Aligning Advanced Practice Clinicians with New Care Models

Transcription

1 MGMA 2017 ANNUAL CONFERENCE OCT ANAHEIM, CA Aligning Advanced Practice Clinicians with New Care Models Trish Anen, RN, MBA, NEA-BC Debra Slater Principal, Sullivan, Cotter and Associates Principal, Sullivan Cotter and Associates MGMA has determined that Trish Anen and Debra Slater have a financial interest in consulting. The content of this session has been reviewed and has been determined not to be a conflict of interest. 1

2 Learning Objectives Assess the evolving role of advanced practice clinicians (APCs) Discuss emerging trends to support the recruitment, onboarding, productivity and top-of-license practice for APCs Classify current trends in APC compensation and evolving team-based compensation models About SullivanCotter 2

3 Who is an APC? Physician Assistants (PAs) Advanced Practice Registered Nurses (APRNs) Other Professionals (depending on organization) Nurse Practitioner (NP) Certified Registered Nurse Anesthetist (CNRA) Clinical Nurse Specialist (CNS) Certified Nurse Midwife (CNM) What APCs Can Do Clinical Conduct history and physical Diagnose and treat illnesses Order and interpret tests Provide counsel on preventive health care Order and prescribe medications Perform procedures Assist in surgery Administrative Committee participation Leadership Research 3

4 Where Can APCs Practice? Inpatient/ Acute Care ER/ Immediate Care Skilled Nursing Retail Ambulatory/ Clinic Home Care Palliative/ Hospice Telemedicine Fact or Fiction? APCs like being called mid-levels, physician extenders or non-physician providers 4

5 Fact or Fiction? There are plenty of APCs to meet the growing demand Demand for APCs Tapping Nurse Practitioners to Meet Rising Demand for Primary Care Studies show that NPs can manage 80-90% of care provided by primary care physicians U.S. News and World Report: Top 25 Jobs of 2017 #2: Nurse Practitioner #3: Physician Assistant #6: Certified Registered Nurse Anesthetists #17: Physician Nurse Practitioner Demand Eclipses Doctors As States Lift Hurdles Only family physicians, psychiatrists and internists are more in demand than nurse practitioners The Merritt Hawkins annual analysis of the U.S. health care workforce showed nurse practitioners are in the top five most requested searches Sources: Van Vleet, Amanda and Julie Paradise. Tapping Nurse Practitioners to Meet Rising Demand for Primary Care. The Henry J. Kaiser Family Foundation. 20 January 2015.; The 100 Best Jobs. US News and World Report Retrieved 12 January Nurse Practitioner Demand Eclipses Doctors As States Lift Hurdles. Forbes. Retrieved 20 June

6 APC Vacancy and Turnover Given rapid employment growth and high vacancy rates, compensation strategies are changing rapidly New graduates have high pay expectations Equity issues with experienced staff Average vacancy rates 7.7% 9.3% 9.3% Average turnover rates External 10% Internal 4% Source: SullivanCotter Advanced Practice Clinician Compensation and Pay Practices Survey Report Fact or Fiction? We lose money on APC services because Medicare only reimburses 85% 6

7 Billing and Reimbursement - Considerations Contribution margin: Revenue minus expenses Opportunity cost: Is there a better (higher value) alternative use of the physician's time? Compliant billing practices: Recent OIG scrutiny of incident-to and shared services billings HEADLINES TODAY The Growing Scrutiny September 2015 Developments and Unsealed Cases. billed for products or services that were not actually provided, engaged in upcoding, or billed for services of non-physician providers under physicians names August 2016 Pay a Total of $3,280,000 billed Medicare and Medicaid for in-person E&M services at the higher physician fee rate, even though the services were often provided by nonphysician providers August 2016 Sentenced to Two Years in Prison In exchange for his referrals, provided free labor in the form of a physician, PAs and NPs... billed Medicare and Medicaid for the services of the PAs and NPs as if he employed them Sources: usao-ndil/pr/oak-brook-doctor-sentenced-two-years-prison-connection-kickback-scheme-sacred-heart 7

