Good afternoon. Welcome everyone we appreciate your engagement and your time today. I'm Ginger Beesbrock, the EVP of Care Transformation and I'm going to transition over to Jerry Blackwell to kick us off. Hi folks, Jerry Blackwell, I'm the President and CEO of MedAxiom and a longtime user of the work and the data that MedAxiom has provided through the years of my practice. We just welcome you to this third annual Cardiovascular APP Compensation Utilization Report. And there's few things that make me smile more than the development of this program over the years. When we talk about team based care inside of cardiovascular care, it's something we've all become passionate about. There is no care provided at a high level these days that doesn't involve the care team. And for most of us, when we talk about the care team, the most important person on that team is the APP and how they support the entire enterprise. So it's a particular delight for me. I believe that we have the country's best expert in Dr. Ginger Beesbrock talking about this. As you know, MedAxiom, we're absolutely committed to having data driven information and you're going to see what we mean with this report. So once again, thank you. Thank you to Ginger. Thank you to the entire MedAxiom team, to our IT and data services department that makes this available and look forward to answering your questions. So Ginger, thank you so much. Thank you, Jerry. I appreciate it. So my goal today is to walk us through what is our third annual APP survey compensation and utilization report. I want to start with just kind of getting you acclimated to our methods and the work. How did we come up with the data and the information that we're sharing with you today? So there's really two sources of data that come into the report that you're going to see. The first one is our MedAccess database. And so, again, there's a number of APP leaders in the audience. You may not be familiar with this database. I want to get you familiar with this database. This is really what we believe to be the premier source of operational productivity utilization data in the cardiovascular space. And there are key measures in here that help us better understand the overall utilization of APPs, as well as our compensation. That piece comes out of here. This is a set of data that many of your organizations provide for us on an annual basis. In fact, we are right now in the process of collecting data from 2022 that will then turn into our 2023 data reports. And I'll kind of point those out along the way as I show you those different data points. The second area or source of data came from our survey. So last fall, we sent out a link for the survey that you're going to see the results. Many of you took the survey. And I want to say thank you for that because we learn best from each other. And data and knowledge is power. So when we look to make decisions related to our teams, utilization of our teams, measuring the effectiveness of our teams, it's this data that gives us that measuring stick in which to make good decisions. And so thank you to all of you because we wouldn't have it if you didn't take the time to fill out the survey. And we're honored to really be the conduit of that information back to you. So I want to start with a couple of key topics. The full report and narrative is in the link or at the link that we provided in the chat. So make sure you go there and download the report, and then you'll have access to this and you can share this. You also have access to the slides from today, which is really a summary of the report. But there's a couple of key topics I want to cover before we get into it. So the first one is just some workforce statistics based on what we saw with this report and then some of the things that we've seen in the industry. But one of our data points looked at the overall ratio of APPs to positions. And what we found is that in the last few years, and I'll show you the graph when we get into the report, we saw that ratio increase from 0.39 percent to 0.6 percent. So what we're seeing is more and more of our programs are not only utilizing APPs or employing APPs, but the number of APPs in our programs compared to positions is going up, making that ratio closer to one. In addition to that, when we looked at our MedAccess data, and we have over 200 organizations represented in that data, 88 percent of our organizations utilize APPs. So when we looked at the billing data, we had evidence that there are APPs in 88 percent of our organizations. So we're approaching 100 percent. In addition to that, that represents just over 2,300 APPs and 3,300, close to 3,400 positions. So when you start to think about the breadth and the depth of the knowledge that we can gain out of that database, 2,300 APPs, their work is represented in those measures. So I think, again, really important and growth, the key to this is, is how we go about this. And that's why we're here today. The second thing I want to talk about is a little bit related to trends and what we think are going to happen. So I doubt there's a single person on this audience today that isn't feeling workforce stresses within their organizations. And in this case, kind of focusing on provider workforce, physician workforce, I'm not sure that I've talked to an organization in the last six months that's not actively recruiting a cardiologist and looking to expand their team. And in some cases, APPs as well. But I want to give you some data to help you better understand the overall national perspective. So from a primary care perspective, we are or the AAMC is projecting a shortage of between just under 18,000 and close to 50,000 primary care physicians where we would be short of by 2034. So 2034, in my mind, still seems like a long time away. That's only 11 years from now. That's well within, for most of us, our career path. We are probably going to feel that. We feel that already. Again, I can't tell you how many organizations I go into. And one of the main concerns or tensions is that we get these referrals, and sometimes we don't know that they're necessary cardiology referrals. And yet, if our primary care resources are limited or stretched, we're going to get more referrals. And we're also going to have to hang on to patients longer and provide more chronic disease and secondary prevention management if we don't have anybody on the primary care side to transition those patients back to. So in many cases, we become primary care for those cardiovascular disease management, as well as the comorbidities in some cases that lead to that. From a medical specialty, we are also kind of in that concern for shortage anywhere from the, it's a bigger range, but 3,800 to 13,400 by 2034. The drivers of this are, when we just, Jerry and I just finished a course related to some economics, and it's an economic equation. It's a supply-demand. Our demand for care is going up because our