Practicing at the Top of Your License

MAY 03, 2017
Heidi Moawad, MD

The term ‘practicing at the top of your license’ has recently taken on popularity in the medical community. It generally refers to the idea that physicians often have to attain multiple certifications and that the ‘top of the license’ is the certification or licensure that takes the longest to attain, has the highest number of prerequisites, allows a physician to perform procedures commanding the highest reimbursement or for which few are qualified. The term can be interpreted differently and is often used to express the idea that it is wasteful for physicians and other medical professionals to do work that involves procedures or tasks that he or she could have been allowed to do without the 'top' certification attained.
The Rationale of Practicing at the Top of Your License 
There are several practical reasons that the medical system benefits from everyone practicing at the top of their license. 
Payers Get More Bang for Their Buck
Payers, hospitals and healthcare systems definitely have much to gain when all healthcare professionals (physicians, physician assistants, nurses...) perform the maximum allowable tasks and almost nothing that someone on a lower pay scale can do. This means that when hospital systems and employers negotiate an hourly rate or a yearly salary, they are getting as much as possible for their money from each employee. In fact, while this may be one of the strongest drives behind the push for 'practicing at the top of your license,' there are benefits for other parties as well. 
Easier Identification of Roles 
When everyone in the healthcare system performs the duties that no one who is less qualified can perform, there is a clearer delineation of tasks and procedures. This makes duties better spelled out and more clear-cut, effectively eliminating grey areas and vague responsibilities, improving efficiency. Instead of one provider expecting another provider to pick up the slack, each provider only does what he or she is formally expected to do. This helps in terms of better anticipating work force needs and hiring enough people to do the job, without expecting high-level providers to fill in the gaps at a disproportionate cost.
The Benefits of Practicing at the Top of Your License 
When most clinical tasks are done under the 'practice at the top of your license’ criteria, there are also benefits for patients and health care providers themselves, not just for the employer. 
Better Reimbursement 
Physicians and other health care providers can spend time doing procedures and providing patient care that is expected to produce higher hourly revenue. While this is not always the case because some complex medical issues are not reimbursed based on complexity, the overall trend is that doctors would spend less time (or no time) doing things that other providers can do, and more time doing work that they can bill for at a higher rate. The same principle holds for nurses, who can spend more time doing the work that requires their highest skill set and that is more financially valued. This should translate to harder work that commands more skill and a correspondingly just and fair compensation for all health care providers at every level.
Valuable as a Referral or Employee 
Doctors who routinely practice only at the top of their license are able to take care of challenging patient cases that few other physicians or health care providers are qualified to care for. This makes doctors who practice at the top of their license valuable consultants that other practitioners can turn to for their most difficult referrals. 
Practice and Experience
And, perhaps the most valuable benefit of practicing at the top of your license is the benefit to patients. When physicians and other health care providers are consistently exposed to the most challenging clinical situations and expected to carry out the most difficult tasks, skills improve. This benefits patients more than anyone else, as doctors can practice and improve knowledge, skills, insight, intuition and expertise, learning to help patients who would have few alternatives because the top licensed experts are few.

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