Better utilization of APPs could aid aging cardiology workforce, boost compensation

Viet Le has talked with other physician assistants (PAs) in cardiology who feel they are little more than “glorified scribes.” Early in his career, he felt confined to that role at times, too.

Now, he and two nurse practitioners work on cardiovascular research projects at Intermountain Heart Institute in Salt Lake City with three physicians who treat the advanced practice providers (APPs) like colleagues, Le said.

“Certainly, the comment has always come back, ‘I’m so glad we have you guys, because I could see myself working another 15 years,’” said Le, who teams with two physicians older than 60 and one older than 70. “We offload them and provide that extra concierge care, almost, to our patients because we’re able to do things that (physicians) would love to do, but we have the energy so we do it.”

Better utilization of APPs may soon become a nationwide necessity. MedAxiom’s annual Cardiovascular Provider Compensation & Production survey revealed 45 percent of American cardiologists are 56 or older and 20 percent are 61 or older.

The alliance of Le and his physician partners—in which the APPs successfully alleviate much of the workload—could be an important blueprint as aging cardiologists confront physician slowdown and retirement.

It’s also a mutually beneficial relationship, according to the MedAxiom survey. Of the 27 reporting groups with the highest APP ratios, 18 showed total physician compensation above the median and 12 were above the 75th percentile.

“The analysis clearly indicates that greater utilization of PAs increases patient access and improves work Relative Value Unit (wRVU) productivity while also increasing physician compensation,” L. Gail Curtis, president and chair of the American Academy of Physician Assistants, said in a statement.

“It highlights the strong correlation that medical practices with a higher ratio of PAs are among the top revenue producing practices. This shows that PAs contribute to an effective team by handling vital services such as post-op care which in turn allows physicians to see additional patients and/or perform procedures. These results are only possible when a PA is able to practice at the top of their education and experience.”

Le said Intermountain Heart Institute has a hypertension clinic run mostly by APPs under the supervision of a physician specialist. He can envision clinics in the same mold to treat hyperlipidemia or discharged heart failure patients—a group that requires a disproportionately high number of follow-up visits.

“These are things that you have the coach, the MD on the team, helping the high-level players on the field,” Le said. “We can do those things and it can be APP-run and that will, I think, make it more efficient.”

It could also make care more cost-effective, said Joel Sauer, vice president of MedAxiom Consulting and the author of the compensation report. The average full-time equivalent cardiologist earns about $580,000, compared to $98,550 for cardiology APPs.

And yet there are no standards in cardiovascular medicine on how best to use APPs. There are barriers, Sauer said, such as compensation models that require a physician to see a patient to collect the work RVUs after an APP has done the “heavy lifting.”

“This doesn’t remove the burden completely from the physician at the end of the day, and we would argue that’s not an efficient way to utilize APPs,” Sauer said. “But it’s expected and we could predict it because of the (compensation) arrangement.”

Le, co-chair of the physician assistants committee of the American College of Cardiology (ACC), said the ACC is working on guidelines for PAs in general cardiology. Expected to be released next year, the guidelines will cover core competencies, evaluation tools and expectations for PAs. The ACC plans to provide guidelines for cardiovascular subspecialties as well, Le said.

Sauer said healthcare consultants are also interested in establishing standards for APP use.

“I would say we definitely have to do a more effective and efficient job at utilizing these resources, because they’re necessary. They help us truly lower the cost of care,” he said.

Just as importantly, APPs may help bridge the gap between an aging physician workforce and the next generation of cardiologists.

“We can certainly eke out another decade in those physicians and give time, hopefully, for the new trainees to get out and now work with experienced APPs—bring them into the fold so they now know how to more efficiently use APPs in their teams,” Le said. “Like it or not, the circumstances I think will make for an interesting expansion of APPs’ roles going forward because of this age issue.”