Nurse Clinician Productivity Using a Relative Value Scale By Geraldine C. Holmes, George Livingston, Rita E. Bassett, and Elizabeth Mils The use of relative value units to measure the productivity of nurse
clinicians in four primary care practices is described. Relative value points and equivalent dollar values assigned to services provided by professionals yielded a different assessment of productivity than that provided by a count of patient visits. The physician-nurse clinician teams studied were only 6 percent more productive than the physician-nurse teams when productivity was measured by the number of patient visits processed during an 8-hour period but were 26 percent more productive in terms of the value of services they produced per day.
Numerous programs have been established to train nurses and other types of health practitioners to serve as physician extenders. The most important objective of these programs has been to increase the supply of primary care services by relieving physicians of routine health care tasks. It has been assumed that physicians employing these new types of personnel would be freed to concentrate on more complex medical problems and that the volume and comprehensiveness of primary care services produced by the physicians and their practices would be increased. The effect of employing physician extenders on the volume of primary care services produced has been assessed in a number of previous investigations. In an earlier paper based on data from this study [1], it was found that a physician and nurse clinician working together were 31 percent more productive than a physician working with a nurse. Of this difference, 20 percent was directly due to visits managed independently by the nurse clinician. Other investigators have found that introduction of nurse practitioners or physician assistants resulted in an increase in the number of families served [2], in the number of patient visits processed [3-6], and in the net income generated by the practices [7,8]. Two studies, however, found only This research was supported by the Kansas Regional Medical Program. Address communications and requests for reprints to Geraldine C. Holmes, Medical Education Specialist, Department of Medical Education, Bethany Medical Center, 51 North 12th Street, Kansas City, KS 66102. George Livingston is a graduate student in psychology at the University of South Carolina; Elizabeth Mills is a graduate student in the health policy analysis program at Harvard University; Rita E. Bassett is a graduate student in health planning at the University of Pennsylvania. All authors were on the staff of the Kansas Regional Medical Program when this research began.
FALL 1977
269
HOLMES ET AL.
limited or no gain in productivity following the employment of physician extenders [9,10]. The productivity measure used in most of these studies was the number of patient visits processed in a standard time period. The number of patient visits per unit of time, however, is a fairly insensitive measure of productivity that does not reflect differences in either volume or complexity of services produced. Some visits require more time and skill than others and should consequently be assigned more weight when productivity is assessed. For visits in which two or more practitioners are involved, a count of patients seen does not allow a determination of the respective responsibility of each practitioner for processing the visits. This article describes the results of a study conducted by the staff of the Kansas Regional Medical Program between 1974 and 1976 to examine the effect of nurse clinicans on the productivity of primary care office practices. The nurse clinicians studied were graduates of a program established by the Regional Medical Program in Kansas to train experienced registered nurses for expanded roles in primary care settings [11]. Data for the study were collected in two practices before and shortly after introduction of a nurse clinician, and in two other practices that had employed nurse clinicians for two years. Two measures of productivity were used: the number of patient visits and the value of patient services produced per unit of time. Two researchers timed and coded all services provided to patients by the physicians, nurse clinicians, and nurses. These data were converted into dollar and point values using a modified version of the relative value schedule published by the Kansas Medical Society [12]. This schedule indicates the worth of one procedure relative to any other on the basis of the amount of skill, time, and other resources judged necessary to produce the procedure. The relative value measure of productivity reflects the quantity and complexity of services provided by each practitioner as well as the number of visits produced. This measure more adequately describes the relative contribution of each practitioner to visits that are managed jointly. For all visits the measure permits comparison of the productivity of different types of practitioners, without the assumption that a procedure performed by one type of practitioner is worth more or less than the same procedure performed by a different type of practitioner. The relative value measure of productivity also reveals the economic effect of a practitioner on a practice, allowing estimation of the potential gross income generated by each practitioner.
