Josh Bennett, MD, a family practitioner by training, is a principal with Premier Inc., the Charlotte, N.C.–based member-owned group purchasing and consulting organization. He says Carle's approach is not yet common—he sees how it could work, but adds there are potential land mines in the shift because it puts APPs technically in the position of serving two masters, the individual physician with whom they work, and the health system.
"Some friction could take place there, but if you've done a good job of screening it could be very effective," he says. "It is an interesting concept because it takes some of the pressure off physicians on a day-to-day basis."
While he doesn't have much experience with Carle's approach, Bennett says the healthcare system nationally has a strong need for APPs, and better management of them.
"We're going to need them in the new scheme of things to see a lot of the walking well," he says. "They'll see those who need to be seen for some minor complaints or chronic diseases that are stable and allow the physicians to see the highly complex cases."
Regardless, even though the dominant model is still composed of a lot of one-on-one oversight, Bennett says the physician still needs input on the interview side.
"Once they get hired, regardless of who's managing, that means sitting down on day one on what they can and can't do and setting up some guidelines right off the bat. As conflicts arise, I advise physicians not to be confrontational but also not uncomfortable advising the midlevel as opposed to not saying anything, which is what physicians sometimes do."
Doing their homework
Literature on this kind of management change is scarce, Bigler says, so Carle did a nationwide peer survey with 12 organizations to gain a deeper understanding of best practices with APPs, she says.
"Once you do that and talk to other organizations who work with as many APPs as we did, you don't have to re-create the wheel, and you can go forward knowing others have done it successfully," says Snyder.