To fill those gaps, health systems and hospitals are elevating APPs and giving them more responsibilities. The resulting change in care team design is forcing CMOs and other executives to think about how they manage their physicians to ensure a productive workplace and positive clinical outcomes.
Since this shift, CMOs have begun to wonder if they need as many physicians as they thought, especially since the APPs are sometimes carrying out the majority of the tasks.
TAKEAWAYS
-
In the primary care setting, physicians need to work with patients who have complex conditions and diagnosis needs, but APPs can do this too.
-
In the specialty practice setting, physicians often establish care plans, but APPs are called upon to carry out to fruition.
-
In the inpatient setting, a physician lead is often responsible for the care of patients, but APPs are right beside them.
-
This begs the question—do CMOs need to keep hiring physicians?
So this begs the question, is it time for CMOs to scale back their physicians and usher in more APPs instead? While the question is in part written in jest, it doesn’t mean there aren’t pros and cons to considering APP-lead teams. Let’s see what the experts have to say.
86,000 physicians, including 40,400 primary care physicians
expected industry shortages by 2036, according to the Association of American Medical Colleges.
An answer to the physician workforce crisis?
Not totally, but 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.
Education and training are primary distinctions between physicians and APPs and can really benefit the workforce gaps clinical leaders are desperately trying to fill.
Thomas Balcezak, MD, MPH
Chief Clinical Officer, Yale New Haven Health
Bruce Scott, MD
Otolaryngologist from Kentucky and the newly-inaugurated president of the American Medical Association
Don’t forget the labor costs too. As we know, the annual compensation is another distinction between physicians and APPs.
The differential between physician compensation and APP compensation makes employing APPs cost effective, Balcezak says.
While some leaders think APPs could be the answers, 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 the newly-inaugurated 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."
2023 Annual Median Compensation
Physicians and surgeons
PAs
Nurse practitioners
126,260
SOURCE: U.S. Bureau of Labor Statistics
64%
Reduction
A study published by The Journal for Nurse Practitioners found that a nurse practitioner-led interdisciplinary team reduced the median hospital readmission rates.
So 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%.
There are circumstances where care teams can be led by APPs, Balcezak says.
"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," he 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, Balcezak 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 Can Not 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," Balcezak 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 CMO Catherine Chua, DO, MS.
Catherine Chua, DO, MS
CMO, Davis Health System
“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.”
—Catherine Chua, DO, MS, CMO, Davis Health System
"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.
Physician-led specialty practices
In a specialty practice, the management of the team and management of treatments must be physician-driven, says Donald Whiting, MD, CMO of Allegheny Health Network and president of Allegheny Clinic.
"In the specialty setting, a lot of the access is created by using advanced practice providers, but the APPs have to work in a physician-driven strategy," he says. "APPs can help provide access, but the management of the practice must be physician-driven because physicians and APPs need to be complementary rather than competitive when they both can be providers."
With the evolution of APPs and their practice at top of license in the specialty setting, they can have their own panel of patients and manage those patients with physician oversight, Whiting says.
“APPs can help provide access, but the management of the practice must be physician-driven because physicians and APPs need to be complementary rather than competitive when they both can be providers.”
—Donald Whiting, MD, CMO of Allegheny Health Network and president of Allegheny Clinic.
Donald Whiting, MD
CMO of Allegheny Health Network and president of Allegheny Clinic
"APPs can be additive to physician clinics, where they work with physicians to make them more efficient and effective in the clinic by helping to see more patients," he says. "APPs can assist in the operating room. APPs can also take on responsibilities from the physicians such as authorization of procedures and tests as well as peer-to-peer reviews."
In the specialty practice setting, it is common for a physician to have the initial interaction with patients, Chua says. For example, she says there is usually a team leader who is a physician who does the initial evaluation of a patient and develops a plan of care in an orthopedics practice. Then an APP carries out the plan of care.
"The physician would decide whether the patient needs surgery, injections, or physical therapy, then the APP would do the follow-up appointments and potentially do injections, make referrals for physical therapy, and do post-op visits after the patient has their surgery," she says.
Redesigning care in the inpatient setting
In the inpatient setting, the composition physician-led care teams depends on the type of hospital because clinical resources vary in these settings, Chua says.
For most large hospitals and academic medical centers, where clinical resources are most abundant, the model looks like a pyramid, she says. There is the physician lead, there are APPs who are doing rounding and coming back to the physician, then there are residents and nurses that form the base of the pyramid.
At community-based hospitals, there are physicians who are the primary responsible party for the patients as well as APPs who cover certain shifts in the hospital while being supervised by a physician, Chua says. Generally, the APPs will practice on their own with supervision from a physician as needed. For example, a physician will sign off on the APPs' charts.
“Physicians lead this process, but case management staff are often the quarterback of making sure a good transition of care happens, with support from APPs.”
—Donald Whiting, MD, CMO of Allegheny Health Network and president of Allegheny Clinic
At critical access hospitals, where clinical resources are most scarce, there are often APPs practicing with a physician in the building who may not be directly supervising the APPs, she says.
In the inpatient setting a physician must serve as the team leader, Whiting says.
"On these care teams, there are physicians, APPs, case management staff, social services staff, and nurses," he says. "In the inpatient setting as opposed to the outpatient setting, there is medical care but there is also the post-hospital disposition of the patient, continuity of care after the hospitalization, and connectivity with outpatient follow-up."
In the inpatient setting, the care team helps create continuity of care, so the patient has a good transition from the inpatient setting to the outpatient setting, Whiting says. "Physicians lead this process, but case management staff are often the quarterback of making sure a good transition of care happens, with support from APPs," he says.
Yale New Haven Hospital has a relatively unique situation: Physician Assistant William Cushing is executive director of the facility's hospitalist group.
"The hospitalist group is led by a physician assistant, who has worked at the hospital for many years and is respected for his ability to manage that group," Balcezak says. "He will readily tell anyone that he is not the expert when it comes to human physiology compared to his physician colleagues. He will defer to their expertise in the clinical realm and clinical decision-making, but he is the boss."
In addition to his long tenure at Yale New Haven Hospital, Cushing has several qualities that make him a good leader for the facility's hospitalists, Balcezak says.
"Cushing embodies many of the characteristics of effective leaders," he says. "He is well known by his team for his emotional intelligence, for his clarity of thinking, for his ability to communicate, and for his ability to be collaborative. He is an effective decision-maker while welcoming input from others. He works hard to gain and maintain the respect of the team that he leads."
Having a PA serve as the leader of a hospitalist group is very unusual and may not be replicable at other hospitals, Balcezak says.
"As I have said in the past, if we were looking for the head of the hospital's hospitalist service, I don't think I would have entertained interviewing William Cushing," he says. "However, he was here as a PA, and he grew into the leadership role. When it came time to pick the executive director of the hospitalist group, there were several directors, of which he was one, and he was the one we promoted over the physicians who were serving as directors."
Christopher Cheney, Senior Editor, HealthLeaders