Unlocking the Power of the Physician Enterprise
In Episode 11 of the “Achieving Health” podcast, host Chad Mulvany shares the latest healthcare policy and legislative updates for the week of November 2, 2025. He’s then joined by Randy Biernat, partner in the Healthcare Consulting practice at Forvis Mazars. They discuss the role of the physician enterprise in improving access and explore innovative strategies and operating models to help improve performance and physician alignment.
Transcript
CHAD MULVANY
On today’s episode of Achieving Health, I’ve got the latest policy and legislative updates from Washington, D.C., for the week of November 2nd, 2025. Then I’ll be joined by my colleague Randy Biernat, partner in the healthcare consulting practice at Forvis Mazars. We’ll explore innovative strategies and operating models that help health systems better manage and align their physician enterprises. Stay tuned for a fascinating discussion.
ANNOUNCER
This is Achieving Health, a podcast from Forvis Mazars, where we delve into the topics that matter most to healthcare organizations across the continuum of care. Our goal is to help you navigate the dynamic healthcare landscape and achieve health at your organization. Here’s your host, Chad Mulvany.
CHAD MULVANY
Welcome to Achieving Health. I’m Chad Mulvany, director in the healthcare practice at Forvis Mazars. Thank you for joining me.
We’ll begin today with our Washington Watch segment, where I share updates on the most recent actions of federal policymakers and their anticipated impact on healthcare providers and payers. Today’s Washington Watch reflects information as of 11:00 Eastern Time on Friday, October 31st. My comments on these discussions are based on what’s being reported by the D.C. trade press at the time of the conversation, mixed with a lot of judgment about where things may go, based on my experience in D.C. So, today’s remarks reflect information as of this moment and will change.
As far as our agenda is concerned today, we are still in the middle of a partial federal government shutdown. The Senate failed to pass the House CR for the 13th time this week. While it has adjourned for this week, meaning that we will likely set a record for federal government shutdowns or partial shutdowns, there may be some movement towards a resolution.
And speaking of shutdowns, if the enhanced ACA subsidies were to expire, analysis projects that between three and four million people could be affected, with young adults facing the steepest rise in insurance rates, up to 25% among those aged 19 to 34. The Urban Institute estimates that the expiration of the enhanced subsidies would increase uncompensated care by $7.7 billion. And so we’ll dig into those numbers in the episode.
Moving to 340B, on Thursday last week, the Senate Health, Education, Labor and Pensions Committee held a hearing on the program. Senators from both parties voiced frustration over the lack of progress on reforming 340B and then earlier this week, we saw HRSA release, or announce, the participants in the rebate model, and we’ll cover both of those items.
President Trump last week also told GOP senators he, quote unquote, “got everything he wanted‚” in the One Big Beautiful Bill Act and is uninterested in another reconciliation bill. While this could temporarily reduce the threat of additional significant legislative cuts to providers, there could possibly be something in the works from Republicans to attempt to make healthcare costs more affordable.
And then finally, we’ll close out by talking about challenging payer-provider relations. Public contract disputes between health plans and providers are rising sharply as both sides grapple with mounting medical cost pressures. As providers enter into these more challenging negotiations, they’ll want to use the plan transparency files to support their request for increased rates.
So with that, let’s get into it.
In terms of our shutdown update, the Senate failed to pass the House C.R. for the 13th time this week. While, again, it has adjourned for the week, there may be some movement towards resolution. It seems this is driven in part by increasing delays at airports due to air traffic controllers calling out. And I’ll note that Reagan National on Thursday, as senators were trying to fly out, was delayed by 90 minutes due to air traffic controller workforce issues.
Also, you’ve got the pending lapse in SNAP, Supplemental Nutrition Assistance Program, funding, which could affect up to 40 million Americans and the economic impacts of federal workers missing yet another paycheck. There is thought that this may be resolved either late next week, November 3rd, or the week of November 10th, although that is preliminary and certainly subject to change. Given that the current House-passed CR only extends government funding for fed fiscal ‘26 through November 21st, there are rumors the House may be back in session next week to pass a CR with a longer duration, possibly punting the need to finalize a federal budget into next year.
