Advance Practice Provider (APP) Compensation Models: Promoting Team Based Care Wayne M. Hartley, Vice President AMGA Consulting Services 1
Presentation Overview AMGA Survey Overview and Demographics APP Survey Data (with select physician comparisons) How NP/PAs are paid What NP/PAs are paid APP Compensation Models Questions and Comments 2
AMGA Survey Overview and Demographics 3
Survey Overview 28 th Annual AMGA Provider Compensation Survey Data on clinical compensation, work RVUs, net collections, gross productivity, comp to productivity ratios, visits, and benefits 134 Physician Specialties 27 Other Provider Specialties NP and PA breakdowns 4
All Participants / All Positions 5
North Region 6
South Region 7
East Region 8
West Region 9
Demographics 251 groups 73,006 providers Average group size 290 providers (up from 255) About 70% were AMGA member organizations Carved out administrative compensation and financial elements 10
APP Survey Data (with Select Physician Comparisons) 11
NP/PA Clinical Work Hours NP & PA Clinical Hours (n=131) 25 to 30 hours per week, 2% 41 to 45 hours per week, 4% 31 to 35 hours per week, 22% 36 to 40 hours per week, 73% 12
Base Salary Determinants NP & PA Base Salary Determinants 2015 (n=98) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Market salary data 81% Percentage of last year's salary Defined salary range 36% 33% Percent increase based on budget 14% Percentage of concurent production Panel size of work units 4% 8% 13
Production Models NP/PA 2015 Physician 14
Incentive Pay Prevalence Physician 15
Incentive Pay Prevalence NP/PA NP/PA Other Incentive and Discretionary Compensation 2015 (n=44) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Patient Satisfaction 45% The top categories are essentially the same for physicians and APPs. Individual Financial Goals SCIP/Core/ACO Measures Access Other Incentives HEDIS 16% 14% 11% 23% 45% The prevalence of incentives across these categories tends to be lower for NPs/PAs. Peer Chart Review Citizenship Dept RVU Goals Market Adjustments Dept Budget / Goals 11% 9% 9% 7% 5% Cost Containment 5% Controlling Outside Referrals 5% Accessibility/Availability 5% Other Discretionary 5% Seniority 2% Ancillary 2% 16
Incentive Pay 2015 Survey 17
Primary Care by Region Physicians 18
NPs by Region by Specialty Grouping 19
Nurse Practitioner and Physician Assistant Subspecialties Total Compensation (2015) Number of Number of Group Physician 90th 80th 20th Standard Specialty Responses Responses Percentile Percentile Median Percentile Mean Deviation Nurse Practitioner - Medical Specialty 114 1,567 128,297 116,729 100,855 88,659 104,532 26,074 Cardiology Cath Lab (Invasive Interventional) 7 23 111,000 99,710 91,923 86,057 92,200 17,697 Cardiology General 36 162 127,604 118,151 101,093 90,281 106,806 24,428 Dermatology 19 28 180,193 158,503 128,002 96,244 135,887 65,073 Endocrinology 24 59 118,309 105,806 95,549 82,608 98,018 24,119 Gastroenterology 21 50 116,287 104,431 96,284 82,806 96,327 13,706 Hematology and Medical Oncology 17 58 124,455 115,963 96,517 86,754 105,273 34,541 Hospitalist Internal Medicine 15 46 134,731 129,974 106,539 91,793 107,710 30,068 Nephrology Only 7 10 130,812 118,749 97,912 90,457 109,426 31,816 Neurology 21 42 129,650 113,520 102,487 93,480 111,395 34,773 Occupational/Environmental Medicine 9 17 138,657 119,896 100,035 84,871 110,351 36,306 Palliative Care 14 49 112,643 105,287 96,571 88,234 97,750 22,948 Physical Medicine and Rehabilitation 12 20 115,194 111,438 92,269 81,273 94,490 18,811 Pain Management Non-Anesthesiology 7 11 136,744 127,793 107,284 94,014 114,375 21,576 Psychiatry 12 25 148,814 126,115 104,351 91,120 111,076 38,120 Pulmonary Disease (Without Critical Care) 13 27 115,148 106,607 94,701 77,813 92,690 26,180 Pulmonary Disease (With Critical Care) 8 34 117,429 112,375 98,735 74,675 95,396 22,276 Wound Care/Hyperbaric 8 20 124,506 114,524 100,799 90,407 104,179 14,917 Nurse Practitioner Primary Care 133 2,566 141,136 122,292 100,780 86,715 106,530 31,075 Family Medicine 58 514 147,947 120,708 99,048 85,510 106,779 36,465 Family Medicine Branch 7 75 136,111 119,613 103,370 89,250 