Optimizing the productivity and placement of NPs and PAs in outpatient primary care sites

Each year, about 85% of adults in the United States visit an ambulatory care center, engaging in nearly 900 million encounters annually.1 Evidence suggests that NPs and PAs to provide safe, cost-effective, high-quality care to complex and vulnerable populations, improving wait times, affordability, and quality outcomes.2-4 More than 325,000 NPs and nearly 140,000 PAs are well positioned to meet patient needs across the lifespan.5,6 This is despite projected shortfalls in numbers of primary care physicians due to shifting population demographics and subsequent demand.5,6

By 2030, Baby Boomers (those born between 1946 and 1965) will account for one out of every five US citizens.7 To meet the growing primary care demand, the number of NPs alone is expanding at a rate about three times greater than physician counterparts, with PAs expecting to grow by 31% by 2030.8 To meet this need, many healthcare organizations are actively including NPs and PAs in workforce planning. The noteworthy organizational benefits of hiring NPs and PAs include salaries lower than physicians, exceptional patient satisfaction, and improved quality of care at a lower cost.9,10

Despite these recognized benefits, organizations must actively monitor NP and PA retention, attrition, salary, and costs. In one systematic review by Han and colleagues, a synthesis of available evidence suggests that salaries coupled with leadership issues lead to erosion at rates more than double that of physicians.11,12 Similarly, PAs report spending too many hours at work contributing to stress, burnout, and turnover.13,14 The direct organizational cost of the loss of a single NP or PA ranges between $85,832 and $114,919, with indirect costs likely much higher.15 Alternatively, autonomy and authentic connections between work and purpose and career satisfaction contribute to higher retention rates and reduced burnout.11,16 What is not well described in the literature is specific organizational decision-making processes or workforce planning strategies surrounding the addition or removal of NP or PA positions in outpatient, primary care settings.

Kapu and Steaban propose an organizational framework and describe the necessary components for determining feasibility and effect of new programs for NPs, including a clear financial business case based on productivity.17 This is similar to the work described by Kleinpell and colleagues, who defined the system and structures needed, including position descriptions and justification, and a sound business plan for hiring NP-PA teams.18 Reliable organizational infrastructure should include six key strategic areas: leadership, human resources, credentialing/privileging, competency assessment, billing and reimbursement, and measurement/effect.19

Organizational leaders must systematically assess NP and PA productivity, turnover, and vacancies. Optimizing the feasibility, effect, strategic placement and monitoring of NP and PA performance and productivity ultimately increases patient access, improves wait times and affordability, increases revenue, and also may reduce burnout and attrition.13,14,17,20-24

NATURE AND SIGNIFICANCE OF THE LOCAL PROBLEM

Success is internally defined as functioning above the 60th percentile based on national benchmarks for productivity (work relative value units [wRVUs]). Our large nonprofit healthcare organization employs more than 600 NPs and PAs across 200 sites, with 58 practicing in primary care settings. Of these, 12 were meeting productivity expectations and 46 were below the 60th percentile. As such, rapid improvement was needed to produce strategies aimed at increasing NP and PA productivity while simultaneously optimizing placement in outpatient primary care sites.

METHODS

Results from this project are reported using the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework.25 The purpose of SQUIRE framework is to provide uniform structure when reporting results of quality improvement (QI) projects. This is in an effort to present the most complete, transparent, and accurate information so other organizations can replicate the work.25 This endeavor was QI in nature and not subject to oversight by the institutional review board.

INTERVENTIONS Enlisting a core quality improvement team

To optimize placement and productivity of NPs and PAs in outpatient primary care sites, we performed an in-depth multidepartmental gap analysis aimed at exploring these issues. This led to the formation of an interdisciplinary QI team comprising organizational stakeholders including key personnel representing system operations, finance, human resources, nursing executive team, physicians, and the PA professional development program manager. The QI team was led by the director of advanced practice clinicians, who oversees NPs and PAs across the organization.

