With heavier patient loads than ever and a physician shortage looming, the demand for physician extenders is increasing. Nurse practitioners and physician assistants are doing more than just filling the gap-they're adding tremendous value to the medical team. Expect continued changes as new laws pass to address the roles and responsibilities of physician extenders.

Oncologist Linda Bosserman, MD, and nurse practitioner Traci Young are a well-oiled medical machine. Young assists Dr. Bosserman daily with medical histories, patient exams and follow-up visits at Wilshire Oncology Medical Group Inc. The pair utilizes the medical team approach to care for hundreds of oncology patients in the group's Pomona and Rancho Cucamonga locations.

"Without Traci, patients experience longer wait times, and I am plagued with mounting emergency visits and mounting phone calls," says Dr. Bosserman, president and managing partner of Wilshire Oncology Medical Group. "With Traci, I treat twice the amount of patients, get emergency visits in faster and patients receive much more personal attention."

Relationships like the one between Dr. Bosserman and Young are a growing trend in medicine, where physicians rely on other health professionals to extend their abilities to serve increasing numbers of patients. These physician extenders are typically nurse practitioners (NPs) and physician assistants (PAs), but may include certified nurse midwives and other allied healthcare professionals as well. Physician extenders often work in primary care settings, such as family medicine, internal medicine, pediatrics, and obstetrics and gynecology. However, they are also found in emergency medicine, oncology, dermatology and surgical specialties, too.

"With the current and future primary care physician shortage, the demand for physician extenders is expected to increase," says Ronald Bangasser, MD, director of external affairs at Beaver Medical Group in Redlands, a multispecialty practice that utilizes PAs. "It's a way physicians can create extensions of themselves who can take care of patients and get things done in the medical practice. Extenders do very many of the things that physicians do, and they expand what our primary care capabilities would be otherwise."

Power of a Nurse Practitioner
As owner of Wilshire Oncology, Dr. Bosserman struggles to keep her medical practice afloat financially. Because of decreasing reimbursement, she must see 16 patients a day to stay in business. And she can't afford to hire another physician because the money isn't there.

"The Medicare Modernization Act of 2003 has cut so much [reimbursement] out of oncology--four to five times more than the Senate projected," Dr. Bosserman says. "In 2006, 400 oncologists retired and only 180 came into medical practice. Physicians aren't entering the field of oncology anymore."

So Dr. Bosserman works with Young, who provides patient care at a substantially lower salary than a physician. However, Young's medical expertise and training are well above average. She is a registered nurse and possesses a UCLA master's degree in nursing with an oncology nurse practitioner certification.

In California, an NP cannot practice independently without a collaborating or supervising physician. The scope of practice for an NP is determined by a document called standardized procedures, which is developed by the medical practice where he or she will work. State law requires physician supervision for the purposes of prescriptive authority only. The physician is not required to be on-site, but simply available through phone or electronic means.

"If I am with another patient or working on another project, Traci can examine my patients, review their treatment plans, collect data and answer questions about medications," Dr. Bosserman says. "In my opinion, she can do everything that a physician does except for determine an oncology treatment plan. Once the plan is determined, she oversees it, implements it, manages the side effects and maintains the quality of life of the patient. Traci helps the patients with emotional and long-term survival issues."

Young also brings compassionate, patient-centered care to the medical practice, which capitalizes on her specialized nursing training. "Traci does a super job at educating patients and answering questions about their cancer diagnoses," Dr. Bosserman says. "She is very in tune with their emotions, quality of life and symptom management, which is essential in oncology. We can't handle the complexity of what we're doing without a team. And each of us is important in contributing to the patient's care."

"I take a lot of stress off of Dr. Bosserman," Young says. "In oncology, there are always new treatments, new research and new data developing. In order for her to stay up to date and on the cutting edge of cancer care, she must be free to attend CME events and meetings on clinical trials. When this happens, she is ultimately able to provide better care."

Physician Assistant Partner
Michael Koshak, MD, finds it difficult to get through a typical day without physician assistant Larry Rosen. As medical director of Noble Community Medical Associates Choice Providers in Reseda, Dr. Koshak manages eight clinics in cities from Granada Hills to North Hollywood and supervises three convalescent homes. With such a busy practice, Rosen's assistance is crucial.

"Larry and I have very good communication and we really respect each other," Dr. Koshak says. "He knows his capabilities and his limitations. He is very versatile: He sees adults, children, seniors and workers' compensation patients. I am in the office most of the time, but sometimes I go to meetings or visit nursing homes, and he is just a phone call away."

PAs must practice under the supervision of an active licensed physician. When their relationship was first formed, Dr. Koshak and Rosen signed a delegation of services agreement outlining the duties that fall into Rosen's scope of practice.

"Since Wednesday is the day Dr. Koshak visits the convalescent homes, I run the clinic," says Rosen, who completed his PA program at the Keck School of Medicine of USC. "I saw 30 of his patients this morning. We share information about patients, I see and read his chart notes, his patients know who I am, and they are very comfortable with me. Rather than patients waiting a few days for appointments, I can see them right away."

