Non-physician providers in the hospital

The ways non-physician providers are integrated into hospital medicine practice vary widely, as do the associated salaries, responsibilities and experience.

The ways in which non-physician providers (NPPs) are integrated into hospital medicine practices vary widely, as do the associated salaries, responsibilities and experience, according to recent survey results discussed at a Hospital Medicine 2011 session.

“State laws vary, hospital bylaws vary, and the culture of hospitals vary, and that affects how NPPs are integrated,” said Jeanette Kalupa, DNP, program manager at Cogent Healthcare of Wisconsin in Milwaukee, who co-presented the session with Mitch Wilson, MD, chief medical officer of Eagle Hospital Physicians in Atlanta.

The presented results came from a Society of Hospital Medicine (SHM) survey sent to members in late 2010 and early 2011 and a survey done during registration at a 2010 Hospital Medicine for NPPs Boot Camp sponsored by SHM, the American Academy of Physician Assistants and the American Academy of Nurse Practitioners. Forty-two people responded to the SHM survey, while 160 responded to the boot camp one.

The boot camp survey didn't ask about age, but 58% of NPPs in the SHM survey were older than 41 years, an interesting finding given that most hospitalists are younger, noted Dr. Kalupa. “We are making [being an NPP] a sustainable career for older folks,” she said.

Combined data from both surveys revealed that 45% of NPPs had been in clinical practice for zero to four years, 20% had been in practice for five to nine years, 11% had been in practice for 10 to 14 years, and 11% had practiced for 25 years or more. Nearly three-quarters of respondents had practiced in hospital medicine specifically for four years or less. “So, many hospitalist NPPs have only recently moved over [from the outpatient side],” Dr. Kalupa said.

Employment setting, schedule and workload

The vast majority of respondents to the surveys worked full time, with nearly half working in a hospital or integrated delivery system. About 22% worked in a local hospitalist group, 7% in an academic/university setting, and 4% in a multi-state hospitalist group. “The last figure doesn't surprise me, since there are different regulations by state” for NPPs, Dr. Kalupa said.

About 42% of respondents worked a Monday to Friday shift, while another 31% worked a rotating block schedule. Nocturnist NPPs comprised 8% of respondents. Of those who worked a night shift, nearly three-quarters worked a shift-based schedule; the rest had a call-based schedule. Overall, about a quarter of respondents took call, whether at night or during the day, and about 63% of them were compensated for taking call.

As for workload, about 23% of respondents had 11 to 19 patients on their average starting team census, while about 16% had 60 patients or more. About 17% had zero to nine patients, and 25% had between 20 and 39 patients. In terms of patient encounters, about 33% of respondents had between 11 and 15 encounters per day, 31% had between six and 10, and 17% had between 16 and 20.

The bulk of the surveys' respondents did between one and six admissions, and one to six discharges, per day. About 20% of NPPs didn't do discharges at all, and less than 5% did seven or more. “This is good, because it means the practice isn't just putting all the discharges on the NPPs. They should be doing the discharges of the patients they are following,” Dr. Wilson said.

About 36% of NPPs reported they don't do shared visits with physicians—also good news, as it suggests those NPPs are responsible for their own patients, Dr. Wilson said. Of those who do share visits, about 23% shared more than 20 visits per week.

Salary and benefits

Base salaries for NPPs looked like a bell curve, with the top of the curve comprising the approximately 27% of combined respondents who reported making between $80,000 and $90,000 per year, and 26% who reported making $90,000 to $100,000 per year. The numbers were raw, not adjusted for full-time employee status. Most respondents made only a base salary, though about 5% reported making a base plus a productivity incentive and 11% reported receiving a base plus incentives based on other factors.

“My opinion is that at least 20% of your salary should be based on incentives,” Dr. Wilson said. “PA/NP practice should parallel and be congruent with hospitalist practice.”

Most (about 83%) of the NPPs didn't receive a signing bonus, relocation compensation (about 81%) or a repayment incentive for things like student loans (about 87%), although many physicians receive these benefits, Dr. Wilson noted.

Nearly all NPPs have their malpractice insurance paid for by employers, though about 42% didn't know whether tail insurance was included. “This scares me. People need to know whether or not they have this, which essentially covers you if you ever leave the practice,” Dr. Wilson said. “You have got to insist on coverage for when the malpractice event occurred, not for when the claim was made.”

Most respondents had some measure of financial coverage for CME. About 41% got four to five days of paid time off for CME, while about 28% got no paid time off for it. “NPPs should get the same level of coverage for [CME] as doctors. Hotels and planes don't cost less, although I guess conference costs are sometimes less. I think there should be a level playing field, here,” Dr. Wilson said.

Future NPP surveys will address issues like paid and unpaid time off, hospital committee work, mentoring and orientation, and ongoing clinical quality peer review, Dr. Kalupa said.