Further concerns about the SNAP impact on beneficiaries and the broader economy may drive Senate Dems to provide the necessary votes then later next week, or I guess now this week, if you’re listening to this, to pass a continuing resolution that reopens the government in exchange for potentially a promise to vote on the enhanced exchange subsidies.
Although, again, this is all very tentative and somewhat rumored. And one of the questions that I have is, if the CR that is passed expires early next year, it’s unclear to me what the forcing mechanism is to extend the enhanced exchange subsidies, unless there are other changes to the program, like extending the open enrollment window for the federally facilitated exchanges.
In terms of a couple of items that we continue to watch: the extenders. So, reports related to the new CR suggest that the healthcare extenders that providers care about will be included in the package. So therefore, I’m optimistic that again, we’ll see an extension of the delay of the ACA Medicaid DSH cuts, an extension of the Medicare dependent hospital and low volume adjustment programs, the COVID-era telehealth waivers, community health center funding, the rural ambulance add-on and the Rural Geographic Practice cost index floor and the hospital at home. So, thinking that all of these things will be extended as we’ve expected.
And with the shutdown, there was some question whether or not we’d get the CMS calendar year rules on time. So physician fee schedule, outpatient prospective payment system, home health, and ESRD. We got the physician fee schedule rule on Friday the 31st, anticipating that the other three rules will come out later this week, the week of November 3rd. And so, we will unpack all of those rules in our next episode once we’ve had time to do a deep dive on them and understand them better.
As we think about kind of the impact of the enhanced exchange subsidies and what happens if they expire, analysis projects that between three and four million people could be affected. Young adults would face the steepest rise in uninsurance rates, up to 25% among those aged 19 to 34. Obviously, children would be less impacted due to Medicaid and CHIP eligibility.
Not surprisingly, income is the driving factor in this. Those earning between 250 and 400% of the federal poverty level could see a 26% rise in uninsured, while higher income individuals would lose coverage altogether. States that have not expanded Medicaid are expected to feel the sharpest effects, as the enhanced credits currently fill that gap.
The ripple effects of this, obviously, would extend through consumers into the healthcare system. Hospitals already strained by Medicaid cuts in some states and increasing uncompensated care as a result of a slowing economy in some areas, are expected to face greater financial pressure as more patients lose coverage. This impact will be especially pronounced in states with high ACA enrollment.
It’s likely that some of those who lose coverage will turn to unregulated alternatives, such as short-term limited-duration insurance plans, exposing them to increased financial risk given the coverage limitations of those types of policies. The Urban Institute estimates that the expiration of the enhanced exchange subsidies would increase uncompensated care by $7.7 billion, so 12%, relative to the baseline of $66.7 billion.
The burden of the additional $7.7 billion in uncapped care would fall on all provider types. Hospitals would absorb approximately $2.2 billion. A billion for physician offices, $3.1 billion on other services, and $1.5 billion on prescription drugs. Not surprisingly, the increase in uncapped care is greater in non-expansion states. The Urban Institute projects a 26% increase in Mississippi, South Carolina, and Tennessee.
In contrast, uncompensated care demand would increase by only 5% in less than 15 states and less than 1% in Connecticut, the District of Columbia, Hawaii, Minnesota, and Vermont. Many of the revenue cycle strategies that were discussed in the third installment of Forvis Mazars OBBBA Tuesday series are applicable for organizations looking to mitigate the impact of increased uninsured if the subsidies do expire, and we’ll include a link in the show notes, and would certainly encourage you to check that webinar out.
Switching to 340B, October 30th, HRSA approved the 340B rebate model for nine of the 10 drugs selected for Medicare price negotiations, with Novartis Entresto being the only one excluded. Beginning January 1st, 2026, these rebate models will apply to all covered entity types and include expanded medical claims data requirements which were not included in the initial announcement.
The nine approved drugs will operate through the Beacon Channel Management System, which is a platform tied to 340B ESP. While HRSA initially allowed manufacturers to limit participation to certain entities, the final approval notice posted on HRSA’s website mandates inclusion of all covered entities. When the pilot was announced, it only required covered entities to submit the 11 pharmacy claims data elements.