Gap analysis as a framework for quality improvement

The team completed a gap analysis. A gap analysis is a QI method allowing organizational teams to assess, compare, and contrast processes currently in place (actual performance) to best practices (desired performance). Gap analyses should flow from organizational performance indicators including benchmarking or other pertinent data points as determined by the QI team. The ultimate objectives of a gap analysis are to understand differences between current and ideal states while assessing and subsequently removing barriers before implementing best practices or solutions.26

Phase I gap analysis of current state—objective and subjective data collection

After team formation, and to define the current state, the QI team collected objective and subjective data identifying root causes of low productivity for NPs and PAs in outpatient primary care settings. Objective information was gathered via organizational data sets including work RVU analysis (trends over the 3 previous years and productivity benchmarking). Correspondingly, we examined internal billing and insurance data including reimbursement rates. We gathered and assessed NP and PA use (percentage of appointments booked, number of patients booked per hour, and schedule cadence/appointment length), work hours (evaluation of full-time equivalent to matching scheduled work hours), and subsequent evaluation of productivity and benchmark data.

Context for performance indicators and benchmarking productivity

In our system, NP and PA productivity benchmarking and ongoing monitoring is overseen by an internal department director dedicated to optimizing the use of these clinicians. Productivity is specifically measured by a weighted/blended average of SullivanCotter and American Medical Group Association data. Recall that productivity benchmarking for individual institutions varies but often is determined via consultation and partnerships with national consulting firms that assist in optimizing workforce strategies, NP and PA output, and performance. In the case of Medicare, the single largest fee-for-service payer for healthcare, productivity, and subsequent revenue generation depend on the following formula:

completed patient encounters or procedures are assigned a current procedural terminology code (CPT) Medicare assigns an RVU to the CPT the RVU is entered into a conversion equation to calculate reimbursement. The RVU equation is weighted across three areas: work (time and intensity = 50.866%), practice (cost of maintaining space, supplies, staff, etc. = 44.839%), and malpractice expenses (insurance = 4.295%) and is updated every 5 years with geographical variations.27,28

In outpatient primary care settings, Medicare reimburses NPs and PAs at 85% of total RVU, with physicians receiving 100%.28 Counting work RVUs (wRVUs) as productivity and linking this directly to compensation is not entirely straightforward, however. Compensation models vary across healthcare systems but typically include straight salary (base compensation), or productivity-based remuneration (RVU, pay for performance, etc.), or some combination of both. Alternatively, reimbursement for patient care typically occurs via four frameworks (fee-for-service, capitation, bundled payment, or value-based) depending on payer.

Subjective information for this QI project was collected via NP and PA interviews, site visits, and the self-reporting of daily activities. To better understand barriers to optimization at individual primary care sites, the interviews were completed by NP and PAs, operation managers, and physicians. NPs and PAs described varying levels of understanding about the exact role expectations. In addition, NPs and PAs were asked to individually track and document their clinical and nonclinical activities during the day. This information was analyzed to identify obstacles impeding productivity, including activities that did not allow for full NP and PA scope of practice, or performance of duties not considered top of license (that is, not practicing to the full extent of education, training, and licensure) as well as other opportunities for improvement.29

Phase II—development of action plans

After examining performance indicators including internal benchmarking and subjective and objective data collected during Phase I, the team analyzed findings and began summarizing these and developing action plans to move from current to ideal state.

RESULTS

Findings from the Phase I gap analysis including objective and subjective data are summarized in Table 1. These findings were synthesized and served as a foundation for action planning. The five priority areas requiring action plans were:

NP and PA placement at sites (NPs and/or PAs were unable to meet wRVU benchmarks due to low patient volumes supporting productivity for all clinicians) inconsistent patient contact hours unclear work expectations and lack of knowledge regarding wRVU (unclear productivity as measured by time and intensity and reimbursed by Medicare) limits on scope of practice variable primary care compensation models. See Table 2 for summary of gap analysis findings and subsequent action plans. TABLE 1. - Gap analysis of current state

Objective data

wRVUs: trends over 3 previous years, compared with external benchmarks (wRVU at 60th percentile)

Internal billing and insurance: collection and reimbursement rates and contracted insurances

Use: numbers of patients booked per hour, percent of appointments booked, and schedule cadence

Work hours: comparison of full-time equivalency to scheduled work hours

Productivity by site: all physician and NP and PA productivity (wRVUs)

Subjective data

Scope of practice: percentage of top-of-license NP and PA activities, identified activities that were not at the top of license

Identified NP and PA training needs to expand scope of knowledge and understanding

Need to determine appropriate patient mix (acute visits versus continuity of care, follow-up, and chronic disease management visits)

Other factors affecting productivity and NP and PA top-of-license practice


TABLE 2. - Gap analysis findings and action plan Current state Action plan Ideal state Placement at site: NPs and PAs placed in low-volume sites, therefore unable to meet wRVU benchmarks.

