The Changing Role of PAs and NPs in the ED

- [Jay] When you... There we go. Great. So welcome, everybody. Thanks so much for joining the Democratic Group Practice Section webinar, kind of building off of last year's really successful anatomy of a democratic emergency medicine group, where we had some great speakers, great topics. We're excited to be offering this year's version. And today we're really gonna be focusing on advanced practice providers. Really, you know, hugely beneficial and also come with some trouble spots that we have to all contend with. And so we've got a great group of panelists here today. Rami Khoury who's from the board of ACEP, is gonna talk a little bit about why ACEP had to kind of get involved as the ever changing environment for APPs really became very evident. Rob Thomas is gonna be talking about some of the business impact of APPs as well as retention. Chris Ross is gonna be talking about hiring and recruiting, and then also talking about the shared visit change, which is really affecting the economic equation for APPs. And then Dave Hall is gonna talk about how to manage the APP group and help make their work satisfaction higher, as well as our satisfaction in managing APPs. Now, my name is Jay Mullen. I'm the section chair. I'm on the reimbursement committee. I'm also a board member of the Emergency Medicine Business Coalition. I'm gonna be the mediator. And the way that we have this set up is that each of our participants is gonna actually give a short presentation on their topic, and then we're gonna have a conversation. We're gonna be monitoring the chat, if you have the chat. There are some participants that are having trouble finding the chat in Teams. If you can't put something in chat and you have a comment, raise your hand and we'll find a moment to recognize you. Though this is pretty fast moving, we really try to cover a lot of topics, and the conversation ends up being really good. I really want to thank Adam Krasinski, who's our ACEP staff person. He's fantastic, keeping our great ideas lined up with an actual deliverable. So really helpful. Thank you, Adam. And also just wanted to point out our leadership team of the Democratic Group Practice Section. We've got Sergio Hernandez, who is our president elect. Rob Thomas, who's our immediate past president. Chris Ross, who's our secretary. Dave Hall, who's our counselor. And Jamie Shoemaker, who's our board liaison. Jamie is listening in. We're also working a shifts, so like every emergency physician, he is multitasking. He may or may not be able to chime in. So let's go ahead and get started with the slideshow, Adam. Great, let's go to the next slide. And the next one. So just each of us, as we talk, we'll give an introduction. We're all at Democratic Groups. We're all just very excited about the Democratic Group Model. We think it's the best model, and each of us is gonna just give a sense of how big we are 'cause some of our groups are really big, some are pretty small. My group we've got about 50 emergency medicine physicians, five hospital medicine physicians, 30 APPs. We're in five different emergency departments from busy, urban to critical access hospital. We also have an urgent care clinic, a hospital medicine program. We see about 120,000 annual visits. Next slide. All right, so first, a little bit of historical context about PAs and nurse practitioners. They've actually been around for a really long time. You know, really over 60 years. And it was developed back in the mid 1960s because there was really a growing shortage and maldistribution of primary care physicians. Probably sounds very familiar to what we were dealing with with emergency medicine physicians up until recently where there was both a shortage and a maldistribution. Now that we've done our workforce study, ACEP is predicting that actually now there's just the maldistribution of emergency physicians, that's the major problem that we're facing from workforce issue. And early on, PAs and nurse practitioners were really there to help the physician. I mean, they really truly were a physician assistant, really acting more in a support role, such that CMS didn't even recognize them as far as reimbursement until 1989 for nurse practitioners and 1997 for PAs. Both professions initially were meant to extend the reach of physicians, but by 2022, there's actually independent scope of practice for nurse practitioners in 24 states. And two states have completely independent scope of practice for PAs, at some point, that's both Maine and California. Unfortunately, Maine is my home state and we worked really hard to try to prevent that, but weren't able to. Next slide. If we'd been having a workforce discussion 20 years ago, it would've been about making sure that we continue to highlight the value of emergency medicine training and board certification and make it clear that emergency medicine was its own specialty. And here, what we see is the number of non-EM trained emergency physicians in our country, and it's really going down really pretty steadily, and probably we're all experiencing that in our own business life. And we've got some fantastic colleagues that we're trained in, perhaps family practice, but we're just not seeing that same level of training or the ability to actually put them into the same roles. Plus, we're finding it easier now to find board certified emergency physicians. So we're currently at about 5% non-EM trained emergency physicians in the country, and that's going down steadily. Next slide. Contrast that to this, which is the rising tide of APPs coming in. And you can see that in 2018, it was about 15,000, and they've been growing since then at about a 6% rate. And so really steadily being more and more available for emergency medicine physicians. And so when there's a void because of that maldistribution of emergency physicians, we're finding APPs are being turned to by a lot of hospitals. Next slide. And this becomes really important to understand the training difference between PAs and nurse practitioners. So let's first think about an emergency physician down at the bottom. First of all, there's about a 5% acceptance rate into medical school, they then have 48 months of very intensive medical school, which is very clearly standardized, and then they have roughly 15,000 hours of postgraduate specialty training. I think that number's a little high. I think probably 10,000 is closer for a three-year residency in emergency medicine. Go back there. So compare that to physician assistant where their admission rate is actually about 20%. And in nurse practitioner programs, it looks like their admission rate is roughly averaging 68%. The duration of their training is roughly one and a half years to two years. And while PAs have a really standardized curriculum based on the medical model where they spend their first year doing didactics and their second year doing standardized rotations, the nurse practitioner programs are really kind of all over the map. Some of them are incredibly rigorous and produce really strong training and others are completely online where some nurses are able to obtain both their RN and their nurse practitioner at the same time, such that when they finish their training for their NP program, they may have only 500 clinical hours of actual patient care time. And at least in my experience, a lot of the times the nurse practitioners working on their rotations are actually just shadowing, and I don't see them actually delivering a lot of care. I don't know if that's the way it is for everyone else in their experience. And you can see that at the bottom, even when they then have the equivalent of specialty certification, which is their CAQ, the physician assistants have about 3000 hours of emergency medicine work before they can apply for that, whereas the emergency nurse practitioner exam only requires 2000 hours of emergency medicine work. And once again, compare that to the 10,000 hours that a emergency medicine resident gets over their three-year training, and even longer if it's a four-year training program. So next slide. So I'm gonna turn this over now to Rami Khoury who's gonna kind of share with us how ACEP has been watching this for years, they've they've had policies related to APPs, and they recently did an update to really address a lot of the changes that have been happening over the last few years. Rami. Rami, you might be on mute.