populations are growing. Our supply is diminishing because we have less and less physicians coming out of fellowship training in order to meet that increase in demand. The other challenge we have is an aging workforce, and more than two of our five physicians will be 65 or older within the next decade. So let that sink in, 40%. So, however, on the APP side, the workforce actually looks much better. So at the end of 2020, so this data is a couple years old, we had close to 300,000 advanced practice RNs working in primary care. We had close to 140,000 PAs working in primary care. And although this isn't totality, this is primary care, you can kind of do some math on that, that usually about 60% to 70% of those workforce focus on primary care. The other 30%, depending on the market, will focus on specialty care. And the supply is projected to more than double in the next 15 years. And I believe that to be true, just from working on the academic side, there's a lot of new programs popping up and existing programs are extending or expanding their student capacity and increasing the number of students that they're putting through their program. So a review of staffing models show an increase in supply for APPs to the fact that maybe we can meet the demand from the patient care. However, the definition of the demand is speculative as our role evolves. So that's really important because utilization and care delivery model are the key. So if we're going to do this effectively, and we're going to balance our provider workforce in a way to meet the demands of our patients, it's the way we organize ourselves around that care delivery model. And that's a lot of the things that we're going to learn about when we get into the survey results. And that's also the key, we need to be very intentional about that work now, because that allows us to scale much better and much more effectively as our demand goes up. So that's number one, workforce, provider workforce, it's really important to understand what's coming down the pike and what we're going to have to work towards over the next decade. Number two, retention, APP retention. We talked a lot about recruiting. I want you to also focus on retention. Retention or lack of retention is expensive. So the cost of turnover for an APP role, depending on how long they were in the role, is anywhere from $80,000 to $120,000. I don't mean $80,000, I mean $80,000 to $120,000. So when you start to think about that in your P&L at the end of the year, if you turned over two or three, 10, 20% of the people on your team, that comes at a significant cost. I would argue there's more than just dollars associated with that. You've got team morale. Sometimes, in fact, I don't have the statistics here. We have them. When you start to lose one person, two people, even under the best of circumstances, the rest of the people in the team start to think, why are they leaving? Even if it was under the best of circumstances, is it better somewhere else? I might need to think twice about why I'm here. And it just starts to put in a layer or a level of maybe curiosity, but sometimes a little bit of dissatisfaction. So it really can have a hard impact on your team morale, which then leads to more turnover. It also disrupts your patient team continuity. So every time you introduce somebody into the care team, you've got a disruption of we left and then came, and that creates just potential issues around patient satisfaction, physician, and the rest of your team satisfaction. Resource use for onboarding, all of your training, all of your credentialing, privileging, that all takes time by your teams. And so every time we turn somebody over, there's a lot of work that has to happen to get somebody new onboarded. And then you're going to have loss of productivity because that 12, even at a, again, best case scenario, 12 weeks, probably closer to six months before that new person is up to speed and really, I guess, producing for lack of better way, or maximizing their role around patient throughput. I like that better. It takes time. Even if you can find somebody that sees it, it takes time. So focusing on retention. And I think there's four areas that you need to think about and actually talk quite a bit about these in the report. And there's some statistics that go with those that I put into the report. But programs that have very deliberate APP leadership, where APPs are leading APPs, have less turnover. Utilization for programs that have the right type, and I wish I would have bolded this, amount of work better. So we need to be busy. We want to be busy. We want to be fully utilized. And so if you've got team members that their schedules are not full, or their roles, and there's a lot of downtime, it does create some dissatisfaction. So type of work and amount of work matter. And in some cases, it can be overworked. There's workload issues. Don't get me wrong. I know those things happen. But sometimes I think we forget that even underwork or a lower workload that doesn't meet our capacity or take full use of our skills can be a dissatisfier. Professional status makes a difference. So allowing for professional and personal growth. So allowing me to expand and do some committee work, some quality work, some leadership work. That creates an environment for professional satisfaction. That matters. And the fourth, and I put this fourth for a reason, compensation and benefits. You don't have to be the highest paid organization in the market, but you do need to be respectful in the amount. So it needs to be competitive. You need to have respectful, competitive benefits. You don't have to be the highest. And I would argue that if you're having turnover and your first focus goes to compensation, it tends to want to go there. I would go to the other three and see where you potentially have gaps in those areas. Because if you solve for those, I can tell you hands down, the compensation and benefit conversation begins to diminish and move to the background. It needs to be respectful. It doesn't have to be the highest. All right. The last key trend is access and capacity and how a team-based care model can help you with this. And this is a data supported point. So one of the things that we've done within our Med Access database, and I'll send the credits to Karen Wilson and Joel Sauer, who did this data analysis. But what we looked at was patient panels. So for those of you that are not familiar with patient panels, patient panels, the number of active patients. In this case, we did it at the physician level per physician across the group. So if you've got 100 physicians in your group and you currently are managing 2 million patients, and I put myself on the spot to do the math. Let's just say theoretically the math comes down to 2000 patients per doctor. I don't know if it does or not. Can adding a team-based care model increase the number of patients that at the physician