107,256 25,195 Internal Medicine 50 254 140,763 123,397 101,172 87,997 108,577 31,749 Pediatrics and Adolescent General 40 153 148,608 138,209 104,009 87,260 113,232 35,831 Urgent Care 26 98 134,153 116,362 98,099 85,772 103,140 34,750 Nurse Practitioner Surgical Specialty 90 732 139,622 124,800 102,981 88,989 107,844 28,748 Pediatrics and Adolescent Neonatology 9 50 138,840 132,556 115,000 104,803 117,697 18,554 OB/GYN Obstetrics 9 26 141,003 126,078 103,203 90,046 113,014 42,959 OB/GYN Maternal Fetal Medicine/Perinatology 5 11 113,092 112,658 104,333 95,189 108,138 25,260 Cardiac/Thoracic Surgery 6 14 152,454 144,405 114,899 106,107 124,611 27,953 Cardiovascular Surgery 6 11 125,092 124,967 110,618 102,233 110,684 16,233 Emergency Medicine 7 23 128,294 122,395 113,000 104,071 115,919 20,843 General Surgery 14 44 127,123 112,119 94,673 88,397 99,537 20,205 OB/GYN General 35 159 147,659 132,714 104,431 88,794 110,174 28,850 Neurological Surgery 16 38 130,440 123,642 102,620 93,038 109,726 25,301 Orthopedic Surgery 11 27 225,442 168,773 110,714 90,211 130,731 59,506 Otolaryngology 12 12 120,530 102,689 89,636 80,943 91,291 22,748 Urology 16 25 126,620 111,442 100,376 82,789 99,821 17,687 Vascular Surgery 9 11 122,081 20 121,186 98,002 86,198 110,851 47,139 National Data
Nurse Practitioner and Physician Assistant Subspecialties Work RVUs (2015) Number of Number of Group Physician 90th 80th 20th Standard Specialty Responses Responses Percentile Percentile Median Percentile Mean Deviation Nurse Practitioner - Medical Specialty 93 946 3,814 3,155 2,084 1,112 2,263 1,306 Cardiology Cath Lab (Invasive Interventional) 6 13 3,040 2,727 2,548 1,095 2,183 1,161 Cardiology General 28 88 3,059 2,574 1,661 984 1,947 1,187 Dermatology 17 22 6,840 5,578 4,798 3,525 4,946 1,836 Endocrinology 20 42 3,424 3,014 2,435 1,520 2,367 1,097 Gastroenterology 18 34 2,462 2,123 1,611 1,136 1,623 632 Hematology and Medical Oncology 11 28 2,581 2,327 1,754 993 1,732 700 Hospitalist Internal Medicine 11 33 3,322 3,011 1,766 727 1,931 1,079 Nephrology Only 3 6 *** *** *** *** *** *** Neurology 15 24 3,199 3,158 2,339 1,350 2,319 892 Occupational/Environmental Medicine 5 9 *** *** *** *** *** *** Palliative Care 10 37 2,834 2,528 2,127 1,356 2,027 665 Physical Medicine and Rehabilitation 7 8 *** *** *** *** *** *** Pain Management Non-Anesthesiology 7 10 7,137 4,007 2,874 2,487 3,579 2,391 Psychiatry 11 16 4,249 3,829 2,852 1,481 2,767 1,238 Pulmonary Disease (Without Critical Care) 7 13 3,094 2,857 2,248 1,345 2,163 816 Pulmonary Disease (With Critical Care) 7 25 4,572 3,078 1,653 949 2,129 1,451 Wound Care/Hyperbaric 7 8 *** *** *** *** *** *** Nurse Practitioner Primary Care 111 1,794 4,939 4,383 3,327 2,203 3,332 1,320 Family Medicine 51 349 4,652 4,191 3,322 2,260 3,287 1,221 Family Medicine Branch 7 75 5,553 5,119 3,786 2,155 3,602 1,539 Internal Medicine 43 192 4,529 3,949 3,041 2,178 3,125 1,282 Pediatrics and Adolescent General 34 122 5,450 4,974 3,952 3,184 4,063 1,234 Urgent Care 23 76 5,432 4,706 3,693 2,169 3,655 1,361 Nurse Practitioner Surgical Specialty 67 422 4,222 3,489 2,174 1,137 2,407 1,422 Pediatrics and Adolescent Neonatology 5 17 3,609 2,723 1,876 934 2,057 1,264 OB/GYN Obstetrics 8 23 3,987 3,772 2,889 2,199 2,912 905 OB/GYN Maternal Fetal Medicine/Perinatology 2 7 *** *** *** *** *** *** Cardiac/Thoracic Surgery 3 8 *** *** *** *** *** *** Cardiovascular Surgery 3 5 *** *** *** *** *** *** Emergency Medicine 5 18 6,247 5,385 2,990 2,404 3,716 2,166 General Surgery 9 16 2,399 2,230 1,478 1,217 1,604 579 OB/GYN General 30 112 4,761 4,038 3,064 2,180 3,209 1,231 Neurological Surgery 9 13 2,586 2,456 2,104 1,039 1,762 775 Orthopedic Surgery 7 11 3,137 3,128 2,672 1,454 2,252 911 Otolaryngology 10 10 4,321 3,457 2,633 2,162 2,733 1,134 Urology 11 15 3,766 3,616 21 2,188 1,790 2,633 1,017 Vascular Surgery 7 9 *** *** *** *** *** *** National Data From our field experience, we know that RVUbased plans are less common for NPs and PAs. However, more and more groups are basing a component of their pay on production to promote efficiency and access. Data show where production is more of an emphasis.
