MGMA 2020: Optimizing ROI for Advanced Care Practice Providers

Ensuring that care models are intentionally designed with each member of the care team truly optimized, has become a focal point for practices and healthcare organizations as a result of COVID-19 financial pressures and ongoing payment changes.

As a part of the virtual Medical Group Management Association's (MGMA) Medical Practice Excellence Conference, Amy Noecker, MEd, and Zachary Hartsell, PA-C, DHA, both principals of APP Workforce Practice at SullivanCotter, gave a presentation outlining why and how practices should be optimizing their Advanced Care Practice Providers (APPs).

Optimizing a diverse care team will be essential for recovering in the aftermath of COVID-19's economy for both health systems and small practices alike.

As some of the fastest growing occupations in the U.S. today, APPs—registered nurses, nurse practitioners, CRNAs, CMAs and other clinical nurse specialists, as well as physician assistants—are in the focus of healthcare organization leaders looking to make significant financial and operation improvements to their care teams' environment.

Noecker says that particular issues plague the current workflow of APPs—namely, a disconnect between staffing and performance. Several primary causes mentioned in the presentation included inefficient care delivery, underutilization of APPs, redundancy in tasks or a duplication of efforts between APPs and physicians, as well as misalignments of physician and APP compensation.

The looming primary care shortage, Noecker says, will exacerbate these already persistent issues.

To improve APP strategy, Noecker says practices should look to structured onboarding programs, fellowships, competency assessments, workforce planning, assessment of hiring APPs (both new and replacements), leadership structures within the organization, and APP compensation.

Overall care team optimization will not only support recovery efforts from COVID-19, but will also increase APP retention.

Noecker says that SullivanCotter views optimization progress in three stages:

1. Underutilized
2. Transitioning
3. Optimized

The goal of an optimized care team, according to the presentation, includes a well-developed, intentional care team strategy that is integrated with an organizational strategy. The team dynamic in these groups should be aligned, coordinated, data-driven, and patient focused. The care model in these organizations is well-defined, focused on patient needs and further care team optimization. Compensation in an optimized care team supports the organization's care model and is aligned with compensation plans and strategic goals.

In this model, APPs are valued with their impact routinely measured; however, there are still barriers to overcome. According to Noecker, these include organization culture, patient needs and perceptions (i.e. how they view being treated by an APP versus a physician; what the practice is doing to educate patients on their abilities); as well as perceived competition between APPs and physicians.

The latter can be remedied with improvements to APP productivity measurements, though Noecker recognizes this may be a challenge for some organizations. New productivity measurements typically come in the form of wRVUs, collections, patient visits, panel size, and productivity ratios. Furthermore, look to work effort data including clinical hours, sessions per week, and shift length.

Other barriers to overcome in APP value are bylaws; affiliation, employment, and/or funds flow arrangements; perceived liability risk by physicians; and compensation plans between APPs and physicians.

"Historically, we have compensation programs that can create an environment of competition between team members, specifically as it relates to work RVUs," says Hartsell. "This is particularly common in primary care and urgent care where APPs and physicians may feel in competition for the same patients or even the same work RVUs. While these models can promote individual productivity, they're often not aligned with things like value based metrics or panel management. Additionally, sometimes the individual productivity has the effect of creating inefficiency within the care team, leading to overall less work RVUs collectively compared with combined productivity of more cooperative models."

Individual productivity may also lead to greater overall team inefficiencies, which then result in fewer work RVUs compared with more cooperative models, he says.

Though Hartsell says a spectrum of compensation models exist, he says SullivanCotter is seeing a transition to team-based compensation models.

Achieving team-based compensation is not typically a quick organizational culture transition, but your goal to achieve total care team optimization will be to develop a compensation program that shares incentives between the physicians and APPs, with both individual and team-based measures for each that include productivity, quality, etc. APPs and physicians both must meet predetermined, mutually agreed thresholds in order to receive payouts.

Regarding APP payments, compensation for these roles is evolving to reflect their expansion into different specialties. According to the presentation, organizations continue to report significant annual increases.

Total Cash Compensation (TCC) for APPs in Primary Care is up 4.6% from 2017-2019, up 5.3% for those in medical, up 4.4% for those in surgical specialties, and up 5.0% in hospital-based specialties.

Similarly, TCC rates for CRNAs are up 3.5% from 2017-2019, while CNM TCC rates are up 5.4%. CAA's, new in SullivanCotter's data set for 2019, reported a $76.92 base hourly rate.

Incentive payments for APPs have also increased: up 6.8% for primary care; up 5.3% for medical; up 5.1% for surgical; and up 5.1% for hospital-based.

Other APP benefits have remained consistent, according to the presentation. APPs typically receive a median of $2,500 for CME expenses; a median of 5.0 days for PTO for CME attendance; and a median capped fee of $1,000 for certification/licensure reimbursements.

Finally, consider APP leadership and engagement in your organization.

Hartsell says that leading employers of APPs are using more intentional strategies to improve APP retention. Like other areas of healthcare, recruitment and retention are becoming very data driven.

"Think about ensuring a piece of a voice within the organization, building structures and leadership that supports the optimal APP practice, and intentionally assessing current culture to ensure that is aligned with APP practice," Hartsell says. "For example, saying the right message to patients, families and referring providers; ensuring an APP is visible on the website; thinking about how staff introduce appointments with an APP as opposed to physicians; and whether physicians are familiar with and understand the rules and regulations."

APP leadership roles consist of three levels: clinical-level leaders, performing clinical duties; mid-levels that focus on onboarding, education, or student placement; and a top APP leader that performs overall management or administrative responsibilities like developing and managing overall APP strategy, structures, and resources.

How does Hartsell say these leadership roles return on investment? By coordinating key processes that are often fragmented; increasing optimization of APPs; increasing coordination between HR, MSO, and clinical departments; decreasing cost of turnover; reducing length of APP orientation; and reducing physician administrative time onboarding, day-to-day management, and professional/disciplinary action.