aggregate level can be managed by the program? And the answer is yes. So when we looked at APP to physician ratio, those that were in the 90th percentile, so the cohort that had the highest ratios, also had the highest median of patient panel. And the percentage overall was 17% higher than the median. The 75th cohort was 5% higher than the median, and then overall you can kind of see where the median was. But you can see the net difference per physician. I would argue, I'm a glasses half full optimistic sort of person, we still have a lot of work to do to optimize our teams. So this is across our entire database. And I would say this is not across every organization having fully optimized. I say that to say I actually think the benefit could and should be much higher than this, but I was thrilled to see that there's a difference. So data that supports the use of APPs do support a higher per AP physician patient panel size. So moving beyond encounters, we can support a higher patient population and more of a population approach. All right, let's get into the survey results. So first of all, huge thankfulness or gratitude. Thank you to all of you who filled out the survey. We had 94 programs represented this year. And you can see it's almost a 25, 25, 25, 25 breakdown with our different regions across the country. So truly does represent the full country. Our survey was conducted from fall to winter of 2022. That's why you see 2022 is the name of this survey result. Even though we're in 23, the data that we captured was the end of last year. So I mentioned this already, but we've got a steady climb of APP to physician ratios starting five years ago at 0.39 and ending at 0.6. Now our MedAccess data, this is actually 21 data because we collect 21 data in 22. We reported it in 22, now in early 23. We are getting the process of collecting 22 data right now. So we will update this as we get that new data in over the next four to six weeks. One of the first questions that we asked had to do with the leadership and the leadership structure. Remember when I went back to our key topic, it was retention and APP leadership matters. So what we learned is that 26% of you have an APP lead. 22% of you use an administrator to lead the APPs. 10% of you have an APP director and 10% of you have an APP manager. And 19% of you use a physician to lead the APPs. I don't have it here, but in some of my other work, I describe, I think once you get to an APP team of somewhere around eight, less than 10, but more than five, it's time to think about a lead. It's time to think about creating a voice for the team, someone that can provide bi-directional leadership so they understand the organizational strategies and what needs to happen, and they can drive, direct, and manage the team to fulfill those strategies, but provide a voice for the team, advocate for the team, make sure we have the right tools and resources for the team. The third benefit is it provides a growth path for your team. So somebody on the team has an opportunity for professional growth and leadership is one of those areas. It's not the only area, but it's one of those areas that you may very well have very competent people that are interested in growing into that space. It creates, it helps with turnover. So it creates a buffer against turnover, for sure, in a couple different ways. All right, APP compensation. This comes out of our MedAccess database, and you'll see we've had a five-year climb over the, and a 16% increase in five years. So it's a good time to be an APP. So any of you who have teenagers and college age and people, it's a good time as far as the amount of education compared to the earning potential. So there's your numbers. And then in addition, on the right-hand side, we pulled in the quartiles. So you can kind of see where the quartiles live. There is significant variation noted between those quartiles, and those things do take into account kind of experience, roles, and responsibilities. The difference between an outpatient role versus an inpatient role, call, place of service, all of those sorts of things take into, you know, need to be taken into account when it comes to compensation. Additional incentives, so one of the questions we asked were what other things do you provide your team? Almost 100% said we give CME dollars, three quarters said CME days, 40% provide extra call pay for those that take call, 37% provide a productivity incentive, and I'll get into that, and then 8% describe a citizenship sort of bonus, so those non-clinical activities and areas of performance that you need the team to be in front of, 8% of you said that you value that, and it is part of their incentive. So 60% of programs provide additional incentives on top of a base salary, and those were the outline of incentives. 30%, 7% of these provide productivity, so I mentioned that, so there's three areas, three, not four, three areas, RVUs, so seven of the programs that provide incentives for productivity, 73% base it on RVU capture, RVU productivity, 48% said patient encounters, and 8% said patient contact hours, and you'll see that does not add up to 100, which it was a check all that applies, so several organizations look at a couple different things, and I think that's fair, depending on how you're able to capture information and the data that you're able to get. So what were their goals? It's one thing to say we incentivize it, it's another thing to understand how we measure and what we measure. So for RVUs, you can kind of see the breakdown here, 17% said less than $1,500, 17% said $1,500 to $2,000, and I'll let you read through that, that 28% of you said that more than $3,000 is what you incentivize. Patient encounters for the day, kind of the bulk live at the $14 to $16, which when we get into what are we seeing for our APPs, it lives in that right around that range, but we do have 4% that said $17 to $19, and 8% that said greater than $20, and then not very many organizations measure patient contact hours, but those that did, you can see that the general expectation was $33 to $36, and remember patient contact hours are the time of the amount of time each week that there's patients on the schedule, and that the APP is responsible to the schedule, if that makes sense. So again, sometimes people build an administrative time or the start and the stop time for the day, what hours or what portion of the hours for the week were actual patient contact where they would be delivering patient care during those hours, and typically they don't count in basket management or time allocated for those things. So it's really the care delivery from a encounter, a cognitive encounter, like a face-to-face visit or a virtual visit. So I thought that'd be a great time to pull in the MedAXis RBU benchmark. So what we have here is the median RBUs per a full-time cardiology APP based on our 2021 data. I also split them up based on if it's a private