Optimal Use of Advanced Practice Providers at an Academic Medical Center: A First-Year Retrospective Review

Abstract

Background Physician assistants/associates (PAs) and nurse practitioners (NPs), together known as advanced practice providers (APPs), practice with a high degree of clinical autonomy and professional respect, and play a critical role in team-based care. Aligning APP care delivery models to promote top-of-license practice is essential to improving ambulatory capacity and bottom-line expectations at academic medical centers (AMCs) in the 21 st century and beyond. This administrative quality improvement study assesses the downstream impact of restructuring our APP care models to promote independent practice sessions. Methods Our AMC formed an APP oversight committee in April 2021 to optimize the ambulatory care model, realign APP funds flow, and set performance standards to which PAs and NPs are being held accountable. We conducted a one-year retrospective review of internal data from July 2021 to June 30, 2022. Certified registered nurse anesthetists (CRNAs) were excluded from this analysis. Results APP productivity year-over-year (YOY) aggregate data across all School of Medicine (SOM) departments, demonstrated a 53% increase in work relative value units (wRVUs), 84% increase in payments, and 79% increase in charges from the prior fiscal year (July to June). Regarding APP ambulatory clinical effort (YOY), there was a 45% increase in the number of APP completed visits (92% return patient visits, 8% new visits). An increase in APP productivity did not adversely impact patient satisfaction, physician-generated wRVUs, or delay programmatic expansion efforts. Lastly, in a recent engagement survey, the majority of PA and NP respondents (78%) reported working either “most of the time” or “always” at the top-of-license. Conclusion This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance. While we acknowledge, there are differences between healthcare institutions in terms of care delivery and compensation models, organizational culture, and distribution of clinical resources, there remains an opportunity among hospitals and health systems to optimize this critical and essential APP workforce.

The Perceived Impact of the New Medicare Rules for Split/Shared Visits: A Survey of Advanced Practice Administrators

“…Nevertheless, the findings demonstrate the versatility inherent in the APP role as these providers are uniquely qualified to address the specific needs of patients. In fact, emerging data demonstrate that utilizing APPs to top-of license improves bottom-line expectations, patient access, patient satisfaction, and provider engagement without jeopardizing physician productivity [ 2 , 3 ].…”

“…Physician assistants/associates (PAs) and nurse practitioners (NPs) collectively known as advanced practice providers (APPs) practice in all 50 states and in a variety of different specialties within the United States and abroad. Although there are differences in certification, educational philosophy, and licensure, both NPs and PAs perform overlapping responsibilities in the clinical setting, including billing for both clinical and procedural services [1][2][3][4][5]. With regard to hospital inpatient billing, APPs and physicians treating patients jointly have been subject to split/shared billing rules since October 2002; however, the Centers for Medicare and Medicaid Services (CMS) recently made substantive modifications to their split/shared evaluation and management (E/M) visit policy.…”

Editorial Commentary

“…Previously published reports have outlined successes in optimizing the use of APPs in ambulatory clinics. 3,4 Such studies offer critical takeaways such as ensuring that all members of the care team are working at the top of their licenses (not just APPs, but also physicians, nurses, etc) and that financial incentives appropriately align. However, replicating these exact models in a different practice environment is not guaranteed to yield the same successful results, as the ideal urologist-APP health care delivery model will likely be heavily influenced by the unique clinical practice environment, available resources, and provider comfort.…”

Sustainable organizational integration of the advanced practice provider

“…14 While this is a single site, it offers the potential within directed process improvement initiatives to demonstrate the financial and patient access opportunities that can be realized by APP infrastructure investment. 15 : UC Irvine conducted a 1-year retrospective review of 220 APPs after the strategic implementation of an APP oversight committee. 15 The university reported that the critical first step of the oversight committee was implementing an APP director to guide role clarity, credentialing, compliance, scope, and optimization, followed by a multidisciplinary engagement survey and consultant input recommending a new infrastructure strategy.…”

“…15 : UC Irvine conducted a 1-year retrospective review of 220 APPs after the strategic implementation of an APP oversight committee. 15 The university reported that the critical first step of the oversight committee was implementing an APP director to guide role clarity, credentialing, compliance, scope, and optimization, followed by a multidisciplinary engagement survey and consultant input recommending a new infrastructure strategy. The deployment strategy had 3 major tactics: 1) Create an interprofessional APP oversight committee to enhance expectations, evaluate APP funds flow options, and monitor the deployment of standards across the enterprise, 2) Set ambulatory practice standards, which included a 36-hour patient-facing minimum and implement independent templates and equivalent practice support to remove shared visits, level the supports providing the APPs measurable top-of-scope measurable professional activities, and 3) Implementing APP funds flow redesign with a shared responsibility between the enterprise and the departments.…”