Implement a consistent and rigorous process to evaluate the need for a new or replacement NPs or PAs at a site (see Phase II).

Consider the transfer of NPs or PAs to higher-volume, higher-need sites, considering their specific needs and those of the clinical setting.

Strategic placement Inconsistent patient contact hours: NPs or PAs not working the standard patient-facing work hours (36), therefore limiting the potential number of patients who can be seen. Consistent patient contact hours

Unclear wRVU expectations. Lack of wRVU knowledge.

Wide variability in NPs and PA awareness of their monthly wRVUs (organization has not set expectations for standard).

Share established primary care productivity benchmarks with NPs or PAs and operations.

Collaborate with operations managers to provide monthly wRVU reports to NPs and PAs with benchmarks.

Provide educational opportunities for NPs or PAs to learn about wRVUs.

Move toward organization wRVU expectations for NPs or PAs.

Clear productivity expectations Limited scope of practice: NPs and PAs seeing only acute, same-day visits with limited or no continuity of care and/or follow-up. Encourage a cultural shift away from NPs and PAs as “access-only” to visualizing clinicians as full-scope primary care clinicians requiring an adequate stream of patients for success. Full scope of practice and at top of license Inconsistent primary care compensation model: Different compensation models for physicians (volume and value) with NPs and PAs (salary and merit) contributing to priority filling of physician schedules before NP and PA schedules in sites with inadequate volume for all clinicians. Evaluate potential for a team-based physician and NP or PA compensation model. Consistent compensation model
STRATEGIC PLACEMENT OF NPS AND PAS

To address the placement or replacement of NPs and PAs, the QI team formed an ad hoc group creating and implementing a consistent and rigorous process to evaluate the need for new or replacement clinicians at the individual site level. This process includes the development and application of a position justification algorithm (Figure 1), position justification tracking form (Table 3), and position justification committee. The position justification algorithm guides users through all phases, including approval, denial, or request for additional evaluation.

F1-9FIGURE 1.:

Position justification algorithm

TABLE 3. - Position justification tracking form Demographics Date of request Facility cost center/name Hospital service area Request form completed by Practice manager Practice director Requested FTE Reason for submission If replacement, provide name and last expected date of employment of NP or PA being replaced Specialty and/or subspecialty Requestor Name of person making the request (hospital physician leader, operations leader) If hospital is directing request, did hospital agree to fund any loss? SBAR Situation Background (Please complete Production Profile) Production Profile is a global view of all clinicians at a specific site Assessment (please include any incremental staff space or equipment needs if applicable) Recommendation Estimated annual profit or loss (see appropriate Income Statement) Income Statement documents revenue, expenses, and net income/loss over time. Overall financial health of clinical site. Director recommendation (if director was not consulted, please comment) Evaluator (name) Approved by one up leader or operations vice president (name) Financial model (Pro forma details) Pro forma estimate of the contribution margin based on actual or projected data of similar clinical site Finance comments on pro forma details

The position justification form frames the business case for hiring a new or replacement NP or PA to a site and is organized in a Situation, Background, Assessment, and Recommendation (SBAR) format. The SBAR is a means for effectively communicating a need and has been modified since inception to meet other organizational communication needs.30,31 The form has several subcomponents supporting a financial case, including the production profile, the income statement, and pro forma financial statement (or an estimate of the contribution margin based on actual or projected data of a similar site).

The production profile provides a global overview of all NPs or PAs in the team at the primary care location with the vacancy. This includes collective clinical, academic/professional time commitments, tenure at the site, extenuating circumstances that may affect productivity, and the percentage of productivity for each NP and PA based on national benchmarks. During this phase of justification, if any NP or PA is not performing above the 50th percentile, further review is needed to determine reasons why (and subsequently the prudency of adding additional NPs or PAs).

Second, the income statement (profit/loss statement) is completed documenting site-specific revenue, expenses, and net income or loss for a period of time. This information demonstrates the effect on the current state of adding a new NP or PA to the specific site.