practice-employed APP or an integrated model-employed APP, and it's different, and I think there's something there, and I actually know there's something there. I'm going to dig into that a little bit more, that better understand that, that you can see that in a private scenario, a full-time, the median for a full-time APP is 2,500 RBUs, but in an integrated scenario, the median is 1,300, so almost twice. Now some of that might be data capture because you all kind of understand the whole split shared and incident too. Oftentimes those RBUs, if we're not capturing them as a rendered provider but capturing them as a billable provider, may roll over to a physician portion of the the RBU accounting sheet, but really was services rendered by an APP, so you have to make sure you take that into account. We have worked really hard to take that into account within our data, but sometimes the way the data is reported, we can only assume that it was reported accurately. So that's one thing that could potentially account for the difference. The other thing that I think definitely accounts for the difference is if you think about the business model between a private group and an integrated group. So in a private group, you have physician owners of the group, physician owners that are likely very in tune to their expenses and their revenue, and very in tune to utilizing that APP in the most effective way, which is delivering care and seeing patients. In an integrated model, although we all work together, the ownership of that effective utilization of the APP doesn't always fall at the physician level. In fact, rarely does it fall at the physician level, and in some cases, because of the way the economics are set up, we might have physicians and APPs competing with each other. So if you have questions about that, we've got a number of webinars that describe that conflict and some solutions around that, and although our data in this survey doesn't tease that out, I can't help but to wonder, is that why we have almost a twice difference, 100% difference in our medians for RVUs between the two different employment models? So something to think about. And then I can't help but to include this, although we talk about the medians being 2,500 and 1,300, or as you work up to the 90th percentile, 5,100 and 3,600, I still want to remind everybody that if you take an APP, put them in a clinic, have them effectively see 15 patients where we're consistently billing and capturing the RVUs for those encounters, 48 weeks out of the year, five days a week, in 21 RVU, because that's the data that we're comparing against, so I want to compare apples to apples, we're still talking 6,000 RVUs. Now that number is not quite as high because we had a little bit of a bump, a decrease in 22, so that number will look a little bit different next year, the encounters are the same, but I want you to kind of remember, we're getting better at the way we use our APPs, but I'm going to still suggest that aggregated across the nation, when we look at our numbers, I think we still have opportunity, and probably pretty significant opportunity. All right, let's jump into other benefits, so for CME, the average was $2,000 with five CME days, those two questions were asked separately, so don't think about it as 2,000 and five, just think about the average for CME dollars was 2,000, the average for CME days was five, as high as seven, as low as three, as high as 4,500, as low as 500, and then vacation days for full-time APP, the bulk, so 51% landed in the 21 to 30 days, we had 19% that was greater than 30 days, and then you can kind of see 26% and then 4%. All right, this next one I think is an important one, we ask this every year, and I think for the most part at this point, the results for the state pretty much the same, but the question is, how many hours a week should we expect from our full-time APP? I'll start with, and I don't have it on here, 98% of you pay your APPs and in a salaried sort of scenario, so versus hourly, so the bulk, almost 100% at this point are salaried individuals, so the question is, what's the workweek expectation? And we ask this question in two different ways, first we ask, what's your schedule look like, what do you expect on the schedule, what's the actual, and again this is estimated, but what do you think the team is actually working? So 60% for a full-time APP said greater than 40 hours, now look, that I offered the option of 45 hours, so it's somewhere between 40 and 45 hours is the typical expectation for 60% of you. When we look at what, how many do they actually work, 31% are working greater than 45, so this would still suggest, and we hear this a lot, the APPs are like, the workload's tough, I'm staying late, this would suggest that is happening, not maybe for every organization or every APP, but there are, in our data would suggest, they're working more than what we initially described to them or initially expected of them, there's a little bit of a mismatch there. And then you can kind of see the different numbers related to those that are less than 40 hours, but I think it's fair to say the bulk of the expectation is greater, 40 hours or greater. So let's get into roles and responsibilities, I split this up between ambulatory and acute care, and then we had a specialty section this year related to EEP. So from an ambulatory perspective, 98% of you said that your APPs work in independent schedules, so Ginger Beesbrock would have her own schedule, Dr. Smith would have his or her own schedule, and we each have our own patients for the day. That doesn't mean that I have my own patient panel, it just, I might be sharing the care with several physicians, but I'm not seeing the same patients they're seeing, I'm seeing my own patients for the day. So the number of patients per full day in an APP independent schedule, 37% of you said 11 to 13, 34% of you said 14 to 16, and 14% of you said greater than 16. So when I bucket those, I've got 48% that say 14 or greater. Now we're going to get into, this was an all in question, we didn't break it down based on program type or clinic type, which in future we may do that. So just remember, this is all in. So I might have some APPs working in heart failure clinics, I may have some APPs working in general clinical cardiology, I may have some APPs doing other specialty areas. So this was aggregated all in average for your program. Now this was interesting, and we, about every three months, this comes up on the listserv, should or do APPs see new patients within the organization? And when we asked the question, 67%, two-thirds of you said that APPs do see new patients. That's up from 61%. So it's not, you know, a huge increase, but it's more than what we hear when we, when the question comes up on the listserv. I would say in general, the majority of those that answer say no, APPs don't see new patients here. When they do see new patients, and