So You Want to Hire an APP? 

Hiring an Advanced Practice Provider (APP) such as a Nurse Practitioner (NP) or Physician Assistant (PA) can significantly benefit health care practices, but it also comes with unique challenges. This article outlines the key considerations and guidance for successfully integrating an APP into your practice.

Benefits

Revenue
APPs can expand a practice’s capacity by handling a higher volume of patients and performing billable procedures and assisting in surgery. In settings where the surgeon’s time is limited, APPs can increase overall productivity and contribute to a more profitable operation.

Accessibility
APPs improve access to care, especially in rural or underserved areas. They can manage chronic conditions, provide routine care, streamline patients throughput and reduce wait times.

Patient Satisfaction
Patients often report high satisfaction with APP care due to increased face time, approachable communication styles and comprehensive attention to their needs. Additionally, APPs frequently excel in patient education and preventive care, fostering trust and adherence to medical advice.

Risks

Malpractice Concerns
Although APPs are well-trained, they operate under supervision. Errors or miscommunication regarding their scope of practice can lead to malpractice issues. Establishing clear guidelines for their responsibilities is essential.

Large Initial Investment
The onboarding process, including recruitment, training and credentialing, represents a significant initial cost. However, this can be mitigated by their long-term contributions to practice efficiency and patient outcomes.

Not Scribes, MAs or Residents APPs are independent providers with advanced training in clinical decision-making and patient management. They are well equipped to assess, diagnose and treat patients. Utilize them as partners in the delivery of health care, not auxiliary staff.  

NP vs. PA: Key Differences

State Laws and Supervision
NPs may practice independently in some states, while PAs generally require physician supervision. This distinction depends on state-specific regulations.

Scope of Practice
NPs are often trained in primary care and holistic approaches, whereas PAs are trained in medical models resembling physician education, allowing them to work across specialties. Understanding these nuances ensures appropriate delegation.

Reimbursement Medicare reimburses APPs at 85% of physician fee schedule. There is some variation in credentialling and reimbursement rates for Medicaid and private payors, but all states and major carriers cover the services of APPs.

Facility Privileges
Hospitals and surgical centers often have different credentialing processes for NPs and PAs. Investigating facility-specific policies is critical to ensuring smooth integration and faster credentialing.

Compensation

Local Averages
Compensation varies by region and specialty. Referencing the American Academy of Physician Associates (AAPA) salary reports provides accurate benchmarks.

Salary vs. RVU/Bonus A fixed salary offers stability, but productivity-based compensation (RVU models) incentivizes higher output. Consider hybrid models combining base salary with bonuses tied to metrics like patient satisfaction, productivity or procedural volumes. When considering compensation models, know that many tasks APPs perform, such as visits in the global period and assisting in surgery in an academic practice, are non-reimbursable. APPs also frequently perform burdensome administrative tasks like Prior Authorizations and Peer-to-Peer Reviews which can lead to burnout.

Advertising the Position
Effectively marketing your job posting ensures you attract qualified candidates. Highlight unique aspects of the role, such as professional growth opportunities, manageable caseloads and strong physician mentorship. Leverage large national professional organizations to reach a targeted audience.

Working with an APP

Interviewing & Onboarding
When interviewing APP candidates include in your questions, “Why Neurosurgery” as onboarding is crucial for retention and productivity. Programs like Sessions in Neurosurgery for the Advanced Provider (SNAP) and other AANS courses provide specialized training and enhance clinical confidence. Implementing SNAP as a structured onboarding training into our practices reduced our turnover rates to under 35% and provided a smoother transition into a subspeciality. Also critical to retaining your APPs is earning their trust from the beginning; this will be a tremendous help when you need their support or buy in on initiatives.

Scope of Practice and Supervision
Revisiting scope of practice and supervision policies ensures APPs are aligned with the practice’s expectations. Regular audits help identify gaps and prevent potential liabilities.

Quality Assurance
Monitoring performance metrics, including patient outcomes, length of stay, rehospitalization, billing compliance and patient satisfaction scores, ensures quality standards are maintained. Consider implementing regular performance reviews and feedback sessions.

Mentoring and Professional Growth
Fostering mentorship cultivates job satisfaction and professional development. Encourage APPs to join professional organizations to access educational resources, networking opportunities and leadership roles. Implementing an APP Journal Club also contributed to increasing retention within my practice.

Conclusion

Hiring an APP is a strategic decision that can enhance revenue, improve patient access and boost satisfaction when done correctly. Understanding their roles, compensating them fairly and providing robust onboarding and mentorship are vital. Hiring a board-certified Fellow of the American College of Healthcare Executives to lead and manage your practice, in addition to investments in APP work life balance, will help increase retention and reduce turnover. An investment in your APPs is an investment in the long-term success and sustainability of your practice.