APP compensation models

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Admin trying hard to push APPs in outpatient practice. We do not get paid extra for APP production. You train them, they take away easier cases and the difficult ones remain for you. What are the appropriate APP compensation models in hospital employed practice ? Our group is purely wRVU based. I know how model works in private practice where you just pay APP her salary and all the production belongs to the practice.

 

[solidonc2020]

Admin trying hard to push APPs in outpatient practice. We do not get paid extra for APP production. You train them, they take away easier cases and the difficult ones remain for you. What are the appropriate APP compensation models in hospital employed practice ? Our group is purely wRVU based. I know how model works in private practice where you just pay APP her salary and all the production belongs to the practice.

In our group, APP sees some number of patients on the MD template and writes the note, places the orders, etc, but if the MD takes time to see the patient as well they bill the visit, cosign the note with attestation, and thus collect the wRVUs. There's variability in how many patients are being seen solely by APPs vs joint visits amongst providers.

 

[osprey099]

Admin trying hard to push APPs in outpatient practice. We do not get paid extra for APP production. You train them, they take away easier cases and the difficult ones remain for you. What are the appropriate APP compensation models in hospital employed practice ? Our group is purely wRVU based. I know how model works in private practice where you just pay APP her salary and all the production belongs to the practice.

Hospital is already taking a large cut off your production. By having you supervise APPs, they get to take a large cut off the APP production while you see a fraction of the revenue while assuming all of the liability. Hard no for me. Only time APP supervision is "worth it" is in private practice where you get see all the revenue.

 

[Mehena]

This setup typically benefits the Admin or Med Group more than the oncologist. You may deal with large panel, excessive workloads and may receive little to no compensation but more stress. Although NPs can alleviate some workloads, which were mentioned before here, Admin's intentions are often a suspect.

 

[gutonc]

Admin trying hard to push APPs in outpatient practice. We do not get paid extra for APP production. You train them, they take away easier cases and the difficult ones remain for you. What are the appropriate APP compensation models in hospital employed practice ? Our group is purely wRVU based. I know how model works in private practice where you just pay APP her salary and all the production belongs to the practice.

Why are they pushing them? Are you all so busy that you have a huge backlog of new consults and they're trying to offload some work so you can see more new patients? Are some of your colleagues whiny little *****es that want to do less work and get paid the same?

I've worked in both systems and the latter infuriates me. The former has pros and cons.

In my prior practice setting (academic hospital employed, community based large practice), we had a couple of great APPs and the best you could say about the rest of them is that they mostly didn't kill people.

In my current (rural CAH) practice, it's just me and an APP. She's pretty good...could be better, but always willing to learn...a 90th %ile APP...basically equivalent to a solid 2nd year fellow in her 20th year of practice. She generally sees chemo follow ups, "urgent care", overflow and chemo education appointments (shared with pharmacy, nursing and SW).

The best situation I've had was one where I shared new patients with an APP. She wrote the H/P, presented to me and then all I had to do was explain and write the plan. I billed the whole thing under me and got full credit. IIRC, there are changes in CMS rules that have or will **** this up, so maybe not a good model going forward.

To answer your actual question, if you are 100% wRVU based, ask for a percentage (40-75) of the wRVU that APPs bill on your patients. If they say no, then just don't share your patients with the APP.

 

[checkpointinhibitor]

Why are they pushing them? Are you all so busy that you have a huge backlog of new consults and they're trying to offload some work so you can see more new patients? Are some of your colleagues whiny little *****es that want to do less work and get paid the same?

I've worked in both systems and the latter infuriates me. The former has pros and cons.

In my prior practice setting (academic hospital employed, community based large practice), we had a couple of great APPs and the best you could say about the rest of them is that they mostly didn't kill people.

In my current (rural CAH) practice, it's just me and an APP. She's pretty good...could be better, but always willing to learn...a 90th %ile APP...basically equivalent to a solid 2nd year fellow in her 20th year of practice. She generally sees chemo follow ups, "urgent care", overflow and chemo education appointments (shared with pharmacy, nursing and SW).

The best situation I've had was one where I shared new patients with an APP. She wrote the H/P, presented to me and then all I had to do was explain and write the plan. I billed the whole thing under me and got full credit. IIRC, there are changes in CMS rules that have or will **** this up, so maybe not a good model going forward.

To answer your actual question, if you are 100% wRVU based, ask for a percentage (40-75) of the wRVU that APPs bill on your patients. If they say no, then just don't share your patients with the APP.

We do have backlog of benign hematology consults abut 2 months. Usually useless mildly abnormal SPEP, anemia (PCP/NP too lazy to even order iron labs), neutrophilic leukocytosis in smokers etc) but all onc seen in 1-3 weeks (depending on where they are in workup).

