The Rise of the Advanced Practice Provider

With physician shortages and the high cost of employing physicians, APPs have become a mainstay of care teams.

The following is an extended excerpt from a HealthLeaders story published in August. Click here to read the full story.

With health systems and hospitals across the country experiencing physician shortages, many are turning to advanced practice providers (APPs) to fill in the gaps.

But does that mean CMOs should scale back their physicians and usher in more APPs instead? There are pros and cons to considering APP-led care teams.

Thomas Balcezak, MD, MPH, chief clinical officer at Yale New Haven Health, sees the workforce benefits in pairing APPs with physicians in a care team.

"There is a long lag time to bring new physicians online because of the years of training that it takes," he says. "You can train an APP in as little as 18 months after an undergraduate degree. If we want to bring more clinical resources to healthcare settings rapidly, using APPs is an efficient way to do that."

"Relying on APPs is a strategy we can use to expand access," he adds. 

The differential between physician compensation and APP compensation also makes employing APPs cost effective, Balcezak says.

While some leaders think APPs could be the answer, others are not so sure.

Although APPs have become key members of care teams, they still need to be led by physicians, says Bruce Scott, MD, an otolaryngologist from Kentucky and president of the American Medical Association.

"The American Medical Association strongly supports physician-led, team-based care, where all members of the team use their unique knowledge and skillset to enhance patient outcomes," he says. "Nurse practitioners, physician assistants, and other advanced practice healthcare professionals can all be valuable members of a physician-led care team and help to provide high-quality care, but they are not a replacement for physicians."

"Models of care that remove physicians from the care team result in higher costs and lower quality of care," he adds. "Numerous studies show that patients have better outcomes when cared for by physician-led teams."

Can APPs lead care teams?

While some studies have said no to APP-led care teams, others have shown the effectiveness of nurse practitioner-led care teams. A study published by The Journal for Nurse Practitioners found that a nurse practitioner-led interdisciplinary team reduced the median hospital readmission rate by 64%. 

"It is going to be hard for physicians to accept in many circumstances, and initially it is going to take extraordinary individual APPs to serve in leadership roles," Balcezak says. "However, APPs leading care teams will become more common over time."

Circumstances that are well-suited for APPs to serve in leadership roles include when the leadership expectations are around organization, delivery, and scheduling, he says. 

"When those are the leadership requirements, the APPs can be outstanding leaders," he says. "APPs who have a clinical background and a mindset that is focused on management can lead care teams."

Where APPs can and cannot take the lead

Yale New Haven Health is moving toward more consistency in its primary care teams, with two APPs supporting each primary care physician along with the nurses, Balcezak says.

"We think this APP model is a much more efficient use of physicians' time and will open up more patient access," he says. "The division of labor in this model is still being worked out, but an experienced APP can do most of what a physician does in the primary care setting. There are some complex patients and diagnostic dilemmas that are better handled in the physician's hands, but most routine screening, health promotion, symptom management, and the urgent care that established patients require such as colds and strep throat can be handled by the APPs."

At Davis Health System, the most common primary care team model consists of one physician with a cadre of nurse practitioners, medical assistants, and nurses working to the top of their licenses, says former CMO Catherine Chua, DO, MS.

"The team approach has been advocated by the American Hospital Association and the American Academy of Family Physicians in order to stretch the ability of a physician to serve patients," she says. "Studies have shown that having the physician as the lead care provider at a primary care practice is the best approach in terms of cost savings, patient experience, and quality. One of the studies that I have seen said that about 72% of patients prefer to see a physician at some point in their care."

Chua says a physician-led primary care team should be designed with specific parameters around decision-making.

"One physician does the primary intake of the patient, then follow-up appointments are handled by APPs," she says. "There are other things like follow-up calls, renewals of prescriptions, and prior authorizations that can be done by the nursing staff. In addition, the nursing staff can prep the patient's visit, so that the nurses get to know the patient and can help the physician field questions from the patient."

The main challenge of this model is when patients present with complex conditions or difficult diagnoses during follow-up appointments. CMOs should ensure that physicians get involved in care when these circumstances arise, Chua says.