PAs by Region by Specialty Grouping 22
Number of Number of Group Physician 90th 80th 20th Standard Specialty Responses Responses Percentile Percentile Median Percentile Mean Deviation Physician Assistant Medical 94 1,011 136,571 123,588 102,804 88,650 107,667 29,672 Cardiology General 26 90 127,398 122,864 103,172 89,999 105,228 16,880 Dermatology 20 35 232,362 188,374 128,175 105,474 153,371 74,917 Endocrinology 9 11 118,116 108,576 94,952 87,900 106,219 39,173 Gastroenterology 16 30 138,387 121,108 100,281 87,275 106,358 22,794 Hematology and Medical Oncology 6 14 130,261 112,512 95,917 89,413 106,917 32,437 Hospitalist Internal Medicine 10 90 122,798 115,411 99,921 87,827 97,709 23,584 Neurology 17 44 120,828 117,472 98,422 86,767 103,458 30,428 Occupational/Environmental Medicine 8 28 146,452 124,871 107,004 97,372 112,378 23,884 Orthopedic Medical 6 12 156,569 145,117 105,037 99,657 110,226 33,266 Physical Medicine and Rehabilitation 11 20 136,213 121,836 103,646 86,400 107,375 36,242 Pulmonary Disease (Without Critical Care) 9 11 112,475 108,692 86,121 82,605 98,817 43,160 Pulmonary Disease (With Critical Care) 7 24 135,817 124,934 103,510 94,173 108,473 19,392 Physician Assistant Primary Care 104 1,443 151,565 130,333 105,060 88,243 111,521 32,480 Family Medicine 41 321 172,980 141,184 106,959 89,349 117,106 40,744 Family Medicine Branch 6 41 124,782 115,544 101,721 92,694 105,307 15,891 Internal Medicine 22 73 136,392 116,459 102,425 86,860 106,776 30,189 Pediatrics and Adolescent General 16 30 159,862 141,386 105,844 88,660 114,937 34,524 Urgent Care 27 155 188,427 144,553 104,548 94,264 120,084 37,695 Physician Assistant Surgical 99 1,151 149,881 133,952 113,733 96,193 118,557 32,499 Cardiac/Thoracic Surgery 9 27 155,852 152,102 138,247 124,166 140,401 24,615 Cardiovascular Surgery 8 23 302,317 153,359 130,821 113,225 156,122 71,731 Emergency Medicine 8 65 130,423 121,048 105,435 97,853 109,792 15,823 General Surgery 28 105 136,395 126,318 109,925 94,558 111,632 23,154 OB/GYN General 19 42 133,560 125,596 107,669 94,236 109,258 18,857 Neurological Surgery 16 35 150,959 136,443 120,372 99,120 122,772 30,770 Orthopedic Surgery 36 197 174,083 139,021 121,000 100,338 128,957 41,430 Otolaryngology 15 24 157,616 137,451 121,848 100,119 121,452 28,234 Plastic and Reconstruction 11 14 178,690 149,722 121,456 99,262 126,178 32,521 Urology 24 49 142,777 130,671 103,356 91,976 114,075 38,464 Vascular Surgery 11 19 159,622 129,604 106,750 92,872 124,482 55,916 National Data Nurse Practitioner and Physician Assistant Subspecialties Total Compensation (2015) 23
Nurse Practitioner and Physician Assistant Subspecialties Work RVUs (2015) Number of Number of Group Physician 90th 80th 20th Standard Specialty Responses Responses Percentile Percentile Median Percentile Mean Deviation Physician Assistant Medical 72 567 4,382 3,526 2,240 1,282 2,517 1,476 Cardiology General 18 47 2,650 2,321 1,764 1,135 1,812 815 Dermatology 19 34 8,821 6,716 4,984 4,030 5,540 2,160 Endocrinology 5 5 *** *** *** *** *** *** Gastroenterology 11 17 4,260 3,895 3,243 2,048 3,105 1,223 Hematology and Medical Oncology 4 8 *** *** *** *** *** *** Hospitalist Internal Medicine 6 49 3,404 3,205 2,542 1,608 2,424 911 Neurology 13 36 3,639 3,127 2,361 1,860 2,476 778 Occupational/Environmental Medicine 6 12 5,244 5,004 4,365 3,096 3,942 1,567 Orthopedic Medical 5 8 *** *** *** *** *** *** Physical Medicine and Rehabilitation 5 7 *** *** *** *** *** *** Pulmonary Disease (Without Critical Care) 3 3 *** *** *** *** *** *** Pulmonary Disease (With Critical Care) 6 15 3,171 2,542 1,382 838 1,614 1,013 Physician Assistant Primary Care 83 990 5,385 4,735 3,733 2,615 3,714 1,386 Family Medicine 37 255 5,489 4,793 3,652 2,446 3,657 1,447 Family Medicine Branch 6 41 4,730 4,283 3,672 2,329 