The clinicians at the heart of value-based care

By Gale Pryor | March 21, 2017

The High-Performing Physician Network

Key Stat

51% of visits at FQHCs are conducted by advanced care practitioners

Key Takeaways

  1. High performers on the athenahealth network empower advanced care providers to work at the top of their licenses.
  2. Workflows and models of care that rely on ACPs vary, but they lower costs and help reduce physician burnout.
  3. ACPs enable care to be delivered according to patients' needs for access, cost, and acuity.

More patients, more chronic conditions, more preventive care, more locations — and fewer doctors. The shortage of primary care physicians is a looming challenge for many healthcare organizations.

But there's no shortage of Advanced Care Practitioners, or ACPs. The number of nurse practitioners is expected to increase by 84 percent between 2010 and 2025, with physician assistants not far behind.

And those trained clinicians serve a far greater purpose than filling empty exam rooms. They also play a pivotal role in the transition to value-based care — and the quest for optimized performance.

When athenahealth researchers set out to identify the key traits of high performing health systems — using key financial and clinical metrics to find top performers across a network of 88,000 providers — they found that many high-achieving practices rely on advanced care practitioners to handle key parts of their operations.

Entrusting protocol-based care and community initiatives to clinical non-physicians “is critical to those organizations who are making the biggest bets on population health management," says Jessica Sweeney-Platt, executive director of physician performance research at athenahealth.

Yet in top-performing practices, expanded use of ACPs is not replacing the role of physicians — or disrupting their relationships with patients.

"High performers ensure that scarce physician resources are used for the highest-risk, most complicated patient needs," says Sweeney-Platt, “while advance care practitioners ensure they fulfill the Triple Aim of a better patient experience, across larger populations, at a lower cost."

At health systems and medical practices with strong operational and financial profiles, NPs and PAs tend to deliver a narrow scope of patient services, urgent care, and treatment for common conditions. But they become experts at managing those conditions. And that allows physicians to focus on the most complex patients — and lessens their risk of burnout.

Regardless of condition, population, or location, the question of which clinician delivers which kind of care tends to be organized into “empiric" and “intuitive" spheres, says Adam Bergquist, executive director of strategy and corporate development at the Colorado Permanente Medical Group.

“The empiric is protocol-driven; you can write up a protocol," Bergquist says. "The really hard-to-manage diabetic that is just not getting their blood sugars under control? That requires intuitive skills, and we want a physician to see that patient."

Advanced care practitioners, however, are not limited to uncomplicated care. In many underserved communities, ACPs disproportionately — and skillfully — care for populations with high rates of complex health and social needs. Indeed, among the Federally Qualified Health Centers on the athenahealth network, nurse practitioners and physician assistants provide care at an average of 51 percent of visits, as opposed to 28 percent at other types of practices.

Other clinical non-physicians are broadening healthcare's reach into patients' daily lives. At CVS Health's MinuteClinics, pharmacists partner with nurse practitioners as specialized care managers in medication adherence — an initiative that can reduce readmission rates by as much as 50 percent.

“If you know how to counsel a woman who's got multiple sclerosis and get her to adopt behaviors that reduce her chances of urospesis," says Troyen Brennan, M.D., chief medical officer of CVS Health, “you end up saving a good deal of money on the medical side."

Across the athenahealth network, organizations are weighing the best models for optimal clinical teams. Their solutions include:

Team-based care

Despite a 500-percent increase in Medicaid patients in the wake of the economic collapse of nearby Atlantic City, Shore Physicians Group, a multi-specialty organization, was honored by the American Medical Group Association in 2016 for “game-changing solutions and inventive techniques to align physicians and create a unified provider/staff culture."

Among those game-changers: Ramping up the hiring of nurse practitioners and physician assistants, while keeping level the count of primary care physicians.

“If you look at the most efficient models out there, it's one or two principal physicians at a given location, then two to three physician assistants per physician," says Michael Miller, manager of population health for Shore Quality Partners, the organization's clinically integrated network. “That's the future of primary care."

The optimized medical assistant

Medical assistants are also providing more care than they have traditionally done. At Colorado's DTC Family Health, medical assistants are trained and empowered to manage what lead physician Lynn Joffe, M.D., calls “cookbook medicine."

Medical assistants identify gaps in care before each patient visit and meet the needs for vaccines, screenings, or refills before the physician even enters the exam room. That workflow preserves the moment of care for the provider — a key to reducing physician burnout.

After all, says Joffe, “the joy of medicine is in the interaction."

Community-based care

In northern Maine, Calais Regional Hospital serves an aging population with high rates of diabetes and obesity across 2500 square miles of forests and farms — yet is among the top performers on the athenahealth network in diabetes quality measures. Calais credits nurse practitioners, nutritionists, and nurse educators who have been working out in schools and town halls to teach patients better self-care.

"I think our success really has to do with the fact that...it's not just the physicians' responsibility," says Theresa Brown, director of practice management at the hospital.

And spreading responsibility from physicians to a growing league of trained, empowered clinical professionals — and to patients themselves — solves the paradox of more and better care at lower cost.

Gale Pryor is a senior writer for athenaInsight.

The clinicians at the heart of value-based care