The HRSA announcement now requires covered entities to also submit 11 medical claims data elements, which include plan ID and plan name. Assuming the participating manufacturers are able to notify covered entities by November 2nd, that would provide 60 days’ notice, and then they’ll be able to launch the pilot on January 1st. The 11th hour inclusion of medical claims data is certainly concerning.
It’s going to be difficult for organizations to gather that data into a format that can be submitted to the platform, and so that may complicate covered entities’ efforts to prepare for the model. Beyond the operational issues, certainly providing the plan name and ID will give manufacturers more insight into who will be getting the discount. So we can certainly anticipate that that data will be used in their advocacy efforts related to the program.
Staying with 340B, want to focus on the Senate Health, Education, Pensions, and Labor hearing from last week. Last Thursday, senators from both parties voiced frustration over the lack of progress on reforming the 340B drug pricing program. Efforts to reform the program have been stalled for years due to clashes between hospital and pharmaceutical interests. Draft legislation, the Sustain 340B Act, from a bipartisan Senate workgroup, what’s known as the Gang of Six, seeks to increase oversight and transparency.
The Gang of Six released a draft of the Sustain 340B Act last spring that would have prohibited pharmacy restrictions by drug companies, tightened requirements for offsite facilities, and had a placeholder that would have redefined what an eligible patient is potentially narrowing that definition. The draft was released with a request for information related to the bill. However, a final version of that bill has still not been introduced, and so a final version obviously would include, if that section was still there, a more specific definition of what a patient is.
Senate Health Committee Chair Cassidy has also called for reforms to the program to ensure that savings are passed on to patients and to also address transparency issues. He has indicated that he intends to release his own 340B reform legislation. Personally, I think it’s unlikely, given the challenges Congress is having passing a 2026 budget, that legislation limiting 340B or reforming 340B will pass this year.
And I’m somewhat doubtful that Congress is going to be able to take up and pass anything that could potentially be this controversial in an election year. However, even a chance of legislation is certainly a concern for covered entities because anything that they pass, while it may provide some benefits, will also likely take some things away and potentially limit savings, which would compound the margin degradation risk facing covered entities as a result of the rebate model, which is now going into effect.
In terms of additional potential sweeping federal legislation, President Donald Trump signaled Tuesday that Republicans are unlikely to pursue another reconciliation bill. He told GOP senators recently that the Big Beautiful Bill already included everything that he wanted, such as major tax cuts, defense and border funding, and a repeal of the green energy tax credits.
His remarks undercut Speaker Johnson’s earlier plans for additional reconciliation measures and cast doubt on the effort, given the narrow GOP majorities, the heavy workload of fed fiscal ‘26 appropriations, and the political risks of another vote-a-rama, which is associated with reconciliation bills in the Senate, before midterm elections. It would be an opportunity, if they were to go for this again, for Dems to put in a bunch of messaging amendments that could potentially put GOP senators who are up for election in a tough spot.
While conservatives had pushed for a second package to address issues like Medicaid funding for states covering undocumented immigrants, skepticism was already high, and the president’s comments suggest reconciliation is effectively off the table for now unless Republicans can unite around a new agenda and sell it to the president. I think one of the things that made this a longshot to start with is, as was noted by the president, all of the quote unquote “goodies” that might make Republican members line up and take a hard vote less than 12 months before a federal election.
So again, the tax cuts, defense spending, border security were already done in OBBBA, and unless they’re able to include an issue that really animates and engages the president, I think the odds were pretty low that they could get him to rally around the package and then leverage him to be the closer that he was in the OB3, or OBBBA, votes, which really helped get that piece of legislation across the finish line in the House and the Senate.
If we do see another reconciliation bill, though, I do or am concerned that it would include additional healthcare cuts. So things like expansion of Medicare or site-neutral payments or changes to Medicare Advantage risk adjustment coding to either pay for increased spending that may be part of other packages, or provide additional deficit reduction to placate fiscal conservatives that are still concerned about the OB3’s deficit impact.
The one place where I think may be possible for an attempt at a reconciliation bill could be around healthcare, given we’re coming into the election and healthcare costs certainly could be front and center at issue, particularly if the enhanced exchange subsidies are allowed to lapse. And so the Republicans may feel the need to do something about it legislatively. Again, something to monitor, not something that I would bet a paycheck on yet, but definitely something to watch.