3,428 1,179 Internal Medicine 18 56 4,799 4,126 2,885 1,604 3,004 1,404 Pediatrics and Adolescent General 12 23 6,233 5,862 4,228 3,477 4,428 1,528 Urgent Care 23 105 6,181 5,361 4,364 3,696 4,517 1,361 Again, you can see the areas where RVU production and RVU reporting tend to be higher. Physician Assistant Surgical 78 771 4,365 3,376 1,930 1,006 2,331 1,660 Cardiac/Thoracic Surgery 8 23 1,726 1,446 877 614 1,228 912 Cardiovascular Surgery 6 16 10,314 5,856 2,364 1,588 3,788 3,516 Emergency Medicine 5 37 7,821 6,708 4,672 3,436 4,988 2,066 General Surgery 25 66 2,781 2,116 1,252 795 1,603 1,113 OB/GYN General 16 34 4,043 3,598 2,603 1,802 2,710 1,050 Neurological Surgery 14 33 3,723 2,902 1,760 913 2,188 1,746 Orthopedic Surgery 32 131 4,508 3,521 2,004 1,035 2,455 1,737 Otolaryngology 12 19 5,099 4,501 2,823 1,511 3,057 1,507 Plastic and Reconstruction 8 10 2,759 1,645 939 641 1,377 1,155 Urology 18 31 3,938 3,440 2,384 1,335 2,461 1,121 Vascular Surgery 7 12 4,516 2,154 1,243 811 1,793 1,487 National Data 24
Panel Size Data 2015 Survey Panel Size Specialty Number of Group Responses Number of Incumbent Responses 25 th Percentile 50 th Percentile 75 th Percentile Mean Std. Dev. Family Medicine 35 1221 1,434 1,866 2,325 1,896 728 Family Medicine With Obstetrics 6 24 1,255 1,575 2,042 1,661 615 Internal Medicine 33 964 1,468 1,938 2,408 1,942 724 Internal Medicine Office Only Pediatrics and Adolescent General Nurse Practitioner Primary Care Physician Assistant Primary Care 6 38 1,213 1,542 1,892 1,569 536 31 589 1,572 2,044 2,464 2,045 731 13 218 519 943 1,372 1,003 627 8 45 462 1,095 1,812 1,130 758 25
APP Compensation Models 26
APP Compensation Models Even though there is great emphasis on value based models and increased use of APPs, their compensation models have evolved slowly In many organizations, APPs were historically compensated on traditional professional staff or nursing wage scales (as opposed to physician type compensation formulas) Today, they are primarily salary based positions that have evolved to include some production and quality incentives 27
APP Compensation Models In our field work, we receive many questions about more contemporary models It is important to have a transitional approach and to think through what you are trying to accomplish Some models to consider include: Salary plus production tiers Salary plus production multiplier Salary plus production and quality incentive 28
Salary Plus Production Tiers If your intent is to provide some incentive for increased productivity or access but to prevent competition with other providers (physicians), this approach may be helpful Consider three or four tiers and work with market data (for example): Tier 1 (P25 production): Base plus $3,000 Tier 2 (P50 production): Base plus $6,000 Tier 3 (P75 production): Base plus $9,000 Tier 4 (P90 production): Base plus $12,000 These tiers may vary by specialty and by your base salary starting point (compensation philosophy). Consider total market compensation; base salary needs to be a reasonable starting point and you get the incentive for the highest tier achieved 29
Salary Plus Production Tiers For example, you could have a base salary for NP Family Medicine of $98,000 If production is 3,300 wrvu, it approximates median from the previous slide for an incentive of $6,000 Total cash compensation would be $104,000 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner Primary Care 141,136 122,292 100,780 86,715 Family Medicine 147,947 120,708 99,048 85,510 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner Primary Care 4,939 4,383 3,327 2,203 Family Medicine 4,652 4,191 3,322 2,260 30
