Marc H. Sencer, MD June 22, 2017
Credit: Chiropractic Economics
Are you starting a new integrated practice or maybe thinking about expanding one?
If so, the subject of whether to hire a nurse practitioner (NP) will certainly come up, if it hasn’t already. The following will help you decide if you need one.
The year 1965 is important for medical historians. At that time, two medical doctors at the University of Colorado started the first NP program in the country (and arguably the world). In 1968, another program was launched at Massachusetts General, and the number of NPs has been growing ever since. Today there are over 200,000 licensed NPs in the U.S.
The early NPs were unregulated, and it was several years before educational requirements and licensing standards and authority over these practitioners were put into place. NPs were expected to work under direct medical supervision.
Today’s NPs can diagnose and treat medical conditions, and order, perform, and interpret medical tests—including radiology and blood tests. They have full prescribing privileges, including controlled substances, in all but two states, and many have hospital privileges.
In 20 states NPs do not need a supervising or collaborating physician and can open their own practice without one.
You’ll find the NPs you come into contact with to be well-trained and knowledgeable, and you should have no reservations about hiring one.
Admittedly, some won’t fully understand chiropractic and what you do, just as you sometimes won’t follow the logic of medical doctors, but they are generally willing to learn.
Make the right choice
In deciding whether to hire an NP, several factors come into play. The most important of these are the type of practice you have or want to create, what the NP will be doing, state laws regarding supervision or collaboration with an MD, financial issues, and patient preferences.
Once you know what kind of practice you’d like to have, and what you’d like the NP to do, you can start searching for one. Nurse practitioners have several specialties and subspecialties they can certify in that require additional training. The most commonly chosen specialty is family practice.
Of special interest to chiropractors are the subspecialties of orthopedics and sports medicine. An NP with orthopedic or sports medicine experience can do basic in-office injections with ultrasound guidance; these include the small, medium, and large joints, tendon and bursa, and hyaluronic acid for osteoarthritis. They can also do or learn to do platelet-rich plasma (PRP) and stem-cell injections.
Dermatology is another subspecialty. These NPs can do botox injections and supervise techs doing other aesthetic and cosmetic procedures. Finding someone with this kind of experience is ideal—whether you are doing aesthetics, physical medicine, or primary care.
You must know if you are going to need a collaborating doctor or not. If you do, there are two things to consider: The first is whether it will increase your overhead. There are no fixed standards for what you should pay an MD to be a supervising or collaborating physician. The more the doctor will have to do, the more expensive he or she will be. This varies from state to state.
In some states the doctor never has to come to the office, in others he or she has to have face-to-face meetings with the NP. The cost of having a collaborating doctor and an NP can approach the cost of having a medical doctor seeing patients part time, and can eat up some of the savings you expect by having a NP.
The other thing to consider is if you need a collaborating physician to work with an NP—you now have two people who you depend on to keep the doors open. If either one is sick, injured, or quits—productivity stops.
There are other financial issues to consider. An important one is reimbursement. Medicare will automatically deduct 15 percent from bills received with an NP as the provider. If an MD is directly supervising the NP, you can use the MD as the provider.
“Direct supervision” means the MD is in the office suite, but not necessarily in the room with the patient. To make matters more confusing, different private payers have different policies.
For example: Some payers will not credential nurse practitioners and only accept bills that have an MD as the provider. Some follow Medicare, and others have their own policy on “incident-to” billing. You must keep a log of each payer’s reimbursement practices.
From the above, you can see it is unrealistic to make a decision to hire an NP based on the amount of their salary alone. NPs are currently in great demand, commanding an average salary between $90,000 and $100,000 for a full-time position. Part-time NPs bill approximately $50 to $60 an hour. MD salaries, by comparison, are about double these rates. A collaborating physician will usually receive $1,000 to $2,000 per month. Use these numbers when making rough calculations.
There is one last factor to consider and that is patient preferences. Some patients are going to want to see a medical doctor and may feel slighted by seeing an NP.
This will vary depending on your patient demographic and the type of procedure in question. One way to deal with this is for you to maintain contact with the patient throughout their treatment. Let them know that even though the actual treatment is being done by someone else, you are supervising and following their case. This is similar to what you would do if hiring an associate to take over someday.
An NP can be beneficial in an integrated practice. Being able to see more patients for half of what an MD would cost is a serious advantage. Using the MD exclusively for procedures that NPs can’t do will result in increased efficiency and more profit for you. Be aware of the negatives and be sure an NP is right for your practice.
Marc H. Sencer, MD, is the president of MDs for DCs, which provides intensive one-on-one training, medical staffing, and ongoing practice management support to chiropractic integrated practices. He can be contacted at 800-916-1462 or through mdsfordcs.com.