Study Reveals Physician-Led Care Teams Outperform Nonphysician Providers in Cost and Quality

An analysis of cost data within the South Mississippi system’s Accountable Care Organization (ACO) uncovered that care administered by nonphysician providers managing their own patient panels was pricier than care delivered by physicians. This revelation prompted leaders at Hattiesburg Clinic to revamp the clinic’s care model and publish their discoveries. Initially employing 26 physician assistants (PAs) and nurse practitioners (NPs) in 2005, the clinic now boasts 118 such providers. Alongside certified registered nurse anesthetists and optometrists, these 186 nonphysician providers constitute what is termed as advanced practice providers (APPs) at the clinic.

According to a study titled “Targeting Value-based Care with Physician-led Care Teams,” published in the Journal of the Mississippi State Medical Association, Hattiesburg Clinic made strategic decisions over the past 15 years to expand their care teams by integrating advanced practice providers, primarily due to shortages in primary care physicians. The study highlights, “Focusing specifically on primary care, because our shortage of physicians there was so dire—due to retirements, massive panel sizes and lack of medical students entering primary care residencies—we allowed APPs to function with separate primary care panels, side by side with their collaborating physicians.”

However, upon retrospect and analysis of extensive internal data, encompassing cost data from over 33,000 Medicare-enrolled patients, the findings were consistent and unequivocal: the integration of advanced practice providers with independent panels under physician supervision fell short of meeting primary care objectives in providing patients with an equivalent value-based experience.

Hattiesburg Clinic, a private multispecialty clinic with over 300 physicians, holds membership in the AMA Health System Program. Its ACO earned the top rank in quality within its cohort in 2016 and 2017 among 471 other participants and has garnered recognition from the Centers for Medicare & Medicaid Services (CMS) for delivering high-quality care at a low cost.

According to CMS cost data spanning from 2017 to 2019, for Medicare patients excluding those with end-stage renal disease or in nursing homes, per-member, per-month spending was $43 higher for patients under the care of nonphysician primary health professionals compared to physicians. This contrast could translate to an annual increase of $10.3 million in expenditure if all patients were overseen by APPs. Following risk-adjustment for patient complexity, the disparity amounted to $119 per member, per month, equating to an annual difference of $28.5 million.

Dr. Bryan N. Batson, an internist and CEO of Hattiesburg Clinic, a co-author of the study, stated, “We didn’t set out to do a scientific study per se. This was really an observational experience that used data to help us drive decision-making going forward.” He added, “This was us looking in the mirror to say: As we’re becoming more advanced in value-based care, how do we do it better?”

Initially, upon receiving the initial CMS reports on care costs, the focus was on identifying the highest-cost physicians and collaborating with them to curtail spending. Dr. Batson mentioned, “When we got the claims data for the first time, one of the first things we did was to look at who our highest-cost providers were.” He further expressed surprise at the stark disparities in costs between physicians and advanced practice providers at the high-cost end of the spectrum.

Further analysis revealed that the additional costs were attributed to a combination of factors, including increased test ordering, more specialist referrals, and heightened emergency department utilization. Dr. John M. Fitzpatrick, a nephrologist and president of Hattiesburg Clinic, noted that “four of the five top highest-cost providers were nurse practitioners,” prompting a comprehensive analysis of the entire population and leading to the findings presented in the study.

Patients whose primary care provider (PCP) was a nonphysician exhibited higher rates of emergency department visits compared to those without a PCP. Moreover, physicians outperformed nonphysicians on nine out of ten quality measures, particularly excelling in flu and pneumococcal vaccination rates, despite these being considered manageable by nonphysician staff. Physicians also attained higher average patient satisfaction scores across six domains measured by Press Ganey.

Acknowledging the invaluable contribution of nurse practitioners and physician assistants to the care team, the study emphasized that they should not operate independently based on a wealth of information and experiences in collaborative relationships with physicians.

Driven by data insights, Hattiesburg Clinic revamped its care model, ensuring that all patients consult with a physician as their primary care provider and no patient exclusively sees a nonphysician. Dr. Batson elaborated, “We had a one-year transition period leading up to that, so that the nurse practitioners could tell their patients that beginning Jan. 1, 2021, you’re going to have alternating visits with me and my supervising physician, but your PCP will officially be the physician.”

Telemedicine has played a pivotal role in facilitating the implementation of the new care-team model, enhancing healthcare delivery in rural settings. Dr. Batson highlighted, “It really changes the way that we’re able to deliver health care in a rural setting—in a positive way—such that a clinic may be able to be staffed some days with an APP, some days with a physician, but in those days that the APP is the lead there, there’s the availability of telemedicine to support more advanced health care delivery.”

The American Medical Association (AMA) asserts that patients deserve care led by physicians, advocating against scope-of-practice expansions that jeopardize patient safety. Dr. Fitzpatrick emphasized the importance of credible, Mississippi-based data in influencing legislative decisions, noting the commendable efforts of legislators in prioritizing patient well-being while devising strategies to reduce healthcare costs.

Both doctors expressed optimism that their experience would encourage other ACOs to conduct similar analyses, potentially stimulating discussions with other organizations nationwide or attracting the attention of CMS.

“We would encourage other organizations to look at their data—like we did—to help them refine their care teams in ways that can improve health care,” Dr. Batson concluded. “That’s what this was all about: trying to improve health care of our patients and for the system.”