The Credentialing Conundrum in Rural Healthcare

Alexander Bushuev
21 Mar, 2024 updated

As the U.S. grapples with a growing shortage of physicians, healthcare organizations are increasingly turning to nonphysician providers, including advanced practice professionals (APPs), to bridge this gap. APPs enhance efficiency, patient contentment, and revenue by reducing costs and attracting new patients.

The term "advanced practice provider" encompasses nurse practitioners (NPs) and physician assistants (PAs), who are trained to offer care under a doctor’s supervision. These providers are qualified to handle primary and specialized care, perform diagnostic tests, and prescribe medications. Advanced practice providers are becoming essential to the success of value-based care—focused on improving quality, broadening patient access, and reducing expenses at the point of care. State laws determine the extent to which licensed APPs can work alongside or in place of physicians, surgeons, and dentists to deliver certain healthcare services.

The role of APPs in the clinical workforce is expanding rapidly:

  • According to the British Medical Journal, a quarter of all U.S. healthcare visits are now handled by non-physician staff.
  • The U.S. Bureau of Labor Statistics projects that from 2022 to 2032, the number of nurse anesthetists, nurse midwives, and nurse practitioners will surge by 38%, and physician assistants by 27%, compared to just a 3% increase for physicians.
  • As reported by Kaufman Hall’s Physician Flash Report, by the end of 2023, APPs constituted nearly 40% of total provider full-time equivalents (FTEs).

With the average salary and benefits for APPs nearing $120,000 annually, it's clear that health system leaders must start seeing these professionals as more than just helpers or costly assistants. There's a pressing need to seamlessly incorporate APPs into clinical environments and track the operational and financial metrics essential for assessing their impact and effectiveness.

Facing a shortage of primary care and specialty doctors, an aging demographic, and escalating chronic disease prevalence, APPs play a crucial role in closing the care gap and enhancing healthcare accessibility for communities nationwide.

The Growth of Advanced Practice Providers

Since the 1960s, advanced practice providers (APPs) have played a pivotal role in the U.S. healthcare system. The profession of physician assistants (PAs) has seen significant growth, surging by 28.7% from 2017 to 2021, with 158,470 certified PAs in practice by the end of that period. Similarly, the number of licensed nurse practitioners (NPs) has risen to 355,000, marking a 9% increase from an estimated 325,000 in May 2021.

PAs are educated to serve as generalists within the medical model, while NPs receive training tailored to specific population needs. Though postgraduate residencies or fellowships are available, they are not mandatory for PAs and NPs to begin practicing or to obtain state licensure. Both PAs and NPs are key players in a dynamic, highly effective team-based care model to healthcare, recognized for providing safe, effective care that yields excellent patient outcomes.

The 2024 NSI National Healthcare Retention & RN Staffing Report sheds light on turnover trends within this workforce, revealing that turnover rates for APPs and other allied health professionals are generally lower than the average across all hospital staff, which stood at 22.7% in 2022. Notably, turnover for certified registered nurse anesthetists (CRNAs) almost halved from 22.9% in 2021 to 12.0% in 2022 and further decreased to 9% in 2023. Nurse practitioners saw their turnover decrease from 15.3% in 2021 to 12.4% in 2022 and 11.5% in 2023. However, physician assistants experienced a slight increase in turnover from 10.7% in 2021 to 13.5% in 2022, before dropping to 11.1% in 2023.

Diverse Roles of Advanced Practice Providers

Advanced practice providers encompass a variety of roles, each with distinct expertise and guidelines for practice, yet all share the common objective of delivering top-tier healthcare services.

Nurse Practitioners (NPs): NPs are registered nurses with advanced academic and clinical training, typically at the master's or doctoral level. They have the authority to perform a wide range of healthcare services, including diagnosing and treating illnesses, conducting diagnostic tests, prescribing medications, and overseeing patient care. NPs often focus on specialties like family medicine, pediatrics, geriatrics, women's health, or mental health.

  • Physician Assistants (PAs) collaborate closely with physicians and are integral to patient care across various specialties. Their duties include performing physical exams, diagnosing conditions, crafting treatment plans, prescribing medications, and assisting in surgical procedures.

  • Clinical Nurse Specialists (CNSs) are advanced practice registered nurses with graduate degrees in nursing. Their training includes advanced courses in physiology, pharmacology, and physical assessment within their specialty areas. CNSs diagnose and manage patient care, support bedside nurses, drive practice improvements, and ensure the implementation of evidence-based practices to enhance patient outcomes.

  • Certified Registered Nurse Anesthetists (CRNAs) play a crucial role in surgical settings. They administer anesthesia, monitor patients throughout surgical procedures, and manage postoperative pain, ensuring safety and comfort.

  • Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) offer a full spectrum of care related to pregnancy, childbirth, and postpartum care, in addition to providing routine gynecological services and family planning.

This diverse group of highly skilled professionals is instrumental in expanding access to healthcare, enhancing patient satisfaction, and improving overall health outcomes across communities.

Where Do Advanced Practice Providers Focus?

