The Evolving Role of Advanced Practice Providers in Otolaryngology: Improving Patient Access and Patient Satisfaction

Abstract

The aging US population requires an increasing volume of otolaryngology–head and neck surgery services, yet the otolaryngologist physician workforce remains static. Advanced practice providers (APPs), including physician assistants and nurse practitioners, improve access across the continuum of primary and subspecialty health care. The rapid growth of APP service is evidenced by a 51% increase in APP Medicare billing for otolaryngology procedures over 5 years. APPs increasingly participate in delivering otolaryngology care; however, reaping the benefits of enhanced patient access and modernizing care delivery is predicated on successful integration of APPs into practices. Few data are available on how best to incorporate APPs into team-based models or how to restructure practices to allow graduated responsibility that supports autonomy and effective teamwork. We compare national APP and physician workforce trends in otolaryngology, consider approaches to optimizing efficiency by integrating APPs, and identify opportunities for improving data collection and practice.

Keywords

advanced practice providers mid-level providers patient satisfaction health care delivery patient safety quality of care health care access Certified Registered Nurse Practitioner Physician Assistant health workforce utilization

The Department of Health and Human Services has projected a workforce deficit of 1620 otolaryngologist–head and neck surgeons in the United States by 2025,¹ and 1 in 5 counties has seen a recent decline in the ratio of otolaryngologists to overall population. In contrast to the relatively static otolaryngologist workforce, the advanced practice provider (APP) workforce grew approximately 35% over the past 5 years with a 51% increase in the number of unique APPs billing for common otolaryngology procedures.² APPs, including certified registered nurse practitioners (CRNPs) and physician assistants (PAs), are thus playing an increasingly important role in filling gaps in access to otolaryngology specialty care.

While APPs have a vital and growing role in health care delivery in otolaryngology, few data are available regarding best practices for incorporating APPs into teams. Part of the challenge in standardizing approaches lies in the diversity of practice settings, which include inpatient and outpatient care within private and academic centers. For example, the needs in a rural setting with a low density of practicing otolaryngologists may be very different from those of a large referral center seeking to coordinate multidisciplinary care or streamline inpatient care. A growing national APP footprint has practical implications for patient access, satisfaction, and care, yet challenges exist in determining the optimal integration and use of APPs in these highly variable otolaryngology practice environments.

Otolaryngology Workforce Trends

Ge et al² studied APP utilization trends in otolaryngology from 2012 to 2017 in the Medicare population and found that there was a 51% increase in the number of otolaryngology APPs, compared to a 2.2% increase in otolaryngology physician providers. The growing APP workforce increased its total share of both new patient visits (from 4% to 7%) and established patient visits (from 11% to 15%) during that time. Patel et al³ similarly found a near-linear growth in number of otolaryngology APPs, with corresponding increases in total Medicare-allowed reimbursement, total number of services performed, and total number of Medicare fee-for-service patients treated by the APP workforce, particularly in regions with lower density of otolaryngologists. APP and physician workforce trends in otolaryngology are shown ( Figure 1 ).

Figure 1.

Otolaryngology workforce trends based on Association of American Medical Colleges physician specialty data report and Medicare provider utilization and payment data, 2012-2017.

Patients, physicians, and APPs may all have differing notions regarding the optimal approach to integrating APPs in patient care. Providing specialty-specific training, evaluating competency, and defining scope of practice for APPs are nuanced, with responsibility shared by both governing boards and supervising physicians. As summarized in Table 1 , CRNPs are registered nurses who have undergone additional education and clinical training at the master’s or doctoral degree level. PAs complete a 2-year master’s degree with didactic and clinical experience. CRNPs are generally governed by a joint committee between the state nursing board and medical board. PAs are governed by their respective state medical boards. These governing bodies set scope of practice standards and training requirements for allowable otolaryngologic procedures. While nurse practitioners (NPs) have independent practice authority in 22 states, NPs and PAs generally work with a supervising or collaborating physician.^4-6 CRNPs and PAs both have prescribing authority and overlap in scope of practice within otolaryngology, despite differences in training and licensure.

Table 1.

Advanced Practice Providers’ Summary of Education, Training, and Scope of Practice.

Advanced practice providers: training and scope of practice
Role	Nurse practitioners	Physician assistants
Degree requirements and clinical training	✓ Master’s degree, DNP, or PhD in nursing ✓ Certified by NP certification board	✓ Master’s degree ✓ Certified by the National Commission on Certification of Physician Assistants
Scope of practice	✓ Full independence in 25 states and the District of Columbia ✓ May see patients independently of physician ✓ Bill independently under individual National Provider Identifier	✓ Practice under physician supervision ✓ May see patients independently of physician ✓ Bill independently under individual National Provider Identifier

Abbreviations: DNP, doctor of nursing practice; NP, nurse practitioner; PhD, doctor of philosophy.