Last thing I want to cover is plan-provider negotiations. We are seeing public contract disputes between insurers and providers rising sharply. So, spilling out into the public as both sides grapple with mounting medical cost pressures with at least 90 disputes becoming public so far compared to the 51 in 2022 and the 133 in 2024.
Providers are increasingly unwilling to compromise on reimbursement rates and prior authorization rules while insurers remain firm in efforts to control costs, particularly for employers. This trend comes amid growing criticism of insurers for frequent care denials and worsening public perception of the industry, as providers need to shift the OB3 Medicaid cuts, the cost of those cuts, and the increased uncompensated care as a result of the growing uninsured to commercial payers.
As providers enter into these more challenging negotiations, they should use the plan transparency files to support their rate increase requests so that these are grounded in data. As providers look to use this data, key questions they should ask include: How does your organization’s payer pricing compare to peers? Is our organization collecting the negotiated rates they’ve established today? How do our organization’s services fit the market? Is our pricing justified based on the services provided? And how will consumers view our organization’s value?
This concludes today’s Washington Watch. Up next, I’ll be joined by my colleague Randy Biernat to talk about innovative approaches to improving physician enterprise performance.
I’d like to welcome back to the podcast, our guest for today’s episode, Randy Biernat. Randy is a partner in the healthcare consulting practice at Forvis Mazars, whose work focuses on physician services, including consulting for transactions and compliance, hospital and physician alignment, and fair market value compensation. Randy, thank you again for being here today.
RANDY BIERNAT
Great to be with you, Chad. Happy to be back.
CHAD MULVANY
Randy, our listeners may remember you from back on our second episode of Achieving Health, when we explored insights from our annual Mindsets survey of healthcare executives. And I’d encourage everyone to go back and give that episode a listen, if you haven’t already.
At the time, you shared some fascinating insights on aligning the physician enterprise with key priorities for the healthcare organization and for healthcare leaders, including insights related to the concept of aligned growth and also the concept of talent optimization. And so I wanted to have you back today for a deeper dive on those topics. Let’s start at a high level. Why is an effective physician enterprise such an important strategic asset for healthcare organizations today?
RANDY BIERNAT
So I’ll focus on one area. It’s about access. So the physician enterprise is a high cost, hard to recruit, generally aging employee cohort. And so what you do with it becomes extremely important. There’s no doctors, no hospital. What that really means, at a strategic level, is access. And so when your physician enterprise functions at a high level, you’re providing the right service in the right care setting at the right time in the right location.
So when you stack all that up and you’re efficiently allocating your human capital, you’re able to drive access where it needs to be to be effective. And there are hard choices associated with that.
But when it’s well done, you’re meeting the needs of the community, and you are driving financial sustainability. When that’s unoptimized, right, the physician enterprise can be a barrier to success and really work with health systems right now trying to think through what do we do with this problem? And it’s like, this is not the problem, right? That we are not optimized. You have this asset. We need to turn it into one.
CHAD MULVANY
No, and I think your point about access is well taken, because when you think about, you get access right, you improve outcomes, you get access right where you’re getting people with the right setting a care, you’re delivering care in a cost efficient manner. You get access right, you’re improving patient satisfaction because they’re able to get in in a timely manner.
And that also, by the way, helps drive financial performance for the health system. So this to me seems like one of the key lynchpins that organizations need to be thinking about. Let’s get into some of the details around when it comes to improving physician enterprise performance. How should physician enterprises manage physician subsidies? I know that’s something that all organizations struggle with.
RANDY BIERNAT
Yeah, another big question and a good one. And so if you’re part of a health system that has an integrated physician group, or if you’re working very closely with independent groups through professional services arrangements, you get to the same place. And the core question is: do we have alignment between the professional side and the facility side and okay, so how do we evaluate that? We go down one level, we start to think, we think a lot about service line or service line rationalization.
So base threshold question: Does it make sense to be in the service line, yes or no? Ten years ago, candidly, you could have an open-heart program as a vanity project and it would be okay. You can’t do that now.
