There is nothing that strikes fear in an administrator’s heart more than their dyad partner saying, "Let’s add a compensation model review for our next group meeting!" Whether you work in a hospital-employed setting, academia, or private practice, an equitable and sustainable compensation plan is paramount to a successful work environment.

Hospitals and providers alike face unprecedented challenges and a pace of change never experienced before. Increase demand, provider shortages and cost pressures abound. While there is physician compensation — and both model design and distribution methodologies are difficult enough — let’s add team-based compensation!

As we continue this journey to value-based care and caring for our patients across the continuum, it is imperative that we design a compensation model that promotes team work, efficiency and exceptional patient outcomes. In order to transform care delivery models and deliver clinical services throughout a patient’s transitions of care, we must incent the correct behaviors.

Compensation for physicians is discussed in many venues — specifically at ACC’s Annual Cardiovascular Summit. I encourage all to attend this year, Feb. 14 -16, in Orlando, FL. Multiple sessions will be held on this critical topic — both physician and team-based compensation.

However, let’s talk about team-based compensation: is anyone really doing this? What is it?

Compensation and productivity need to be discussed in tandem. It is crucial that you have mechanisms to measure and report APP (advanced practice nurses and physician assistants) productivity. Monthly reporting of independent visits, incident-to, shared-services and triage activities are also important. Clinic schedules need to be designed and supported as they are for any provider. APPs should not be rooming their patients or doing chart prep — remember that top of license? Seeing two to three patients an hour in four-hour clinics for cardiology seems to be the norm.

Designing your electronic health records to capture “incident to” in the office and shared services in the hospital (inpatient and outpatient) settings is critical, along with aligning all practices with complex legal, regulatory and compliance regulations. Understanding how you utilize your team (this is not a one-size-fits-all) is a major first step.

Tiered bonuses that are based on care of a “team” panel of patients (how many “unique” patients are under your team’s care) or on achieving “team” quality goals (quality, patient satisfaction and access) are slowly emerging. While the typical cardiology panel is evolving, it ranges from 900 - 1,800 patients and is measured over an 18-month time frame for unique encounters.

Ensuring that everyone is working at the top of their license is the first and most crucial step. Essentially all physicians, APPs, nurses, patient care technicians, secretaries and others have critical roles to play in the care of our patients — and everyone needs to perform appropriately to make it all work. Pay is dependent on this concept. To ensure the incentives are aligned, we must resolve the work RVU (wRVU) tug.

If the physician compensation model is a strict $/wRVU — with no acknowledgement of the collaborative nature of the team — the use of APPs will most certainly lag. Legal and regulatory changes are needed to allow this redesign and ensure financial equity. Compensation of physicians for APP supervision is prevalent in many systems, which may help.

As call becomes an increasing burden — both the frequency and call burden — it is imperative that we align our APPs and physicians. Many practices are implementing various designs for this from APPs triaging calls to 24/7 in-house coverage. Payment for this is complex and challenging since data is sparse. Deciding if call is a routine component of the job or is paid separately requires discussion, data and market analysis.

Alternative payment models (APM) may serve as the needed catalyst in redefining compensation for team-based care. These models will continue to shift clinical and financial risk to providers, which will then facilitate the search for mechanisms to deliver high-quality care while minimizing costs.

Trying to design these models keep me up at night! Can a shared wRVU model work? Are we even ready for this approach? For guidance on focus areas for potential APM participation, the ACC developed an APM Framework at ACC.org/APM.

Structuring your physician and APP programs in a complementary vs. competitive manner will reduce tensions and competition, help with recruitment and retention, allow for a team approach to care redesign goals, and show support of a culture that supports the growth of team-based care.

This article was authored by Cathleen Biga, MSN, RN, chief executive officer at Cardiovascular Management of Illinois in Woodridge, IL.