The development of a visual dashboard report to assess physician assistant and nurse practitioner financial and clinical productivity

Physician assistants (PAs) and nurse practitioners (NPs) often referred to as advanced practice providers (or APPs) have been a part of organized medicine in the United States since the late 1960’s. Nurse practitioners are advanced practice registered nurses (APRNs) who are graduate-educated in a specific population foci (e.g., pediatrics, acute care, women's health, family), whereas PAs are graduate-educated as a “generalist” in the medical model, which complements physician training [1]. These providers are an integral part of a team-based approach and are employed in almost all medical and surgical settings within the United States [2]. Health care services provided by PAs/NPs are reimbursed by insurers at rates slightly lower than that of a physician. Research consistently demonstrates that patients receiving care from PAs/NPs have high satisfaction rates and clinical outcomes comparable to that of primary care physicians [3‐5]. Although, AMCs have employed PAs/NPs for decades, the vast majority of AMCs have not successfully documented the financial impact or outcomes associated with individual PA/NP care [6]. In today's evolving healthcare environment, AMCs nationwide are taking cost-cutting measures to try to recoup lost revenue from canceled surgeries and higher care costs for treating patients with more severe conditions [7]. Given the year-over-year declines in provider productivity experienced by some hospital systems because of the pandemic, it’s imperative AMCs enhance KPI tracking and consistency to identify opportunities to improve profitability, population health, clinical outcomes, patient access and experience. A failure to appreciate, which KPI metrics drive improvement efforts and effect real change can lead to undesirable organizational outcomes such as insufficient clinical productivity and revenue growth.

In the United States, the relative value unit (RVU) is the most popular payment model for most types of clinical practice activities as each Current Procedural Terminology (CPT) code is assigned an RVU, which is multiplied by a conversion factor and geographic adjustment to determine the Medicare-allowed payment [8]. RVUs are often used in compensation formulas and productivity metrics by AMCs, however, there is a growing recognition of the potential impacts of a wRVU-based compensation model on unremunerated activities, such as teaching and scholarship [9]. Unlike faculty physicians, most APPs employed at AMCs do not receive protected time for academic activities and are expected to carry out the clinical mission of the enterprise.

The aim of this article is to discuss the development of a highly visual APP dashboard report coupled with financial KPI metrics to gain a more transparent view into APP financial productivity and potentially drive practice improvements at our institution. Prior to this engagement, our institution consistently struggled to track and report APP clinical effort and the impact to productivity and revenue. Moreover, APPs requested more feedback regarding their productivity.

To our knowledge, this is the first article to discuss the development, and deployment of an APP specific dashboard at an AMC. The comprehensive dashboard enables APPs and administrators to access and compare APP productivity metrics against department standard performance expectations without having to extract data from multiple sources to compute wRVUs. Dashboard acceptance and usage has increased significantly among our outpatient APPs and managers since the initial go-live in 2021. The dashboard is particularly helpful in providing a consolidated view of financial and clinical data, which aligns with the needs of end users. One immediate benefit to end users occurred because of an institutional change to align the APP funds flow model with top-of-license practice for outpatient APPs, which began shortly after the implementation of the dashboard.

To help offset department-paid APP salary/benefit expenses, departments are now paid a dollar per wRVU ($/wRVU) payment based on the wRVUs generated by the outpatient APP as the performing provider, and at the appropriate $/wRVU benchmark (general or specialty rate). The department also receives 13% of collections associated with the outpatient APPs revenue by billing provider to offset other departmental expenses. Tracking total APP wRVUs and net payments is essential in calculating breakeven point. Needless to say, non-RVU generating activities are not captured within the dashboard. The APP dashboard allows end users to review comparison data for a selected time period. For example, at the enterprise level, APP productivity year-over-year aggregate data across 6 departments demonstrated a 115% increase in wRVUs, 77% increase in payments, and 100% increase in charges from the prior fiscal year (July to February). It should also be noted that the increase in APP productivity did not negatively impact the physician productivity model. In light of the new funding changes, APPs have found it easier to access and monitor their KPI metrics through the dashboard.

Another benefit of our dashboard is the ability to track the required number of APP independent clinic sessions required under our newly adopted ambulatory practice standards. Under the new guidelines, a clinical full-time equivalent (cFTE) ambulatory APP is expected to have nine independent clinic sessions totaling 36 patient contact hours each week. This equates to a monthly total of 144 available hours on an APP’s template to schedule patients. In addition to available hours, the dashboard tracks the number of booked hours defined as the total number of hours that the APP is scheduled to see patients. These dashboard metrics are extremely useful in identifying departmental adherence to and compliance with the new enterprise practice standards, and pinpointing opportunities for redistributing resources, improving session standardization, and template optimization.

The dashboard report along with other factors is also used as a resource in evaluating recruitment requests for net new or replacement APP career and non-career positions. The dashboard’s template utilization percentage (booked hours divided by available hours) with an anticipated goal of 85% template utilization is particularly helpful in identifying and assessing untapped capacity that may exist within a department or division to absorb incremental increases in patient volume, which may negate or necessitate the need to hire an additional APP.

Lastly, while lag times are prevalent within dashboard reporting systems, our institutional data lag time (4 weeks) did not negatively impact dashboard performance or acceptance.

Given the double-digit growth of APPs in the healthcare workforce over the last decade, it is becoming increasing important to understand the financial impact of these providers on hospitals and health systems [10]. The development of an APP dashboard can provide a real-time snapshot to help health systems improve efficiency gaps and care team scalability. While there is no-one-size fits all solution to dashboard reporting, we have taken the opportunity to highlight steps our organization undertook in the creation of our novel APP dashboard report. By leveraging our in-house data analytic tools, we were able to create a highly visual report that categorizes APP productivity levels across wRVU performance targets using multiple volume-based metrics. Our success in the execution of an APP dashboard was facilitated by the selection of standardized financial and productivity metrics, which are generalizable and accessible at the individual, department, and enterprise level. Additionally, we used end-to-end data testing and validation procedures to ensure that our data was reliable and reflected accurately in the dashboard report. Lastly, benchmark patient satisfaction metrics will be included once APPs have been added to the contracted vendor’s surveying process.