UC Irvine

Background Physician assistants/associates (PAs) and nurse practitioners (NPs), together known as advanced practice providers (APPs), practice with a high degree of clinical autonomy and professional respect, and play a critical role in team-based care. Aligning APP care delivery models to promote top-of-license practice is essential to improving ambulatory capacity and bottom-line expectations at academic medical centers (AMCs) in the 21^st century and beyond. This administrative quality improvement study assesses the downstream impact of restructuring our APP care models to promote independent practice sessions. Methods Our AMC formed an APP oversight committee in April 2021 to optimize the ambulatory care model, realign APP funds flow, and set performance standards to which PAs and NPs are being held accountable. We conducted a one-year retrospective review of internal data from July 2021 to June 30, 2022. Certified registered nurse anesthetists (CRNAs) were excluded from this analysis. Results  APP productivity year-over-year (YOY) aggregate data across all School of Medicine (SOM) departments, demonstrated a 53% increase in work relative value units (wRVUs), 84% increase in payments, and 79% increase in charges from the prior fiscal year (July to June). Regarding APP ambulatory clinical effort (YOY), there was a 45% increase in the number of APP completed visits (92% return patient visits, 8% new visits). An increase in APP productivity did not adversely impact patient satisfaction, physician-generated wRVUs, or delay programmatic expansion efforts. Lastly, in a recent engagement survey, the majority of PA and NP respondents (78%) reported working either "most of the time" or "always" at the top-of-license. Conclusion This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance. While we acknowledge, there are differences between healthcare institutions in terms of care delivery and compensation models, organizational culture, and distribution of clinical resources, there remains an opportunity among hospitals and health systems to optimize this critical and essential APP workforce.