- [Rami] Jay, thank you very much. What I'd like to do is start off to talk about the role of ACEP. ACEP is a physician membership organization which represents effectively board certified, board eligible nursing physicians. ACEP is not a governing body or a credentialing body. And that's really important when we put up our policies or best practice statements or guidelines. And our goal is to look out for the best interest of our patients by looking out for our physician hours. And that is really the guiding light here and why ACEP changed its tune. It really didn't change its tune, it just fine tuned it a little bit. Next slide. So our new ACEP PA/NP statement was adopted in April 2022. Reasons behind that statement. Now, historically, ACEP has always stated PAs, NPs are members of a physician-led team and that physician leader is a board certified, board eligible, emergency physician. The reason for this change is a lot of scope creep, and that has happened a lot of changes, including behaviors from AAPA, the ENA and AANP. What's interesting is SEMPA, which is our emergency medicine PA organization, actually is much more in line with ACEP stance than any of these other organizations. You add into that the workforce study that came out in 2021, which was predicated on pre-COVID data, plus, COVID-19 volume loss, and then practices replacing with physicians with PAs or NPs. We're actually just hiring PAs or NPs instead of additional physicians for multitude of reasons, including cost. And then you add in state law and state law changes. There's been a massive clamoring for this from our membership. So that is kind of the reason behind the statement change. Next slide, Adam. So ACEP has always stated, like I mentioned, that they are a member of our team, but that team is headed by an emergency physician. So the new statement takes a stronger stance due to these external pressure and it's really to advocate for what we are, which is advocating for our members, which are the physicians. The new statement really defines what direct supervision means, what indirect supervision means, and what oversight means. Direct supervision is them presenting every case to you, you oversee the case, do the external documentation. Indirect supervision is them presenting cases to you, and you can actually say, no, you're good with that, and just eyeball 'em like you would do a senior resident as an example, for those that have residency programs. And oversight is effectively a QA process, which they choose to see on their own, and you filing whatever compliance process you have internally, and being compliant with your state, you oversee their cases to nature, everything's good. So oversight, as I mentioned, is more of a QI process, which is not supported. So the new statement effectively says that you can... The use of APPs in the emergency department is through direct supervision and indirect supervision, but not oversight. The statement was loosened up a little bit and wanted some indirect supervision via Telemedicine or other avenues at rural areas. Nonetheless, the statement is a little bit, I would say, trying to get us to the next level where we want every patient in this country to be seen by a board certified, board eligible emergency physicians. Knowing full well that that's not the reality, but because of our situation with the members, we thought this was the best way to go. Thank you, Jay.

- [Jay] Great. Thanks, Rami. So I got some questions for the panel, and then also for any of the audience, if you'd pop an answer in the chat or raise your hand if you have a comment to make. My first question to the other presenters is, are you getting pressure from your hospital clients to use more APPs and less physicians?

- [Chris] Yeah, I could say that we are not, our hospital is pretty happy with our services, so whatever we're doing, they don't really wanna mess with the suit per se. So it's, they haven't really pressured us to do things one way or the other. If anything, they're pressuring us to use more physicians on some circumstances, because a lot of our leadership are physicians for our hospital network, which is nice because we've had some QA cases that went through that were from APPs and they kind of asked about our staffing and stuff like that just to clarify things. But, yeah, we haven't had any pressure to use more APPs.

- [Jay] Great, thanks, Chris. And Robert, it looks like you're saying no also.

- [Robert] Correct, yeah. In fact there was a group in town, we're in the twin cities of Minneapolis, they tried to go to more of a staff resident model in one of their sites, and it was shot down after about three or four months. Poor outcomes, and it just, it was sort of wiped away and no one's tried since.

- [Jay] Yeah, I know from my group, two out of the three of our newest contracts had either complete APP staffing of their emergency department or some days where only an APP was on and they wanted to move away from that. So that kind of mirrors what you guys were seeing too. How about from a state perspective? I know I mentioned that Maine has had independent scope of practice for nurse practitioners for almost 20 years, and we recently passed a law which allowed independent scope of practice for PAs after 4,000 hours of clinical care. Anyone else fighting those battles or seeing those things happening in your state?

