QUESTION:
We are amending our medical staff governance documents and considering giving Advanced Practice Professionals (“APPs”) a larger role in medical staff affairs. Do you have any recommendations based on your experience working with other hospitals?
OUR ANSWER FROM HORTYSPRINGER ATTORNEY CHARLES CHULACK:
With the ever-increasing role that APPs, such as physician assistants and nurse practitioners, play in the delivery of health care in hospitals, we are seeing many hospitals across the country wrestle with this question. Unfortunately, there is not a “one-size-fits-all” answer and the appropriate solution needs to take into consideration federal and state regulations and the culture of your medical staff and hospital, among other things.
Let’s start with the regulations. The Centers for Medicare & Medicaid Services Conditions of Participation (“CoPs”) defer to state law when it comes to appointing APPs to the medical staff: “The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope-of-practice laws, the medical staff may also include…non-physician practitioners who are determined to be eligible for appointment by the governing body.” 42 C.F.R. §482.22(a) (emphasis added). However, you want to be sure to check your state’s laws and regulations to determine if those sources are more restrictive. By way of example, Pennsylvania limits medical staff membership to physicians and dentists. 28 Pa. Code § 107.2. Even though Pennsylvania has a “structured exception” allowing hospitals to admit podiatrists to the medical staff, there is no corresponding exception for APPs. Compare Pennsylvania’s restrictive approach with the approach taken by Colorado, which allows both physicians and non-physician practitioners to be on the medical staff.
Even in the states that permit APPs to be on the medical staff, we are seeing a variety of approaches. Some hospitals make APPs eligible for medical staff membership, including appointment to the Active Staff. That being said, these hospitals impose appropriate limitations on their prerogatives when compared to physician members of the Active Staff such as not being able to serve as the President of the Medical Staff (the Interpretive Guidelines to the CoPs say that the President of the Medical Staff “must be a doctor of medicine or osteopathy, or, if permitted by state law where the hospital is located, a doctor of dental surgery, dental medicine, or podiatric medicine”). While we don’t see this approach taken frequently, it is more common with Critical Access Hospitals or smaller hospitals where the majority of clinical services are provided by APPs.
A more common approach is gradual integration of APPs into medical staff functions. For example, the medical staff may begin by creating an APP Credentials Committee which reviews applications of APPs and reports to the regular Credentials Committee, or appoint APPs to the Credentials Committee to tap into their expertise when it comes to state scope of practice laws for APPs, how they practice, and what they are permitted to do in similarly-situated hospitals. Some hospitals are also appointing an APP to the Medical Executive Committee and Multi-Specialty Peer Review Committee. It varies with respect to whether they are given voting rights since we have seen some physician members of the medical staff express discomfort with an APP, who may have a supervising agreement while practicing in the hospital, evaluating the care they provide as a part of one of these committees.
In conclusion, APPs are increasing in number and have a growing role in providing clinical services in hospitals. If your medical staff has not yet addressed this issue, the odds are that it will need to in the future. Nevertheless, these are interesting and exciting issues whose solutions can result in a more vibrant and robust medical staff and hospital.
If you have a quick question about this, e-mail Charles Chulack at CChulack@hortyspringer.com.