Busy and steadily-growing practices may benefit from the services of PAs and NAs[sic]. An experienced physician guides you through the staff expansion process.

IF YOU WORK IN A BUSY DERMATOLOGY practice, you might sometimes feel overwhelmed by the number of patients passing through your office for routine treatment. Adding to the daily chaos, you have also probably noticed an increased number of patients demanding cosmetic dermatology procedures. The continued growth in your patient base and your menu of services brings obvious benefits, but it also tests your endurance and stretches your office resources, forcing you to seek methods to increase productivity without adding to an already crippling work load.

In this article, one of an ongoing series on different aspects of dermatology practice management, I will explore the possibility of increasing services while decreasing your work load through the acquisition of mid-level providers in the specialty of dermatology.  I will discuss the proper method of incorporating a midlevel provider into your office, focusing on practice introduction, positioning, and financial gain. I will also give advice, based on personal experience, to help anticipate and minimize patient objections as well as concerns from referral sources with regard to patients being seen by mid-levels.

Mid-level providers, primarily Physician Assistants (PAs) and Nurse Practitioners (ARNPs, NPs), are enormously successful in many medical fields, especially primary care. Over the past two decades, these groups have begun to sub-specialize. In the case of NPs, a more formal progression led to involvement in anesthesia, midwifery, and pediatric nurse practitioner. PA specialization has been less formal, although perhaps more widespread. An early split occurred with regard to medical vs. surgical training, and this preceded the sub-specialty training into areas such as orthopedic, cardiovascular, and neurosurgical. PAs. On the medical side, office ENT, allergy, and dermatology all witnessed the development of specialty PAs. As the mid-level specialties have matured, as in the case of dermatology, they have begun to formalize their association and training (see the accompanying article by Joseph Monroe).

When a dermatology practice decides to expand (or, rarely, to downsize), options include adding trained staff such as RNs, dermatology technicians, estheticians, etc., or recruiting another physician. The time and resources of the current physician(s) limit the former approach, which may not fully address the needs of the practice in a long-term fashion. But the addition of another physician can become an expensive and time consuming process, easily lasting one to two years. The practice may lose this time, combined with the expense, if the employed physician chooses not to become a partner, and subsequently leaves the practice.

A dermatology mid-level may represent a desirable middle ground between these two extremes. PAs expand the practice volume more effectively as compared to additional staff, and at the same time incur less cost and time than an additional MD. A mid-level can assist the dermatologist in seeing additional patients, develop his/her own schedule of patients, add gender/race balance to the practice, and expand the scope of the dermatology practice by adding or specializing in procedures that the physician, for whatever reason, declines to perform. Regulated by state laws, mid-levels may also be able to open the practice in the absence of the physician, minimizing unmet overhead-expenses during vacations, conferences, or periods of medical leave. They can also "prime the pump" for a practice prior to adding another physician, by expanding the new and active portion of the patient base. 

Patients may also enjoy and benefit from the quick access a mid-level  provider can offer. Especially during periods of peak seasonal demand,  holidays, or altemative hours, including evenings and weekends. The office  staff may find that having another provider, especially a non-physician,  allows them easier access for questions, messages, refills, as well as for  suggestions, concems and complaints.

Clearly then, a mid-level provider can bring a host of benefits to the  expanding dermatology practice, but what about the downsizing practice?  Consider the practice scenario in which the dermatologist makes a decision  to practice part-time, perhaps for medical reasons, to raise a family, or as a lifestyle change/prelude to retirement. Or imagine a situation in a small group practice where a full retirement is looming, and there are reservations about adding a new physician. Reservations may stem from  financial concems, managed care induced revenue contraction, declining  referral base, or an increase in community dermatology providers. Here the  wisdom of considering a midlevel provider is apparent, and, in fact, it may  be the best option.

The introduction of any mid-level provider to a dermatology practice will only be as successful as their acceptance by the patients and referring physicians. We will explore the latter first.

Because most referrals by physicians to dermatologists originate from  primary care, the potential for acceptance is relatively high. Most primary  care practices utilize mid-levels, and these patients are already accustomed  to being seen by someone other than an MD. It should be clearly communicated, however, that all referred patients are seen initially by the dermatologist, with follow up visits, when necessary, on the mid-level schedule. Take great care to accommodate the wishes of any referring physician who requests that their patients be seen only by the MD. This will minimize, if not eliminate, the potential for loss of referral sources.

The issue of patient acceptance is potentially more problematic. The history of the practice and the individual styles of the dermatologists involved will have a great impact on acceptance.  The payer mix, and percentage of  managed care patients, age of the patient base (younger patients are  generally more accepting), gender of both the patient and mid-level, and  economic/education demographics (with increasing education and income, there is generally a greater demand for physician specialization) will influence acceptance to some degree.