Although Dr. Koshak is very satisfied with Rosen's work, he knows that relationships between doctors and physician extenders aren't always rosy. If a physician extender does not communicate with the supervising physician or ask for help when he needs it, healthcare and patient safety can be severely compromised.

"If physician extenders participate in any activities that are outside of the delegation of services agreement or outside of their scope, patient conditions can be undiagnosed or misdiagnosed," Dr. Koshak says.

When physician extenders don't follow protocol, liability issues can also result. "PAs operate under the physician's license and malpractice coverage," Dr. Koshak adds. "So if a mistake is made by the PA and the patient decides to sue, he is actually suing the doctor."

Scope-of-Practice Issues
The notion of nonphysicians providing medical services brings up a fair amount of controversy. In recent years, professional groups of acupuncturists, chiropractors, physical therapists and podiatrists have all been trying to expand their scope of practice to elective surgeries and other medical procedures.

"My gut feeling is that legislators who offer scope-of-practice proposals are trying to lower the cost of healthcare," Dr. Koshak says. "And they are compromising quality to do it."

The California Medical Association has defeated several bills from nonphysician groups to expand their scope of practice to the medical arena. In 2004, the dental lobby asked that state law be rewritten to allow oral surgeons to do elective facial plastic surgery (SB 1336). CMA and the California Society of Plastic Surgeons teamed to fight this bill and it was vetoed. However, the bill was reintroduced in 2005 and signed by the governor in 2006. The CMA and CSPS were not able to kill it a second time.

"It is the CMA's position that patients are put at risk when nonphysicians provide care or perform procedures that they are not adequately trained for," says Sandra Bressler, vice president of the Center for Medical and Regulatory Policy at the CMA.

This past year, the American Medical Association even formed the Scope of Practice Partnership, a group of state and national medical societies, to contest scope-of-practice expansion bills and proposals that threaten patient safety.

Legislative action has recently expanded to include physician extenders as well. In January, Gov. Arnold Schwarzenegger presented a health reform plan proposing to remove various barriers for NPs and PAs, allowing them to practice without physician supervision. This would increase access to and expansion of lower-cost models of healthcare delivery such as retail-based health clinics. So far, his proposal has received mixed reviews.

"Current state law does not allow nurse practitioners to practice independently without a supervising physician," says Susanne Phillips, director of health policy and practice at the California Association for Nurse Practitioners in Sacramento. "But they can open, own and work at a clinic by themselves. However, a supervising physician must be available via phone or e-mail for prescriptive purposes.

"California is not an independent practice state for nurse practitioners, and there is nothing in the governor's proposal that indicates he plans to change that. Our position is that we would like the governor to clarify what NPs can and cannot do legally beyond the nurse practitioner standardized procedures."

On the other hand, the California Academy of Physician Assistants is resistant to the idea of working without supervising physicians. "Physician assistants embrace physician supervision and have no intention of ever practicing independently," says Bryce Docherty, JD, president of the Docherty Group, a Sacramento-based government relations and consulting firm that represents the California Academy of Physician Assistants. "In response to the governor's health proposal, we issued a statement saying we oppose any attempt to completely remove physician supervision or oversight in any clinical setting."

Regulations adopted by the Medical Board of California require that a supervising physician review, countersign and date at least 10 percent of a PA's medical charts. A PA must receive prescription authority from a supervising physician to furnish controlled substances Schedule II through V. The supervising physician must also be available to the PA in person or by electronic communication at all times.

Since 2004, CAPA and the CMA have worked on correcting some components of the law to ensure that physicians can supervise PAs appropriately, and most of all, realistically. (See "Physician Assistant Legislative Actions," below.)

"For example, the law requires a PA to get specific authority from the supervising physician to furnish a drug order for a controlled substance," Docherty says. "Just imagine a PA in an emergency room trying to call the physician to get authority every single time he needs to issue a drug order for a controlled substance. It is a tremendous burden not only to the physician, but to the PA, and it does a tremendous disservice to patients. Some of these regulations need to be changed.

"At the end of the day, a PA's scope of practice is largely what the supervising physician has determined he wants or does not want his PA to do," Docherty adds.

Headed Toward Value
Dr. Koshak and Rosen believe that not only will the demand for physician extenders increase, so will their value. As NPs and PAs continue to hone their skill sets and gain medical expertise, they will be trusted to do more. That is, as long as it's within their scope of practice.

"Each doctor operates from a document that outlines the scope of practice of his or her physician extender," Dr. Koshak says. "I believe that contract must be updated yearly, to give the physician extender more experience and responsibilities."

However, a large part of the value that physician extenders bring to the health system and patient care derives from their close relationships with supervising physicians. A recent survey by the American Academy of Physician Assistants found that PAs rated the level of respect they receive from physician co-workers as "very strong." Although they are in a team relationship with physicians and have the word assistant in their titles, that same survey found that PAs feel they garner high respect from patients as well.