You truly have to evaluate what does it cost us to run this? Should we be doing open hearts in our community, yes or no? And it needs to really make financial sense because the spend is so much not just on, you know, the proceduralist doing the work, we think about is specialized anesthesiology. And you think about the call coverage and things like that.
So, you know, is it really cool to be able to do open hearts locally and not have to drive 50 or 100 miles? Yes. It is really neat. But that stuff, from a decade ago that worked, that doesn’t work today with all the economic pressure. So, you know, service line rationalizations, are we doing what we should? Is it aligned?
And so there are going to be, you know, if you think about expanding circles, there are going to be some core circles that we’re going to say yes to no matter what in our community. The most obvious example is an obstetrics program, right? Are we really a hospital if we don’t deliver babies? If you ask boards, community boards especially, the answer is no, we’re not a hospital if we don’t deliver babies.
So are we, is it rational to be in this business? No, it’s mission. Okay. And that’s an okay answer. Once. Twice, three times. It’s not an okay answer 15 times. Right? At some point, you start to have to say, no, it’s not rational. We’re out of that first ring of we must do it into things that we maybe could do or we should do, and sort of figuring out where to direct resources becomes more and more financially oriented as it gets away from the core.
And so, we think about service line rationalization. It has to inform the target operating model, to meet the community’s need in the most efficient manner. And if it’s core, does it make sense to be in this productivity or access model? Usually, it’s going to be the access model for your core programs that are loser programs, net net. And then if you go out a circle, it should be more of a productivity orientation operating model, to fulfill patient demand. And those should be financially sustainable.
And it’s in that second ring of, you know, cancer care, orthopedic care, cardiac care. That’s where we’re generating margins to sustain the whole enterprise. Right. And having that balance between the money moneymaker programs and a service line basis and our community support payments, you know, community support programs where we aren’t, you know, standalone, financially sustainable.
Right. Having the right portfolio balance to stay in the game is what you need to do. And sometimes that means trimming things like the open-heart program I mentioned. To get to the right answer.
CHAD MULVANY
And, Randy, I like that model of sort of thinking about what’s in the core, being disciplined to limiting that to a number of factors. Then everything else needs to not only support itself, be able to support the core as well.
You started to touch on this in your answer, particularly as it, you know, across the things that are core and also the things that are non-core. But how can physician enterprise leaders determine whether their workforce is structured appropriately? What should they be looking at?
RANDY BIERNAT
Chad, I will tell you, I think, it’s the same answer. It first depends on whether or not it’s access or productivity. If it’s an access model. And we’re really, again, trying to deliver care to the community. It’s absolutely about the cost of care and that visit as cost per metric. And this does tie into accountable care.
And it does tie into sustainability and those other things. But we need to be managing costs per visit and our access models and managing that down. We still want to maximize reimbursement by all acceptable means, but from an operations standpoint that that’s not in their control, whether or not we’re a rural health clinic or we’re provider based or participating in 340B, it is cost per visit in the clinic for access models.
Now, if we think about productivity models that are really the key drivers of financial sustainability in our organization, cost per visit is still a good metric to look at. But we’re really gonna flip to margin per visit, and we cannot pay our doctors for margin that we earn. But we can make investment decisions, whether it’s technology. Should we buy this robot?
Should we get ambient AI to help us, you know, manage, the physician’s time better? So charts pre-populated where we make technology investments, how we staff. Right. So we can get a physician to be more productive by adding human resources or technological resources. We should do that in a productivity model if it’s accretive to margin.
For an access model, that’s the wrong decision. I mean, it’s the wrong framework. And so again, I like to bucket things into, hey, it’s core service access focus. Well, we’re going to focus on cost per visit. I’m trying to fulfill the community need at the lowest, you know, cost per visit. And then if it’s a driver of growth, it really is about net margin, which is why the service line rationalization becomes important. It helps us know what investments we should make to allow for financial sustainability.
CHAD MULVANY
As you start to think about operating models, what does a more efficient one look like?
RANDY BIERNAT
When we think about a more efficient operating model, what’s happening in in healthcare, almost a surprise. But it fits the demographic trends. This is, of course, it’s to some degree anecdotal, but, employed medical staffs in a lot of markets were the result of, primarily reimbursement pressure. And. Okay, well, we’ll employ this group of surgeons or, oh, okay. We’ll bring in the hospitalist. Or, oh, okay. We’ll bring in the OBs, right? And so we brought these groups together.