- [Rami] Jay, I can tell you in Michigan, a couple of things happened. The first reach at this was, the MLC bill that came out through Michigan State Medical Society a number of years ago, and the plan from the legislature was to actually open that up to hospitals and all specialties. The big issue was with ABIM and the perceived cost of board recertification, and they did not believe that tied to anything quality. So what the state of Michigan did was held that bill up at the outpatient practices for primary care, effectively, pediatrics, internal medicine and family practice in the outpatient setting, but did not allow it to continue through on the hospital side because the hospitals and the other specialty associations put a stop to it. The goal was to open that up to anything with the next step to have period of time to practice. What you currently have is a state law in Michigan, and what they define that the PA or NP cannot practice independently, and oversight has to be within a hundred miles. Oversight within a hundred miles, right? So they're practicing under physician, and as long as that physician's doing ex-audits, they can still see independently, effectively. That's what that means. Now, recently, and this has just gone down recently at the state with our governor's office, was a push from the CRNAs to actually go to complete independent practice and multiple associations led by the state chapter for the Anesthesia Association plus Michigan State Medical Society, and the Michigan College sent letters directly to the governor's office and looks like there's a hold on that for independent practice there. So that's Michigan.

- [Jay] Thanks, Rami. And so Chris Ross looks like they fought that battle four years ago in Indiana and won. And Mike Becker, former section chair noted that in Wisconsin, APRN independent bill passed both houses, but was struck down by the governor. So that's great. I'd vote for that governor again. Let's move on. I'm gonna move on to Rob Thomas. We may circle back to some of this independent scope of practice, so please continue to add your comments in the chat. But let's turn to you, Rob, to talk a little bit about the business side and the retention side.

- [Rob] Yeah, sounds good. Well, I would just start by saying that I am not an expert, but I was asked to speak about this topic. So I think I'm knowledgeable, but I think that everybody who's on this call likely has a lot of experience in managing PAs, so this is, and NPs, so this is really just a conversation starter. Just as by way of introduction, I'm in Minnesota, that's our exclusive state of practice. We have 250 ER docs. Vast majority are EM residency trained, otherwise they're legacy. We have only about 50 PAs, and so that kind of gives you a sense of our ratios. We're in 11 emergency departments. We have three freestanding acute care clinics, and we see about 600,000 annual patient visits per year. So the sites that we're in are really pretty busy. I would just, as a way of just background, so with our acute care clinics, we staffed them with single physician coverage, but as volumes started to ramp up, we added in double coverage with PAs because it's kind of an expensive model to run, but we knew if we added more physician coverage, we would actually end up losing money. So we had to have that double coverage. And that actually was our entry into adopting PAs and NPs as secondary coverage at our urgency rooms, but also as assistance in our hospitals. So these ratios are a result of just kind of longstanding practice. We've really only been interfacing with PAs and NPs in the last 10 years. But since that time, we've actually introduced our own training program where we'll bring in PAs and NPs right out of school. Mostly now we're turning to PAs. We're bringing them right out of school, so two years, and then we put them into a training program in our emergency departments for about nine to 12 months, depending. We aren't sending them, it's not like a residency where we're sending them into the ORs to do anesthesiology, do assistant surgeries and things like that. But at the end of it all, they become fairly proficient, but it takes everybody a couple more years to really become valuable in our organization. But here's where our group is starting to experience a lot of tension. You guys are probably experiencing the same thing, and that's why you're interested in this call, is that PAs, they have so much more flexibility in terms of what their opportunities are, and it has to do with the amount of time they put in, and it has to do with their ability to kind of work under physicians, so they don't have to be the expert right outta the shoot. And so we're finding that PAs and NPs in our program, they're not lifers like we are. And I think it's important. And I'm reminding at a board meeting this morning, I have to kind of remind our physicians in our board to say, don't panic if they leave. They're leaving because there are other opportunities out there that they wanna pursue, and they may not have the same lifestyle that we have and we're locked into. So we can't panic. We just have to realize, that's a reality. But having said that, we've just gone through an evaluation of our full compensation, our benefit package, what is the lifestyle that we're providing our PAs and NPs? And it turns out, and maybe you know this, but it turns out that money is not everything. So we sometimes think, oh, just throw more money at it, shift differential, do more weekends, more nights, whatever. We'll just put more money to it, and that's not what's keeping people. We even provided retention bonuses and we required a year to stick around and people still bail. And it's not because we have a toxic culture, it's because they were offered something that just fit with their lifestyle. So that's kind of the point, is that there comes a point at which money won't talk anymore, and you have to start looking at how are you going to provide flexibility or lifestyle changes for your PA program or your NP program that maybe you don't get to offer the physicians. And that's an interesting. We haven't hit that yet, but I think we're gonna end up hitting that. There are things we have to offer our PAs to keep them in the program that we can't offer our physicians. So lastly, what I would say on that is that, you think about culture and culture and how they're treated or how they're valued, there's such a wide variety of that. I mean, there's some people who are just, they're clock punchers. They don't need to be involved in decisions, they don't want to be asked, they wanna just show up, they wanna do the work, and they wanna leave. That's the same for physicians as well. But then there's this other cohort of PAs and NPs that really wanna be involved. They don't like the fact that they might be viewed as second class citizens because they don't have an opportunity to own the group, things like that. That seems to be just kind of a wild card, but I would say flexibility and lifestyle are the things that are gonna allow you to hold onto your people. And go to the next slide.

- [Jay] Hey, Rob, can you just comment a little bit more about when you said offer things that we might not be able to offer to the physicians? Like, what are some examples?

