Faced with a growing number of potential patients and either a fixed or shrinking care capacity, many community-based oncology practices are seeking new ways to reshape their practice models to produce better clinical results for patients and better business results for themselves. One solution gaining traction with oncology practices is to incorporate advanced practice providers, or APPs, into their practices' clinical skill mix.
Advanced practice providers are mid-level providers who safely and effectively perform many of the same routine clinical functions as an oncologist. In a community-based oncology practice, APPs can execute provisions of a treatment plan, such as administering chemotherapy and routine follow-up visits, after the patient's initial visit with the oncologist.
In discussing this solution with a number of time-strapped and administratively-burdened oncologists, the four most commonly asked questions are:
- How does a practice evaluate whether it needs an APP?
- What qualifications should an ideal APP candidate possess?
How does a practice integrate an APP into its delivery model?- How does a practice measure the success of adding an APP?
The following suggestions and recommendations will assist community-based oncology practices in making the decision that's right for them.
Evaluating an Oncology Practice's Readiness for an APP
The benchmark question an oncology practice should ask itself is whether it has the capacity to accept new cancer patients. If the answer is yes, consider how many new patients APPs can treat after the oncologist has set a treatment plan. If the answer is no, incorporating an advanced practice provider may still be a viable solution.
The practical approach to the evaluation is similar to incorporating a new physician and includes these five steps:
1) Space: Determine whether the practice has the physical space to absorb another clinician. There should be enough patient care areas to allow the new APP to treat patients in tandem with the practice's oncologists and other clinicians and staff.
2) Staff: Decide if the practice has the staff to support another clinician. There should be sufficient enough clinical and administrative coverage to support the work being performed by the new APP to avoid adding to the clinical and administrative burden of the oncologists.
3) Payer Contracts: All contracts should be reviewed and updated. Evaluate whether the practice's payer contracts recognize and reimburse for the work to be performed by the new APP and that a new provider can be added to the existing contracts. While most do, the reimbursement rates for work performed by APPs can be contracted lower than for an oncologist - outside of incident to.
4) Patients: Assess if the practice's current patients are comfortable receiving care from an APP. A practice should seek feedback to learn more about patients' willingness to have an APP provide chemotherapy or follow-up care rather than an oncologist.
5) Volume: Determine whether the practice's patient volume -- now and in the future -- can financially support the addition of an APP. An APP's typical compensation is similar to a salary plus benefits employee, unlike an oncologist whose compensation or ownership return is based on patient-generated revenue.
Identifying Qualified APPs to Join an Oncology Practice
After the decision is made to incorporate an APP, who should an oncology practice hire? There are three qualifications an oncology practice should put at the top of its list:
1) Oncology experience: Look for a clinical nurse specialist, nurse practitioner or physician assistant who has spent most of his or her career in oncology, with five to 10 years of experience. This candidate has the clinical experience and expertise required but is ready to take on a bigger role.
2) Clinical philosophy: Seek an APP who shares the practice's unique clinical philosophy. This fit is a critical component of success. Does the APP believe in clinical pathways or evidence-based care? Does the APP track the latest cancer research, clinical trials and oncology drugs? Is the APP interested in value-based care programs, such as the Oncology Care Model? Is the APP willing to take on ancillary services, such as in-office dispensing, pharmacy, etc.?
3) Medical practice experience: Find an APP who has worked at another medical practice as opposed to a hospital. APPs from hospitals may come with their own institutionally-biased clinical philosophies. Practice settings typically are much more flexible, nimble and personal.
Integrating a new APP into an Oncology Practice
A community-based oncology practice must effectively integrate its new APP into its operations and care in order to enjoy the clinical and financial benefits that should come with its new practice model.
One of the most important steps during this phase is to remember why the practice chose to incorporate an APP. The new APP isn't there to replicate or replace the work of oncologists. The new APP should expand upon the care oncologists provide. An APP can do that by performing essential clinical and administrative tasks, which frees up more time for oncologists to practice medicine.
Keeping that in mind, these next four steps will help practices onboard a new APP and successfully integrate their tasks into the practice's operations:
1) Billing and compliance: The practice's administrative staff should know how to submit claims for payment for the work of the new APP and be familiar with the clinical documentation needed to support those claims. The proper training and education of office staff is essential to ensuring payment is received for services rendered.
2) Scheduling patients: The practice should introduce its APP care delivery model with new patients, rather than established patients, as the accepted way of providing care at the practice. Practices may find this method allows for a smoother transition rather than convincing established patients that the new model is as effective as receiving care from an oncologist.
3) Educating patients: Oncologists should talk to patients about the change in the practice's model and the benefits of receiving care from an APP. Explaining upfront what the APP will do -- and won't do -- will help alleviate any patient concerns. At the same time, the new APP should wear the same lab coat as the practice's oncologists to visually reinforce to patients that the level of care they're receiving is the same though the person delivering a piece of that care may be different.
4) Informing referral sources: Oncologists should inform their referral sources about the change in the practice's model and the benefits of receiving care from an APP for the referring provider's patients. They should know when and why the new APP is caring for the referring provider's patients before it happens.
Measuring the Success of Integrating an APP into a Practice
Assessing whether a community-based oncology practice made the right decision in adding an advanced practice provider to its clinical skill mix should become apparent fairly quickly. At minimum, the practice should track these three quantifiable measures of success:
1) Productivity: Is the practice seeing more patients in the same amount of time or seeing the same amount of patients in less time?
2) Revenue: Is the practice billing for more patient visits and additional patient services?
3) Patient Engagement: Are the practice's patient satisfaction scores higher? Are more patients using the practice's online portal to engage with clinicians?
There are also less quantifiable measures of success that are equally, if not more, important. Among those are quality of work life, time freed up to pursue other activities, like research, and a cultural shift that positions the practice for successful participation in new value-based oncology reimbursement models.
Adding an advanced practice provider to a community-based oncology practice requires careful evaluation, knowledgeable hiring, effective execution and performance measurement. Success in all four of these requirements will not only position the practice to gain operational and financial benefits, but it will also allow the practice to pass those benefits along to patients and payers in the form of more cost-effective cancer care.
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