Third, the pro forma financial statement details an estimate of the contribution margin based on actual or projected data of similar NPs or PAs. A pro forma is a method of calculating financial results using certain projections or presumptions.17,32 Beyond the whole site income statement assessing the current state, this tool is useful in identifying organizational cost and profit margin(s) as a new clinician is added. When possible, pro formas are based on an existing clinical profile of a similar specialty. If the NP or PA position occurs in an area without historical data, best estimates are used. Since inception, this algorithm has been used multiple times and the team continues to refine processes.

To address inconsistent patient contact hours, an existing practice guideline was communicated to operations managers. This guideline includes criteria for patient-facing work hours. Correspondingly, unclear or variable wRVU expectations as well as the need to fully understand the nuances of the roles resulted in the QI team creating and deploying a productivity SBAR. This SBAR form captures overall productivity and allows the NP or PA to understand all variables affecting productivity (Table 4). The SBAR allows for effective, consistent communication of action plans and follow-up if wRVU benchmarks are not met. The confidential SBAR includes site productivity data as well as an assessment and recommendations. The SBAR is useful in communicating wRVU expectations, targets, and importantly the need for further evaluation, assistance, and support. Since inception, more than 20 SBARs have been created and communicated, and the process remains unchanged. When issues arise, the SBAR continues to be used for communication about productivity.

TABLE 4. - Productivity SBAR

Initial assessment date

PA or NP

Practice site

Specialty

Operations

Start date

Extenuating circumstances

Collaborating physician

Registered with the call center? (Y/N)

Types of patients (walk-ins, new, established)

Scheduled for 36 patient hours per week? (Y/N/how many)

Bills under NP or PA name (Y/N, mixed)

Accepts all types of insurance? (Y/N, if not, which are not accepted?)

Productivity data

2016 wRVUs

2017 wRVUs

2018 wRVUs annualized

60th percentile benchmark wRVUs

Patients/hour (2017)

Hours booked percentage (2017)

Collection percentage (2017)

Situation

Background

Does this NP or PA need further evaluation or assistance?

Assessment

Recommendation

Completed by:

Next follow-up:

Similarly, the same SBAR is used to convey issues surrounding limited scope and top-of-license of practice concerns. Specifically, if an NP or PA describes an on-site issue (for example, insufficient support), these issues are outlined in the SBAR document. To further address the gap, education about top of license and full scope of practice was completed with each NP, PA, and manager.

Finally, we continue to hold systemwide discussions about the need to evaluate and modify clinician compensation models ensuring that NPs and PAs are fully used and fairly compensated. We are piloting team-based compensation models addressing volumes and value instead of compensation via the typical salaried structure. Results of these endeavors are communicated to the QI committee.

DISCUSSION

Findings from the Phase I and II data collection indicated that several factors led to low productivity. However, the most salient finding was that NPs and PAs were placed at sites with insufficient patient volume to support wRVU productivity expectations. As a result, NPs and PAs were experiencing unfilled schedules, low patient demand, and thus were underused. Some NPs and PAs were leveraged for improved patient access, seeing only acute same-day patients rather than building a patient base of their own. This gap in use and subsequent low productivity is similar to the findings of Lowe and colleagues, who found that organizations struggle to integrate NPs due to barriers surrounding professional culture.33 In a scoping review examining facilitators and barriers to implementation in primary care settings, Torrens and colleagues found that team factors were the most frequently cited.34 A lack of awareness of the role, acceptance from physicians and other team members, ambiguity, and issues with lines of responsibility were all obstacles impeding full integration.34 Little literature addresses integration issues for PAs in primary care settings. This may be due to a longstanding history of mutual collaboration between PAs and physicians, where practice models are collegially developed on an individual basis.35

Full integration must be weighed against patient preference when examining factors that lead to low NP or PA demand. In a study by Leach and colleagues examining patient preference in primary care settings, 55% of those surveyed would choose care delivery by physicians over NPs and PAs.36 Respondents primarily cited qualifications, previous experiences, and bedside manner as rationales.36

In contrast, when NPs and PAs are chosen as the preferred primary care provider, bedside manner, convenience, and cost savings are cited.36 These findings are similar to Torrens and colleagues, who noted multiple examples of issues surrounding negative beliefs and patient preference as reasons patients did not seek an NP or PA for primary care.34 Collaborative relationships among physicians, NPs, PAs, and patients must be established. Role expectations should be clearly outlined for full team optimization. Long-term, this is key to full integration and use for NPs and PAs in outpatient settings. In our organization, once the productivity SBAR was in place, we began discussions with solutions ranging from scope change to voluntary transfers of NPs or PAs to other higher-volume sites. NPs and PAs were highly engaged when discussing confusion about wRVUs and productivity. They were interested in understanding how to bring increased value to their department. However, recommendations to redeploy clinicians from low- to higher-volume sites proved difficult to implement.