I don't have that data, the graph on here, it's in the report, but the average amount of time given is 30 minutes for those new patients. This is the other thing that I would say, just based on our experience and the work that I've done and what I've seen, these new patients, the majority of the time, they're in a structured disease management type clinic, like heart failure, atrial fibrillation, structural heart, where it's a very deliberate approach around which new patients those APPs are seeing. I will say, though, we're seeing more and more APPs seeing new patients in general clinical cardiology as a pop-off valve, because the way we have our physician schedules set up, we can't get those new patients in, and so in order to maintain patient throughput and not run into challenges around market share issues, organizations are starting to use APPs for those new visits. To me, that's a little bit of a mismatch. Not that we can't, but the overall, typically, the objective is that the new patients are seen by the physicians and get kind of get a care plan started, and then the APP facilitates the care plan. So in many ways, this is a reactive versus a proactive type model. And then for follow-up patients, again, timeline or what sort of time allocation, 58% of you said you give those APPs 30 minutes to see a follow-up patient. 19% said 20 minutes, and 10% said 15 minutes. So if you kind of add all that together, you've got over 80% of the organizations giving maximum of 30 minutes and back off from there. We only had just a, not just over 10%, 13% that said greater than 30 minutes. The other thing I would add to that, I can't help myself because there's always a narrative with there. It's not just a blanket statement. This has to do with how well we support the visit, just the same way with the physicians. If we don't have good chart prop, we don't have appropriate schedule management, so we don't have the right patients on the right schedules, we don't have the information teed up for the APP to see the patient, that also takes extra time. We don't have our documentation processes in place to easily document the visit, that all takes time. So I guarantee those 29% that are doing it less than 30 minutes, in order to do it effectively, they've got to have those resources in place and that work happening to make it appropriate, allow them to get those patients through. So team support models, we've got a couple of things here. MA for rooming patients, almost 100% at this point are using an MA to room patients for APPs. I would and have always advocated for that when the APP is up to seeing a full, you know, close to full day. Sometimes when you're starting something up and we're just seeing three or four patients, it's hard to figure out where that it's hard to figure out where that support comes from, because you can't assign a full day MA for that, it won't keep them busy enough. So there is a little bit of attention there as you're kind of getting somebody on boarded, but once we've got them ramped up to a full schedule, absolutely, that's important. In addition, MA for assistance, so that includes some patient callbacks and things like that. RN for in-basket management, or again, other more complex patient callbacks, you can see that the majority of the programs the APP fits in is part of that care team. And there's other team members that are surrounding and supporting that work. So let's talk about patient types, the types of patients that APPs are seeing, and I'll take you to the bottom of the graph. 98% of you said routine follow-up patients, surveillance of chronic disease management. Close to that, actually 100% that one got cut off in the bar, 100% said post-hospital follow-ups. It doesn't mean all your post-hospital follow-ups are seen by your APPs, it means that all your organizations, all the organizations use APPs at some perspective within that role as far as managing that. 87% said urgent patient needs, 95% said post-procedure, 71% we're going to get into EP in just a minute, but said device clinic patients, then 46% of you said that you use APPs in specialty clinics. And if you look to the right, you'll see by far heart failures the most common, followed up by EP, AFib that's specific to AFib, and then you can see the other structural heart, lipids, prevention, adult congenital, cardio metabolic, and kind of all the way up to a couple of you that are doing cardiovascular genetics, sports medicine, that kind of thing. So what are their clinic duties outside of seeing patients? 81% said they do peer-to-peer for prior auth, 71% said they do EKG interpretation. I'm going to add a little flavor to this one because typically what you're really saying, and this is only because this is a common question on the listserv and I've been, I've worked with a lot of you, usually that's for the EKG that the APP orders. So if I see Mrs. Smith today and there was an EKG done as part of her encounter, I will interpret that EKG. It doesn't mean that I'm doing the official interpretation and that you're billing under my name for that, although in some cases that happens, but it does mean that I have the, I would say, a clinical ability to interpret a 12-week EKG and allow it to contribute to the clinical decision-making that I'm doing today. That's what that means. 63% of you said in-basket management, that's just for the things that the APP ordered. So if I order it, it ends up in my in-basket, I manage it. 55% said, nope, we also attach them to the physician in-basket. So I'll be looking at the things that come in there too. I may not know the patients, but I know the physician. I work with the physician and I help manage that. 47% said stress test performance and 36% said device interrogation and interpretation. So call responsibilities, this is another big question. Now we'll just kind of preface this by saying we asked call on the acute care side as well. In this case, we are really focusing on ambulatory call. So taking calls from patients that are calling in from home after hours and only 18% of you said that you use the APP in that way. So not very many at this point. Now when it comes to weekend coverage, that's different. 