8 Organizational APC Strategy Drivers How can optimizing all providers (physicians and APCs) help achieve organizational goals? Increase access Improve quality and patient satisfaction Reduce cost of care Manage at-risk populations Increase provider productivity and satisfaction Hidden Drivers Misunderstanding of regulatory requirements Outdated bylaws requirement wrvu attribution (credit to billing provider vs. rendering provider) Additional 15% reimbursement Historical practice 8

9 APC Utilization: A Sample Only 10% of APCs perceived being utilized to their maximum capacity Maximum Utilization 10% Significant Utilization 36% Moderate Utilization 48% Minimal Utilization 6% 0% 10% 20% 30% 40% 50% Source: 2016 SullivanCotter Individual APC Survey APC Utilization and Variation One state, one health system and eight hospitals APC Scope Write discharge orders Write transfer orders Obtain history and physical Order and interpret diagnostic testing and therapeutic modalities Order and perform referrals and consults Order blood and blood products Order inpatient non-schedule medications Order inpatient schedule (II-V) medications Prescribes outpatient non-schedule medications Prescribes outpatient schedule (II-V) medications Health System Sample A B C D E F G H N Y Y N Y Y N N N Y Y N N Y N N Y Y Y N Y Y N N N Y Y N Y N Y N N Y N N N Y Y N N Y Y N N N N N N Y Y N Y N Y N N Y N N Y N N N Y Y Y N N N Y N Y Y N N N N N N Source: 2016 The Center for Advancing Provider Practices (CAP2 TM ), APRN Core Privileges Report 9

10 APC Perspective: A Sample APCs reported being involved in activities which might be completed by other team members Follow up to patient phone calls Order prescription refills 72% 81% Complete forms Complete prior authorizations Coordination of services 55% 51% 60% 0% 20% 40% 60% 80% 100% Source: 2016 SullivanCotter Individual APC Survey Organization Continuum APC Role Developing Organizations Misunderstood or invisible Unplanned Non-existent Optimized, recognized Underutilized and highly valued Models of Care Well defined; focused Driven by on patient needs and reimbursement care team optimization APC Strategy Developed and Fragmented continually evolving Leading Organizations 10

11 Evolving Role of APCs in Value-Based Health Care APC Roles and Practice Models 1 Team-Based Care Model - APC works with a team of primary care providers to manage a shared panel of patients 2 Individual Practice Model - APC manages and treats their own panel of patients 3 Niche-Based Practice Model - APC gains expertise in one or multiple chronic disease states and works with other providers to manage the specific population 4 Specialty-Based Model - APC develops expertise in a certain specialty and works with specialist physicians 5 Continuum of Care Model - APC manages patient populations beyond acute and ambulatory through home, skilled nursing and telemedicine visits 11

12 Organizational Priority: Access to Care Situation Growing wait time to first appointment Inability to recruit enough primary care physicians Approach Hire more APCs Physicians 278 Hired an additional 75 APCs in one year Physicians and APCs share large patient panels Outcomes Increased APC primary care visits by 80% over 4 years Increased appointment availability Decreased wait times and increased patient satisfaction Source: SullivanCotter 2016 Physician Compensation and Productivity Survey Report SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report Organizational Priority: Reduce Readmissions Situation Cardiac surgery patients could not be seen by cardiologists for three weeks post discharge Approach Develop a transition clinic run by APCs Outcomes Patients seen within two days of discharge Increased patient satisfaction Reduced readmissions Source: SullivanCotter 2016 Physician Compensation and Productivity Survey Report SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 12

13 Organizational Priority: Lower Cost of Care Situation Organization could not hire enough Intensivists to provide 24/7 coverage for new closed ICU model Approach Added APCs to Intensivist team to ensure 24/7 ICU coverage Outcomes Standardized care processes, increased quality outcomes Reduced LOS and cost of care Ensured 24/7 coverage Source: SullivanCotter 2016 Physician Compensation and Productivity Survey Report SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report Organizational Priority: Optimize Provider Utilization Situation Planned to hire two Urologists Approach Assessed and elevated the use of current PAs to manage majority of pre- and post-op visits and special population clinics Outcomes Re-evaluated staffing and hired one Urologist for projected cost savings of $440,000 Source: SullivanCotter 2016 Physician Compensation and Productivity Survey Report 13