Methods Comparability of Practices and Patient Populations HEALTH
SERVICES
RESEARCH
270
Three of the practices studied were located in small Kansas towns. The fourth was a suburban practice in the Kansas City metropolitan area. The physician in each practice had been in general or family practice for over 20 years, and the patient demand on each practice
could be described as moderately heavy. The patient population RELATIVE VALUE served by each practice was predominantly white middle or working PRODUCTIVITY class. In each practice the patients seen during the study were fairly evenly divided by sex, except in practice 2, where two-thirds of the patients were female. The patient visits observed during the course of the study were classified according to 15 problem categories and five types of well-care visits. No one practice was extremely deviant from the norm in terms of problems presented. In all practices more acute disorders than chronic disorders were presented in initial office visits, and reevaluations of problems during return visits were about equally divided between acute and chronic conditions. There was some variation in the types of personnel employed by the physicians. Physician 1 and physician 2 were each assisted by an office nurse and two office record keepers during the first observation period. Physician 1, in the second observation period, and physician 3 were each aided by a nurse clinician, an office nurse, and two recordkeeping assistants. Physician 4 employed a nurse clinician, two office nurses, a laboratory technician, and three record-keeping personnel. In practice 2 the same individual was observed as a nurse in the early part of the study and as a nurse clinician later, but in practice 1 the nurse and nurse clinician were different persons. A number of limitations should be noted concerning the beforeand-after comparisons that could be made in practices 1 and 2. In practice 2, posttraining data were available only for the nurse clinician because the physician left the practice after the nurse clinician completed her preceptorship with him and the physician who replaced him did not wish to participate in the study. In practice 1, a substantial increase in malpractice insurance rates during the nurse dinician's training period led to a decision by the physician to discontinue performing surgery that required patients to be hospitalized. This decision apparently reduced the physician's need to delegate responsibility for the care of office patients and undoubtedly affected the nurse dinician's impact on the productivity of the practice. Data Collection Two researchers observed, timed, and coded activities of the physician and nurse or nurse clinician during six data collection periods, each from 9 to 15 consecutive workdays. Timing of activities began when the professional arrived in the office and continued through the working day. All services provided during face-to-face contact with one patient on a given day were defined as a single patient visit. Each visit was identified by the age and sex of the patient, type of visit (initial visit for a problem, return visit for a problem, return visit for a treatment procedure, or a well-care or service visit), and nature of the problem(s) presented. Problems were coded according to 16 general and 103 specific categories based on the ICDA [13]. Time spent in each patient visit was classified using the following activity categories: conversation
FALL 1977
271
HOLMES ET AL.
HEALTH
SERVICES RESEARCH 272
(to establish rapport), history taking, physical examination, special tests and measures (e.g., less-common tests such as visual acuity, throat cultures, EKG, or drawing blood), charting, treatment procedures, education and counseling, and other (activities not classifiable elsewhere, e.g., preparing the patient or equipment or consulting with a colleague). For each professional in each patient visit, examination steps, procedures and special tests, and diagnostic tests and recommended treatments were also recorded. In some cases the observers were excluded from part or all of a visit. Because application of the relative value formula depends on a record of the time spent in activities within visits, visits for which data were incomplete were excluded from the relative value calculations. Nonvisit activities observed included patient and nonpatient telephone calls; reading charts, laboratory, and x-ray results; reading office correspondence and educational material; writing in patient charts; filling out insurance forms; working on office administration; writing professional papers; consulting with staff; social conversation with staff and patients; performing laboratory tests; preparing equip. ment and rooms; dispensing medication; conversation with the observer; and breaks and waiting periods. These activities were coded using behavior-specific categories that facilitated observation and timing. They were regrouped in functional categories in the subsequent analyses. The observed professionals were also interviewed briefly each day regarding the time they had spent in professional activities outside of office hours, and each staff member of each practice was interviewed to obtain qualitative data about the practice. In each practice the reasons for the study and the observation methods to be employed were explained in advance to the physician and nurse or nurse dinician; they participated out of concern for the objectives of the research and received no payment for their cooperation.