38% of our ambulatory teams cover the weekends. So almost 38%, almost 40%. For those that do, the rotation was described as one out of five or less. Half described providing an extra stipend or overtime. So additional earning for doing that work. Half of you said, nope, it's part of their salary. It's an expectation and we don't pay extra for it. It's baked into their salary. Most said, in addition to whether we pay them or it's part of their salary, we also give them days off the following week for their weekend work. So if they work the Saturday, Sunday, sometimes they get one day, sometimes they get two days, but we give them value both in time back as well as some sort of stipend or overtime for half of you. All right, transitioning into acute care roles and responsibilities. I'm just doing a quick time check. I'm going to speed up here. 86% of you said APPs are used in the acute care setting. And the typical roles and responsibilities include rounding, consults, most say discharge planning, E&M billing. So they're doing their billing under their NPI at times, admissions, and care management. So care coordination is really what falls into that bucket. A few of you said procedures, night coverage, and bed management, where I might be monitoring the use of the beds that are in my department. So if I am department-based, I may be the gatekeeper for that. And that actually number was a little higher than I had expected. All right, workload and shift length. As you can imagine, it's highly variable, but the majority of you described 15 to 20 patients per shift. Now the shift is different, 8 versus 10 versus 12, but at a shift definition, 15 to 20 patient encounters is what you model for when you staff your acute care services. Most programs describe their acute care service model to include days and weekends. So that team is covering an occasional weekend. Only 14% have described the 24-7 coverage model. And I would say I'm sure that's volume related and the amount of work. It also has to do with whether or not you're an admitting service versus a consulting service. Primarily, do you admit your patients versus just consult on your patients? That's a big difference when it comes to what you need for nighttime coverage. Shift length, the majority ran between 8 hours and 10 hours. A few of you, less than 10%, said 12. And a fifth of you said, we don't really have shifts, we stay until the work is done. So that's going to be a daytime role. You may start at a certain time, but you finish up when the last consult comes in and the last patient's been rounded on. So what about call responsibilities for this team? 76% of you said they don't take any call, which I actually thought was interesting, although I think aligns with some of the things that we've seen related to the listserv. 11% said yes. And for those that do cover call, they may have to come in. And 14% said yes. So a total of 25, 24, 25% said yes, they do take call. A little over half said, yep, if they do take call, they have to, they take it from home, they don't have to come in. A little less than half of those said they take call and they may have to come in if there's an admission or something that needs to be done on service, they may have to come in for that. And then we asked about ICU responsibilities. And so 53% of you noted that the APPs work in the ICU and have some level of ICU responsibilities. Only a third of those said you actually have an ICU focused APP team. And again, I'm sure that has to do with volumes, and the size and the need within your ICU patient population. For those that have ICU coverage, 24% said it's business hours and weekends, so just during the day. 29% said just during the week. So day shifts during the week, not weekends. And then 48% of you, so almost half said we have a 24-7 APP ICU model. The roles and responsibilities, very similar to the general clinical cardiology, rounding consults, direct patient care management, admissions, they bill for some of their own services, night coverage, higher number of procedures, which makes sense. And then again, a little bit of that bed management. And then for those of you that have a focused ICU team, a third of you said it's a 12-hour shift. So I don't know, 7A to 7P, 6A to 6P. 22% said 10 hours, 22% said eight hours, and another 17% of you said no shifts, they stay until the work is done. So that doesn't necessarily mean that all of these are in a 24-7 coverage model, they're not, but they are a team that only works out of the ICU. And then in that coverage, I just mentioned 48% said 24-7, 29, and 24, you can kind of see how that sets up there. And then the last question we have on the acute care side, which really pulls in probably our CV cardiovascular slash cardiothoracic surgery colleagues, what sort of CV OR responsibilities do they have? And those that are working on that team. So 89% do chest tube removal, 78% line removal, 70% first assist in the OR. And then you can see line placement, chest placement for more than half, a 44% assist in chest closure, 41% second assist in the OR. And then we have 7% that are involved in transplant harvest. That again, may be more related to the number of programs that have transplant is very small. So likely a fairly common responsibility with that team when they work on that transplant service. Okay, the last section here, and then I think we'll be able to have a couple minutes for questions is EP. So our goal over the next few annual surveys is to start to bring in some specialty areas. We won't ask these questions every year. But I think as we get into whether in this case, we started with electrophysiology, next year, I'm hoping for heart failure, and we'll start to cycle in some of these specialty areas. So for EP, APP is working in EP, these are the common roles, 96% of you that use them in EP said EP clinic, 85% said hospital service and 49% said device clinic, 21% mentioned the EP lab. So then I went through each of these and I said, well, what's the primary responsibilities or the common responsibilities? In the lab, it's pre-procedure H&Ps, procedure orders, only 22%, they actually provide procedure assistance and scrub into procedures. Now, again, I'll give you my word on the street, I believe that most of those are related to loop recorder implants. I see that a lot as far as EP, APPs being the implanting provider or remover for those procedures. EP clinic responsibilities. So now what's happening in the clinic, 33% said they do a third, do new patients and consults. So new referrals, they will start those referrals. 100% said follow up visits, 78% said urgent and 59% said device interrogation. So for all of you, they're asking, should my EP, APPs learn about device management and device interrogation? Almost two thirds of you that use them in that space say yes, they do interrogate. And I would say that's a great place for professional development and a great additional skill for that team member to have. And in fact, I'm going to talk about education here towards the end. But we've got a really good EP set of modules around education for your EP, APP team members. All right, from an acute care responsibility. So in the hospital, 58% do admissions, 91% describe consults, 100% do daily rounds, 95% do discharges and 44% do device interrogations in the hospital. So again, I think another valuable skill for your APP team. They are not meant to be your primary device clinic person doing all the interrogations. This is for patients that in the time and we need to make a clinical decision. And I need to understand what's been happening with their device in order to do that. I need the skill to be able to grab the