Letter: Palliative Medicine Advanced Practice Provider Productivity in Academic Medical Centers

Dear Editor:

As demand for high-quality palliative care (PC) grows, optimizing advanced practice provider (APP) productivity is crucial for sustainable health care while maintaining patient-centered care. PC teams create value beyond Relative Value Units (RVU) by improving patient experience and reducing avoidable readmissions. However, PC teams must ensure productivity within an RVU fee-for-service model without compromising quality.

While some organizations have internal benchmarks based on their specific patient population and practice setting, there is a lack of standardized, widely accepted benchmarks for PC APP productivity across different health care systems. ¹ The Department of Medicine at our institution sets a minimum non-PC APP encounter target of 2760 annually per full-time equivalent, or 24 encounters per week over 46 weeks, accounting for a six-month ramp-up for new hires across the department. This target excludes PC APPs given the nature of prolonged care visits. This framework aligns with academic medical center financial constraints, as APP services should strive to but often do not fully cover their costs. Outside the PC Division, missed targets convert to negative RVUs, distributed among compensation plan-eligible faculty receiving incentive pay for exceeding targets. This practice underscores the need to balance productivity expectations with the complex care APPs provide.

Comparative PC productivity analysis shows APPs achieve 77% of physician productivity benchmarks, with reimbursement at 85% of physician rates, per an informal unpublished email survey of academic medical center leaders from Duke. For PC physicians, annual average RVUs ranged between 2100 and 2400 as reported by MGMA and an AAHPM survey. ² A 2012 MD Anderson study found PC physicians averaged 6.2 encounters per day, while APPs managed 4.0 encounters per day working 190 shifts/year. Therefore, APPs generally see fewer patients per shift than physicians, likely in part due to their need for physician backup support for certain complex cases. ³ The Center to Advance Palliative Care benchmarks suggest APPs working in the inpatient setting handle 6–8 daily encounters, including an average of 2 new and 4–6 follow-ups, though not specific to academic medicine. ⁴ At our institution, the PC APP target is six encounters per each 10-hour shift.

While patient volume is a key metric, APPs contribute significantly to non-billable but high-value activities, including care coordination, staff and educational meetings, quality improvement, bereavement services, and interdisciplinary trainee education. Several factors impact productivity at academic centers, including mandatory meetings, hospital site travel, and complex patient cases inherent to quaternary care centers. At the University of Florida, for instance, daily responsibilities for all team members extend well beyond patient encounters, necessitating flexible productivity measures.

To enhance APP productivity without sacrificing quality, CAPC recommends optimizing team efficiency, tailoring follow-up schedules, improving symptom management, refining billing and coding, and leveraging documentation efficiency with dictation and, hopefully, AI in the future. Thoughtful workflow improvements, such as administrative triage support, can reduce administrative burdens, allowing APPs to focus on patient care. Aligning encounter targets with both billable and non-billable contributions ensures APPs remain integral to high-functioning PC teams.

In conclusion, while productivity metrics are necessary for financial sustainability, APPs play a multifaceted role in PC. Expectations should balance encounter volume with essential non-billable functions that foster high-quality care. Academic institutions must refine productivity measurement to ensure palliative care teams remain both financially viable and clinically effective.