14 APC Strategy Educate Communicate APC Leadership 65% of organizations have a designated APC Leader. Of these, 47% have a dyad reporting structure. 50% 40% 30% 20% 10% 0% 33% 47% 12% Physician Nursing Executive Executive and and Other Nursing Executive Executive 2% Physician Executive and Other Executive 23% Nursing Executive (CNO) 16% Physician Executive (CMO) 6% 8% COO Other Source: 2016 The Center for Advancing Provider Practices (CAP2 TM ), Leadership Structure Report 14

15 Time allocated to leadership role varies by type of organization APC Leadership 50% 40% 30% 20% 10% 0% 40% 40% 21% 21% 21% 17% 13% 10% 8% 5% 5% 0% <10% 10-30% 31-50% 51-70% 71-90% % System Single Entity Source: 2016 The Center for Advancing Provider Practices (CAP2 TM ), Leadership Structure Report APC Engagement 55% of medical groups/faculty practices have an APC representative on the Governing Committee 76% have a voting right 36% of acute care organizations have an APC representative on the Medical Staff Credentialing Committee 59% have a voting right 46% of acute care organizations have an APC Committee 77% are involved in the credentialing of APCs Source: 2016 The Center for Advancing Provider Practices (CAP2 TM ), Acute Care Organization Report and Ambulatory Organization Report 15

16 APC Orientation and Onboarding Only 30% report having a formal APC-specific orientation program 70% 30% Of those with a formal APC orientation program, only 24% perceive it to be very effective Formal APC Orientation No Formal APC Orientation Source: 2016 The Center for Advancing Provider Practices (CAP2 TM ), Acute Care Organization Report Primary Care APC Workforce Trends Increased utilization of APCs to address demand and efficiency Average number of Primary Care APCs per organization Percentage of organizations total Primary Care APC workforce 2013: : 43 30% increase 2013: 29% 2016: 32% 3% increase Note: This sample includes 76 organizations that participated in both the 2013 and 2016 surveys. Source: SullivanCotter 2013, 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 16

17 Total Cash Compensation $115,000 Nurse Practitioner Median TCC by Specialty Group $110,000 $105,000 $100,000 $95,000 $90,000 $85,000 $98,260 $99,507 $100,256 $105,685 $100,714 $104,000 $103,456 $108,160 $104,114 $108,560 $109, $114,230 Primary Care Medical Surgical Hospital -Based Source: SullivanCotter Advanced Practice Clinician Compensation and Pay Practices Survey Report Total Cash Compensation $115,000 Physician Assistant Median TCC by Specialty Group $110,000 $105,000 $100,000 $95,000 $90,000 $99,740 $99,004 $104,000 $102,270 $101,920 $102,648 $106,213 $104,978 $107,532 $106,631 $112, $109,699 Primary Care Medical Surgical Hospital -Based Source: SullivanCotter Advanced Practice Clinician Compensation and Pay Practices Survey Report 17

18 Increasing Specialization Increasing specialization is resulting in pay differences between specialty groups $114,000 $112,000 $110,000 $108,000 $106,000 $104,000 $102,000 $100,000 $98, Median TCC by Specialty Group $112,750 $107,532 $108,560 $109,166 $106,631 $104,114 Primary Care Medical Surgical Nurse Practitioner Physician Assistant Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 42% Average of organizations report utilizing incentive pay for at least some of their APCs 32% of incentive programs contain a team-based component Use of Incentive Compensation maximum incentive opportunity is approximately 9% of base pay Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 18

19 Primary Care Incentives Outpace Other APCs Reported incentive amounts for APCs with a base pay + incentive plan Primary Care APCs $7,134 Surgical APCs Medical APCs Hospital-Based APCs $5,468 $5,209 $5,553 CNM $3,969 CRNA $3,050 $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 Note: These figures represent APCs with a base pay plus incentive plan only. Percentages represent the incentive proportion of corresponding base pay. Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report Incentive Plan Metrics Work RVUs 42% 46% 47% Value-Based 33% 37% 44% Patient Experience 33% 31% 38% Visits/Encounters 18% 17% 14% Organizational Financial Incentives 13% 17% 18% Panel Size 0% 0% 5% Primary Care Medical Surgical Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 19