interrogating machine and place it on the patient's chest and understand the data that's coming out and understand how to make appropriate adjustments. So I'm not talking about utilizing them as your full time device interrogators and device clinic management, device management, I'm talking about when clinical decisions need to be made as part of their evaluation of the patients that they're seeing. So that brings me into device clinic responsibilities, 83% that use them in the device clinic, they do you do interrogations, I would advocate that again, you're not using them as your primary device management team. That's an RN, that's a device tech. And so if that's the case, I would transition them away from that as their primary role and put them in more patient care delivery type roles, 58% so that they can do device programming, and then a smaller portions that other with that behind that other is really patient management. So patients that come in for device, how many times do they come in and I'm a little more shorter breath than I was and oh, by the way, our optimal numbers are up or, oh, we had a run of a fib last night, or they went into a fib using an APP and that in that environment can allow for very quick decision making on those patients and reduce time to treatment, and as well as offload your device clinic team in a way that they can continue to manage the devices, because you've got somebody readily available to manage the patient care that's required when those things come up. So with that, I'm going to leave you with and I've got a few other things to talk about, but that's the end of the survey results. But transforming care together, APPs are an important part of your transformation strategy. We proven by data that they can assist with access and program capacity. We've proven by data that they can assist with patient throughput. And we've proven with data that they are a valuable member and really all settings of care when it comes to cardiovascular care delivery. So a couple more things I want to leave you with one is over the last five years, we have, I think, done a nice job of putting together an APP Academy, you go all the way back to one of my original kind of key topics for this year, it's workforce. And at the bottom, I said, you know, I think we have access to APPs, certainly much more access than we do to new physicians. And that's not going to get any better in the short term when it comes to the physician side. So APPs and adding to your team to manage appropriate provider workforce is a really great way to do that. But it's about the way we use them and about the way we prepare them for the use, it's going to make the difference. And I will tell you all the difference in the world. So our Academy is really set up to help with your onboarding, help set up with the essentials of cardiovascular care and getting them into the guidelines. And then we've developed a number of specialty courses, we launched a heart failure last year that includes general community heart failure, all the way to advanced heart failure and some genetics. We launched the year before our electrophysiology course that talks about arrhythmias and device management, it's not going to teach them to be full blown device interrogators, but it's going to make them and help them understand the devices and the way they work and how to understand what the device is doing, and then therefore understand when it's not working appropriately. And then we are in the process this year of putting together a peripheral vascular education opportunity and lipids and starting to get into some of the prevention cardiometabolic lipid, that certain thing. So those are all literally in the process of the content being developed. And we will be launching them later this year. We also have an acute essentials course focused on inpatient care that came out a few years ago as well. I will also tell you I'm thrilled. We have over 1000 learners that have been through those courses. And the number every month continues to go up. I'm grateful to those of you that have built it into your onboarding strategy, and have offered it to your team members. And we've gotten some really nice feedback. We're happy for all the feedback. So if there's things there's gaps there, please, please let us know we're striving to continue to improve that and make sure we meet the needs of all of you and the team. The second one is this report, you can download at medvaccine.com backslash reports. And the actual full link to the report was in the chat if you want to pull it from there. But please download it, socialize it, send it to all your friends and family, but send it to your leaders, send it to your team, send it to your colleagues. I think there's some really valuable information in here that will make us all smarter. So with that, I'm actually going to stop sharing screen. And we do have just five minutes for some questions if there were or Jerry, if you have any additional remarks. We do have about 10 questions, Ginger. But Jerry, I'll let you go first if you have anything you want to add. No, I think it was beautiful. Ginger is always I think the fact that so data driven is crucial. And I think that we need to work as you said to make every year, a little every year's data a little bit better than the year before. And I think that we're well on the way. But there's a handful of really good in fact, a couple of handfuls of really good questions. So why don't we go ahead and let you get started on that. The first question, I'll take the softball that is will there be a live recording available for this session? The answer is yes. So from this point on Ginger, it's you. Okay, there's nothing new there. Katie, go ahead, please. Perfect. Okay, the first question Ginger was for an APP working in the clinic, what percent of their time should be doing independent clinics versus other role roles? Does MedAxium have an industry standard? In Ginger, I'm going to I am going to let's make this a lightning round. Okay. Okay. All right, 80%. And we've said that before, we've got webinars that describe that. So 80%. Perfect. Do you have any data on how many organizations bill incident to? We do not. And it's less and less so as because there's a lot of rules around it. And frankly, depending on how your system is set up and the types of patients your patients are seeing, not very many of them fall within the rules these days. And so a lot of organizations have just gone away with it. I would say it's less than half, but don't quote that as a data driven opinion. It's an opinion or Perfect. Is there a regional breakdown of average salaries? There is. So whoever asked that, we'll get your name and we can give you some information that's more specific to your region. I believe there is a regional breakdown in the full report. But if not, we can get that out. We do have the ability to segment it. This is a comment regarding