There are many ways for the physician and staff to introduce the mid-level  to both new and existing patients. First and foremost, the physician must  express confidence in his/her new associate and personally ask if the  patient is willing to schedule follow up on the mid-level's schedule. This  would be a good time to personally hand the patient a provider biography  brochure on the mid-level. At the front desk, all appointments with the  mid-level "dermatology specialist" PA/NP, should be confirmed again whether by phone or in person, as this gives the patient the opportunity to gracefully reconsider their decision.

Some self selection occurs naturally in terms of preference, especially for  quick follow-up appointments, prescription refills, and ease of scheduling.  If the dermatologist chronically runs an hour late and the midlevel runs on  schedule, patients may come to appreciate and prefer the efficient schedule.  The same is true if it always takes six to eight weeks to get an appointment  with the MD, but only a few days with the PA/NP. With regard to expansion of hours and procedures, the mid-level may be the only option for certain  appointment times and some procedures.

 Once you decide to incorporate  a mid-level provider into your practice, and you have selected and trained an individual to your satisfaction, your next step is to position the person in the practice in a way that will maximize their contribution. Three steps are involved, and you must reach a mutual and flexible agreement on the transition.

Step one--Introduction

The dermatologist must introduce the new staffer to  each member of the office staff individually. A well thought out process for the introduction of the mid-level to the practice will speed integration and minimize confusion.

Establish a plan of action and share it with the staff. Questions to answer  include: Will the mid-level see only follow-up patients previously seen by  the dermatologist, or will they also see established patients new to their  schedule? What about new patients? How will physician-referred patients be  handled, especially those referred by physicians who have reservations with  regard to their patients being seen by a mid-level (the so-called downhill  referral)? Will the mid-level be working on their own or continue to work  alongside the dermatologist, at least part-time? What about walk-in patients? 

Step two: Development

As the practice, and the patients, become accustomed  to the new mid-level, a practice style will naturally form. This niche may  be based on ease of access, efficiency of scheduling, optional hours  available, gender preference, languages spoken, disease or procedure  category (e.g., acne clinics, lasers), or simply patient preference. As the  confidence level among the physicians, staff, and patients continues to  grow, the mid-level's schedule will develop accordingly.

Step three. Expansion

The third and final phase of positioning of the new  mid-level is practice expansion--expanding the number of patients seen in  a day or expanding the days and hours -available for appointments.  Accomplish practice expansion by introducing new procedures such as  sclerotherapy, collagen injections, Botox treatments, or certain types of  laser procedures. The dermatologists may not be interested in personally  performing these procedures or the demand for these procedures may exceed the amount of available appointments. However, once accomplished, practice  expansion is the value-added benefit of working with a mid-level provider.

Should the employment of a mid-level provider have a positive financial impact on your practice?  Yes.

Does the fact that a dermatology practice has one or more mid-levels mean that it will instantly begin to make a profit on their production? No. 

The difference between these two statements is simply this: mid-levels are  an investment in terms of time, resources, revenue, and opportunity. View  them as a long term benefit to both the practice and patients. They will  help to define the practice and, hopefully, expand the menu of services  available. They can provide a cushion towards expenses in the event of unanticipated personal or financial crisis, and over time positively contribute to the bottom line. Like any investment, they will require work and attention to maximize return.

The ultimate productivity of a mid-level really depends on optimal utilization. The rewards may be measured in increased production, or  reduction of work effort, or increased time off for the physician. Consider  this hypothetical example from a billing standpoint: if a mid-level pursues  a full schedule of patients (20/day), five days per week, 48 weeks per year,  at an average charge per patient of $60, this would equal $288,000 in billed charges.

Assuming a discount rate of 20 percent, and overhead of 50 percent, net income prior to wages and benefits would equal $115,000. Subtract from this a salary of $50,000, with a 17 percent benefit load, and one full time medical assistant salary ( $20,000) with a  similar load, and the net is approximately $33,000. This is a very conservative calculation; however, it is based on actual historical data.

Now consider costs to the practice, which include training for six months,  followed by at least six to twelve months of practice development to  result in a full schedule. Actual costs hover in the neighborhood of $50,000  to 75,000, before a net return on production is realized. Thus, in this  simple calculation, the mid- level may have to work for the practice for up  to two years before costs are recovered.

Following this period, a salary based on production is usually negotiated,  and hopefully a win-win situation is the long term result. Be sure to check  with your practice manager and/or accountant prior to making a decision on  this or any significant financial commitment.

A mid-level provider offers many advantages to the rapidly evolving dermatology practice that is facing the challenges of managed care, revenue contraction, and increased competition from both primary care and the cosmetic surgical specialties. PAs and NPs can be valuable assets to practice positioning and promotion, and they can help achieve goals set on the continuum of cosmetic office practice development which affects virtually all dermatology practices today.

Success depends, in part, on the attributes mid-levels contribute, and on  the support they receive from the dermatologist. And while financial  considerations obviously play a role in the decision making process, their  overall contribution should be measured not by the profit margin, but rather  by the patient satisfaction they generate.