Optimization of APPs in Otolaryngology

Otolaryngology care increasingly occurs in the context of team-based practice. The contribution of APPs to quality of care may be evaluated using patient access and patient satisfaction metrics.^5-7 For example, hiring APPs in the Dartmouth Head and Neck Tumor Clinic was associated with an increased number of new patient visits and decreased wait times while maintaining patient satisfaction and surgeon productivity.⁸ Formalization of APP training and competency in otolaryngology may facilitate this type of integration into the care team. Improved outcomes data collection can better support and establish models for coordinated, team-based care from otolaryngology physicians and APPs. APPs can play a key role in managing volume efficiently, as well as diagnosing and treating a variety of otolaryngology conditions. The approach to integrating APPs should consider patient-centered factors, particularly in relation to access, as well as preferences of providers and operational efficiencies.

Many variables affect the optimal utilization and compensation of an APP within an otolaryngology practice, as well as selection of type of APP ( Table 2 ). For example, CRNPs have certifications specific to populations (eg, pediatric, adult, or general) or emphasizing inpatient vs outpatient settings, whereas PA training encompasses the general population.^9,10 Compensation models may include a fixed-salary model, productivity-based compensation, or a hybrid of both. Practice models include fully integrated care teams, collaborative practice with direct supervision, semiautonomous practice, or fully independent practice models. The options are infinite, and there is no singular model that is appropriate for all practices, contexts, subspecialties, and locations. A few principles hold across settings, however. It is advantageous to (1) reduce the impact of lower reimbursement for APP vs physician care; (2) increase availability of surgeons for consults, referrals, and surgical cases; and (3) use the APP workforce to improve patient access and satisfaction.

Table 2.

Practical Considerations in Engagement of Advanced Practice Providers.

Integrating advanced practice providers into otolaryngology–head and neck surgery
Dimension	Implementation considerations
Independent vs team	Consider a hybrid of independent APP care and team-based practice to achieve maximum efficiency and revenue streams. For example, when the otolaryngologist is in clinic, consider a team-based approach; while otolaryngologist is in surgery, the APP works independently with own patient panel. An experienced APP who possesses a nuanced understanding of the specialty may exercise significant autonomy within constraints of state laws.
Medical vs procedural	APPs can dramatically improve patient access to care for common otolaryngology complaints and in-clinic procedures, streamlining many aspects of evaluation and perioperative care (eg, treatment of cerumen impactions, surveillance scope exams, annual allergy immunotherapy visits, follow-ups to assess response to medications/treatment regimens).
RVU vs salaried	RVU-based models promote a sense of ownership of the practice and may motivate enhanced productivity, particularly for experienced, independent APPs; however, in this model, APPs may have less opportunity for direct collaboration with physicians and are less suited for new hires with limited experience.
General vs specialty	An APP who can see patients across the scope of the specialty maximizes opportunities for improving access and addressing needs for general otolaryngology practices, but subspecialty expertise may facilitate perioperative planning, interpretation of diagnostics, and procedures.
Advanced practice nurse vs physician assistant	CRNPs and PAs have a similar scope of practice in otolaryngology, but training and state regulations should factor into deciding best fit. Both CRNPs and PAs can see patients independently to diagnose and treat, yet supervisory responsibilities may vary between the 2 based on state requirements. CRNPs are specialty/population focused, so a pediatric CRNP may not be the best fit for a busy general ENT practice that sees both adults and children.
Physician vs APP recruitment	APPs and physician care are complementary. For a practice that has difficulty with patient access, APPs can improve patient wait times and satisfaction and streamline operations. While APPs may also free up surgeon time to address surgical backlog, additional physician recruitment may be needed to meet surgical demand.

Abbreviations: APP, advanced practice provider; CRNP, certified registered nurse practitioner; ENT, ear, nose, and throat; PA, physician assistant; RVU, relative value unit.

Conclusion

The demand for health care services in otolaryngology care will increasingly exceed otolaryngologist surgeon workforce capacity. APPs are valuable partners in meeting growing needs of the population. While further data are needed to determine the optimal models of high-quality care, it is clear that APPs will be play an ever-greater role in shaping the specialty. Successful growth in otolaryngology–head and neck surgery requires a culture that supports effective integration of APPs across diverse practice settings. Progress also requires open-mindedness on the part of both providers and patients in embracing evolving models of care.

Footnotes

Acknowledgements

We thank Nui Dhepyasuwan, MEd, Director for Quality and Performance Measurement, and Elise Swinehart, Senior Director for Membership & Global Affairs, for assistance with procuring data on Academy membership.

Author Contributions

Pratyusha Yalamanchi, conception, design, and drafting of the work, acquisition, analysis, and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work; Meredith Blythe, drafting and analysis and interpretation of data for the work, critically revising the work for important intellectual content, approval of the final submission, agreement to be accountable for all aspects of the work; Kristi S. Gidley, analysis and interpretation of data for the work, critically revising the work for important intellectual content, approval of the final submission, agreement to be accountable for all aspects of the work; William R. Blythe, analysis and interpretation of data for the work, critically revising the work for important intellectual content, approval of the final submission, agreement to be accountable for all aspects of the work; Richard W. Waguespack, conception, interpretation, critical revision, approval of the final submission, and agreement to be accountable for all aspects of the work; Michael J. Brenner, conception, design, and drafting of the work; analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

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