Health care reform is based on a model of care that encourages patients to be seen by a provider with the correct skill set for the clinical issue at hand. Sometimes this will be a specialist or a subspecialist; other times a primary care physician will be appropriate. But there also will be times when an extender is a patient’s ideal provider.

Traditionally, practices added physician extenders (or mid-level providers) — such as nurse practitioners, nurse midwives, surgical assistants and physician assistants — to increase patient capacity and operational efficiency, as well as enhance patient education. Yet practice capacity is just the start in this age of health care reform.

A practice that uses an extender only to bulk up patient capacity may fail to reap the full benefits of his or her skills and coordination of care abilities. Indeed, the right use of extenders can increase the quality of care, improve patient satisfaction and make every physician’s professional life at least a little better.

Hiring and Implementing Physician Extenders-Vital Decisions

Many physicians think of extenders as allowing the practice to increase patient volume at a lower cost than adding another physician. But the decision to add extenders should be based on more than just economics.

Physicians must carefully decide what the practice needs and how the extender will be used and supervised. These vital decisions will affect patient experience, practice quality, malpractice risk and billing practices.

Each physician’s specialty and clinical philosophy will help determine the type of extender the practice needs and how much autonomy the extender will have within the practice. If a physician wants the extender to see patients for follow-up appointments without the physician’s direct involvement or to allow the extender their own pool of patients, consider nurse practitioners (or, in the case of obstetrics practices, nurse midwives).

Physician assistants also may be used in a practice that performs physicals or in an emergency department setting. Surgical assistants are helpful in busy surgical practices to prepare patients in the office for surgery, conduct surgical follow-up and serve as assistants in the operating room.

Legalities and Philosophies

Be sure to check your state’s rules for mid-level providers and clinical duties. To determine the applicable rules, contact your state’s medical and pharmacy board.

It’s very important that you contact your practice attorney before deciding what type of extender you need. Your attorney can assist by reviewing the language regarding extenders in your managed care contracts. In addition, you should contact your malpractice insurance carrier to determine the liability issues and coverage that may affect you.

Legalities aside, the practice’s physicians and partners must be ready philosophically to employ extenders. The physicians must clearly define the role they have in mind for each extender. If the role isn’t defined, the practice risks uncomfortable situations between the physician and the extender.

In addition, avoid conflict over how much clinical responsibility extenders expect to have and how much the physicians are willing to allow. Physicians must have this defined before interviewing and hiring.

Financial Analysis

Once the practice has determined what type of extender it needs, perform a financial analysis to estimate the expected return on investment. Key tasks include:

  • Establishing the volume of patients available for the extender by checking the physician calendar for next available new patient appointments,
  • Reviewing the schedule for patients with clinical needs appropriate to be seen by the extender,
  • Estimating employment costs (such as salary, benefits, continuing education, and malpractice insurance); salary ranges vary by the type of extender, state, experience and prescriptive authority, with $60,000 to $80,000 generally being a good estimate,
  • Calculating other necessary expenses, such as additional exam rooms and equipment,
  • Projecting potential revenues by using billing data, and
  • Determining how many additional patients the practice will be able to see per day, the average billing charge, and potential quality bonuses (or Patient-Centered Medical Home reimbursement, etc.).

The number of additional patients will vary by extender type and depend on state and managed care contract rules regarding the use of extenders. When determining the volume of patients that an extender can see, remember that he or she may be ideal for working with patients who need education on their diseases or medications. When used properly, extenders typically don’t see as many patients as physicians.

Best Procedures

Develop policies and procedures for supervising the extenders before the interview process. At a minimum, the procedures should include what the extender can and cannot do, what type of patients/ cases will be handled, and how patients will be scheduled. In addition, procedures should include a monthly chart review and meetings with the supervising physician to evaluate the quality of patient care, charting and communication skills.

When it’s finally time to recruit and interview for the position, follow your established hiring procedures. In addition to conducting interviews and performing reference checks, ask candidates to spend a day in the office observing the clinical style of the physician(s) and practice so all parties can determine whether the extender in question would be a good clinical and philosophical fit.

After hiring, watch out for common pitfalls such as a lack of supervision and training; poor integration with existing staff; the extender winding up with the wrong type of patients (or too many); and physicians simply ignoring the extender’s existence.

Terrific Assets

Extenders can be terrific assets to any practice — financially and for patient satisfaction. But physicians and practice managers must take the time to properly plan and integrate these new team members.

Learn more by contacting Andrew McDonald at or call 615-309-2474 for more information on implementing physician extenders.