APP Productivity – The Challenge Remains

Thursday, August 15, 2019 | Ginger Biesbrock

MedAxiom’s 2019 Cardiovascular Provider Compensation and Production Survey, based on 2018 data, will be released in the coming days. This annual report will reveal trends across cardiology, surgery, advanced practice providers (APPs) and non-clinical compensation. Anyone who has heard me speak on the subject of APP utilization, watched my webinars, worked with me on a project or read my blogs is well aware of my passion around the care team and the value that an APP can bring to the cardiovascular delivery model and to our patients. I am happy to see an improvement in the four-year trending data concerning APP productivity, as we really pushed this work starting in 2015.

As an industry, we are getting better, but we are still so far from the mark. I always start this discussion by saying that I don’t love the work relative value unit (wRVU) measure, but it is currently the best that we have to provide comparison. Another principle that I feel strongly about is using APPs as providers, meaning that the majority of their work should be reimbursable work that is tied at some level to a wRVU.

One could argue that the wRVU is a surrogate to assuring that an APP is doing the right type of work. Although we have seen the median wRVU productivity per APP FTE double in the last four years, we are still so far from maximizing APPs to the top of their license. I want to share with you three areas I believe get in our way and urge you to analyze your team to see if any of these challenges exist.

1. APP utilization – an economic conflict of interest

I can honestly say the most common challenge that I have encountered to effective APP utilization is an economic conflict of interest that commonly exists in the way physicians are paid. When their compensation is directly tied to an individual’s wRVU incentive that does not include support for the work that the APP is performing, it can place the APP in direct competition with the physician. Some programs are insightful and are very aware that this challenge exists. Others are less aware, but it is often obvious when I look at utilization patterns. I see physician schedules double/triple booked with routine patients while the APP is partially utilized – 50-70 percent slot utilization with patients that are reactively scheduled. There simply is nowhere else to put these patients and they are often a mix of acute symptom changes and follow-up patients. This model also typically limits access, patient panel size, and program growth and development. The APP resource simply isn’t utilized to the full capacity. Another example of this challenge is programs that want to develop niche programs such as heart failure or preoperative clinics. Although the pro forma makes sense, the clinics are never fully utilized as physicians are incentivized to ‘keep’ these patients rather than ‘share’ in their care. Finally, I have yet to see a program where it makes clinical and operational sense for the physicians/APPs to see the patients in tandem. Many programs still utilize this model and I assure you the underlying reason is economic. There are multiple ways to rectify this challenge and create a physician compensation model that encourages shared care and utilization of the team. Many programs have seen significant improvements in their APP utilization and productivity metrics when they manage the economics.

2. APP utilization – no definitions or structure

The second common challenge that I encounter is lack of structure or definition around the use of the APPs. Which patients, how often, and who is on the team are often missing in the structure of the program. It’s really about the clinical strategy. A great best practice is developing small teams where three to five physicians work with one or two APPs to create a strong relationship for both the providers and the patients. In addition, developing a plan of care where the role of the APP is defined around which visits and the objective of visits for each patient or patient population. This best practice will create a smooth management pattern for patients and expectations for the provider team. I also recommend a communication or escalation policy that defines when the APP should get the physician involved and what level of communication is required. These best practices will create standards to assure effective utilization and a proactive approach to assuring adequate productivity for the APP.

3. APP utilization – valuation challenges

Finally, the ability to track APP productivity from a wRVU standpoint can be challenging for services that are billed as split-shared, incident to or global as the billing occurs under the physician National Provider Identifier (NPI) number. Many programs will develop a ‘dummy’ code in the electronic medical record or utilize the APP as the rendering provider and then assign wRVUs to allow productivity tracking. To be fair, our data may not take into account the services provided under the physician NPI although they are rendered by the APP. I do feel strongly, however, that these are tracked as it allows your program to really measure the value that the APP is providing to the program. I also feel strongly that there are multiple ways to show the value that the APP is providing as I outlined in a previous blog.

In conclusion, I am happy to see the APP productivity numbers go up year over year. I am hearing success stories and seeing improvement around team-based care effectiveness in my travels. As an industry, we are moving the needle. Which means that we are becoming more accessible to our patients and ultimately, that is what this work is all about.

Stay tuned to for the release of the 2019 Cardiovascular Provider Compensation and Production Survey Report.

Illustration: Lee Sauer

About the Author
Ginger Biesbrock

Ginger Biesbrock, PA-C, MPH, MPAS, AACC, is Executive Vice President, Care Transformation. She is a respected executive, provider and teacher with 20+ years of experience in the health care industry with a concentration in clinical care and operations. Before joining MedAxiom Consulting, Ginger was Director of Operations at West Michigan Heart, a 39 Physician practice with 24 mid-level provider. At West Michigan Heart, Ginger oversaw all operations for ambulatory services, tertiary care and rural health practices. Prior to that Ginger was the COO of the Cardiovascular Group at Centra-Health.

Her areas of consulting expertise include APP Utilization, Care Team Optimization and Transitions of Care.

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