Relative Value Computation The relative value of services provided by each professional observed during patient visits was derived by applying a modified version of the Kansas Medical Society (KMS) relative value schedule [12] to the patient visit time and activity data. Values for services are expressed in points which, as in the California relative value system [14], are presumably based on the prevailing state median charge for identified services. The KMS relative value system does not provide separate values for all of the types of office visits distinguished in this study, nor does it indicate how points should be distributed among activities performed during visits. Therefore 12 general practitioners in Kansas were asked to provide estimates of the relative value of visits not listed in the KMS system and to indicate how the relative value points for all types of visits should be allocated among activities usually performed in the visits. The types of visit activities to which values were separately
Table 1. Relative Value Units and Dollar Equivalents for 14 Types of Primary Care Visits
RELATIVE PRODUCTIVITY
(Mean responses of 12 physician-judges) Dollars
Unit value
Dollar value
3.00
15.08
5.03
3.50
21.04
6.01
7.00 1.00
32.50 6.67
4.64 6.67
history and exam ............................ 1.25
9.38
7.50
14.02
7.01
Visit type
Problem visit 1. Initial problem presentation, limited* history and physical exam ........ ............ 2. Initial problem presentation, extendedt history and physical exam ........ ............ 3. Initial problem presentation, complete* history and physical exam ........ ............ 4. Return for scheduled procedure or test§ ..... .... 5. Return problem visit, limited*
per
unit
6. Return problem visit, extendedt
history and exam ............................ 2.00 7. Return problem visit, complete*
21.46
7.15
.........
1.09
6.32
5.80
............
4.00
27.08
history and exam ............................ 3.00 8. Retum visit for test information .......
Well-care visit 9. Comprehensive general exam .......
10. Limited exam ................................. 2.07
12.46
11. Prenatal or postnatal exam ........
1.85
10.10
6.77 6.02 5.46
12. Well-baby checkup ............................ 1.91
11.50
6.02
............
6.47 13. Insurance, work, school, or camp physical ...... 2.75 17.79 14. Service visitS (e.g., ear piercing or vaccination) .. 0.98 6.38 6.25 * Limited = examination of one or two of nine body areas or systems. t Extended = examination of three to six of nine body areas or systems. * Complete = examination of seven or more of nine body areas or systems. § Points for the visit do not indude the value of the test or procedure performed.
assigned were social conversation to establish rapport, history taking, physical examination, evaluating the problem and prescribing treatment, charting, and patient education and counseling. The responses of the physician-judges were averaged to produce the required values for visits and activities within visits. The average values assigned are presented in Table 1 for each type of visit; values for activities within visits are shown in Table 2 (p. 274). Table 1 also shows the average charge estimated by the physician-judges and the resulting dollar value per relative value unit for each visit type. The relative values shown in Tables 1 and 2, plus other values from the KMS schedule, were used to compute the relative value generated by each professional in the visits and activities observed, as follows: 5
RI'1 = Ve + V,p + Via + E Wa [t.a/(t,a + tia)] a=1 where RV, = the relative value generated by practitioner i in a visit V. = the relative value assigned for evaluating the problem FALL and prescribing treatment (this quantity was always as- 1977 signed to the physician in shared visits and was set at 273 zero when i represented a nurse or nurse clinician)
HOLMES ET AL.
Table 2. Relative Values of Activities Within Visits (Mean responses of 12 physician-judges) Visit
type*
A
Conver- History Physical Evaluation, Charting Euain sation exam prescription coseling
1....... 3.00 0.22 0.94 2 ...... 3.50 0.20 1.19 3 ...... 7.00 2.50 0.41 4 ...... 1.00 ... 0.12 5 ...... 1.25 0.09 0.30 6 ...... 2.00 0.12 0.52 7 ...... 3.00 0.83 0.21 8 ...... 1.09 ... 0.14 9 ...... 4.00 1.47 0.24 10 ...... 2.07 0.19 0.64 11 ...... 1.85 0.13 0.42 12 ...... 1.91 0.48 0.12 13 ...... 2.75 0.17 0.85 14 ...... 0.98 0.14 ... * See Table 1 for visit description.