- [Rob] Every third weekend. So we do not have enough physicians in our group to offer every third weekend. I would try to hire every one of your doctors to get that done, and then everyone would work about 600 hours a year. On the other hand, we could offer that to our PAs if that keeps them on the team. Does that mean that physicians might have to work a few more weekends? We're not quite at every other weekend, but we might have to go to every other weekend in order to get that done. So this is where this, the efforts that you're gonna make to retain your PAs and NPs versus what reward you're gonna get, you gotta understand what that ratio is, 'cause it tells you how far you're gonna bet. It tells you how far, what investments are you gonna make. These are things we haven't done yet, so I have not offered every third to our PAs yet, and I haven't told our physicians that we might offer every third to our PAs. And it's not an exclusive decision of mine, but it would be a group's decision, but the way I would frame it up is, it would be really, really important to understand to what degree you're willing to affect change for your PAs and NPs on comp, on flexibility, and on how they're perceived or valued within the group, and then understand what are the things that you are gonna get for it? So get an understanding of what your effort to retain, and what you're gonna get out of it. Go to the next slide, Adam. And so my recommendations to you would be this. Three things. One, research your own data. Two, involve the people on your team. And three, adjust frequently. So what does research mean? We've just gone through a process of understanding, what are we actually getting, from a financial standpoint, what are we getting on a per hour basis from our PAs and NPs? And we're getting a granular in terms of, at this site, it's this, at this site, it's this, at our urgency rooms, which are our acute care clinics, it's that. So that even tells you a little bit like, okay, if we aren't able to retain people, where are we gonna prioritize we place them? Because when we place 'em over here, we're delivering more financial value to our group. So I would encourage you to do that. I would also encourage you to find, sometimes they're expensive, but benchmarking, what things look like in your own environment, I think is pretty important. And then finally, kind of understanding what are the things that are beneficial? What are the people in your group really value? I'm talking now PAs and NPs, 'cause they're all gonna have is a wide spectrum, but try to categorize those things. And then as you're gonna implement something, explain to them what you've found, what you're gonna try to implement, bring them along, but I would not, this is not a set it and forget it type of thing, you're gonna adjust on a regular basis to make sure that you're hitting the mark to keep your people.

- [Jay] Great, thanks, Rob. So along those lines of the granular metrics, has anyone else looked at your group and really figured out, like, what is the cost per RVU you produce with a physician versus APP? I know that for my group, I was on a panel once with Jesse Pines, and I was trying to make the argument that, you know, if we wanna maintain our compensation, we have to use a lower cost provider to take care of the lower acuity cases. And he challenged me on that and said, I'm not sure that the economic equation works the way that we think it does. So I went back and did the same thing that you did, Rob, or a similar thing. And I said, how much does it cost us per RVU we produce if we are using a physician or if we're using an APP. And interestingly, we only saved about 15% in cost per RVU produced by our APPs as opposed to our docs, which sounds awfully similar to the 15% pay cut that you get from Medicare and Medicaid if the PA is seeing them. So it turns out that for my group, there's not a good economic argument for them. We've found other reasons why we still really find them a valued member of the team, but it it's no longer the economic reason. How about others?

- [Dave] I'll comment to how our group has sort of looked at this from a financial standpoint. We kind of look at it as a cost per case and how much you look at now. The issue is, is that, like any math, it's kind of propaganda to yourself. So you can look at it in different ways, but one of the things we recognize is that the doc and an APP both have to see the case, of course, that drives upset cost. So even though the cost doesn't necessarily parallel, the RVUs generated by the total team, there are some extended values to having that extra APP on the floor. What it came down to us was not the financial value, but so much of what else do you get for it. Patient flow, work with your metrics. And you start to add these other components to it that are not just cost. The issue is, is that, if you can't see that with an APP, you have to see it with a physician as well. And how many patients can doc see without APPs or without residents sort of helping you out. So the conversation changes when you're seeing them just with the APP. But another way to look at it is, what does it cost to see each patient when you consider your entire workforce, which is all your docs and all your PAs, and how many they see independently, how many did docs see independently, and then what is that really high cost of them seeing it by themselves? So similar to what you've done, Jay, but I think it's good to hear from different groups on the different ways that they can look at it. Again, recognizing it's all propaganda, depending on whatever message you wanna spread, but that's one of the ways to do it as well.

- [Chris] We have not, and I've heard from several of you guys that have, and it sounds great, and I really wish we would kind of dive into the numbers, but it really depends on how granular you wanna get, kind of to Dave's point. We have a lot of our APPs do our time intensive procedures, so if somebody has a big scalp laceration, that's gonna take, or facial laceration, it's gonna take a lot of time, it's really hard to put that into numbers because that's gonna take up a lot of your physicians time then afterwards, and they're not gonna be free to see patients then otherwise. So it's... The more that I think about it, the more I kind of get lost a little bit. So that, for me, at least, it's been kind of a personal struggle, but our group has not kind of delved into that quite yet, but maybe we will in the next coming couple years as per my slides coming up.

- [Dave] I'd like to add one more thing to that whole equation, which is the, the docs that never look at the numbers and the finances. And I'm talking about the docs that are purely clinical in our group. Obviously, I sit in an administrative seat and I'm privy to a lot of information, board members, same idea, and other leadership, but the docs on the floor, there's always this assumption that APPs are cheaper in care. And to Jay's point, I do think there's some value to looking at it because you may find that there's not, it's not necessarily cheaper. You may still wanna go with them, to Chris's point, 'cause you're utilizing them differently. But I think, I'd be interested to hear, but the general sort of floor doctor as it were that doesn't see those numbers, automatically assumes that you're saving money by having APPs in your department. And without considering all the intangibles that Chris is saying, you may exactly, you may find out something different that you're not in fact saving money, as much as you thought anyway.