Delving into the distinct roles within healthcare, Physician Assistants (PAs) stand out as versatile practitioners trained to deliver medical care across all specialties. They assess, identify, and manage patient conditions, complementing physicians in a collaborative care setting. Importantly, PAs enhance the reach of healthcare, allowing more patients to receive timely and effective treatment.

The scope of a PA's responsibilities can shift dramatically based on their medical specialty. In some settings, such as primary care or gynecology, a PA might be the main healthcare provider a patient interacts with. In more specialized fields like orthopedics, PAs often partner with surgeons to provide comprehensive patient management. For instance, in orthopedic settings, PAs not only consult with patients independently but also play a crucial role in surgeries, aiding the primary surgeon and managing patient care post-operation, including administering treatments like injections.

While PAs and Advanced Practice Nurses (APNs) might seem similar to patients, their training and certification paths have distinct characteristics. PAs follow a medical training pathway akin to that of physicians, completing extensive coursework and clinical rotations over two to three years, focusing on a broad spectrum of medical fields. They can also opt to continue their education towards a doctoral degree.

Conversely, APNs start as registered nurses and advance through a rigorous graduate program, obtaining either a master's or doctoral degree. This education prepares them to undertake between 650 and 1,000 hours of clinical training, deepening their expertise in specific patient care areas. APNs, which include Nurse Practitioners, Certified Nurse Anesthetists, and Clinical Nurse Specialists, are empowered to diagnose conditions, prescribe treatments, and manage patient care independently.

In their day-to-day roles, both PAs and APNs perform a variety of critical functions:

  • They gather patient histories and conduct thorough physical examinations.
  • They diagnose and oversee the treatment of acute and chronic ailments.
  • They order and analyze diagnostic tests.
  • They craft and execute comprehensive treatment plans.
  • They prescribe medications and carry out minor medical procedures.
  • As primary caregivers, they uphold the continuum of care for their patients.

Moreover, APNs and PAs play a vital role in promoting health, preventing disease, and educating communities about maintaining wellness. While their educational backgrounds may differ—with APNs often focusing on areas like family medicine and PAs on surgical practices—both are equipped to excel in diverse healthcare environments.

The Advantages of Having Advanced Practice Providers

Delving into the benefits of working with Advanced Practice Providers (APPs), it's clear they are indispensable members of healthcare teams, boosting both care accessibility and quality. These professionals often offer more appointment slots and potentially longer visits, enhancing patient satisfaction significantly. In bustling healthcare environments, APPs work closely with doctors, ensuring care is timely, coordinated, and of the highest quality. They are pivotal in connecting patients to specialized services and fostering strong, trust-based relationships over time.

Advanced Practice Providers are Highly Trained

Advanced Practice Providers bring a robust level of training to their roles. Upon completing their education, Physician Assistants (PAs) must pass the Physician Assistant National Certifying Exam (PANCE) to earn their certification and state licenses. This rigorous preparation involves over 2,000 hours of clinical training, and it doesn’t stop at graduation. PAs are committed to lifelong learning, engaging in continuous medical education and recertification every ten years to keep their skills sharp and up-to-date.

Advanced Practice Nurses (APNs), including Nurse Practitioners, need to clear a national board exam post-graduation to practice. They choose their specialty early in their training, aligning their education with specific patient care needs—from pediatrics to geriatric care. Like their PA counterparts, APNs undertake a significant number of clinical hours to refine their ability to diagnose, treat, and manage patient care independently.

Both APNs and PAs are required to engage in ongoing education to maintain their licenses and certifications, adhering to rigorous standards that ensure they remain at the forefront of medical practice.

Advanced Practice Providers Care for All Patients

The impact of Advanced Practice Providers extends across all demographics and specialties. They perform a slew of essential services:

  • Conducting comprehensive exams and assessing patient health.
  • Diagnosing and managing acute and chronic illnesses.
  • Ordering and interpreting diagnostic tests.
  • Creating detailed treatment plans.
  • Prescribing medications and performing procedures.

Furthermore, these providers play a crucial role in health promotion and disease prevention, dedicating themselves to educating patients on how to maintain and improve their health.

APPs in Ambulatory and Inpatient Settings

In both ambulatory and inpatient settings, APPs are key to enhancing patient access. They ensure more people receive timely medical attention, which is critical in today's competitive healthcare landscape. Particularly in primary care, APPs often serve as the first point of contact, providing immediate care and determining if specialist attention is needed.

In hospitals, as patient volumes increase and the demand on services grows, the role of APPs becomes even more vital. They help optimize team efficiency and patient flow, contributing to better outcomes and increased revenue. Effective teamwork in these settings ensures that patients receive the right care promptly, enhancing overall satisfaction and reducing wait times and cancellations.

By integrating APPs effectively, healthcare systems not only meet current health demands but are also well-prepared for future challenges, ensuring they deliver top-notch care exactly when and where it's needed.

Case Study: Advanced Practice Providers at an Academic Medical Center

In a compelling study from Cureus, an University of California Irvine (UCI) Health AMC embarked on a mission in April 2021 to refine their ambulatory care approach. They set up an APP oversight committee tasked with fine-tuning financial flows and establishing clear performance benchmarks for their PAs and NPs. Their analysis spanned from July 2021 to June 2022, specifically excluding Certified Registered Nurse Anesthetists (CRNAs) from their review.