0.64 0.86
1.87 ...
0.49
0.48 0.81 ...
0.24 OA1 0.68 ... 1.18 0.49
0.22 0.36 0.53 ... ...
0.58
0.58 0.95
... ... ...
...
...
...
0.27 0.30 0.67 0.21 0.13 0.20 0.29 0.20 0.47 0.27 0.19 0.19 0.37 0.28
0.44 0.47
0.74
0.67 0.27 0.39 0.46 0.75 0.64 0.48 0.53 0.54 OA1 0.56
Vip = the value of any treatment procedures performed by practitioner i during a visit V = the value of any spedal tests and measures performed by practitioner i during a visit a = 1, . . . , 6, representing the types of activities (other than treatment procedures and special tests) within visits for which time was recorded and relative value weights were assigned ta= time spent by practitioner i in activity a during a visit tja = time spent by practitioner j in activity a during a visit Wa = the relative value weight (from Table 2) assigned to activity a
HEALTH RSEARCH
274
A computer program was designed to assign visits to relative value classes on the basis of type of visit or primary problem presented and on the extensiveness of the physical examination steps performed in the visits; the program also selected the appropriate relative value weights for visit activities and computed the relative value totals for each practitioner. The output of this program was then used to calculate the average relative value per visit, the projected relative value per time period, and the projected potential dollar income per time period for each practitioner (computed using the average dollar value per relative value unit for all visit types). Independently performed direct care activities were emphasized in assigning relative value units and in calculating potential dollar values generated. For example, no relative value points were allocated to a practitioner for assisting during examination of a patient, assisting with a procedure, consulting with a colleague, or observing during a
visit.
of Data Collection and Analysis Procedures RELATIVE The projected dollar amounts found for each practice may not VALUE reflect the actual income these practices generated. The KMS relative PRODUCTIVITY value schedule, published in 1966, is not used in all Kansas practices. The office visit rates in the schedule are similar to rates charged in many Kansas practices, but the definitions of patient visits used in this study do not necessarily conform to the definitions used in these practices for billing purposes. Dollar amounts are given only for Limitations
comparison, to emphasize differences in productivity in a way that is easily understood. Allocation of relative value points on the basis of time spent in various activities ignores possible differences in productivity due to differences in the speed with which professionals performed similar tasks. Another limitation is that office personnel not observed in this study were sometimes involved in completing patient visits (measuring vital signs, for example). Such services constituted part of a patient visit and accounted for some relative value, but they were not induded in the calculations. Thus the relative value totals assigned to observed practitioners in such cases were somewhat inflated.
Results Differences in Workday and Role Variations in workday among the persons observed reflect role differences related to individual and practice productivity. The average time spent by all three types of professionals in and outside the office
Table 3. Average Workday and Distribution of Office Time Physician Activity Activity
nurse With With_nurs #1 #2*
#1
8.20 8.69 2.36 1.86 5.84 6.83
9.50 7.58 0.20 0 9.50 7.38
8.53 8.51 8.13 8.15 3.64 1.49 0.63 2.11 4.89 7.02 7.50 6.04
55.9 54.4 8.2 1.0 0.3 0.2 3.1 10.3 5.4 3.9 5.5 10.2 6.7 2.9
18.5 27.1 6.3 3.6 2.3 0.7 8.1 4.5 2.6 0.8 6.7 7.8 36.4 1.6 0.4 0.7 9.7 9.3 0 0.7 4.8 12.6 1.5 27.4 2.8 3.2
62.3 35.7 479 40.7 1.1 3.2 15.3 1.5 1.1 0.7 0.4 0.7 4.7 15.8 9.3 18.0 0.4 2.3 6.3 2.2 5.1 17.0 4.0 6.7 1.8 0.5 1.1 IA 3.0 0.1 2.5 0.6 5.6 3.7 2.4 5.9 1.6 3.1 0.9 5.7 3.6 9.2 1.1 5.0 5.2 7.1 6.3 8.5 4.5 1.7 2.6 3.2
dinician
Total working day, hr. 9.33 10.03 7.77 Outside office, hr ...... 2.83 4.91 1.83 5.94 ... 6.50 5.12 In office, hr ... Patient visits, % of office time ............... 64.2 57.0 63.3 1.6 1.6 5.6 Telephone, patients, % . Conversation, patients, % ... 2.5 0.5 2.5 Charting, % ................ 5.7 11.1 6.2 1.6 Telephone about patients, % . 2.1 2.3 8.5 Conversation, staff, % ....... 4.9 7.7 1.4 Administration, % .......... 32 3.7 OA lab tests, % ............... 0.7 0 Equipment upkeep, % ...... 0.2 OA 0.1 1.0 0.4 Study, % ..................0. 7.1 Breaks and personal, % .... 4.3 4.5 4.5 2.8 6 Transit and other, % .....4. 2.4 Time with observer, % ..... 42 3A * Before nurse dlinician joined practice.