- [Rob] You're on mute, Jay.

- [Jay] We've only been doing Zoom for how many years, and Teams. So Rob to your... Thinking about what Dave just said, have you shared at all with your APPs the fact that there's actually not, that the group's not actually making money off of them? 'Cause I think that, just like Dave was saying, the average pit doc is thinking that it's cheaper to use APPS. I would imagine APPs oftentimes think too, like, the group is just making money off of me because I get paid less.

- [Rob] Well that... Your premise is not true for us. We actually do make money per hour for our PAs. Now, I don't know if Dave, I guess I was kind of hearing maybe you were in like, you're not talking about the expense to the testing, right? It's not like a total, you're not a total cost of care thing where PAs are costing the organization more money because they're doing more testing. That's not what you're talking about, right?

- [Dave] No, I'm saying, when you start cost, when you start looking at, if you just take the variables of your workforce, don't count any leadership, just count doc hours and APP hours, and how many patients the PA see by themselves, how many of the doc sees by themselves, and then what they see together, the cost per case, when they see them by themselves is really good, the cost per case when the doc sees them is a little more costly, but, of course, it needs to be done 'cause it's proper care, but to combined of a doc and a PA seeing the patient together can really drive up that cost, and that's a large percentage based off of the guideline and stuff. So hopefully that answers what you're saying, Rob.

- [Rob] Yeah, yeah. So we are working on creating that dichotomy where, we don't want overlap. As soon as we think there's gonna be any degree of overlap, just elevate it to the doctor, elevate it to the doctor, elevate it to the doctor, 'cause we don't wanna mess around with wasting time and add expense. But given our 2022 ability to bill and we haven't hit this 51:49 ratio thing yet, given that, we are still making money off of our PAs in every single location how we use them. We are not necessarily advertising to our PAs how much money we're making off of them. We would never do that. But I guess the reason I'm suggesting that you look at it is because to the degree that you are making some money off the use of your PAs, that then delivers to the profitability, that then you give as compensation to your physicians and physician owners, you need to know when those things start to get asymptotic to like, you know, this isn't worth it. Because there hasn't been a physician leader that I have talked to that has had to manage PAs and NPs in their group that hasn't said, this is the most difficult group that I have to manage. And so you're gonna go, you know, you're going through all these gymnastics, all these contortions to make 'em happy, and again, if you're getting asymptotic to zero on profitability off of 'em, what's the point? Just put the doc in and they can see everybody and you're better off. I guess that's, it's a little bit of that. That's kind of where I was going with that comment.

- [Jay] Makes sense. Great. Thanks, Rob. And actually this makes a great segue to Chris for his slides. Gonna pull those up. Adam. Chris is gonna talk a little bit about hiring and recruiting, but then also about the shared visit and about how that changes affecting groups mathematics.