There’s been a lot of focus in the last 5 or 7 years on one medical group to supplement the demand and to sort of stitch things together. There’s been a big infusion of advanced practice providers. So whether it’s physicians assistants or nurse practitioners, these advanced practice providers, or APPs for short, they have flooded the workforce.
And so when we think about a more efficient model, like, you know, in our business, like accounting and consulting, getting some human leverage from a billing standpoint, is part of the answer. So advanced practice providers can get used in a lot of different ways. I think we’re in a phase of optimizing the use of advanced practice providers with him within employed medical groups.
And so when we talk about what’s a more efficient operating model, clearly it’s figuring out how to, especially by specialty basis, make the most of advanced practice providers. But for the most part, the ability to get production, even with the difference in licensure, even with the 15% differential reimbursement, there is low cost, reasonable quality service to be had out of the APRN group to get your physicians to top of license in those productivity models.
And there’s a great opportunity for access, with team-based care led by a physician running with two or three or four APRNs to provide access.
CHAD MULVANY
So kind of what it sounds like you’re sketching out is if we’re talking about a proceduralist, making sure that we’re keeping them in the operating suite or the procedure suite, and then having an APRN or two back at the clinic doing consults and kind of keeping using the APRNs to make sure that, you know, they’re doing the thing up with their license.
And then anything that the proceduralist is touching is really worth their time given what they’re being compensated. And, to your point that that is a different operating model than what most the world is running on today, which then sort of leads to the thought that, you know, change management is going to be incredibly important to get to this optimal model. If you were a physician enterprise leader, how would you plan for moving towards this different target operating model?
RANDY BIERNAT
Yeah. So when we talk with folks about target operating model and pay a lot, you know, physician alignment and compensation plans and all the things that are the ingredients to success to run a highly aligned physician enterprise, a lot of times the immediate reaction is tactical. Hey, I can’t change everything tomorrow. You know, that’s going to be very disruptive.
And so, you know, the approach that we like to use, especially where we’re, you know, dipping our toes into value based, enterprise type physician alignment, where we are compensating the physicians, in part based on the shared success of a service line, which directly ties into service line rationalization.
We don’t want to force everybody into a model to force people out or to force, and I’ll say instead of people say physicians, we don’t want to force physicians out. We don’t want to force them to fail. And we know that if we slam top down a new operating model, a new pay plan, it’s going to drive some level of chaos, some level of turnover. And filling in the gaps around call coverage with locums is incredibly expensive. Right?
So just because we have this belief that we need to do things differently doesn’t mean we can do all of it differently today or tomorrow or next month. And so we think about how we want, a service line or a set of service lines to look and act and be modeled and how they we want them aligned.
We do need to think about a multiyear time horizon. And typically we can get a third to half of providers on board with a new pay plan, right? Because they want to be heard. They want the opportunity to perform better. They do want to be aligned. So there’s a core group that you can lead towards change that are open to it.
And a lot of times what we want to do is allow for a pilot and, or an opt in for something new. And it’s a really the old plan alone for a year or 2 or 3. So, doctors, if this doesn’t sound good to you, you can just wait and see. We’re not going to give you a big raise, right?
But we are going to permit status quo for a period of time. And we’re going to take the coalition of the willing forward into our target operating model. And that’s obviously from a change management standpoint; we’re going to provide incentives for the physicians who are open to change or provide financial incentives. And if we’re able to change the cost of care, those incentives pay for themselves.
And so if we think about, hey, what’s our medical roster, what’s our team look like in three years or five years, what do we want it to be? You know, that’s a lot easier to manage. Especially we’re talking about something like call coverage. It’s a lot easier to manage if we permit different operating models. But I do think it’s useful from an alignment standpoint to, you know, current state, future state, timeline out what we want it to look like, what’s the amount of change that we can tolerate over a period of time, and plan accordingly?
CHAD MULVANY
No, I think I think that makes sense as a model, particularly, you know, I’m not trying to force anything down, but really allowing those who want to move forward to do so and giving those who maybe aren’t as immediately as excited an opportunity to either become a customer or think about something else.
