The use of mid-level providers has become increasingly controversial as the workforce realignment in emergency medicine picks up steam. Even the naming structure is unclear – mid-level provider, advanced practice clinician, advanced practice provider? It’s enough to make your head spin.

Understanding how mid-level providers fit into the ED can be a puzzle. Here’s why emergency physicians need to leverage – not compete with – this growing segment of the EM workforce.

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The use of mid-level providers has become increasingly controversial as the workforce realignment in emergency medicine picks up steam. Even the naming structure is unclear – mid-level provider, advanced practice clinician, advanced practice provider? It’s enough to make your head spin. But for our purpose here let’s stick with mid-level provider (MLP) from this point forward. The issues only get more complex. The central and more controversial issue is whether mid-level practitioners have a place in emergency medicine in our EDs in the United States. In many ways, I think that issue has been settled – mid-level providers are in our emergency departments and the numbers are increasing rapidly. There is no going back and we are not going to change that momentum. The task for our specialty now is to understand this workforce dynamic, own it, manage it and leverage the opportunity to make emergency care in this country better, faster and less costly. As Chair of AAEM’s Operations Management Committee it has been my focus and as System Chair of Emergency Medicine for the Ochsner Health System in Louisiana it has been my job to optimize workflow, workforce and workload. The addition of MLPs have been key to our strategy to this optimization in the ED for over 10 years and now represent 40% of our EM workforce. We have found MLPs to be integral to solving thorny problems related to both demand and cost.

Who Exactly are Mid-Level Providers?

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Specifically in emergency medicine, mid-level providers include two distinct groups, physician assistants (PAs) and nurse practitioners (NPs). Certainly their educational requirements and training are quite differ- ent. PAs receive three times more clinical hours in training than NPs. On the flipside, NPs usually have more clinical work experience, which frequently balances out their lack of clinical training hours and, in my experience, levels the playing field.

How do PAs and NPs differ?

The big difference between PAs and NPs lies less in training and ability, and more in a cultural difference, or a difference in practice expectations. NPs increasingly, state by state, are being delegated as independent practitioners free of the requirements of physician supervision. In our experience, that reality tends to set them on a career path that often sweeps them right through the emergency department into other venues where that independent practice can be fully realized such as in a traditional clinic practice or urgent care facility. In contrast, PAs appear to have a career goal that takes them along a path directly into a practice environment like an emergency department, where the goal is to work dependent to practicing physicians. This has not been studied yet. More importantly it must be said, and it has been my observation, that any clinical differences between the two groups of mid-level providers disappear for those that stay in the practice of emergency medicine for more than a year. The cultural and clinical training and competencies of the two groups aside, PAs are explicit in their desired scope of practice – that being to leverage the emergency physician’s practice and work dependent and under close supervision in the ED environment. The difference is subtle, often nuanced.

How Much is Too Much?

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This begs the big question: how much independent practice by mid-level providers should be allowed in our emergency departments. An op/ed in the New York Times in April of 2014 by Dr. Sandeep Jauhar questioned the increasing autonomy allowed to nurse practitioners to practice independently without physician oversight. I would tend to agree with his concern; the emergency department is a unique environment where by definition a patient’s presentation is deemed to be an emergency until proven otherwise. That risk valuation drives the expectation (if not the absolute need) that all patients evaluated primarily by a mid-level provider also require emergency physician supervision and oversight. This does not have to be a workflow constraint and can be done effectively and efficiently without distracting from the productivity improvements and cost efficiencies that mid-level providers bring to our practice. Sure we know that in the end, only one out of every five patients in the emergency department truly requires the knowledge and experience of an emergency physician; the question is “which one?” And that is where the unique skill set of an emergency physician is critical in managing outcomes and driving quality.

Additional Training

There are a dozen or so emergency medicine one year “internships” for mid-level providers in the US today. These are not yet required for practice and are not yet a mandated training requirement in our organization. Recruiting is difficult enough already. In time, I have no doubt that this will be a requirement to practice in an emergency department. A one-month rotation in an emergency department plus on the job training – which is the current path to MLP proficiency – will fade from acceptability in time. However, the risk of requiring more training is that it may drive up MLP staffing cost and blur the “credentialing” even further. Nevertheless, considering the training of an EM resident is 8000 hours and 1800 and 600 hrs for a PA and NP respectively, a one year structured program in EM seems both needed and acceptable for a career oriented MLP. The big push back I get on this from MLPs is that it will limit their “marketability” and work options.