- [Chris] Hey, I'm Chris Ross, and less so than Rob, I am definitely not an expert, but I can kind of share my experiences here in Indiana and how my group operates. So we're 43 emergency physicians. Last I counted, we have 57 APPs. A lot of those are PRN. We also run two observation units that use APPs as well. We have five separate emergency departments. Most of them are urban. We have a specialty hospital and also a rural hospital. And the average of those, or the total patient volume out of all those sites is 235,000 patients per year. So hiring and recruiting. I guess APPs, NPPs, I don't know what you wanna call 'em. So I've been somewhat involved in the hiring recruiting for our group for a while. We have a dedicated leadership or a leadership position in our group that takes care of a lot of the hiring and recruiting APPs just because it's so labor intensive, kind of to Rob's point. We've noticed some obvious things that I'm sure you guys have noticed as well. Demographics for the APPs, they're younger, we seem to notice equal male, female, and most of them don't have kids, haven't established families, or if they have established families, have a non-working spouse. This is again is towards the lifestyle thing that Rob was pointing out. That's the night's weekends, all that stuff that you're... You have to work in the emergency department as opposed to other specialties where people will jump ship to take those nicer shifts. So who do we hire? We've noticed over the past several years, especially with kind of the numbers, I think Jay put them up, or maybe it was Rob, I think it was Jay, that the numbers are booming. So nurse practitioners schools are blowing up all over the place, there's online nurse practitioner schools where you don't have to do much in person at all, and it's seemingly all of my emergency department nurses are going through nurse practitioner school at this time. So we have people knocking on the door constantly asking for jobs, looking for work, a nurse practitioner and PA alike. I know several of us have talked about this before. I think it's been talked to at some of our other meetings. Nurse practitioner versus PA. We generally get more bang for our buck out of PAs. They seem to have more clinical training, seem to hit the ground running a little bit better from the start. We have hired some nurse practitioners with the extensive emergency department experience, but still doesn't translate well to being a provider. So that's kind of been a little bit more difficult. Rookies versus veterans. Again, back to the lifestyle thing, and back to the demographics, we get more people fresh outta school than probably any other specialty. Not very many other, not very many second sort of career or second position PAs are coming to us. They're coming to us straight out of school. We have had a few from other emergency departments, but that's been kind of tricky because a lot of those left for, you know, maybe they got in conflicts with other people at their previous departments. And so they've been, I'd say our veteran PAs have had a tougher fit than our rookie PAs coming out. So just something to consider and something that I've noticed. Recruitment opportunities. So our group has been fortunate to partner with Butler, a university that since the inception of their PA program in 1995. So most of our PAs have come from Butler, and we actually started with PA usage around then with the first graduating class of Butler. So we have pretty extensive experience with that. We also have noticed with our previous scribes that seem to enjoy working with us, think we're decent people, come back and work for us and they really hit the ground running 'cause they know documentation really well, they're good with medical decision making 'cause they sit side by side with us for a year plus and talk through cases. So that really has been a boon for hiring and recruiting. So moving on, and kind of changing subjects and back to our previous discussion about financials, I know most of you are aware about the CMS split shared visit rules. So CMS has been king on paying 85% of care for the shared NPP physician visits. So that's gonna be scaling up over the next couple of years. For this year, they still pay a hundred percent for you doing a substantial portion of the visit, that could be the history physical exam or the MDM or greater than 50% of care. And we all know, if we're going to get involved in this, we're probably not gonna be doing the 50% of care, which is the only thing that's gonna pay a hundred percent of Medicare rates next year. So options going forward. What are you doing? So we've talked about this a little bit as a group. We've talked about this in Indiana ACEP. I've talked about this with a bunch of people on the call, and it's kind of all over the board. People are definitely scrambling trying to come up with solutions and it's interesting to see, and I'd be very interested to hear what everybody on the calls group is planning. But these are the things that I kind of thought of. So screen for Medicare patients. Those patients older than 65 dialysis patients, those are easy screens, so those patients would be seen by physicians only and not APPs, kind of to Dave's point, where you're not redoing a lot of work there. You could further limit patients seen by APPs. Jay kind of brought this up as well, that this may or may not make financial sense having them see the lower acuity patients. I think you have to run the numbers for your group and see if that works. You could do what some groups, I guess I would put us in that group probably so far, is just to watch closely and see how things go. We don't know quite how, kind of how I alluded to previously with how our APPs do a lot of the time intensive procedures for our group. So if we really scale back on our APP coverage and ramped up our physician coverage, well then maybe we wouldn't be as efficient because then our physicians would be doing those time intensive procedures. So I think we're probably in the watch closely and see our reimbursement goes and kind of react not unless we come up with some fancy numbers or somebody else has great suggestions. I've talked to other groups. I think, Jay, you were talking about that, how, considering dropping a lot of the NPP hours just because, financially, it doesn't make much sense. And if you're losing 15% on those cases, then it's not gonna be very helpful. So I'd like to know when it works for everybody's group. As everybody knows, what happens with CMS is gonna happen, is probably gonna happen with a lot of the big commercial payers as well. I can't imagine over the next five to 10 years that they're not gonna follow suit and see the savings right there. So I think we need to come up with a plan or at least be able to react appropriately, but I'd really be interested to hear what everybody has to say. And, yeah, it's definitely gonna be a problem to have over the next few years.

- [Jay] Yeah, thanks, Chris. Let's turn that question over, maybe Rami. Is your group doing anything different with APPs moving forward, based on all the things that we've talked about, or is your group, you think, likely to use in the similar way to what you've been using them for the last few years?

- [Rami] So we we've been trying to do a transition for a while, and some of the culture piece is not working, talking to, you know, similar to what Rob said, where you're trying to avoid that overlap. And I still think that's the right... If you're gonna use 'em, leaving the ACEP piece aside, I guess, from a business perspective, you're gonna use 'em to do it that way. I think our focus is gonna be primarily on the low acuity cases because we've actually had very good success with that model historically within our group, and they've produced enough to, well, more than covered their cost there, in addition to help with some throughput stuff, similar to what Chris said. So, but reduction probably in the hours I would suspect.

- [Jay] Great, thanks, Rami. Rob, how about your group?

- [Rob] I think we're pretty well positioned because we just looked and we only, at least in our hospitals, we only have about an 8% overlap. So it appears that in our emergency departments, our PAs and NPs are pretty good at self-selecting cases that are appropriate for their scope of practice. So, you know, can we start to fine tune... Would we potentially cut down on the number of patients they see so that we can capture that extra 15%? Maybe, but we have to do quite a bit more analysis, I would say.

- [Jay] Yeah, and I would say my group, as far as the shared visit go, we actually really try to avoid the overlap as well. So typically, when the emergency physician getting involved, it's usually either just a quick touch base, or it's actually, you know, hand the patient to me. I'll take them from here. So we're not really changing very much in how we do things because of the shared visit. Wanna turn down to one of the things that you were mentioning before Chris, is about your pool of PA candidates that are coming out, or PA graduates. And I also wanna thank Fred. Fred put in a note in the chat that his group has found that precepting PA students is a great recruitment tool. Works out to be a one month on the job interview. I couldn't agree more for our group that that's what we're doing. And we actually have a post graduation, a postgraduate training program that we found to be incredibly successful. Is your group doing anything like that, Chris?

- [Chris] No, we do kind of a warmup shift sort of situation where they work double covered shifts for, I think, it's a month or so, and then they hit the ground running. We also have, I think it's emergency medicine boot camp that we require them to kind of go through. It's like an online course, more or less, to try and help get them up to speed. To Fred's point though, I think a lot of us, I mean, we're trying to recruit people, we're trying to recruit people we know. So people that have done rotations with us that we like, and we've kind of taught our way the scribes. I mean, I don't know how many of you guys have scribes out there in your groups, but I can tell you, it's night and day, 'cause you don't have to have any sort of training afterwards. They know exactly what we're kind of tuned to do, they know how practice patterns are, so whenever we get a previous scribe that applies to our group that we liked, you know, that seems to work out really well. So that familiarity with our group, the familiarity with the APP and how they practice is pretty key, I think. And then the training afterwards is helpful, but I think that screening upfront is more important.

