One of the key aspects to the success of such a program will be recognition of the capabilities of the midlevel provider. Despite the fact that some of these individuals are exceptionally skilled, I have seen them treated poorly by some physicians and even nurses because they are not a doctor. Establishing clearly to everyone on the team the value that the mid level brings be important to delineate responsibilities in expectations for performance and behavior.
One model that I have seen be successful is to incorporate the mid level in to the clinical care team with full participation in rounds just like an additional resident. Specific patient types and acuity levels can be defined for what type of patient is cared for by the mid level and what type is cared for by the resident. Once the residents realize the skill an expertise of the mid level as well as the fact that this mid level enabled them to spend more time in the operating room, the resident will understand the value of these providers. From the billing standpoint, developing specific tasks that the mid level can perform an Bill for enable is a collection of a considerable amount of revenue that can help offset the cost. For example, line insertions when performed by the resident may not typically be a billable event unless there is direct attending physician supervision. Insertion by a mid level however is and this can’t eliminate much of the drudgey of ICU care for residents who are already per physician in these procedures.
I agree wholeheartedly with the above comments regarding the need for front line decision making at the service line level. These best know the business needs, but in order to make the best decisions it requires ensuring that they have the knowledge and resources available to make the best business decisions. Operational and financial performance metrics have to be a key part of the accountability process with periodic assessment with the executive teams. These teams need to understand the overall goals and expectations, but importantly need to also know the “do not do” (at least not without further discussion) list.
This is definitely a challenging problem in the rapidly evolving landscape of healthcare. Large academic medical centers have historically prided themselves on the traditional tripartite mission–often focusing more heavily on research or education than clinical care. The clinical care was always there because there were the publicly funded patient’s and the commercially funded patients who had extreme problems. In the past, as physician salaries in academic were lower, reimbursement was better and research dollars more concentrated this model seemed to work. Now with demand for higher salaries, lower reimbursement, tighter competition for research dollars, and new competition there is a need for change. I have seen some AMCs hold steadfast, declare their unique contributions and subsequently lose their local marketshare to more innovative providers. I think the keys for AMCs are to 1) have a leader who recognizes the need to change/evolve, 2) be willing to try soemthing different and innovate even if it might fail, and 3) accept that without good clinical care there will be no research or education because there will be no patients.
I think one of the ways to do this is to bring the team together and clearly define everyone’s capabilities. Based on a skills assessment open discussions can be had regarding the roles and expectations of the different team members. In the process, I have found that we have often identified holes in the team where we had individuals performing below the lvel of their licensure because we did not have the adequate staff to perform a function. For example, as we looked at clinic workflow, we found that we had nurses in the EHR checking patients out and scheduling appointments as opposed to a scheduling clerk. This was creating a huge bottleneck in the clinic but after discussions, we decided to proceed with additional schedulers and enhancing their training as opposed to hiring additional/replacement nurses.
Having worked in a system where everything was based on a flat salary with expectations for clinical an academic productivity, I saw far too often that people were under productive because there was not a note off of a direct incentive to encourage them to go out of the way to see an extra patient or go the extra mile. Clearly will always have some people who are more committed than others, but it is a matter of trying to motivate everyone. Using RVUs as the only metric does have the potential to encourage waste and unindicated care so I dont think this is the answer, but I think it does need to be blended with metrics that are focused on patient outcomes and the value of care delivered. Many front line physicians have no concept of healthcare economics and hospital reimbursements and only understand the direct impact on their reimbursement. By educating on the hospital finances, buidling alignment and focusing on shared savings this may not only help fund a better physician compensation plan but may hopefully help engage the physicians as stakeholders.