As part of that culture, Leonard recognized individual physician management of APPs can create inconsistency in relationships, oversight, and how things are done from one physician or division to the next.
"Those inconsistencies can be helpful," he says. "They're part of the art of medicine, but often they are not advantageous and create risk and inefficiencies."
Thanks to health insurance exchanges and Medicaid expansion, which will happen by 2014, many health systems are about to have a lot more patients to deal with, and a lot of the organizations are unprepared to meet those volumes. Count Carle among that group, says John Snyder, the system's chief operating officer, who, with Chief Nursing Officer Pamela Bigler, was charged with implementing a new management philosophy with APPs.
"Carle Clinic was a for-profit physician group. Primary care was a loser and wasn't high on their list of recruitment," says Snyder. "You can't blame them, given their business model, but that meant everyone was doing their own thing and it was a nightmare to figure out where to fit a patient in."
So access, already a challenge prior to the expected volume of newly insured patients, was seen as becoming a major problem. For example, waits for patients to see an OB-GYN ranged up to eight weeks, and many patients trying to access primary care just went to the emergency room in frustration with the inability to arrange a timely appointment.
In addition, individual physician management, says Bigler, led to inconsistent quality, compensation discrepancies, performance incentives that didn't line up with organizational goals, and inconsistent scope, among other issues, from reporting structure to inconsistent billing practices. And with plans to hire in the next few years approximately 70 physicians, with a significant number in primary care, and up to 50 APPs, the problem at Carle could have gotten worse without reform.