Nurse clinician#4 #2 #3
Nurse #1* #2*
With nurse
#1
#3
#4
1.9 0.6 0.9
0
4A 42 3.0
4.0 7.5 3.8
1.0 0.8
HOLMES ET AL.
and the distribution of their office time on a typical workday are shown in Table 3. (Note that in tables and in the text, physician 1 and nurse 1 constitute practice 1, physician 2 and nurse 2 constitute practice 2, and so on. Physician 1 and nurse clinician 1 constitute practice 1 at a later period of the study.) Relatively few differences were found among the physicians in the general use of professional time. All of the physicians spent over half of their time in the office seeing patients, and there were no uniform differences between physicians with and without nurse clinicians in the time spent in any office activity. Minor differences in time spent in conversation with staff, on the telephone with patients, or in other activities appeared to result from physician preferences rather than from presence or absence of a nurse clinician. Physician 1 spent about 34 minutes less time in the office per day after addition of the nurse clinician. However, the other physicians working with nurse clinicians did not spent less time in the office than the physicians with nurses. All of the physicians with nurse clinicians had shorter total workdays than the physicians without nurse clinicians. For physicians 1 and 4, some shortening of the workday resulted from the nurse clinicians' making some hospital, home, and nursing home
visits. There were significant role differences between the nurses and nurse clinicians in the practices observed. All of the nurse clinicians spent more of their office time in patient visits than did the nurses. The nurse clinicians spent from 35.7 to 62.3 percent of their day in patient visits, whereas the two nurses spent 18.5 and 27.1 percent of their time with patients. The nurse clinicians also spent more time studying and less in -upkeep of equipment and office than did the nurses. Other differences in the workdays of the nurses and nurse clinicians resulted from task assignments and work conditions specific to each practice. Nurse clinician 3 spent more of her time than did the others in telephone calls to patients because she was given the task of reporting laboratory test results as they became available. Nurse clinicians 2 and 4 often worked on patient records when patients were not present. Nurse clinician 2 spent a relatively high percentage of her time consulting with other staff members, particularly with the physician, regarding visits she was managing. Nurse 1 was the primary bookkeeper for the practice and consequently spent a large part of her day in office business and administration. In practice 2 a substantial part of the nurse's time was spent waiting for patients to arrive or for duties to be assigned to her. The nurse clinicians averaged less time per day in the office than the nurses, but their workdays were equivalent to those of the nurses since they spent time in hospital, home, and nursing home visits, study at home, patient telephone calls, and consultations outside the office. HEALTH Nurse clinicians 1, 2, and 4 reported spending between 1.13 and 2.22 SERVICES RESEARCH hours per day in hospital, home, and nursing home visits; only in practice 2 did a nurse report any time spent in home visits. The practices differed in the independence with which physicians 276
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and nurse clinicians managed patient visits. Physician 1 was assisted by the nurse clinician in over half of the visits he processed, whereas physician 3 and his nurse clinician worked more independently of one another. Nurse clinician 2 managed many more visits independently than she managed with the physician. Nurse clinician 4 managed few visits independently but assisted the physician in a large number of visits. Table 4 shows that the nurse clinicians independently managed more complex types of problems and spent more time in most aspects of both shared and independent visits than did the nurses. The nurses managed few evaluations and reevaluations of problems by themselves; most of the visits they managed independently involved procedures such as injections or ultrasound therapy. Nurse