The Rise and Potential Consequences of Using Advanced Practice Providers

Utilization of APPs (advanced practice providers) or MLPs (mid-level providers) such as nurse practitioners and physician assistants, has increased geometrically all across the medical field. The APPs have filled huge gaps in medical care and have performed quite well. However, with growth comes the concerns and responsibilities of supervision, training, continuing education, and liability.

The recent article Medical Supervision of Mid-Level Providers written by a malpractice insurance company contains an extensive list of concerns. They are:
·         Ensuring proper credentials.
·         Delineating scope of practice.
·         Being sure a MLP’s clinical activities do no exceed the supervising physician’s Clinical privileges.
·         Teaching sufficient communication skills to the MLP.
·         Conducting regular and periodic reviews of the MLP’s activities and clinical responsibilities.
·         Encouraging each MLP to seek supervising physician oversight as needed; encouraging questions.
·         Require MLP badge identification to make credentials clear and avoid misunderstanding.
·         Provide patients a mechanism to access the supervising physician, if they choose or request.
·         Be familiar with local laws related to the scope of practice and supervision requirements for MLPs.
·         Be sure each physician who oversees MLP activities is authorized/approved to provide supervision.
·         Ensure that the MLP is properly trained for the nuances of your individual practice setting.
·         At least yearly, review/update MLP job descriptions, policy statements, practice protocols, collaborative and employment agreements.
·         Keep a copy of the collaborative agreement on file in each practice location where the MLP works.
·         Develop and approve guidelines concerning prescriptive practices. At minimum, the guidelines should:
o    Identify the supervising/collaborating physician(s);
o    Identify the types of medications to be prescribed as well as limitations;
o    Define provisions for managing emergencies; and
o    Specify the frequency of reviewing prescriptions written for controlled substances.
·         Regularly review and update protocols for frequently encountered clinical problem(s).
·         Plan scheduled meetings with each MLP at least monthly for the first six months and at least quarterly thereafter or as often as otherwise required by state-specific requirements.
·         Document any clinical problems discussed and a plan for improvement.
·         Be sure that professional liability insurance includes coverage for MLPs.
·         Contact your malpractice carrier immediately whenever adding MLPs.
 
While this may seem to be quite an extensive list, it is actually the same general conditions under which most physician providers function. Additional suggestions are:

1.    Make sure that the chain of responsibility of the supervising physician is specifically spelled-out, and understood by all.

2.    Be careful of having different malpractice vendors for MLPs and supervising physicians. This can generate adversarial situations when a case appears.  
3.    Have clear, specific policies regarding when the MLP should ask for an immediate consultation.
4.    Make sure APPs do not identify themselves as doctors, even if one has a PHD. Juries are sensitive to potential misrepresentation.
5.    Send your APP to specific courses for the care setting in which you work. Remember how practical knowledge comes with time, but is not innate.
6.    Understand your malpractice coverage. A consultant may help make sure everyone is adequately covered. The APP needs to be named on the policy.
7.    Have a cordial and professional relationship with your APP.
8.    Avoid allegations of fraud by following CMS billing guidelines; your degree of clinical involvement in any case should never be overstated.

Times are changing and it is important to adapt to the new realities. The Advanced Practice Provider is the political answer to lack of access to health care for the near future.