May 6, 2014:
As the market for non-physician providers (NPPs) such as nurse practitioners (NPs) and physician assistants (PAs) heats up, health care employers should assess their needs and consider key practical differences between NPs and PAs prior to jumping into the hiring process. This article focuses on Ohio and presents an overview of some key considerations in selecting NPPs, including education and training, level of practice autonomy, scope of prescriptive authority (if applicable), salary, payers and liability.
Education and Training
Both NPs and PAs require at least a Master's degree. Additionally, NPs must be registered nurses (RNs); some hold a doctorate in nursing practice (DNP).
Collaborating vs. Supervising
Practice autonomy varies between NPs and PAs. This may fit different practice settings and preferences. NPs "collaborate" with, while PAs work "under the supervision, control and direction of "one or several physicians." NPs must have a "standard care arrangement" with at least one physician, not necessarily within the same practice, provided the physician is continuously available to communicate with the NP in person, by radio, telephone or other form of telecommunication. PAs must have a "supervision agreement" with every physician wishing to supervise the PA, but "supervision" does not require physical presence at the location where the PA practices. Physicians can have multiple agreements but shall not, at the same time, collaborate with more than three NPs in the prescribing component of their practices, or supervise more than two PAs.
Scope of Prescriptive Authority
First, not all NPPs have prescriptive authority. Ohio law mandates strict educational, training and administrative requirements for prescribing. Second, several factors limit NPPs' prescriptive authority. NPs and PAs must adhere to preset formularies, which differ for NPs and PAs. Credentialed NPs may prescribe Schedule II controlled substances, including narcotics and stimulants. PAs also have Schedule II prescriptive authority but cannot yet write prescriptions for Schedule II. Collaborating and supervising physician(s) may further restrict said prescriptive authority. Ultimately, NPPs can only prescribe in accordance with the scope of practice of collaborating or supervising physicians.
PAs typically earn more than NPs. In 2012, PAs earned an average $92,460 ($89,800 in Ohio), while NPs earned $91,450 ($87,990 in Ohio). Salaries vary significantly according to practice settings, gender and experience.
Medicare as Payer
While NPs may bill Medicare directly or through an employer or contractor, PAs can only bill Medicare through an employer or contractor. PAs cannot reassign payment for services, and employers or contractors cannot bill Medicare for PAs' reassigned services.
Collaborating physicians are not automatically liable for the acts of NPs. Vicarious liability may attach if the physician "controlled" the events and procedures conducted by the NP (merely directing an NP is not control). On the other hand, physicians expressly assume legal liability for the services provided by PAs under their supervision. These considerations represent only the tip of the iceberg. Ohio law provides additional requirements and nuances. Health care providers should carefully assess needs and practice settings in considering NPPs.
The information in this section was written by Isabelle Bibet-Kalinyak, JD, MBA. Isabelle is an associate in the Health Care and Labor & Employment practice groups area with Brouse McDowell. She is developing her practice in all facets of health care and corporate law, as well as workers’ compensation. Brouse McDowell is a full-service business law firm based in northeast Ohio. Brouse subscribes to a cross-disciplinary approach to the health care practice, engaging specialists who are able to counsel and advise clients in the areas of organizational design, regulatory compliance, reimbursement issues, corporate financing, labor and employment, real estate, taxation and employee benefits, mergers and acquisitions, life science patents and licensing, joint ventures and strategic alliances, and litigation. Their broad spectrum of expertise allows them to deal with the complex problems that may arise in today’s health care businesses and turn them into opportunities.
This Article is intended to provide information generally and to identify general legal requirements. It is not intended as a form of, or as a substitute for legal advice. Such advice should always come from in-house or retained counsel. Moreover, if this Article in any way seems to contradict advice of counsel, counsel's opinion should control over anything written herein. No attorney client relationship is created or implied by this Article. © 2014 Brouse McDowell. All rights reserved.