Making the Case for Improving PA Utilization and Retention

Andrejs Avots-Avotin, MD, PhD — widely known as the nickname “Triple A” — vice president for medical affairs at Baylor Scott & White Health (BSWH) in Texas, has long been a champion of PAs and is a leader in developing the new structures and processes that will allow PAs and nurse practitioners (NPs) to flourish at BSWH. This Q&A was originally published in December 2016.

Andrejs Avots-Avotin, MD, PhD.


Q. Why did Scott & White Healthcare and Baylor Health Care System merge in 2013?

A. There were three main reasons, following the triple aim:

  1. Improve the patient experience. Honestly, we had become quite doctor-centric; we needed to become more patient-centric. Healthcare is a unique service industry — we have to put the patients’ needs above our own.
  2. Reduce the cost of healthcare. The U.S. spends 18 percent of our gross domestic product on healthcare, and our results are only middle of the road — it’s unsustainable. It has become part of our culture to try to cut costs when we can. Some things we do may seem like small savings, but when you multiply a few pennies a day by 40,000 employees, over the course of a year, it becomes real money.
  3. Practice population health. This was probably the biggest challenge for us. We have been great at taking care of sick people, but the challenge has been flipped now — we have to keep people healthy and well and keep them out of hospitals and clinics as much as we can.

These are three difficult things to accomplish, and we can’t do it by doing the same things we have done in the past.


Q. You have more than 800 PAs, NPs and others now. When did you start hiring so many?

A. Back in 2000 we had two — [current AAPA Board of Directors member] Laurie Benton was one of those. We started recognizing the need to expand access and services and grew quickly to about 120 [PAs and NPs], then stayed fairly steady for a few years. Then around 2009, all of these things started happening: healthcare reform, the triple aim, new compensation models, patient satisfaction, increasing access. We hired as many physicians as we could but knew it would not be enough and we needed to start hiring more [PAs and NPs] as well.

We have a same-day-access program — if a patient calls in the morning, they’ll get in that day; if they call in the afternoon they’ll get in the next day. And we could not do that without our [PAs and NPs]. So we have a very large system with many [PAs and NPs]. And I can get two good PAs for one doc; it’s not a bad deal.


Q. How do you recruit and retain PAs?

A. It is competitive out there; it can be hard to find them. We are often looking for experienced PAs, with experience in medical and surgical subspecialties or with administrative experience. It is particularly difficult to find intensivists, so we are developing a program where we train [PAs and NPs] to become intensivists. It can also be hard to recruit in Temple, Texas, or some of our smaller communities. So we pay a geographical stipend.

We have a dedicated APP recruitment team now. We go to schools and try to recruit people, we offer preceptorships, we go to meetings and conferences. And we are trying to build the infrastructure that will attract and retain [PAs and NPs]. We need to create an environment where it’s not just the salary that attracts an APP, but we have a collaborative environment and we encourage our [PAs and NPs] to stay and grow and become leaders within the organization.

We are also looking at things like enhanced training, loan repayment, increase in CME time and money, more flexible schedules.


Q. What kinds of things are you doing to build that collaborative environment?

A. We are really working hard to move toward having our [PAs and NPs] work under a medical model, reporting to other [PAs and NPs] and physicians rather than through our HR system. We do have an APP Council, which is being modified with the merger.

And scope of practice is very important: Every one of us has to practice at the top of our licenses. Our [PAs and NPs] are not staff; they are providers. If we are really going to bend that cost curve and really impact population health, we have to take the [PAs and NPs] out of HR and put them under a medical model and pay them like we do physicians on that type of a productivity model.


Q. Tell us about the new administrative structure you are introducing for PAs and NPs.

Avots-Avotins with Robert Probe, MD, BSWH executive vice president & chief medical officer, and PA Laurie Benton, system director of PAs and NPs for the health system. Benton is also a member of the AAPA Board of Directors.

A. We are working hard on that. We have an [PA and NP] system director and also [PA and NP] practice administrators and managers, who will oversee 10 or so [PAs and NPs]. Managers have one day a week protected time for administrative duties like hiring and onboarding. We’ll give them training in management and leadership. Some people are naturally adept.

We are also starting to document competencies and provide a ladder that our clinical [PAs and NPs] can move up as they grow and learn — from advanced practice provider I to II to III. One day we hope to have a C-suite level position.


Q. You have a lot of quality initiatives under way at BSWH; what role do you see PAs playing in those?

A. You can’t pick up a newspaper without reading about quality these days. And our [PAs and NPs] are intimately involved in our quality initiatives. It can be hard to pick out the value of an APP in this process. But we have many quality measures — like The Healthcare Effectiveness Data and Information Set (HEDIS), for example — where our rates have gone up because of [PAs and NPs]. I know they have in colonoscopy. They are everywhere — being aware of who is ready for discharge and getting them out the door.

In osteoporosis management, our HEDIS measure for managing women who had a fracture was 17 percent in 2013. In 2014 we hired a PA, and now the rate is up to 36 percent and rising. It’s about paying attention to detail and getting the right people involved in these various initiatives.

And our length of stay has decreased because we are able to get people in and out of hospital more efficiently, thanks to our [PAs and NPs].


Q. In the reorganization that BSWH has undergone since the merger, what have been some of the challenges and opportunities?

A. One of the biggest challenges is communication. We had two large systems coming together, with different cultures and ways of doing things, different electronic health record systems, and we have had had to develop communications to get everybody on the same page.

You have to know who your stakeholders are, and that means everybody — including physicians, administrators, PAs and NPs, nurses, your communities, Medicare and other payers, students. You have to know your champions; figure out who you can trust and who will support you.


Q. How have you been able to sell this new structure to the physicians at BSWH?

A. This was not an easy sell. Some of the older, more traditional physicians were not keen on the idea of working with [PAs and NPs]. It’s a cultural shift that took some time and will take some more time.

The most important thing was that we had pockets of excellence where we had data to show the value of our [PAs and NPs]. We showed people this is not a bad thing.

And it is not just the physicians that have to be sold. You have to tell the stories about patient access and quality and cost, over and over again. You have to figure out how to tell the story a little bit differently to different stakeholders. You have to tell the stories to the patients and the community too — ultimately they are the end users.


Q. What is your take-away message regarding [PAs and NPs] for others considering going down the road that BSWH has taken?

A. I think [PAs and NPs] are the future. The reality is that there is a projected shortage of physicians of nearly 100,000. Who is going to fill that gap? It has to be [PAs and NPs]. And you have to think of [PAs and NPs] as providers. You need a collaborative model, not a supervisory one. Everything we do is based on a team model. We all have to work together as a team if we are going to accomplish the triple aim.


Steven Lane, MA, MPP, is the senior director of communications for the PA Education Association. Contact him via email or at 703-667-4349.