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APs Fit the Bill for Productivity

March 23, 2023

April 2023

Emma Yasinski

Emma Yasinski is a science and medical journalist based in South Florida.

Sandra Kurtin, PhD, ANP-BC, FAPO

Sandra Kurtin, PhD, ANP-C, AOCN
Hematology/oncology nurse practitioner, assistant professor of clinical medicine, and adjunct clinical assistant professor of nursing at the University of Arizona Cancer Center in Tucson.

 

 

In July 2022, the Centers for Medicare & Medicaid Services (CMS) announced new billing guidelines set to take effect in 2023.1 The goal of the guidelines was to increase access to care, but attendees at JADPRO Live 2022 realized that health care professionals have a variety of perspectives on how the guidelines will affect provider workflows and effectively improve patient care in hematology and oncology.

ASH Clinical News spoke to four advanced practitioners (APs) who attended the Advanced Practitioner Society for Hematology and Oncology (APSHO) Leadership Summit at JADPRO Live 2022 about what the guidelines might achieve and what it will take to implement them. Sandra Kurtin, PhD, ANP-BC, FAPO, is director of advanced practice at the University of Arizona Cancer Center in Tucson. Sara Toth, FNP-C, AOCNP, AGN-BC, is a senior director of AP services at Texas Oncology. Aaron Begue, MS, RN, NP-C, OCN, is vice president of advanced practice providers at Memorial Sloan Kettering Cancer Center in New York. Therese Hennig, PA-C, MPAS, is the director of Oncology Advanced Practice at Duke Cancer Institute.

What are some key takeaways from the discussion at the third annual APSHO Leadership Summit?

Dr. Kurtin: The big takeaways were, number one, there is a need to adequately measure AP productivity. There are no national benchmarks specific to APs in hematology and oncology. APSHO is conducting a survey on productivity to establish a national benchmark. Then, leaders will need to decide how to take that data to executive leadership to negotiate productivity expectations for APs in hematology and oncology. The second big takeaway was that there is a struggle to retain an AP workforce. Leaders need to determine how to minimize burnout, facilitate work-life balance, and keep these people in their roles. And then the last piece is how do you develop new AP leaders?

Ms. Toth: Overall, the takeaways are about measuring AP productivity and contribution. Currently, there are no standards for how to measure that. We, as leaders in APSHO, should come together to create and define metrics.

What are the goals of the new CMS guidelines?

Ms. Toth: Billing can be very challenging when it comes to APs and collaboration, so this is an attempt to better define billing practices as they relate to physician and AP collaboration.

Ms. Hennig: CMS is trying to achieve non-duplicative work and they’re trying to capture who is doing the work as opposed to having someone who is not doing the majority of the work bill for that work.

Dr. Kurtin: CMS is advertising it as a program to improve access to care. Many years ago, in our practice, we did away with shared visits completely with the thought that having APs working collaboratively, but on a separate template, increases productivity – or visit volume per day – and access to care. This does require the AP to earn the trust to practice independently through gained experience, decision-making, and critical thinking.

One of the other topics that we discussed at the Leadership Summit was the need to expand AP fellowship programs to grow APs so they have that in-depth, organized, and focused training in hematology and oncology specifically before they are set free.

Mr. Begue: Ultimately, the goals of the new guidelines are to enhance and improve patient access. It’s challenging sometimes to get initial appointments with the new provider, and the shared model doesn’t allow for more timely access to being seen. In cancer, timely appointments are critical because the earlier you catch things, the better the outcome.

How do the guidelines affect access to care?

Ms. Hennig: They should improve access to care. And that is what I would like to see: an overarching improvement in access to care, allowing APs to practice more independently, and opening access for new oncology patients to the attending physicians so that we don’t have as long a wait time – for example, if we offload the attending physicians’ return patients.

Mr. Begue: The guidelines are going to improve access to care. CMS is encouraging providers not to default to shared visit models when they’re not necessary. For example, when patients can be seen independently by the AP or can be seen independently by a physician, they’re encouraging the providers to work that out as opposed to creating a model that is consistently shared for every visit.

Ms. Toth: I can see it going both ways. The guidelines will enable the AP to actually bill for the services they provide. My hope is that it does not decrease access to care because AP reimbursement in the hospital is at 85% compared to physician reimbursement. While some might focus on that 15% reduction in reimbursement, I hope we focus on the AP’s ability to provide care to patients in the hospital setting immediately.

How do the guidelines affect APs working in hematology/oncology settings?

Ms. Toth: It will be imperative to have crystal clear collaboration with our physician partners on who is rounding on the patient and what is considered the substantial portion of the visit because that is who can bill for that visit.

Ms. Hennig: I think there continues to be a lot of split-shared billing across multiple institutions in the U.S.2 Part of that is because the workload is high for a new patient, especially in hematology and oncology. Hopefully this will push providers to separate out those split-shared visits3 and have one person do the work versus two.

Mr. Begue: Depending on your current model, it does require a different workflow and probably a more proactive conversation and collaboration with your partnering physician to understand what types of patients and what types of complexity would be appropriate to transition to the AP versus what should be maintained by the physician. Or, it could be simply setting up a plan where the visits alternate between the AP and the physician. It’s creating an opportunity to have those discussions ahead of time and be proactive when setting up the patient visits.

Dr. Kurtin: I don’t know that everybody’s figured out how to onboard new APs who are not experienced, who may not have any hematology or oncology experience, or who may not have any AP experience. Maybe you use a shared model to grow their experience and then gradually let them function more independently. This will require clarity in billing and coding visits to comply with the new CMS standards. The other key point is the time required for an AP to reach expected productivity metrics, what we call the ramp-up period. This will also require more clarity.4

How are the guidelines being interpreted by practices, and how does this interpretation affect provider workflows?