- [Jay] Great. Dave, how about your group? Are you doing anything for the new grads to get them ready?

- [Dave] Yeah, it's been an evolution over the years. We've had PAs in our group. I say PAs 'cause that's the majority of what we have. But PAs and NPs in our group, since way back before, sometimes in the early 2000s, we've had 'em. And that evolution has changed. We actually found that as, the way that we used to utilize them was, is just that they pick up more charts, they helped us with flow, the docs were able to raise their patients per hour. So they were seeing them, and that led to a ton of dialogue with our APPS. So we'd talked to them about the case much like any resident or medical student rotating with you. But the evolution of, that's how we trained them, sort of on the job, the docs always saw their patients, but as we caught more up with the times and they got into independent care, we recognized that that no longer was working and that we had to develop a program. So we developed a program that has educational oversight, everything from survey tools that show us how they can be quantitatively looked at to see how they're doing from a 1 through 10 standpoint, for instance, surveying our docs to, these are the modules you have to complete to run your system. The issue I think we're having now is, if they are gonna see patients independently and more so with, let's call it the oversight type model, that they really have to have a pretty good gestalt at what's going on, and the best way to do that is to directly supervise them. So we're running into a problem where, how do you directly supervise them, but also not drive up the cost of training a new one every three to five years? And I think that's where the rub is with us, with our group and our training program.

- [Jay] Great. And I'm gonna turn it over to you, Dave, for your presentation, but I wanna thank Fred for his group. What they're doing is, as they're waiting for new APPs to go through the credentialing process, they're giving them an option to work as a scribe, which helps 'em get used to the local culture as well as the EMR. And then Becker has a question that, Rami, maybe I can punt over to you. So the policy that ACEPS recommending about supervision, does that apply, does that oversight model apply in the fast track as well?

- [Rami] If your fast track as within your emergency department, then the answer is yes. That's kind of the whole point. It's an emergency care visit, it's an emergency care visit. So that's where that policy stands. So it is across the emergency department, and in emergency departments, we have fast track, we have chest pain module, we might have an OBS unit, et cetera. It's the same concept.

- [Jay] Great, thanks, Rami. Interestingly, it was a little bit cathartic as this group got together to talk about how we were gonna present this webinar, because we all realized that although we really value our APPs as individuals and actually find them indispensable in their role of being proceduralists and helping do a whole bunch of things in the emergency department, we also found that the group was really hard to manage, kind of like what you said, Rob. So we decided to give Dave the hard question of, so how do you manage your APP group to make sure that they're finding the satisfaction that you want them to in their job?

- [Dave] Sure, yeah. I agree, it's a challenging topic, and I think there's lots of difference of opinions on it. You can go to the next slide. Just a little bit about my group and sort of my perspective on where we're coming from, which is, we have four hospitals. We see about somewhere between 60 and 90,000 patients at all four of our hospitals. They're all level two trauma centers, heavy stroke centers. Rural is the incorrect term in there, but nonetheless, that's sort of our emergency departments that we manage. My group's a little different because we have sort of a multi-specialty approach. So I'm coming at a perspective of looking at a lot of different service lines that carry APPs to some models. And that is our urgent cares that are independently owned and operated by us. There seven of them. We also have this hospital medicine service line. So three of our hospitals, we have an admitting service where we have IM physicians and APPs that manage that service from a rounding side perspective. Like many of you, we have some OBS units and we have a scribe program. So we've sort of looked at all of these different services. You can go to the next one. So as Jay kind of said, there's major challenges amongst these PAs, but I think where we all are probably standing is, is there is in fact a role for these APPS. You have to consider the financial ramifications of it, and you have to consider throughput and metrics and what you're willing to sort of put up with, as Rob said, because it is a difficult population to manage. And what I'm gonna talk about is something that is a challenge for me because I do manage a lot of these APPs and different services, but to get there, we probably have to recognize, what are the differences between them and the physicians, and maybe even consider it from their perspective. And I think that, I'll personally say that I have a challenge with the APPs because of the population's difficult, but that we're committed to doing it because we believe that there's a place for them in our practice, and they make us better, we just have to find out how that looks. But to do that, maybe going from their perspective. So let's look at a couple different things here. First of all, you have differences between PAs and NPs, of course, and I believe a lot of you know that. It was talked about earlier in the presentations. Their schooling is much, much less than the ED physicians. So a lot of their learning comes from on the job and what they see next to you. And they work next to us in the ERs, and they think because we are very open folks in the emergency departments, we talk about a lot of things that maybe we shouldn't. We talk about how much money we make at times, and our boats and our cars and our traveling. And they look at us as peers, which develops a problem because, in their minds, we're close to peers that we make a bunch of money off of them, and that's a challenge. And that initially brings some angst there, but when they come into this, they don't have to have any widespread training. They jump into the program and you're generally on the job training, as Chris said, but they have this ability to move specialties, which makes them a real challenge because the second that they don't like some things, they can start looking at at the grass green or on the other side. And then, of course, there's these financial drivers that exist between trying to make them profitable because they are not physicians. They don't provide the same amount of care that we do, they can't see through the same things that we do. But these are challenges, and from their perspective, these are challenges that sometimes they miss out on and when they're looking at it. Next slide. So, going back to this positivity thing and what role do they in fact fill, and I think that's a lot of our discussions that we're having, but we have to find out where that fits. There was a quote that one of my APPs told us in a meeting when we started talking about, you know, going to this model where they're seeing more of the fast track type patients, and they're seeing more of the procedures to help out the docs, and a little bit less of picking up patients and sharing them with providers. And one of 'em said, you know, "I didn't go into emergency medicine to see urgent care patients. I want to go see the sick ones." So their perspective is, I went the emergency medicine to see some fun stuff, and you guys are doing all the fun stuff and I'm just your sort of workhorse at times. And although that's not true, that is the perspective that some of them come with. Some don't feel that, some love their position. They're more than happy to see the non-hyper acute medicine, but they do want that fun emergency medicine feel. So we've found that they want a little bit of both. If they can intubate once in a while, it's good to let 'em do it as a fun thing, but we don't want them intubating. So we have to live in that world of trying to keep them happy, feeling like they're fulfilled, but then also saying, you're in emergency medicine, not family practice, to do some emergency medicine things. As we mentioned before, this all fits with the way that we utilize the APPs. We as a group, have to find a way to make them feel that they're a part of that team by recognizing that we are part of one team, but we have to be very cautious on how physicians behave in the fishbowl when we're with them. I think there's another one, another slide here. So when you're looking at how they try to get there, they just wanna be part of the team, and we need to value that. They are working side by side with our providers and some emergency departments, even if they're not seeing all of the acute cases. And we just have to find that happy mix where they're seeing what they need to see, providing a financial improvement to the department working on flow, but also keeping them happy and letting them know that they're a part of it. Things like discussing monies and vacations and that stuff in the fishbowl is a problem for us because it puts us on the same level, but not financially. And there's this concern of, how do you keep them real busy and happy, but not feel like they're getting, quote, unquote, "scutted out" by doing something that they perceive. They don't wanna do all the pelvic exams or all the difficult lacerations. They wanna feel like they're moving the meat and they wanna feel like they're seeing these high level cases, and they love that emergency medicine perspective. So the consideration really is, and I'm watching the time here, is just how do we make sure, we as a collaborative, and I'd ask this to everybody else. How do you try to find a way to keep them happy, but also make it make sense, especially in the setting of this new CMS rule that's coming out?

