PHOENIX Physician assistants and nurse practitioners should be trained to treat, biopsy, and bill patients as if they were the physicians for whom they work, Dr. Allan Wirtzer said at a clinical dermatology conference sponsored by Medicis.

"Your extender should be your clone," said Dr. Wirtzer, who has a practice in Sherman Oaks, Calif., and endorses the hiring of physician extenders as an alternative to recruiting first-year dermatologists.

Extenders can enable a practice to see more patients and to significantly increase revenues, he said. Patient acceptance is critical, however, and can be undermined if the extender is not consistent with the physician.

As an example, Dr. Wirtzer offered the hypothetical situation in which an extender recommends a course of treatment for a skin condition. For the dermatologist to disagree and suggest changing the plan on a follow-up visit could be worse than embarrassing, he warned: "It is not going to bode well for the patient's confidence in the practice."

Here are more of Dr. Wirtzer's tips on how to incorporate a physician extender into a dermatology practice:

Whom to Hire

A third of dermatologists are seeking associates, he said. Not only is patient demand for services high, but also dermatologists are in short supply. As a result, he contended, some new dermatologists are pricing themselves out of the market with unrealistic expectations of their first-year earnings.

Physician assistants and nurse practitioners are easier to find, according to Dr. Wirtzer. They also can be easier to work with and may contribute more to a practice. He cited a 2002 survey that found the average extender was paid $100,000 annually while revenues increased by $500,000 each year.

He said that he has chosen to hire physician assistants because they "are trained to be physician assistantsexactly what it says" as opposed to nurse practitioners who can work independently and want to expand the number of states in which they can practice without physician supervision. A physician assistant cannot establish a competing practice.

Another consideration, he added, is whether your patients and staff will accept an extender. Be sensitive to the feelings of long-term employees who might see their turf as threatened, he advised. Provide patients with literature describing what a physician assistant does and the professional biography of the person hired.

How to Train

In 2004, 38% of physician assistants had less than 2 years' experience and 23% had more than 6 years, according to unpublished data cited by Dr. Wirtzer. Education levels ranged from an associate's degree (16%) to a bachelor's degree (41%) to a master's degree (43%). He said he prefers to hire an extender who has just completed schooling rather than risk hiring an experienced extender introducing incompatible treatment approaches from another practice.

Most training is by direct observation and proctoring, he said. He recommended that the new extender follow the physician for 36 months. The person also might attend courses or use continuing medical education materials. If the extender is experienced, the training period could be shorter, Dr. Wirtzer said, but oversight should be greater to ensure compatible approaches to treatment.

Training should include coding and office management, he added, again to ensure consistency when dealing with patients. He advocated developing clear treatment plans for common conditions, policies on when biopsies are appropriate, and fee schedules.

Rules to Know

Dr. Wirtzer noted that state regulations vary on how many extenders can be supervised by one physician and whether the physician must be in the office or available by phone when the extender sees a patient. Medicaid covers physician assistants and nurse practitioners, he added, but policies vary and there are no set rules for private insurers.

Medicare has strict requirements on "incident to billing," he continued. It requires that the physician examine the patient on the first visit for a particular condition. The physician assistant can provide subsequent care as long as a physician is in the office.

If these criteria are met, services provided by a physician assistant or nurse practitioner can be billed at 100% under the physician's name, according to Dr. Wirtzer.

If the physician is not on site or the physician assistant treats a new Medicare patient or a Medicare patient with a new problem, then only 85% can be billed and it must be done under the physician assistant's name. Defining a new condition can be "a gray area," he warned, suggesting a check with the local Medicare carrier.

Smart Practices

Design a contract that covers the initial mentoring period, starting salary, and bonus arrangement, Dr. Wirtzer advised. He suggested putting a dollar value on training and including a noncompete clause in case the person leaves the practice. "Don't be cheap," he said, warning that inadequate compensation can lead to loss of valuable staff members.

Consider paying for employee practices insurance, he added. It covers the practice against lawsuits by employees.

These are not covered by malpractice or office overhead insurance, and can be expensive to fight even when the practice is in the right.

Make Your Extender a Dermatologist Clone