You know, over the last several years, we’ve seen more and more care, in particular primary care, be delivered by advanced practice providers. What kind of governance model do organizations or should organizations set up to set up APPs for success?
RANDY BIERNAT
I love this question, Chad. So, thank you. Organizationally, we need to match skills to roles, and we’ve got to support that with training and development. So it’s a big enough employee cohort that in my mind, the APRNs or the PAs need a place to go for training, education, mentorship that isn’t just the collaborating physician or the docs in that office or on the floor or whatever.
So having, you know, even at a maybe a VP level, an APRN that is helping with training, leadership development, how to work with physicians who aren’t always the easiest to work with folks. And so I do think that the workforce in so many organizations is big enough that having a counterpart to the VP or the CMO or other clinical leadership, that’s a physician having, someone who’s walked in their shoes, you know, with that background and leadership would be very helpful.
And so that is something that makes a ton of sense to me is as they become a bigger and bigger part of the employee provider workforce.
CHAD MULVANY
What else can physician enterprise leaders do to set APPs up for success? Right. You talked about the training, but obviously maybe it’s not a one size fits all training model.
RANDY BIERNAT
Yeah. So again, if half of your workforce, provider workforce, is APRNs and PAs, which is not uncommon right now, that’s still expensive talent to acquire. So do they cost much less than physicians. Yes. Are they still expensive workforce or highly paid workforce. Yes. And so, what we want to start to do is to manage turnover, you know, to screen better for fit.
And one of the most important things is skills-based evaluation. If you’re hiring a physician, you know, who’s board certified in urology, you know what you’re getting. You can do background check and understand the kind of procedures that the physician is skilled and doing and so forth. And licensure is a pretty good indicator of their clinical capabilities.
For APRN, licensure is not nearly as good of an indicator of clinical capabilities. So it really is about skills. So, skills-based evaluation, training, development, helping the APRNs we’re bringing in land in the right place, giving them runway to be successful, helping them with engagement. If they are paired with a physician who, and they’re sort of forced into that and there’s not a great fit, that can drive turnover.
That’s so counter to what we want to do to be efficient and sustainable. So, bringing them in in a way that they’re supported, setting the expectations with collaborating physicians, moving into a team-based care model where the physician success is linked to the APP success, you know, is a way to help this. But there are, APPs render a lot of patient care in this country.
It’s increasing every year in every setting, setting them up for better success. You know, as they come in, as they develop and grow and sustain with your organization, is incredibly valuable work.
CHAD MULVANY
No, I think I think what you’ve laid out makes a lot of sense, particularly as it’s sort of figuring out once you’ve hired them, meeting them where they are and their skill sets, figuring out how to develop them, and also how to deploy them in roles that they can be most effective in.
You know, going back to kind of this new model that you’re talking about, you know, it’s predicated on physicians leading a panel of APPs. If you were running a physician enterprise today, how would you change the physician comp model to reward or encourage physicians to step into that leadership role?
RANDY BIERNAT
Yeah. So I mentioned team-based care a couple of times. Team-based care exists in places and pockets. How I view it, Chad, is just how you describe it. You have a physician leading a panel and really having dedicated time with a group, you know, led by the physician with two, three, four, mid-level providers or advanced practice providers, rather having them really focus on executing the care plans, working through the visits, working through the follow ups, working through the messages in a team setting is a little different than what’s happening in most places.
Lots of physicians get paid for nurse practitioner collaboration, or they’re getting paid to review charts. They’re getting $500 a month to be available and do some chart review. And then, over-read some charts, do some sign-off things like that. That’s not team-based care. Team-based care really is a programmatic, and by programmatic I mean operational, approach where a patient understands they are being seen by a team of providers.
They may never see the physician, but they understand that the physician is involved in their care, through oversight and through planning and execution. It’s done in that team setting. We want to think about how much access that creates, how that influences cost of care, how much that saves us, financially, we want to reward the physician to do that, which isn’t $500 per month per nurse practitioner.
That is not enough to compensate for the time it takes to lead the team. And so we want to, and over-reward is the wrong term, but we want to appropriately reward the level of commitment to that type of program. And in my mind, that is worth more than the physician seeing patients on their own.
