Series: Achieving Credentialing Excellence—Know Your APPs
Medical credentialing success is more journey than destination. In this series, symplr explores areas where the healthcare landscape creates an evolving path toward best practices. We focus on tangible checkpoints, goals, and reminders to help you maintain credentialing excellence. In part 1: Advanced practice professionals are poised to shoulder a greater percentage of primary and specialty care, warranting a close look at policy and procedure for these clinicians.
Advanced practice professionals’ rise
The factors contributing to the U.S. physician shortage continue to shape our healthcare practitioner workforce. For example, the percentage of primary care positions filled by fourth-year U.S. medical students was the lowest on record in 2019. A new report by the Association of American Medical Colleges reiterates long-term predictions that:
- The aging population requires more physicians, just as one-third of all active doctors prepare to retire.
- Rural hospitals are closing and care is harder to access outside urban areas, despite the rise in urgent care sites and use of telemedicine.
- Healthcare delivery trends (e.g., mergers, accountable care organizations) aren’t helping to alleviate the physician shortage.
But there are great expectations for non-physician practitioners to continue filling the gaps left by the physician shortage. Two major practitioner types, physician assistants (PAs) and NPs, have experienced 13% and 15% employment growth, respectively, in recent years. Now 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Challenges do remain, as physician associations often oppose their expanding scopes of service and states weigh in on precisely how much care they can provide independently.
Calling all credentialed and privileged non-physician practitioners. But what to call them?
Best practice #1: Use current professional titles
Physicians are categorized as licensed independent practitioners who don’t require the supervision or direction of another clinician (e.g., MDs, DOs, dentists, podiatrists, and often licensed clinical psychologists).
Non-physician providers abound and work under hundreds of titles—from acupuncturists and audiologists to nutritionists and radiologic techs. Here, we focus on practitioners that the medical staff services department must concern itself with. CMS and The Joint Commission requires individuals other than licensed physicians who provide a medical level of care and/or conduct surgical procedures in the hospital to be credentialed and privileged through the medical staff process, commensurate with physicians.
Credentialing of this group in hospitals depends on some combination of factors: state scope-of-practice laws and professional licensure laws, perhaps a supervisory relationship with a physician (PA), the organization’s accreditation body standards, and Internal bylaws, policies, and procedures.
Best practice is to refer to the following clinicians as APPs:
- Advanced practice registered nurses (APRNs): Includes certified registered nurse anesthetists (CRNAs), certified nurse midwives, NPs, and clinical nurse specialists
- Others providing complex care and/or requiring clinical privileges, as defined by the organization and its state/accreditor(s), for example:
- Clinical social workers
- Clinical psychologists
- Occupational, physical, and/or speech-language therapists
Terms still in use but out of favor for this group include midlevels, ancillary staff, affiliated staff, and allied health professionals. Because so many nonphysicians were lumped under those terms, the APP moniker emerged as a better way to describe the set most often credentialed and privileged through the medical staff process.
Best practice #2: Check your APP policy
Medical staff membership rights, expansion of services, quality monitoring and improvement—these are key areas where policy change may be in play regarding the growing number and type of APPs credentialed and privileged through the medical staff process.
It’s been almost eight years since CMS expanded its definition of the medical staff, allowing nonphysician practitioners to have privileges like other medical staff members. While it did not name the group of APPs, CMS broadened the concept of medical staff and have allowed hospitals the flexibility to include other practitioners as eligible candidates for the medical staff with hospital privileges to practice in accordance with state law.
Regarding APPs’ expanding roles, physician associations and boards regularly fight the expansion of APPs scopes of service. Their stance: There is no substitute for physicians’ extensive education, training, and experience for certain services and procedures. But limited access to care, advancements in training for specialization of APPs, effective lobbying efforts by nurse and PA associations, and other factors foster increased independence for APPs in their practices. It’s a trend expected to accelerate.
As a result, it’s best practice to follow a consistent policy regarding the expanding scopes of APPs to avoid violating licensure laws and/or privileges allowed and granted—also known as scope creep. The following tips can serve as a guide for creating a policy or evaluating an existing one:
- Determine whether your organization’s policies:
- Define the roles categorized as APPs
- Including “core” privileges and special procedures requiring additional training, education, and experience
- Specify whether and what APPs can be members of the medical staff
- Specify whether and what APPs can hold office and/or serve on committees
- Investigate whether your organization has a mechanism to address the growing trend of scope expansion:
- Is training up allowed and by whom? (E.g., supervising physician, sponsor, other)
- Does the governing body and organized medical staff have a documented formal position on training up?
- Does the organization’s insurance carrier have a documented formal policy on training up?
- What do bylaws, P&Ps state about patient consent in circumstances where APPs are in training for expanded scope?
Best practice #3: Understand APP reimbursement
Achieving maximum reimbursement for APPs’ services is essential for the financial health of the healthcare organization. More MSPs’ roles are expanding to include payer enrollment. The responsibility carries with it a need to understand foundational elements of Medicare enrollment for nonphysicians, commercial payers’ requirements, and other topics as defined by the specific setting in which the APP works (e.g., inpatient versus outpatient).
CMS provides a fact sheet with basics of enrolling APPs and reporting changes in order to be eligible to receive Medicare payment for covered services. Unfortunately there’s no single resource for APP reimbursement by commercial payers, and guidelines vary from payer to payer.
Best practice #4: Establish performance indicators for APPs
Because the definition of APPs remains fluid and their scopes of service vary by state and organization, it can be difficult to create metrics for their performance. But in healthcare today, quality measurement reigns supreme: You can improve only that which you can measure. These tips can serve as a guide for creating, measuring, and reporting APP quality performance indicators and targets:
- Conduct FPPE and OPPE for APPs. Gathering quality data can be more difficult for APPs than for physicians due to a lack of access to clinical activity and the nature of team-based care. Still, as we learned from the Joint Commission’s Ongoing and Professional Practice Evaluation (OPPE and FPPE) for physicians—measurement must start somewhere, and some measures are better than none. Another lesson from O/FPPE: The best measures come from involving the practitioners when developing the criteria.
- Consider creating or adapting a peer review rating form that allows reviewers—peers or supervisors—to use an APP’s privileges.
- Determine whether your Credentials Committee is equipped to address performance oversight for APPs, or whether the establishment of an APP Committee is warranted. It’s best practice for “like” practitioners, departments, and/or subspecialties to be reviewed together. The APP Committee can be a subcommittee of the Credentials Committee, or a standalone. Legal experts note that adding it as a subcommittee may offer better protection from discovery.
Nearly every cost and quality initiative in healthcare delivery today will depend on the contributions of APPs. Their growing potential makes APP credentialing a best practice area to monitor closely.
In Part 2 of this series, we'll explore telehealth's effects on credentialing as it progresses toward becoming a primary vehicle of healthcare delivery.