As the Advanced Practice Practitioner (APP) role evolves and the industry moves toward value-based care and alternative payment models, establishing a method for tracking and monitoring the productivity and performance of APPs is more important than ever. In fact, I would argue that more important than productivity is tracking/quantifying the value that they bring to the team. In addition, per Peter Drucker, “What gets measured gets managed,” continues to hold true.
Most programs don’t yet track performance metrics for APPs, and those that do typically use work relative value units (wRVUs) as their metric. But although wRVUs can track E/M services and other billable activities, they may not be the best option for quantifying team-based services, or those performed during the global service period.
The good news is that there are several other options to consider. The method you choose will vary depending on your organizational structure and culture. What’s important is to choose something that is reliable and easy to manage.
But before I get into the details of metrics and methods, there are a few essentials that set the stage for optimizing APP performance.
First, for APPs to achieve success, they've got to perform at the top of their licensure. They must be enabled to perform as independent clinicians and that requires physician and staff support. No amount of metrics tracking can fill the gap of underutilizing their clinical skill and education. My philosophy is to define the objective of care that needs to be met by the APP/team and build the role for that objective based licensure and patient care needs.
Second, it bears repeating that whatever method you choose for measuring performance is easy to manage. If you can’t easily track or report on certain measurements, don’t use a method that requires them.
And third, understand the services that the APP is providing, and the billing associated. Incident-to and Split-shared visits are billed under the physician NPI number and unless they are tracked specifically will not show up as attributed to the APP on the billing reports.
Here are four ways to track the metrics that provide some measure of APP performance.
1. Encounters
This is straightforward math: track the number of patients seen per day, week, or month. Set targets for the number of patients you want to the APP to see in the clinic as well as the inpatient setting, and review data from the charge capture utilization report to determine if these targets have been reached.
Using encounters as a performance metric is a good option if your culture rewards volume, or if you are looking for ways to improve patient access. Although an APP may perform multiple services during the encounter, what you are primarily concerned with in this metric is patients seen - which translates into improved access and larger panel size. Looking at the data by encounter enables administrators to identify when volumes are on target or lagging, then turn to the appointment schedule to dig deeper and determine where there are gaps to be filled in the schedule. Another report for this is the slot utilization report. This report is a great way to understand APP utilization at a glance.
Many members ask me how many encounters an APP should see in a day. The answer is that it varies widely depending on the patient population being treated by the APP as well as how you have structured the role in your practice. Generally speaking, I recommend a range of 12 to 22 encounters per day. If the APP is primarily treating and educating a lot of complex, polypharmacy patients, set your targets toward the lower end. If it’s primarily a population of established, less complex patients and post-procedure follow up visits, set the target at the higher end. Review the data monthly to make sure targets are being met.
2. Work RVUs (wRVUs)
Practice administrators are intimately familiar with wRVUs and this familiarity makes it the most common choice for setting APP metrics. It is also a way to monitor provider level responsibilities by the APP, as most provider level responsibilities are reimbursable and therefore would have wRVU associated.
But there are some limitations with using wRVUs for APPs. For instance, what do you do when they deliver services as part of a shared visit in the hospital? Or, when they see patients during the post-procedure global? Neither of these have a direct wRVU to the APP providing the service. So, there is some additional work to be done, and that will require you to develop some assumptions, as well as set up dummy codes in the practice management system to track activity. In addition, for the split shared visits, programs need to decide where the credit is assigned. Some programs split the value 50/50 between the physician and the APP while other programs give 100% of the credit to the physician as that follows the billing logic. For programs that incentivize Physicians and APPs on productivity, this can be a significant challenge. In fact, it can set up a competitive relationship as a result.
3. Time Value Units (TVUs)
This is the most labor intensive of all the measurement options, but for programs that are highly team-based and those moving quickly toward value-based contract arrangements it can be worth the effort. Essentially, this system views performance less as weighted to reimbursement and creates an internal system that quantifies performance for all responsibilities. Individual programs can use TVUs to quantify the value of all activities whether they be reimbursable or not.
The pro of this system is that you can design something that works for your local program and all stakeholders can be involved in its development. And, the TVU system can do what the other systems can’t, which is to attempt to quantify the contribution of multiple roles in ways wRVUs and patient volumes do not. For instance, you can include the APPs role in quality improvement, program development, and care coordination initiatives.
4. Other
The fourth category goes back to defining the objective of care that needs to be met with the APP and the team. If performance in areas such as access, readmission reduction, length of stay, discharge timing, quality initiatives, or patient satisfaction are important objectives for the team, then measure those. They are all great ways of showing not only the performance but also the value of the APP and the team. These are really ‘outcome’ measures in contrast to volume measures that we see in the first three categories.
Although there is no one size fits all way to track APP performance, any one of these options is a sound way to measure performance. Establish targets that are specific to roles and responsibilities. Set expectations in advance and develop performance targets with input from clinicians. You will likely find that your team wants these expectations and measures in place. They too, want to quantify the value that they are bringing to the organization. In addition, enable APPs to perform at the top of their licensure by providing the right structure, information, and support. I would love to hear any additional thoughts you have and what has worked for your organization.