RVUs are blended data from Sullivan Carter and MGMA reflects a medium of 1550. I appreciate this data. It's clearly consistent. So thank you for that comment, Mark. Next question, how many hours is considered a full day for this survey? I believe you covered that with one of the graphs this question came in. Yes. So we asked it more in a 40 hour work week or I shouldn't say 40, a full work week. And it was that 40 to 45. So the majority of the respondents said greater than 40, less than greater than 45. So I'm going to estimate that it's somewhere between 40 and 45. Perfect. What is your estimate as to how the attribution of RVUs is handled for integrated practices? Say that again, Katie. What is your estimate as to how the attribution of RVUs is handled for integrated practices? So that is where I think I want to put the caveat in when you saw the difference between the private median and the integrated median that we spend, especially on the hospital side where we're doing split shared visits, and the bulk of the work that we do, although we all know it's a little harder to meet though, the guidelines that are needed for that these days, but the bulk of the work that the APPs are doing are on the split shared side, meaning that those those RVUs are allocated under the NPI of the provider that it was dropped, which would be the physician. Now here is the take home that you should all go back to your revenue cycle team and your accounting team. We add We advocate that you keep track of rendering provider, that means I'm the one that provided the service, I may not have been the billing provider, the billing provider would happen under the incident to setting or the split shared setting, although again, split shared, we are both rendering a portion of the service. And so we all do that math a little bit different. Some people they do keep track. And those RVUs that they were rendered by the APP, come back over to the APPs assignment or allocation. And others, we don't keep track of rendered. And so if I got billed under provider, there's an assumption that that provider performed that service, even though if it's an APP or team based model, likely that's not what happened. So it's important to go back to your organization and kind of find out how that's kept track of. But that's a couple of options. And to be fair, those if you're an incident to organization, and that's how it's that it's captured under the billable provider, then likely your APP team is going to look much less productive. And I think that's that's one of the things that we're seeing. And I'm glad that our data and the other survey data is consistent, though it should be because we're measuring the same things. But I would say that our even though I would say that our measurements sometimes aren't always accurate reflection of the work that's being done. I would also say, though, I get into enough organizations, and I see still a significant mismatch of our roles and responsibilities, that sometimes that's not a math problem. That's a role and responsibility problem. I think we're at time ginger. So the remaining questions, I don't know if you want to take any more. Do you want to answer them via people want to stay on? I got another minute. So why don't we just answer them? It's in the recording. And if anybody wants to jump off and come back to the recording, they got them or if they want to stay for another five minutes. Perfect. Okay. Um, this one's another question about how the data is broken down. Do we have it between APP involvement and inpatient versus outpatient stress test performance? I do not. So we can make a note of that for next year. Yeah. Are the APP to see patients in the ICU critical care certified? I do not know that either. I know that's for some, that's an opportunity. It depends. I think PA versus nurse practitioner and what some of those opportunities are for additional training. But I we did not capture that. So in my experience would suggest not very often, they get that extra training working with those ICU physicians, whether those are cardiologists or intensivists. And so they you know, there's the competencies, they are credentialed to do certain types of procedures and see certain types of patients. So there's definitely infrastructure around that. But it's usually at the local level. And then competency assurance and sign off so that there can then go on to take care of those patients. All right, another question about salary salary breakdowns, are we able to break it down by experience, i.e. newcomers or early career versus established? At this point, we do not have that level of data. But again, I'll make my list as far as our opportunities for next year, if we're able to capture that. Perfect. And then last question, looking to add the first two APPs to our small group of six physicians, any suggestions or trends and how to split their time between clinic and hospital? So I think the question you need to think about is where are your biggest access needs? And the way even from a physician time perspective, how and where you want the physicians focusing their time. So if you have a procedural physician working out of a hospital that has to be there either way to do a handful of procedures a day. And so their assignments going to be in the hospital, you may and you've got access issues and needs for follow up care in the clinic, a great place to start would be putting the APP in the clinic, start to see a lot of those follow ups that frees up the physician to spend more time in the procedural space, and or seeing the new patients. So when they are in clinic, the bulk of their patients are the significant portion, maybe a third of their patients are new patients. That's a great way to start to start that. If the flip side of that is you've got multiple hospitals that you're covering, and you're not necessarily doing procedures and things and it's lower acuity at the hospitals, and have an APP provide some consistent coverage, patient throughput, and just being available, that might be a great place to start in that offloads a physician from having to be there so that they can spend more time in the clinic. So a little bit of the answer to the question has more to do with your coverage needs, and where the bulk of your work is and how you want to utilize your positions and then where the APP fits into that puzzle. Right, I believe that is it. And if there's any, any that we missed, we can always follow up offline. All right. Thanks, everybody. Thanks, Ginger. Thanks, Katie. We really appreciate everybody's support about Axiom. Anything we can do to help you give us a call. Thanks. Have a great day.

Ginger Beesbrock

EVP of Care Transformation

Cardiovascular APP Compensation Utilization Report

MedAxiom's database

healthcare organizations

advanced practice providers

cardiovascular care

utilization of APPs

compensation and benefits

workload and responsibilities