And so, this is not to get into necessarily opportunity costs, but a physician can produce three RVUs per hour, four RVUs per hour. Or they can lead a team that’s producing 15 RVUs per hour. The latter is more valuable, on an apples-to-apples basis. And so pay plans that reward that are going to far outstrip the stipend model, like I said, $500 or $1,000 per month.
And so, does that look like two times or three times or four times as remunerative as traditional APP collaboration? Yes. And the economics are there for it. It promotes financial sustainability and really recognizes the value of that work.
CHAD MULVANY
No, I know, but I think that makes sense. And, you know, want to just, you know, the model where you’re providing a stipend and that, I guess goes back to kind of the distinction between being a leader and being a manager. Right?
We’ve all worked for people that basically managed us versus those who led and certainly, at least in my experience, working for those who led it had always been more fulfilling and I was always more productive in those models. And so you kind of think about it from the stipend model, which kind of is more of a management model versus that greater level of engagement that gets a physician to be more of a leader into that leadership role. Seems to make a lot of sense.
RANDY BIERNAT
I totally agree.
CHAD MULVANY
And so, Randy, last question before we wrap up. What are you seeing in the market in terms of interesting use cases of telehealth?
RANDY BIERNAT
So we work with facilities all over the country and access to specialists, especially expensive specialists. So, think a urologist, really hard, really hard in some markets to get critical mass. But there’s a clear need. Again, urology is a really good example. So, you know, a patient has a need to drive 50 or 75 miles to see a urologist.
You know, if we can’t get a physician in place, but it’s hard to just get a founder. It’s almost even harder to get the second physician in. But then for call, you really need three physicians, maybe four. So there are a lot of facilities are just struggling to get enough physician staff to really have a program.
But there’s a clear community need, and so one of the interesting things with telehealth, I’ll get around to telehealth in a minute. One of the interesting things about telehealth is the idea that instead of having a local group of three fill in the blank, but we’ll just go with urologist, instead of a local group of three, that we may not be able to clinically keep busy.
So again, going back to my earlier example, we would like to have proceduralists like urologists in a productivity model. But we may only be able to keep one and a half busy, but we need three for call coverage purposes. So there are these markets that are sort of in-between enough local patient demand that there’s real work to do, not enough to have a big enough panel to provide call to meet the level three trauma designation or whatever for that section.
And so what is interesting is I’m seeing a couple of my clients get into agreements where they are accepting a physician parachuting in just to sit in the hospital and do procedures at the hospital. And that’s being fed by an advanced practice provider in a clinic, working under the support of a remote telemedicine physician to do some of the team-based care stuff we mentioned.
But, you know, planning for the day, chart review, what tests have been ordered, what those tests might mean. So, some true collaboration. The nurse practitioner does the visits. Where a procedure’s indicated, the physician again zooms in on a telehealth visit and talks about the procedure with the patient. The patient then gets scheduled for a procedure at the hospital.
The on-call physician, that sort of just sitting in the hospital, again, they’ve got coverage now and it’s just not that hard to slot in a handful of procedures. And so we’re able to get the access in the community through telehealth. We’re able to get the procedures done in the community and the call coverage accomplished.
And honestly, the price point versus keeping three in the community ends up being less. So, even though you’re paying for restricted call coverage, you’re able to set that model up to be financially viable. Couldn’t happen without telehealth. So that’s something I’m seeing right now that’s pretty cool. And I expect to see more just like that.
CHAD MULVANY
Randy, thank you for sharing that. That is a pretty creative model to check. A lot of boxes, get the care delivered, improve physician quality of life, and also sort of pencils out financially.
RANDY BIERNAT
Yeah, mileage may vary. Right. You know reimbursement matters. The market matters. You know, there’s different things. I’m not sure it’s a universal approach. But in the right setting. And for a couple of my clients, it’s been a great set.
CHAD MULVANY
Well, Randy, thank you again for joining us today. Always an insightful conversation. I also want to thank our listeners for tuning in. If you’re looking for more insights on physician enterprise strategies, we have links to related content in the show notes. I hope you’ll join me in two weeks for the next episode of Achieving Health.
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