Is the Ambulatory Provider Workforce Shortage as Bad as We Think?

by Christen Hunt, DNP, NP-C, CPNP-AC

Vizient Senior Director, Clinical Team Insights

Much of the care patients need and receive is performed on an outpatient basis in individual provider practices, clinics and other types of ambulatory care sites. These sites have historically struggled with operational efficiency and staffing challenges that have the potential to force them to close their doors. The pandemic has exacerbated those challenges and ambulatory clinic leaders are looking for ways to achieve greater efficiency.

The efficiency they are searching for may be standing in front of them. Their staff.

Vizient Clinical Team Insights recently reviewed staffing data from a diverse group of 422 ambulatory clinic sites across the United States. What we found was that clinics staffed only with advanced practice providers (APPs) have a 139% better operating margin over clinics only staffed with physicians. And clinics staffed with a team comprised of both APPs and physicians have a 90% improved operating margin over physician-only clinics.

It’s not surprising to find APP-only clinics have higher operating margins, but organizations need to have the “right” provider mix for their patient population. For ambulatory clinics to improve their operating margins, they need first to understand the scope of patients’ needs and then build a care team to meet those needs in an effective and cost-efficient manner.

Another significant finding was related to providers spending time performing administrative tasks such as care coordination, form completions and prior authorizations, which could be performed by other members of the care team. Nearly 43% of clinics with APPs are tasking APPs with administrative tasks and 46% of clinics with physicians are tasking physicians with administrative tasks.

This is significant because on average when providers are tasked with these administrative duties, it accounts for 24% of a physician’s time and 38% of an APP’s time. As a result, data collected from the 422 clinics identified 131 physician FTEs and 68 APP FTEs being utilized on administrative tasks that could have been utilized on revenue-generating patient visits.   

Achieving staff efficiency by understanding patient demand

Many ambulatory clinics focus staffing ratios based solely on medical specialty without fully considering various factors that make up patient demand. Start your assessment by gathering practice data on variables such as age, gender and social economics. It is also important to understand the capabilities of the providers. Both APPs and physicians have unique and essential skills. Taking this comprehensive approach will help leaders make informed staffing resource decisions instead of decisions based on traditional care delivery models.

Data from Vizient’s review of ambulatory clinics show that APPs were included as part of the care team in about 60% of both the primary care clinics and surgical specialty clinics and only half of the medical specialty clinics. Of those clinics that employ APPs, 81% of primary care clinics allowed APPs to see new patients, 76% of surgical specialty clinics allowed APPs to see new patients, and 66% of medical specialty clinics allowed APPs to see new patients.

Adding APPs to the provider team is only successful if they are fully optimized leveraging their full scope of practice. The full scope of practice for APPs includes integrating them as part of the provider team and allowing them to see new patients. This is a topic that frequently surfaces mainly revolving around specialty services, specifically if patients were referred by another physician. The opportunity here is to change this mindset and think about what is best for the patient.

The APP needs to be viewed as part of the specialty care team that can get the patient into the clinic and start the appropriate work-up so when they are able to see the physician, it will expedite diagnosis and treatment time improving patient outcomes. This also helps the organization retain patients that would otherwise seek treatment elsewhere instead of waiting for a physician’s availability. This change requires work to educate the public and providers as well as deploying a fully collaborative team approach.

The next finding is related to the roles and responsibilities of the clinical team, specifically RNs working to the top of their scope of practice performing Medicare annual wellness visits, chronic care management and transitional care management.

Only half of the primary care clinics were staffed with RNs and only a fourth of primary care clinics allowed RNs to perform these types of visits. About half of the medical specialty clinics employed RNs and 65% of surgical specialties, with only a fourth performing chronic care management and an eighth performing transitional care management.

RNs are in high demand and can yield a high return on investment when allowed to practice to the top of the scope of practice. It is within the RN scope of practice to perform chronic care management, Medicare annual wellness visits and transitional care management which can improve patient access and outcomes as well as reimbursement. We saw one organization that staffed RNs in 69% of their primary care clinics and the RNs were fully optimized performing all the Medicare annual wellness visits, transitional care and chronic care management visit. This organization had the lowest lag time for established patients.

Next steps

The COVID-19 pandemic has expedited the opportunity for health care organizations to revolutionize. New and innovative ways to deliver care are being explored with organizations focusing on the patient’s needs instead of tradition. To identify the opportunities that exist within your health care organization, start with a critical assessment. Data is essential to not only identify opportunities but also measure success. Contact Vizient Clinical Team Insights to learn more about how to assess and measure your organization.