The assessment of APP productivity focused on work relative value units (wRVUs) that strictly came from billable actions performed by APPs themselves. A year into their revised standards for both ambulatory and inpatient care, the School of Medicine observed a remarkable 53% increase in wRVUs, alongside an 83% rise in payments and a 79% growth in charges compared to the previous fiscal year. Importantly, these gains did not compromise the output of faculty members, as physician-generated wRVUs also saw a modest 3% year-over-year increase.

Digging into the specifics of APP engagement, there was a notable 45% surge in completed patient visits by APPs, with the vast majority (92%) being return visits and the remainder (8%) new patient encounters. This uptick in activity was clearly reflected in the patient satisfaction metrics collected via surveys by the National Research Corporation (NCR Health). For fiscal year 2022, the ambulatory APP group earned a net promoter score (NPS) of 85.7, indicating that nearly 90% of patients were not only satisfied but would likely recommend these providers to others, showcasing their trust and appreciation for the care received. Additionally, these APPs scored an impressive 88.2% in provider ratings.

Overall, the year-over-year data across all departments showed consistent enhancements in APP productivity and financial returns without affecting patient satisfaction or delaying expansions in service. A significant 78% of PAs and NPs reported consistently operating at the top of their licenses, underlining the effective use of their skills.

This study illustrates the successful application of targeted initiatives to maximize the utilization of PAs and NPs without detracting from physician performance. Despite the variances across healthcare settings in terms of operational models and cultural practices, it's clear there is substantial room to further leverage the vital capabilities of the APP workforce within hospital and healthcare systems.

Credentialing Advanced Practice Professionals

Credentialing advanced practice professionals (APPs) is a critical step in ensuring that they are well-prepared and authorized to deliver high-quality healthcare. APPs bring a high level of training and independence beyond that of allied health professionals. They include a variety of roles such as certified nurse-midwives, optometrists, and psychologists, all integral to the medical staff and subject to rigorous credentialing, privileging, and peer review processes.

Credentialing for Advanced Practice Providers (APPs) mirrors the process used for physicians but shifts its focus slightly. Instead of confirming medical school and residencies, credentialing teams must validate the graduate-level education relevant to an APP’s duties. This involves direct primary source verification from educational institutions or designated sources like the National Student Clearinghouse. If an APP’s profile from the online AMA service lacks certain details, further verification from educational institutions may be necessary. Typically, verifying an APP's undergraduate education isn't needed unless specifically mandated by an organization’s credentialing policies.

For all APPs, the credentialing team must ensure that their highest level of education aligns directly with the clinical privileges they seek. This requirement can vary from one organization to another, with some requiring comprehensive verification of all educational and training backgrounds, regardless of the standard set by accreditation bodies.

When an APP applies for clinical privileges that will result in billable services, they must go through a rigorous credentialing process. This process, notably the primary source verification, is as stringent as that for physicians. The credentialing activities might be conducted together or separately, depending on whether they aim to grant clinical privileges or enroll a provider into health plans for service reimbursement.

Healthcare leaders are increasingly looking to streamline these processes to enhance efficiency. Successfully enrolling APPs with CMS or private health insurers involves adhering to each payer’s specific billing regulations, which can be navigated using advanced contract management tools to ensure compliance and optimize financial returns.

Privileging for APPs, as per requirements from bodies like CMS and the Joint Commission, focuses on ensuring that all practitioners meet the high standards necessary for delivering medical-level care. This term typically encompasses services that are traditionally within the physician's scope, such as diagnosis, patient management, and treatment.

Joint Commission Standards

The Joint Commission outlines that each healthcare organization is responsible for defining which roles qualify as Licensed Independent Practitioners (LIPs), a classification that varies based on state laws but generally includes roles such as physicians, dentists, podiatrists, and clinical psychologists. The Commission also mandates specific privileges for PAs and APRNs, including nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists.

CMS Regulations

In 2012, CMS expanded its definition of medical staff to potentially include non physician roles, allowing hospitals the discretion to grant privileges according to state law. This flexibility means that all practitioners identified to provide a medical level of care need to be evaluated individually by the medical staff to confirm their qualifications and competencies.

Remain in Compliance with Credsy

It’s essential that privileges reflect the complexity of the services offered by APPs rather than merely their professional titles. With our tool, Credsy, healthcare organizations can manage all aspects of APP credentialing efficiently. Credsy simplifies gathering and validating provider information, ensuring compliance with evolving state laws and accrediting standards.

For healthcare organizations aiming to streamline their credentialing processes and maintain compliance, embracing sophisticated management solutions like Credsy is not just beneficial—it's essential. By ensuring that all practitioners, not just physicians, are appropriately credentialed, healthcare organizations can safeguard the quality of care and expand services confidently and legally.

Reach out to us at Credsy to see how we can transform your credentialing processes and help you keep pace with healthcare's dynamic requirements.

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