Salary Plus Production Multiplier This approach is similar except that there is a small per wrvu payment Consider a base of $95,000 and $4 per wrvu with production of 3,300 wrvu Then, compensation is $95,000 + [$4 x 3,300 = $13,200]= $108,200 This approach may work well for APPs with their own panels where you are providing incentives for production and access 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner Primary Care 141,136 122,292 100,780 86,715 Family Medicine 147,947 120,708 99,048 85,510 Model out the impacts before you finalize your formulas!!! 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner Primary Care 4,939 4,383 3,327 2,203 Family Medicine 4,652 4,191 3,322 2,260 31
Salary Plus Production and Quality Incentive In team based care settings, you may wish to evolve to more sophisticated models similar to physician pay formulas Again, think about what you are trying to accomplish with the model Consider, for example, the continuum of care for chronic populations like heart failure and cardiology NP/PA roles where you want to promote: Quality care provision Patient education Coordination of inpatient/outpatient/home based care [Notice that wrvu productivity hasn t been mentioned yet ] 32
Salary Plus Production and Quality Incentive In this model, quality and production are included With several APP specialties, market data is limited but it can be directionally helpful Let s develop a model that is predominantly base salary, with a production incentive and 10% quality incentive 33
Salary Plus Production and Quality Incentive 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner - Medical Specialty 128,297 116,729 100,855 88,659 Cardiology General 127,604 118,151 101,093 90,281 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner - Medical Specialty 3,814 3,155 2,084 1,112 Cardiology General 3,059 2,574 1,661 984 The market compensation data includes base, incentive and other compensation As dollars are shifted toward incentives, base salary may need to be lowered (or held in place) For this example, you might choose the following: Base Salary: Approximates median Production Tiers: P25=$2K, P50=$4K, P75 or higher = $6K WRVU may not be the focus and you may wish to avoid NP/PA competition with MDs for WRVU. Quality Opportunity: 10% of median compensation for specialty ($10,109) or 10% of actual base salary 34
Salary Plus Production and Quality Incentive 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner - Medical Specialty 128,297 116,729 100,855 88,659 Cardiology General 127,604 118,151 101,093 90,281 90th 80th 20th Specialty Percentile Percentile Median Percentile Nurse Practitioner - Medical Specialty 3,814 3,155 2,084 1,112 Cardiology General 3,059 2,574 1,661 984 So if there is a base of $98,000, wrvu production of 2,200, and 10% quality incentive: Base Salary: $ 98,000 Production Tiers: $ 4,000 (P50=$4K, P75 or higher = $6K) Quality Opportunity (10%)*: $ 10,109 Total Opportunity: $112,109 *Paid based on goal achievement. You might decide not to have a wrvu component and make future increases to the quality opportunity. 35
APP Compensation Models Historically, many organizations minimized the role of wrvu productivity on APP compensation In cases where APPs work independently (carry large panels), production and access may be areas for incentives When the focus is on care improvement and quality outcomes, it may be advisable to limit the role of production and focus on care coordination and quality Quality goals may be the same, or supplemental to, the physician goals (e.g., cardiology Core Measures and related goals) Like with physicians, new pay approaches cannot always be additive; you may need to switch around elements of the compensation plan Production based models are possible but market data on production levels and conversion factors are limited 36
Questions and Comments Wayne Hartley (612) 615 1098 whartley@amgaconsulting.com 37