Ask an Advisor: APP models for cardiovascular and thoracic surgery programs

Advanced practice providers (APPs), also known as advanced practice clinicians — for example, physician assistants (PAs) and advanced nurse practitioners (ANPs) — are frequently utilized by hospitals and cardiovascular surgery practices to assist surgeons with perioperative care, daily rounds and surgical procedures.   

According to Cindy Borum, MSN, APRN, FNP-C, assistant vice president for Advanced Practice Nursing, HCA Healthcare, Nashville, Tenn., APPs can greatly benefit practices and patients alike. “By utilizing APCs, practices can consistently improve access to care, particularly for disadvantaged populations,” says Borum. “This in turn improves medical outcomes, as more people can receive the treatment they need when they need it. Unlocking access to care in a timelier way is key since studies show no significant difference in patient outcomes or patient satisfaction when treated by APCs versus physicians.”1

One MGMA member recently sent the following inquiry to MGMA Ask an Advisor concerning APPs:
I am in search of some information regarding APP models for cardiovascular and thoracic surgery programs.  

Per MGMA’s subject-matter experts, in addition to the job responsibilities mentioned above, APPs can help supplement cardiovascular and thoracic surgeons through patient education, post-op follow-up care, established patient office visits, call coverage, among other duties. Although cardio-thoracic surgery practices could employ either ANPs or PAs, it’s more common for surgeons to bring in the latter, who have surgical assist background, especially with experience in CV surgery.

Per the 2018 MGMA DataDive Cost and Revenue, the median nonprovider-to-provider ratio was 0.69 APPs to one surgeon. Their standard contract typically includes salary, benefits, incentives/bonuses, malpractice insurance, continuing medical education, dues/subscriptions and often cell phone use. On-call and call-back pay are usually spelled out in their letter of agreement (LOA) or contract. Also, in addition to their base salary, APPs can earn incentives tied to productivity (2.91% for PAs*) and/or quality and patient experience (1.04% for PAs*) metrics, which vary by experience.

If APPs are part of a hospital-owned practice, they are hired through the practice; however, if they are a hospital employee, they are hired by a hospital. If the former, practice expenses — including those incurred by bringing on PAs/ANPs, physicians and staff — are reallocated back to the hospital.

Much like physicians, APPs work a combination of weekdays and weekends to round on patients seven days a week. They are typically staggered between providers to ensure coverage every day of the week.

In many states, APPs can provide an array of services to patients. However, Florida — the location of the querier’s healthcare system — is a restricted practice state, so APPs are not permitted by law to engage in at least one element of practice. As the American Association of Nurse Practitioners notes, “State law requires career-long supervision, delegation or team management by another health provider in order for the NP to provide patient care” in restricted states. These APPs have contracts with physicians who charge them to supervise the practice, determine the type of patients they see and services they can provide, and the supervising physicians must sign off on these services. 

Conversely, in full practice states, such as Washington and New Hampshire, APPs can practice independently of physicians. They are fully authorized by state law to see patients, refer patients to specialists, order tests, provide diagnoses and prescribe medications.

As the physician shortage becomes more pronounced, APPs will be able to meet care gaps in states in which they have similar scope of practice to physicians. In a comprehensive study (30 million patient visits were analyzed) published by Med Care, APPs “achieved equivalent or better results on quality metrics (e.g., smoking cessation, depression treatment, statin therapy) and utilization (e.g., physical exams, education/counseling, imaging, medication use, return visits, referrals) as physicians.2

Patient satisfaction with APPs is just as high in specialties such as cardiology. According to another study that assessed 650,000 patient encounters, teams with PAs or NPs provided “equivalent to or better than care” than physician-only practices.3 In addition, the American College of Cardiology (ACC) advocates team-based care as a means “to increase access and expand services to underserved populations and geographic areas,”4 particularly as the population ages, obesity rates increase and the number of cardiologists continues to decline.

MGMA offers a range of content on APPs:

• "The critical role of advanced practice clinicians" (Insight article)

MGMA also recommends the following resources regarding APPs:

• “Current evidence and controversies: Advanced practice providers in healthcare” (American Journal of Managed Care) 
• “State Practice Environment” (American Association of Nurse Practitioners)
• “This policy change could be the solution to our physician shortage” (Daily Beast)
• “Advanced-practice providers are key to America's healthcare future” (Forbes)

What’s your question?

Do you have a crucial question or need help with a complicated medical practice management issue? With MGMA’s Ask an Advisor program, you can depend on our team of experts to provide answers, recommendations and the tools you need to be successful.
* Data based on 2018 MGMA DataDive Cost and Revenue

Notes:

1. MGMA. “The critical role of advanced practice clinicians.” Aug. 13, 2018. Available from: bit.ly/39qqVO1.
2. Kurtzman ET, Barnow BS. “A comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers.” Med Care. 2017;55(6):615-622.
3. Virani SS, Maddox TM, Chan PS, et al. “Provider type and quality of outpatient cardiovascular disease care.” J Am Coll Cardiol. 2015;66(16):1,803-1,812.
4. Brush JE Jr, Handberg EM, Biga C, et al. “ACC health policy statement on cardiovascular team-based care and the role of advanced practice provid