Dr. Kurtin: The biggest effect for my practice will be in the in-patient setting because it’s a very different model. Access is largely based on bed availability and staffing. And right now, there are beds but no staff. It’s not just APs and physicians, but nurses, medical assistants, techs, and every other level of health care – there’s just a shortage. What’s happened in the in-patient setting is the APs on services generally round, get everything ready to go, and then the physicians come and do rounds and consult on the case or troubleshoot and collaborate, and then the APs or fellows finish the work. With the new standards, you can’t have more than one person bill for the same episode of care in an in-patient setting; rather, it is based on percentage of the work contributed to the visit. These scenarios are going to be a little more difficult to navigate because it’s not clear how to define a percentage of the work based just on documentation. 

For out-patient visits, it’s really about each patient visit or encounter. In many practices, a patient who needs to see their oncologist may start by seeing the AP and then that AP takes the history, looks things up, gets the note going, and then reviews the case with the physician. The physician generally sees the patient briefly after that and confirms the plan, signs orders, etc. In this scenario, the physician bills for the visit. With the new CMS guidelines, there is greater scrutiny for shared visits and the actual work being done by each provider, including documentation. What they are advocating is that providers split the template, and the APs see patients who are appropriate for them to see, physicians see patients who are appropriate to them, and collectively, the providers are going to see more patients because they have two templates as opposed to one. I see it in a positive way because we’ve been doing that already, where we can see more patients but still practice collaboratively.

Ms. Hennig: For many institutions, the APs are still creating note templates for new patients on behalf of the attending physicians. That is not the case everywhere and it’s still a mixed bag. The new guidelines will change the physician workflow because they will be doing their own notes for new patients. I also think there will be fewer dual visits if we implement these guidelines, and we’ll help the APs to work to a higher scope of practice.

Mr. Begue: The interpretation is that the provider who spends the majority of the time with the patient is the one who the bill is going to be sent out under or credited to. That gives us an opportunity to look at how we set up templates and practices a little bit differently. We now need a more proactive conversation with the patient on what exactly those visits are going to look like. In the past, with the shared visit model, the providers could explain to the patient that the physician and AP are partners and will see them together every visit. But now, providers may need to have a conversation, something to the effect of every other visit will be with the physician, and the AP will see them at the alternate visits. It’s a matter of open communication with the patient on what the expectations are moving forward.

How can AP managers facilitate consistent implementation and collaboration from AP teams?

Mr. Begue: Getting the providers together and having conversations about how to approach this early. Every type of provider in the clinic may deal with a different complexity of patient. Creating a model that suits the patient’s needs and achieves buy-in from the providers themselves is critical. The manager is really a critical piece in making sure that those conversations happen and that staff are available appropriately to meet the needs of the patients.

Ms. Toth: By being involved. It’s really important for AP leaders and managers to be involved throughout the education and implementation process. APs have a unique perspective and understand the challenges of billing within our scope and changing state laws to ensure the workflow is effective.

Dr. Kurtin: This can’t be a battle, like you, us, and them. This must be built in a positive way that first and foremost serves the patient, but that takes work, planning, and communication. We have to really work together. As AP leaders, we need to make sure that our APs understand the new guidelines and how our individual programs plan to integrate them into practice. 

Ms. Hennig: The AP teams are ready to move this dial. It will include working with the physician leaders to really institute it and to push the dial from the physician side of things as well.

How do the relative value unit (RVU)-driven productivity metrics play into this discussion?

Ms. Toth: Currently, if a physician and AP see the patient together, the physician can bill for that service, but unfortunately, it looks like the AP didn’t have any RVUs. With the new CMS guidelines, if the AP does the substantial portion, they’ll be able to keep the RVUs from that visit. These changes will be helpful in monitoring and measuring productivity and RVU metrics.

Dr. Kurtin: The other struggle is now with the financial crunch that’s happened with the COVID-19 pandemic. AP productivity is under scrutiny, so the APs are feeling like they don’t have enough people if a patient is taken off of their template. That’s where we’re trying to determine, productivity-wise, what are all the other things we do that aren’t tied to a patient visit? We’re trying to quantify non-billable services like refills, triage, peer-to-peer meetings, and others to really show the executive leadership what it takes to run a practice.

Ms. Hennig: It is going to change some of the work RVU production for the APs. It may increase for them. It may decrease for some of the physicians. And this may also happen on in-patient services. Overall, if it’s done well and it’s done right, and access is really increased, nobody is going to see a huge shift, except the APs may see a little higher RVU production if they’ve been doing a lot of split-shared visits and the physician has been billing.

Mr. Begue: I can imagine in models where the RVUs are a significant part of the productivity measurement, that could create some challenges. Personally, it helps to make the case for a more team-based approach in which RVU productivity could be set at a team level as opposed to an individual level to help ensure the team is achieving the desired outcome rather than focusing so much on the individual provider.

References

  1. Centers for Medicare & Medicaid Services. Calendar year (CY) 2023 Medicare physician fee schedule proposed rule. July 7, 2022. Accessed January 6, 2023. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule.
  2. Nagle J, Mujumdar V. Reporting split/shared visits in 2022 and beyond. Bulletin of the American College of Surgeons. April 1, 2022. Accessed January 6, 2023. https://bulletin.facs.org/2022/04/reporting-split-shared-visits-in-2022-and-beyond/.
  3. Baklid-Kunz E. Medicare’s split/shared visit policy. AAPC. August 8, 2008. Accessed January 6, 2023. https://www.aapc.com/blog/23741-medicares-splitshared-visit-policy/.
  4. Kurtin S. Maintaining a stable AP workforce. ASH Clinical News. 2023;9(2):4.

This interview has been edited for length and clarity.

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