20 Recruitment Incentives Overall Prevalence 61% 70% 37% All New Hires 16% 12% 4% Select Specialties Only 2% 12% 9% Any APC as Needed 82% 76% 87% Number of Incentives Offered 37% 31% 32% Two Incentives One Incentive Three Incentives Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report Special Benefits 78% 63% Continuing Medical Education Expense Allowance Minimum 0.5 FTE typically required for eligibility Median Allowance: $2,225 Paid Time Off for Continuing Medical Education 63% have a CME allowance in addition to paid time off Median: 5 days 65% Certification or Licensure Pay/Reimbursement Of these, pay is separate from the APC CME allowance 30% of the time Median Annual Cap: $1,000 Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 20

21 Special Pay Practices Although APCs are often exempt employees, many non-exempt pay practices still exist Exempt Exempt and Non-Exempt Non-Exempt 61% 33% 6% 66% pay at least some of their exempt APCs for working extra shifts 26% of organizations use employment contracts for APCs 59% of organizations provide APCs with shift differentials 56% provide a flat rate and 37% use a straight pay rate 4% of APCs are covered under collective bargaining agreements 53% use a flat dollar amount per hour of coverage approach Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report On-Call Pay Practices Call Panel Size Specialty Group* Mean Median All Specialties 10 4 Medical 15 5 Surgical 7 3 *Insufficient data reported for Primary Care and Hospital-Based Unrestricted On-Call Coverage Hourly Rates Provider Type 25 th Percentile 50 th Percentile 75 th Percentile CRNAs $3.54 $8.63 $11.10 NP Only $2.92 $7.00 $7.50 PA Only $5.00 $9.38 $9.76 Both NPs and PAs $2.20 $7.25 $9.38 Source: SullivanCotter 2016 Advanced Practice Clinician Compensation and Pay Practices Survey Report 21

22 Align Physician and APC Compensation Develop a team-based primary care compensation plan Base Salary 85% of median survey TCC + Productivity Incentive Team acuityadjusted panel size + Value-Based Incentive Up to 10% of base salary = Total Cash Compensation $70 Physician (split pro rata based on individual panel size) $100/Panel Member > 85% of Median (adjusted for FTE and provider specialty) $30 APC (split equally per clinical PTE) Team Clinical Quality Up to 5.0% + Team Patient Satisfaction Up to 5.0% Sample Care Team Payouts Align Physician and APC Compensation Provider Type Count Clinical FTE Acuity- Adjusted Panel Size Threshold (85% of Median) Rate ($) Paid per Patient in Excess of Threshold Incentive ($) Physician , $70.00 $51,520 APC , $30.00 $22,080 Total ,683 6,947 $ $73,600 NOTE: Sample payouts do not reflect additional Quality and Patient Satisfaction components 22

23 Align Physician and APC Compensation Develop a team-based surgical specialty incentive plan Goals Structure Improve surgeon productivity and patient access by utilizing APCs in lower-producing wrvu activities Avoid creating a competitive productivity-based incentive model with surgeons APC wrvu productivity > threshold AND Surgeon wrvu productivity > threshold = APC productivity incentive + Combined surgeon/apc patient satisfaction results > threshold = APC patient satisfaction incentive APC Strategy Educate Communicate 23

24 Continuing Education ACMPE credit for medical practice executives. 1 AAPC Core B, CPPM credit 1 ACHE credit for medical practice executives 1 CME AMA PRA Category 1 Credits.. 1 CNE credit for licensed nurses 1 CPE credit for certified public accountants (CPAs) 1.2 CEU credit for generic continuing education 1 Let the speakers know what you thought! Evaluations are available on the MGMA mobile app Trish Anen Debra Slater trishanen@sullivancotter.com Sullivan Cotter and Associates 200 W Madison Street, Suite 2450 Chicago, IL debslater@sullivancotter.com Sullivan Cotter and Associates 110 Peachtree Street, Suite 620 Atlanta, GA