For physicians, the use of physician extenders comes down to the value added to the practice. Are patients happier because their questions are answered promptly? Do physician extenders allow the physician to focus on patients with medical conditions requiring more extensive training and knowledge? Can physician extenders increase reimbursement to the medical practice? Are physician extenders cost-effective?

Many physicians would answer yes to all of the above.

"I like to call physician extenders 'physician partners,'" Dr. Bosserman says. "When there is good communication and a good working relationship between the two individuals, we become partners in delivering medical care. My nurse practitioner adds a ton of value to the medical team, and I'd be lost without her."

FEATURE ARTICLE SIDEBARS

Medical Team Members Defined
Physician Extender: Most commonly refers to nurse practitioners (NPs) and physician assistants (PAs) who treat patients in conjunction with a supervising physician or physicians in a medical practice environment. Also referred to as "mid-level providers," physician extenders may also include nurse midwives and other allied health professionals. Physician extenders can be utilized in both primary and specialty care settings. NPs and PAs take medical histories, examine and treat patients, order and interpret laboratory tests and X-rays, and make diagnoses.

Nurse Practitioner: An NP is an advanced practice nurse who provides nursing and medical care in collaboration with a licensed physician. Although California state law requires physician supervision for the purposes of prescriptive authority, the physician is not required to be on-site, but available through electronic means.

Standardized Procedures for Nurse Practitioners: The contract under which NPs operate that defines their scope of practice in the medical setting where they work.

Profile: More than 80 percent are female.

Training: NPs must have a degree in nursing (RN), a master's degree in nursing (MA), a degree from an accredited nurse practitioner program, and pass the national certifying exam by the American Nurses Credentialing Center or American Academy of Nurse Practitioners. NPs can choose a specialty, such as geriatrics or oncology, in their master's program. Many go on to complete a doctorate in nursing.

Education Maintenance: NPs must complete 30 units of continuing medical education every two years to maintain their RN license/NP certification.

Median Income: $65,000

Number of NPs Practicing in California: 13,000
 
Physician Assistant: A PA is a healthcare professional who provides medical care and services under the supervision of a licensed physician.

Delegation of Services Agreement for Physician Assistants: The contract that governs the practice of PAs and outlines their responsibilities and duties, which are determined by their supervising physicians and the California Business and Professions Code 3502.

Profile: About 62 percent are female.

Training: PAs must graduate from an accredited physician assistant program and pass the certifying exam by the National Commission on Certification of Physician Assistants. PA programs run for approximately two to three years and contain a family practice component. Sometimes PAs obtain a residency in another specialty, such as obstetrics/gynecology or orthopedic surgery.

Education Maintenance: PAs must log 100 hours of continuing medical education every two years and take the recertification exam every six years.

Median Income: $70,000

Number of PAs Practicing in California: 6,200


Physician Assistant Legislative Actions
With the support of the California Medical Association, the California Academy of Physician Assistants has sponsored several bills to help streamline specific physician supervision requirements in California. According to the Docherty Group, which represents CAPA, here are the latest actions:

AB 2626 (Plescia) of 2004: This bill removed the 7-day co-signature requirement for drug orders issued by a physician assistant under the supervision of a physician except for Schedule II drugs.
STATUS: Signed by the governor

SB 252 (Alpert) of 2004: This bill allowed a physician assistant to supervise a medical assistant in community and free clinics as directed by the supervising physician without that physician needing to be specifically on-site at the point of care.
STATUS: Signed by the governor

AB 859 (Bass) of 2005: This bill expanded upon SB 252 to allow physician assistant supervision of medical assistants in physician offices and other clinic settings such as those owned and operated by the state and/or counties.
STATUS: Failed passage in the Assembly Business and Professions Committee

AB 139 (Bass) of 2006: This bill would clarify an inconsistency in existing law by allowing physician assistants to conduct medical examinations on applicants seeking a license to drive a school bus, youth activity bus, farm labor vehicle and paratransit vehicles. Current law already allows clinically competent physician assistants to conduct these medical examinations on applicants seeking a license to drive standard commercial vehicles.
STATUS: Introduced, pending further action
NOTE: The CMA and Kaiser Permanente have expressed initial support.


10 Advantages of Physician Extenders
Have you thought about bringing on a physician extender? They can:

1. Deliver medical care to higher numbers of patients, increasing healthcare access;

2. Increase patient satisfaction through shorter wait times;

3.  Spend more time educating and counseling patients;

4.  Improve efficiency and flow of medical practice;

5.  Assist with reviewing and signing labs;

6.  Aid with signing medical charts and prescribing drugs;

7.  Provide a team approach to medical care;

8.  Offer additional medical expertise;

9.  Free up a physician's hectic schedule; and

10. Give a physician the freedom to leave town, without worry or hesitation.