Institution in general is more headed towards hiring more APPs than MDs and to offload work from MDs. The issue is that other gullible (or FIREd MDs) have accepted this in other departments with minuscule (10-20K per year) supervisory stipend and this is being now forced/discussed.

Thank you for your suggestions. This is helpful.
Will look in to productivity share (% wRVU) or bust.
Will give updates if anything changes. TYSM.

 

[MD46]

I was in a similar situation and admin tried to push NPs on all the doctors.
The NPs would see new anemia patients and couldn't order proper tests, miss simple things and out side of clear iron deficiency could not do any thing properly.

Eventually just increased work load for us as they would see the new patient and put follow-up on the physicians schedule. I argued this and stopped this follow-up nonsense, subsequently stopped giving patients to NPs as their billing goes directly to the hospital and we are technically taking all liability without any financial benefit. They didn't give any extra stipend to supervise either

NPs think its not fair that we aren't sharing patients with them but I am super glad that I don't have to as now my day goes much faster and smoother without. If it was a private practice I would train them accordingly and benefit from the full collections.

 

[ONC2023]

I've been offered three models of APP support during my job search:

1) My academic home program offered me the "cushiest" version - an NP is with you in clinic and sees patients with you, puts in orders, etc. They can do this because my home program is notorious for low pay.

2) My hospital employed positions expect me to see patients on my own and also supervise a parallel APP patient panel. APP supervision is part of my base salary and there's nothing above that.

3) My private practice offer will give me an APP once I am busy enough, and the APP will see followups. The RVUs are assigned to me minus the salary for APP + a cut of the RVUs for the APP.

It seems like options 1 and 3 each have their benefits - convenience for option 1, compensation for option 3.

Option 2, which is what we are discussing in this thread, appears primarily geared towards what benefits the hospital.

 

[HemOncCheng]

I've been offered three models of APP support during my job search:

1) My academic home program offered me the "cushiest" version - an NP is with you in clinic and sees patients with you, puts in orders, etc. They can do this because my home program is notorious for low pay.

2) My hospital employed positions expect me to see patients on my own and also supervise a parallel APP patient panel. APP supervision is part of my base salary and there's nothing above that.

3) My private practice offer will give me an APP once I am busy enough, and the APP will see followups. The RVUs are assigned to me minus the salary for APP + a cut of the RVUs for the APP.

It seems like options 1 and 3 each have their benefits - convenience for option 1, compensation for option 3.

Option 2, which is what we are discussing in this thread, appears primarily geared towards what benefits the hospital.

I agree, what the option 1, you basically enjoys lots of support in practice in exchange of getting paid less, but has admin days that is typically 2-3 days, although you have to do curb side consult etc during these days

 

[gutonc]

I agree, what the option 1, you basically enjoys lots of support in practice in exchange of getting paid less, but has admin days that is typically 2-3 days, although you have to do curb side consult etc during these days

This varies widely. That was essentially the model my prior practice had. Docs had their patients. APPs worked alongside them (usually 1APP/2.5 Doc FTE). See chemo patients and long-term surveillance/survivorship follow ups (alternating with the doc), urgent care add ons and dealt with infusion room issues. There was no "signing off" or formal supervision rules, but they might come to ask questions (sometimes major, sometimes minor) and if it was a big deal that they stumbled into, I would often take over and make it my patient unless I was too busy that day. I had my admin days, but I wasn't curbsided or consulted on anything on those days.

 

[HemeOncHopeful19]

We do have backlog of benign hematology consults abut 2 months. Usually useless mildly abnormal SPEP, anemia (PCP/NP too lazy to even order iron labs), neutrophilic leukocytosis in smokers etc) but all onc seen in 1-3 weeks (depending on where they are in workup).

Institution in general is more headed towards hiring more APPs than MDs and to offload work from MDs. The issue is that other gullible (or FIREd MDs) have accepted this in other departments with minuscule (10-20K per year) supervisory stipend and this is being now forced/discussed.

Thank you for your suggestions. This is helpful.
Will look in to productivity share (% wRVU) or bust.
Will give updates if anything changes. TYSM.

Other departments may not mind as much because our field along with a few select others is a little different in that a lot of the revenue we generate comes through the infusion center that doesn't directly generate RVUs for the physician to get credit for.

A GI doc might not mind getting $10k to supervise an NP because if that NP can lighten their clinic duties and allow them to spend an extra 1/2 day - 1 day in the endoscopy suite = many more RVUs from scoping than sitting in clinic. Same goes for a surgeon if they can get an NP to run their pre-op/post-op clinic while they spend an extra day in the OR.