Advanced practice providers can solve plenty of capacity challenges and they're critical to implementing population health strategies. But the secret to success is not having them on staff – it's in their management.
This article appears in the September issue of HealthLeaders magazine.
Hospitals and health systems are under unprecedented pressure to remove waste from healthcare, whether it stems from using too many expensive services or having high patient readmissions or poor quality. There are dozens of other bogeys out there that waste resources, but much of the waste lies in ineffective management and inconsistent approaches to care.
As a concept, team-based care has emerged as a critical element for removing waste and other inefficiencies in healthcare. It's essential for health systems that intend to deflect the effect of declining reimbursements and seek to improve patient care and quality—and meanwhile grow volumes. An important aspect of these efforts resides in the advanced practice provider group, otherwise known as nurse practitioners and physician assistants.
While most hospitals and health systems employ advanced practice providers to one degree or another, the organizations often have not invested in management of the group as a whole. Instead, many times, management of advanced practice providers is left to the individual physicians with whom they work.
That's where many problems can crop up, says James Leonard, MD, president and CEO of Urbana, Ill.–based Carle Foundation Hospital, who, in his 25-year career as both a family practice physician and an administrator, has had plenty of experience with the APP provider class.
"As we came together three years ago with Carle Clinic, we have tried to make strides of inclusion—bringing people together so that there's really one bowling shirt we all wear," he says. "This group is really involved in a new day in providing care, so they need a place at the table. This is incredibly important."
Carle Foundation Hospital, a 345-staffed-bed regional care hospital, acquired Carle Clinic Association (the formerly independent 350-physician Carle Clinic) three years ago, and since then one of the key cultural transformations has been the management of APPs.
Until about 18 months ago, when Carle implemented the new management philosophy, training oversight and activities of APPs were based on individual physician preferences, leading to significant variation in quality and productivity. With no consistent oversight, as a group, APPs really had no voice, and compensation varied significantly within specialties and across the organization.
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.
Josh Bennett, MD, a family practitioner by training, is a principal with Premier Inc., the Charlotte, N.C.–based member-owned group purchasing and consulting organization. He says Carle's approach is not yet common—he sees how it could work, but adds there are potential land mines in the shift because it puts APPs technically in the position of serving two masters, the individual physician with whom they work, and the health system.
"Some friction could take place there, but if you've done a good job of screening it could be very effective," he says. "It is an interesting concept because it takes some of the pressure off physicians on a day-to-day basis."
While he doesn't have much experience with Carle's approach, Bennett says the healthcare system nationally has a strong need for APPs, and better management of them.
"We're going to need them in the new scheme of things to see a lot of the walking well," he says. "They'll see those who need to be seen for some minor complaints or chronic diseases that are stable and allow the physicians to see the highly complex cases."
Regardless, even though the dominant model is still composed of a lot of one-on-one oversight, Bennett says the physician still needs input on the interview side.
"Once they get hired, regardless of who's managing, that means sitting down on day one on what they can and can't do and setting up some guidelines right off the bat. As conflicts arise, I advise physicians not to be confrontational but also not uncomfortable advising the midlevel as opposed to not saying anything, which is what physicians sometimes do."
Doing their homework
Literature on this kind of management change is scarce, Bigler says, so Carle did a nationwide peer survey with 12 organizations to gain a deeper understanding of best practices with APPs, she says.
"Once you do that and talk to other organizations who work with as many APPs as we did, you don't have to re-create the wheel, and you can go forward knowing others have done it successfully," says Snyder.
High-performing organizations, Bigler says, had clearly defined and standardized APP roles. For instance, were they a practice extender, collaborative provider, or independent provider? They also had to develop governance structures and a centralized forum for practices and policies.
"We had to develop governance structures, because you don't want some of your most valuable people wondering where they fit in," she says.
At Carle, as with other systems, APPs are used not just in primary care, but all over: in surgery, rounding, screenings, consults, acute care, ED, convenient care, and case management, for example.
"There's a lot they can do, and we needed to push those roles to a coordinated team delivery model," she says.
To implement best practices they learned, Snyder says they were helped by a "strong dyad medical director VP structure" with physician leadership fully integrated into operations.
"In other words, we have docs leading other docs," he says. "When you have that dynamic you can be effective."
Holes in evidence-based medicine
Leonard, Carle's president and CEO, is comfortable with the change because to him it doesn't mean that physicians don't have input into management of their APPs, it just means they do it as a group, and not individually. And management of the group as a whole doesn't mean necessarily always following treatment protocols and evidence-based medicine guidelines that may not fit a particular patient's diagnosis.
Yet he did face some resistance.
"What I heard is that 'If it's working for me, why do we want to change it?' " he says of discussions with fellow physicians who were hesitant to give up some control in managing their APPs. "I just had conversations with them and we agreed that in the long run it's advantageous to all of us because healthcare is more and more of a team sport."
The other thing to realize if you are considering a similar management change, says Leonard, is that not everything is contained in policy, explaining further that he makes the case with his physicians that the change is not an attempt to "control the world, only some parameters and consistency," he says.
The access issue is even more compelling. "We're preparing for bringing a large group of people into our system as patients and as providers, and if you don't have established direction and culture, [then] you have more chaos than you expect to have."
Above all, he says, communication—in some cases overcommunication—is the best approach when implementing such a big change, no matter whether it's in compensation, management of APPs, or integrating a merger.
"The most difficult thing for CEOs is that your good intentions aren't always clear in this kind of project," he says. "Be consistent and really transparent about what you're trying to do. The APP people are undergoing tremendous change in expectations in healthcare. Roles, scope of practice, compensation, and benefits are all on a wild ride, so you have to recognize that in the middle of such change, that is disconcerting to a lot of people."
This article appears in the September issue of HealthLeaders magazine.
Philip Betbeze is the senior leadership editor at HealthLeaders.