Hire midlevel practitioners to lower costs in EDs

NPs, PAs can ease physician workloads

Hospitals nationwide are finding that hiring midlevel practitioners can ease problems with physician shortages and sometimes lower costs.

Ukiah (CA) Valley Medical Center recently expanded its emergency department (ED) to include an urgent care center. The move would have been more difficult if the hospital hadn’t hired some midlevel practitioners to team up with ED physicians to expand the coverage, says ValGene Devitt, president and chief executive officer of Ukiah Valley.

The ED has nine full-time emergency physicians, some of whom have other jobs, such as serving as a public health officer for the county. The department also has six part-time physicians and five full-time, midlevel practitioners, including nurse practitioners (NPs) and physician assistants (PAs). (For NP and PA guidelines, see box, p. 103.)

Devitt says the midlevel practitioners primarily are assigned to the urgent care area, although occasionally one works the ED. An emergency department physician is available to provide back-up support to the NPs and PAs.

If two physicians are on duty in the ED, then one is assigned primary responsibility in urgent care, Devitt adds. "The need for a physician in urgent care is not routinely a high priority."

The hospital used midlevel practitioners before opening the urgent care center.

"We had midlevels working in the emergency department before we spun off urgent care, but we’ve had to expand the number of midlevels in order to staff the urgent care center," explains Ron Gester, MD, FACEP, medical director and emergency physician at the Pacific Redwood Medical Group in Ukiah. Gester helped the hospital establish an urgent care center two years ago.

Volume may swamp lone doctor

Low-volume hospitals might consider hiring midlevel practitioners when volume becomes too much for a single physician to handle, suggests Pamela Bensen, MD, MS, FACEP, medical director of New England Medical Services and Dictate Inc. in Oxford, ME. Bensen formerly was president of Emergency Medicine Associates in Oxford.

"If they’re having trouble getting patients through in a timely manner, then using nurse practitioners and physician assistants is a wonderful adjunct to having a physician on duty," Bensen says.

However, Bensen doesn’t recommend hiring midlevel practitioners solely as a cost savings since in many states, midlevel practitioners must work under a physician’s direct supervision.

Bensen says the hospital might reap cost savings by hiring a midlevel practitioner to supplement physicians already on staff, instead of hiring another physician. That way, the staff physicians could be asked to supervise the employee as part of their duties. That has been Ukiah Valley’s approach.

Gester and Devitt say they have no data to show whether the Ukiah Valley Medical Center is saving money by using more midlevel practitioners. "I’m sure if we had to have a physician here in all these times it’d cost us more, but we haven’t tracked it that way," Devitt says.

But they say there is no question that the employees help save patients and payers money. And the midlevel practitioners appear to please patients.

Devitt says some urgent care center patients have no problem with not seeing an MD when they come to the hospital. "They said, ‘I got what I needed, and it was less expensive for me, and that was very appropriate,’" Devitt says.

"When I receive those kinds of comments it’s kind of heartening because people are starting to look at health care the way we’re all going to have to look at it, which is to control costs," he adds.


American College of Emergency Physicians. Emergency care guidelines. Ann Emerg Med 1991; 20:1,389-1,395.