Making the Most of MLPs

Training aside, it is important to understand that for lower acuity patients, beyond the diagnostic work, 80% of the tasks (and time) to manage these patients do not require the skill sets of an emergency physician. These tasks involve data-gathering, reviewing past history, keyboarding and documenting the patient encounter using current electronic health records, tracking and reviewing results, writing prescriptions and other routine patient management tasks. Our job as emergency physicians is to engage in the critical portions of the patient encounter, that being the diagnostic decision-making, management and treatment planning. By off-loading the perfunctory work, we gain a huge amount of leverage both in productivity and cost, at the same time providing that critically important contribution to quality of patient care. This is the direction we should be adopting regardless of whether the mid-level provider is a PA or an NP immune to supervision requirements by state regulations. Since the real deliverable of emergency medicine is time-critical time-sensitive care, the mid-level provider model allows emergency physicians to better achieve this objective and to be more productive, more available, and more responsive operationally. This has to improve the quality of care, and from the patient perspective, improve patient experience and satisfaction with their care.

Return on Investment

Clearly it is important to understand the productivity and workflow advantages generated through the employment of mid-level providers. Let’s look at this in a little more detail. The average cost of an emergency medicine mid-level provider in 2014 is $114,000 per year. That’s only a 25-35% of the cost of a board-certified emergency physician. According to our data, the average productivity of a mid-level provider in the emergency department is 1.6 patients per hour or about 80% of the productivity of a board-certified emergency physician in the same environment. Adjusting the cost of a mid-level provider for this variance in productivity generates at a minimum a 50% improvement in the cost of care for this lower acuity subset of patients. That’s a significant improvement in financial margins. Theoretically, should we choose to reinvest those margins – one could significantly increase the number of providers available to evaluate patients; thereby reducing wait times and im- proving both patient safety and patient satisfaction. This is where this workforce strategy begins to solve our demand management dilemma balancing cost and service.

Mitigating Risks through Rules of Engagement

Some emergency physicians would argue with the ROI of mid-level providers by pointing to increased costs associated with their higher utilization of tests and labs. However, there is little data to support this argument, and though this is largely perception, my experience working with MLPs for over 10 years supports this assumption in broad terms. This does not mean that resource over-utilization is not a practice issue for many individual emergency physicians. What is important is that the practice model as outlined earlier, requiring oversight and appropriate supervision, allows the emergency physician to mitigate this risk. In our department we have mid-level “rules of engagement” that flag both complicated patients requiring complex work-ups and/or high-cost procedures early triggering physician engagement and oversight.

Outcomes and Liability

In our organizational model, mid-level providers function dependently such that outcomes related to cost, quality, risk and other performance metrics aggregate to the physician as the responsible supervising provider of record. Malpractice costs for mid-level providers are 10 to 20% of the cost of emergency physicians. However, practice variance does not mean that there is significant claims prevalence in emergency medicine for independent mid-level practice. There is no evidence in the literature supporting increased litigation or larger malpractice claims related to independent mid-level practice in emergency departments. In fact, the overall incidence of malpractice claims per provider has been shown to be fairly similar between mid-level providers and physicians and payments for claims involving mid-level providers appear to be lower than claims against physicians. I believe the more important question is: if there is a bad outcome, will the mid-level provider or physician, or both, be the target of the malpractice claim? We all know that when there is a bad outcome, everyone remotely near that patient will also be named in the suit. We also know for case reports that there have been claims made independently against the mid-level provider and not the physician, in cases where the specific guidance directed by the emergency physician was not executed.

Conclusions

Despite the issues and controversies surrounding the use of mid-level providers in emergency practice, I have no doubt that this workforce model is going to continue to grow. At this time there simply is not enough objective or experiential data regarding issues as noted above to dissuade our specialty from continuing on this path. These issues become less important if we develop a workforce model that appreciates and values the specialized clinical training, knowledge, and experience of the emergency physicians and leverages mid-level providers to their full potential. This model is one in which mid-level provider work under the direction of emergency physicians, working dependent to that physician as a clinical team utilizing clear rules of engagement. We have great respect for our MLPs and our patients are better off by virtue of this team. It’s all about workflow, workforce and workload management. This model I believe will afford more responsive, higher quality and more cost-effective emergency care.

Dr. Guarisco is the System Chair for Emergency Medicine at the Ochsner Health System.