Productivity model captures ‘vast spectrum’ of APP contributions
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APPs, including nurse practitioners and physician assistants, bring a complicated definition of value to health care.
Most anyone who has worked with an APP will agree they are a valued part of the health care team, but it is not easy to put onto paper the vast spectrum of contributions APPs make to their teams.
Relative value units (RVUs) or billing collections are common metrics used to determine what returns providers are bringing to the health care system to define their value. However, much of the work or value that APPs provide cannot be captured in these models, as APPs create value by taking on different parts of the work that contributes to the greater good of patient care.
APPs can provide value by providing an additional focus on patient education and coordination of patient care. These components of value do not fit into older models, yet they require a lot of time and resources. Having APPs fill this role can expand access to care, freeing up time for other team members to see more patients.
Productivity model
We think it is vital for leaders to create systems to define the value their APPs bring to health care. At The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, we created a productivity model to make APPs visible to C-suite leadership by defining their value to the health system.
The productivity model is an expanded version of the traditional volume-based model and captures the role of APPs in the complexity of today’s health care system.
We completed time trials to determine how much average time was spent with patients in ambulatory settings between the physician and APP’s time. We found that, on average, there were time differences between independent vs. shared visits, new vs. return visits, and surgical vs. medical clinics. With Medicare-published work RVU per CPT codes, we used that average time the APP spends for each encounter along with the fraction of the work RVU to create units of service, which in turn drive our model (see image). This model is then based on those variable units of service created based on their patient encounters.
In the inpatient setting, the model incorporates metrics for service, admissions, discharges, patient days, procedures and consults. These traditional measures are then expanded to include all the “other” APP responsibilities that add value for our oncology patient population.
Source: Scott Cackler, MPAS, MBA, PA-C, and Robin M. Rosselet, DNP, APRN-CNP, AOCN
For example, most APPs do not receive in-depth education about the oncology patient population in regular academic settings. So, we have a long onboarding process whenever a new provider is hired and, being an academic medical center, it is our expectation that our APPs are precepting graduate students. Built into our model is the time spent onboarding a new hire or student, appreciating the time it takes away from regular tasks to successfully complete this process.
Another example is telehealth services. We realize our APPs spend a large amount of time on telephone calls with patients discussing symptoms and reviewing testing and treatment plans. Time spent on calls coordinating care with other providers or prior authorizations with insurance companies or pharmacies is captured and built in as valued time spent by the APP.
Most important and unique to our model is that it will interface with our HR timekeeping system in real time. That way, APPs are not penalized for “nonproductive” time when they are utilizing their paid benefit time.
The APP director uses these data at a macro level to show executive leadership productivity in all areas, highlighting overproductive and underproductive service lines. The data are further used to justify new positions and have been used to fill open positions when presented to the executive director of patient care, chief nursing officer and chief financial officer. APP managers use the tool to look at day-to-day operations and projections for staffing. The data also are useful to evaluate the need for staffing changes for extended leaves, manage work equality among teams and forecast for budgeting.
Model as a ‘common language’
Today’s complex health care landscape has APPs working in different models throughout the health care system. Therefore, value can and will be different for each system and reflects the role APPs play within their organization.
APPs stand in the gap between medicine and nursing and are frequently seen as scope creep. APPs can be asked to complete tasks that are within the scope of practice for registered nurses and should be assigned accordingly.
Our institution created the APP productivity model to create a common language we can use across the system when talking about the role our APPs play within the system. It helps us to ensure that their work stays within the scope of practice for an APP. We use this common language regularly to raise awareness among executive leadership, assist in justifying additional APP positions in areas of overproductivity and reduce burnout by leveling out the utilization of the entire APP workforce.
In the health care landscape, where cost reduction is paramount, it is important to develop metric tools to help define your APPs’ value and contribution to your institution.
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