised midlevels in Mayo's division of hospital internal medicine (HIM) from 2000 to 2008.

In 2004, while looking to fill gaps left by resident work-hour restrictions, the HIM division moved to using midlevels for internal medicine patients, in addition to the perioperative medicine service. The division then added midlevels to its observation and monitored services. Between 2001 and now, it moved from nine midlevels to 20, all of whom regularly rotate among the services. (By comparison, there are about 30 hospitalists.) Here, too, a team approach is used.

“At the beginning of the morning, the hospitalist and midlevel will sit down and divide up the patients, and determine who will be primarily responsible for things. This makes it clear who is responsible for follow-up—for ordering labs, and talking with the subspecialists and the families,” Ms. Heathman said. “In some cases, we may decide to visit a patient together, but the person in charge will lead the discussion with the patient.”

When the team approach works well, it frees up the physician to see more patients because most of the “daily grind” has been done, said Jina Saltzman, a certified physician assistant who is chair of the Society of Hospital Medicine's nonphysician provider committee and founder of the Association of Physician Assistants in Hospital Medicine.

“By the time the physician gets there, the patient has been seen, the order is in the chart, the notes have been written, and all the doctor needs to do is have a quick face-to-face encounter and scribble a quick note,” Ms. Saltzman said. (See for alternatives to the team approach.)

Laying the tracks

Once a hospital service decides to hire midlevels, it should figure out the federal laws associated with their use—including how to bill for them—as well as state laws and hospital medical staff bylaws. These might vary depending on whether the midlevel is a PA or an NP, experts said.

“Each hospital has a different set of rules and regulations. For example, does the doctor have to see the patient with the midlevel, or can he or she see the patient alone? When does the doctor have to sign the chart, and what kind of note has to be written?” said Dr. Singer.

When looking to hire, the hospitalist practice needs to have a clear idea of the skills its midlevels should possess, as well.

“A new graduate might have an easier transition working in a short-stay observation unit, while you might want a more experienced (midlevel) to do the long-term care of patients from admission to discharge,” Ms. Saltzman said.

As to whether to hire an NP or a PA as your midlevel, most experts agree there isn't much difference.

“If you didn't know our academic backgrounds, you'd have no idea which one we were,” said Ms. Heathman. “The role is exactly the same—we can all do admission and consults, we can examine and prescribe and develop a plan of care. When hiring, I never focused on whether a person was an NP or PA; I looked at the background and experience.”

A difference may arise, however, in terms of an individual state's laws and what they allow NPs or PAs to do. In Minnesota, for example, PAs need to have a supervising physician identified in order to practice, while this isn't required for NPs, Ms. Heathman said. Mayo, like most hospitals, has its own standards of practice, which basically require that a physician supervise a team, whether the midlevel is a PA or NP, she said.

The importance of training

Even if the midlevel you hire comes in with many of the skills needed for the position, he or she is likely to need training about the job and the particulars of the hospital. Unlike hospitalists, NPs and PAs don't have residency programs, so some of their learning is going to be on-the-job, Dr. Nedd said.

“Their ‘residency’ can be the working time of their first two years; in our experience it takes about two years for the average midlevel to really get the hang of things,” Dr. Nedd said. “The rest of the team, especially the doctors, needs to understand their role in providing continuing education, helping train and mentor the midlevel to perform in the same way they do.”

Coding and billing is an area many midlevels need training on, and physicians will also need to know the dividing lines between when the hospitalist bills and the midlevel bills, Dr. Singer said. Both will also need to be trained on what the federal, state and hospital bylaws say in terms of what a midlevel can and can't do in the facility, he said.

At the Mayo Clinic, a new midlevel is paired with an experienced midlevel for three or four months, depending on the service s/he is on. This helps the new person learn the system, the order sets and the standards for care. The HIM division is also developing an e-curriculum, adopted from Society of Hospital Medicine resources, which will allow practitioners to look up information in “core competency” areas, such as acute renal failure or diabetes, when they have a question about care. Eventually, the midlevels in the division hope to build a system that can test the competencies of the group using the e-curriculum, Ms. Heathman said.

It can also be helpful to pair a new midlevel with only a few physicians to start out with, then work up to rotating the midlevel among all the hospitalists, according to Ms. Saltzman. “Having a (midlevel) work with a lot of different doctors at once can be overwhelming, because they all have different styles. It might be good to pair him or her at first with a doctor who has had great success at working with residents, or who likes to teach,” Ms. Saltzman said.

Indeed, at UMHS, one of the factors that caused the midlevel program to fail was the fact that the service was hiring new hospitalists very quickly, and turnover was great. It became exhausting for midlevels to constantly adjust to new doctors and their unique styles, Dr. Chang said.

“When 15 different doctors have 15 different ways of doing things, how does a PA handle that?” Dr. Chang said.

Hospitalists also need to be trained to accommodate the addition of an NP or PA, experts said.

“You may have the greatest NP in the world, but then you have your own physicians' attitudes toward the use of (midlevels). Very easily, you can get into interpersonal dynamics where the NP feels abused, or not part of the team, which happens commonly in these practices because of the physicians' own ignorance or attitude,” Dr. Singer said.

Hospitalists need to be reminded about the general skills of midlevels, and what working together will mean, Ms. Heathman said. The HIM division at Mayo ensures that a toplevel NP or PA talks to every new hospitalist that is hired, to explain about the system of working with midlevels and to explain that midlevels don't have the sort of residency training doctors get.

“It's hard for doctors to understand that, unlike them, midlevels won't necessarily hit the ground running,” Ms. Heathman said.

Educating hospitalists about the roles and duties of midlevels is also important to avoid the common problem of physicians using midlevels in disparate ways, Dr. Nelson said.

“I've talked to NPs who say their job is totally dependent on the hospitalist on their team that day—sometimes they are totally unsupervised and other times the physician will go around to patients and repeat everything they've done. In both cases, the practice isn't making good use of the NP,” Dr. Nelson said.

With the right sort of preparation—defining of goals, background research and training—the segue into using midlevels should be much smoother, and ultimately rewarding.

“If you have the right person in the right practice situation with the right attitudes, a (midlevel) is of tremendous benefit to a practice,” Dr. Singer said.