- [Jay] Yeah, and interestingly, in the chat, there's been a lot of discussion about the retention or lack thereof of APPs, and the general consensus in the comments have been, that all of our democratic groups have had really good retention of physicians and really pretty significant churn of the APPs that's actually gotten much worse in the last few years. So for the panelists, if you're seeing that in your group, do you think that that's related to the COVID related stresses of a pandemic, or more to the overcrowding and total change in the work environment over the course of the last several years, or something else?

- [Rami] So, I'll say a couple of things. I've had the lovely pleasure of having, done some oversight with 'em for 14 years. First of all, one of the things that Chris said was, a lot of 'em are very young coming out. And then the moment they have a lifestyle change, the moment they get kids, this is a 24/7, 365 practice. Most of their shifts are afternoons, some night shifts, holidays, weekends, et cetera. Because they can jump specialties, they wanna find the lifestyle. So we see a lot of people, historically, have left for lifestyle. That's a big thing. So that still happens, and it still happens on a regular. Every time there's a market adjustment in your area, somebody wants to jump to the highest payer. I do think COVID has hurt some stuff, but I would probably say that it's actually been more damaging on the hospitalist inpatient side than I would say on a PA side. I think what it's done on the PA/NP side and the EDs, is where it's driven, at least in our group, we have significantly less lower acuity cases, that's actually driven some of that out of the emergency department as you see more urgent cares open up. I think that's driving more of that volume there, which is probably hindering them. Then lastly, because you're combining PAs and nurse practitioners, the fact that you have 1.5 million nursing shortage around the country and traveler jobs paying more for the nurse to work as a nurse than a nurse practitioner, you might see some stuff change there. A number of people have gone into NPs rules, lowly for the simple fact of actually making more money, not necessarily because they actually wanna take care of patients as a provider like a physician. So I think you're gonna start seeing some stuff happen there, but the trend is always gonna be the trend in some capacity, and that has not changed except for that last piece with NPs.

- [Jay] Great, thanks, Rami. Anyone else have a comment to that question? If not, it looks like there's a demand for Joe to create a webinar for why he has such high retention of his PA. So once we get your slides, Joe, we'll add them to the slide deck and make sure that they're all available for everybody. And I just saw a comment from Kyle. "I think rural ED retention is multifactorial. Many feel like a large part of the community in the rural setting. Docs are in..." Wow, we're getting so many comments. I'm having trouble keeping track of it. "Docs are in and out, going to multiple sites with two to three APPs to make sure all the shifts at a certain hospital and create real team environment." And I definitely, we see that in my group. They also get a bit more freedom. I think Mike Bell, who's one of our medical directors in our critical access hospital 30 miles off the coast, probably would agree that the team spirit of having the APPs in a lower volume site, usually, that are able to actually manage a little bit sicker patient with a physician right there to help them, really helps them enjoy the work that they're doing. With that, I'm gonna draw this to a close. Thank you, everybody. We had almost 40 people on this webinar. Once Adam has it all cleaned up, he'll have it posted to the Democratic Group Practice section. And feel free to enter in engagED, your thoughts about any of the things that we talked about. This has been a great conversation, and it would be great to keep it going. Any last thoughts from any of the panelists or Adam? All right, thank you, everybody.

- Thanks everyone.

- [Rami] Good job, thank you.

- [Jay] Thanks, guys.