Organizational leaders must create systems and structures ensuring cost-effective decisions before hiring and placing NPs and PAs. The QI initiative reported here drove the development and implementation of an integrated position justification. Our processes are similar to the work described by Kapu and Steaban, who sought to delineate various components of developing NP programs.17 Like our initiative, Kapu and Steaban described variability in productivity among NP teams.17 They compared initial projections with current productivity and after discussing their findings with senior financial, medical, and nursing leadership, developed a standardized eight-step process to evaluate the need for new NP teams.17

Our improvement method differs in that the framework was applied to NPs and PAs and requires that all clinicians in a particular site be optimized before an NP or PA is added or replaced. This is key, because NPs and PAs must view productivity in a team framework focused on patient outcome and not individual performance. The evaluations described here occur from a weighted perspective, including team and NP or PA performance and productivity. Productivity drives revenue and should be key when justifying any addition, removal, or transfer of an NP or PA. As previously described, revenue streams are supported by consistent patient contact hours and an understanding of wRVUs. The complexity of these processes is documented in the literature; however, cost-evaluation and cost-effectiveness should be systematically addressed optimizing placement, use, and revenue generated by NPs and PAs.37,38

Full use and subsequent cost-benefit analysis cannot occur if NPs and PAs do not consistently exercise full scope and work at the top of their licenses. Top of license in primary care is well understood conceptually but not always implemented because NPs and PAs often are used for access and are prohibited from developing their own panels of patients. However, ample information supports optimizing the scope of practice for NPs and PAs by policy or regulation.39-41

Surprisingly, few peer-reviewed studies specifically examined compensation modeling for NP and PA salaries; this is an area of great national discourse. Establishing solid, honest, and fair compensation guidelines is imperative.42 Leaders should recognize that discordant compensation models affect clinicians and need to evolve. Newer compensation models should ideally be directed at creating whole-team ownership of productivity while acknowledging each member's contributions toward excellent patient outcomes.

LIMITATIONS

In our organization, practice is monitored and directed by an internal department dedicated to optimizing NPs and PAs in the organization. This is supported via a full-time director, support staff, and practicing NPs and PAs with advanced business acumen and leadership abilities. These benchmarking, monitoring, and communication activities have strong internal support. Multidepartment involvement and oversite of initial and ongoing NP and PA performance is critical for engagement and organizational financial stability. QI processes described here may not be generalizable to smaller organizations with less infrastructure (including human resources, financial/business support services for indepth analysis, and access to national data bases for productivity data). The roles of NPs and PAs are evolving and top-of-licensure activities warrant further examination. Communicating concepts and new workflows in larger healthcare systems is challenging. Similarly, shifts in traditional thought paradigms about the role of NPs and PAs takes time, especially when onboarding new clinicians.

Finally, little literature explores and describes the development and integration of NP and PA care models in large healthcare systems' outpatient sites. Nuances addressing interdisciplinary relationships, scope of practice, and top of licensure and education may not transfer between disciplines. Results from this project should be interpreted with caution.

CONCLUSIONS

The focus of this QI team was to develop and implement a standardized way of placing NPs and PAs in primary care settings and optimize their talents through adequate volume and top-of-license activities in a team environment. This was achieved through the development and integration of a position justification algorithm and tracking form, implementation of consistent patient contact hours, and clear communication of productivity expectations via the use of an NP- and PA-specific SBAR. Our team continues to focus on scope/top-of-license activities and discussions about compensation modeling. Much of the work completed by our QI team could easily be implemented in other outpatient and inpatient settings. Organizational leaders should focus on benchmarking performance and analyzing barriers to NP and PA optimization. These efforts are most beneficial when they are multidisciplinary in nature, involving business, human resources, operations, physicians, NPs, and PAs. Finally, it is fiscally imperative for healthcare system leaders to leverage the talents of NPs and PAs, meeting the needs of patients while achieving professional and organizational benchmarks and goals. NPs and PAs must be fully vested in all aspects of their own productivity, including the fiscal well-being of the healthcare systems in which they practice.

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