clinicians 2 and 3 independently managed a significant number of evaluations and reevaluations of chronic and acute conditions; the visits managed alone by nurse clinician 1 were most often well-care visits. Within both shared and independent visits, the nurse clinicians generally spent more time in history taking, physical examination, special tests, charting, and education and counseling than did the nurses. The physicians in these practices managed similar types of visits. After he hired the nurse clinician, physician 1 managed a smaller number of well-care requests than he had before because he delegated many of these visits to his nurse clinician. For the physicians with nurse clinicians, there were few differences in distribution of problems managed alone and with the nurse clinician. The exception was physician 3, who handled well-care visits with the nurse clinician more often than by himself. The distribution of physician time within visits was quite similar, but the physicians with nurse clinicians spent less time per visit, on average, than the physicians without nurse
clinicans. Number of Patient Visits Table 5 shows the projected numbers of patient visits that could be processed by the professionals in this study in an 8-hour day and a 240-day workyear, based on the observed output of the practices. The three physicians with nurse clinicians processed an average of 5.3 more visits per day, or 14.7 percent more than physicians working with nurses. Nurse 2 saw the largest number of patients with the physician before she was trained as a nurse clinician, and she saw the largest number independently after training. The nurse in practice 1 saw fewer patients than any of the nurse clinicians. However, the patient visit data do not reflect the full productivity differences among the nurse clinicians and nurses or among the physicians. The relative value of services provided during visits reveals a greater difference in productivity than is shown by the number of visits managed. HEALTH
SERVICES
RESEARCH
278
Differences in
Productivity
The differences in the productivity of individual physicians, nurses, and nurse clinicians studied are shown in relative value units and gross
Table 5. Projected Visits per Day and per Year That Could be Processed at Observed Rates of Work Visits per 8-hr day
Visits per 240-day yr
38.3 33.7
9192 8088
Physician with nurse clinician #1, all visits ................... 40.9 #1, shared visits ............... 22.1 #1, unshared visits ............. 18.8 #3, all visits ................... 42.5 #3, shared visits ............... 14.3 #3, unshared visits ............. 28.2 #4, all visits . -.........-.-.-.-.-.... .40.5 #4, shared visits ............... 17.5 #4, unshared visits ............. 23.0
9816 5 304 4512 10200 3 432 6768 9720 4200 5520
Personnel Physician with nurse #1* (all visits) .................
#2* (all visits)
.................
Nurse #1, shared visits .............. #1*, unshared visits ............
6.0
#2*, shared visits .............. #2*, unshared visits ............
23.9
6.1
9.5
Nurse clinician #1, shared visits ............... 22.1 6.1 #1, unshared visits ............. 2A #2, shared visits ............... #2, unshared visits ............. 10.1 #3, shared visits ............... 14.3 7.7 #3, unshared visits ............. #4, shared visits ............... 17.5 #4, unshared visits ............. 1.2 * Before nurse clinician joined practice.
VALUE PRODUCTIVITY
1 440 1464 5 736 2280 5 304 1464
576 2 424
3432 1 848
4200 288
dollar amounts in Table 6 (p. 280). Relative value projections for each subject were based on mean values per visit and the projected number of visits per 8-hour day; the projected dollar amounts were calculated as $6.21 per relative value unit, the average of the ratios shown in Table 1. The productivity of the physicians for a projected 8-hour day ranged from 68 to 105 relative value units ($422-$654); the productivity of the nurses and nurse dinicians ranged from 17.9 to 43.8 relative value units per day ($109-$272). Based on a 240-day workyear, the projected average annual gross amount generated was $51,345 for the four nurse clinicians and $36,508 for the nurses-$14,837 more per year for the nurse dinicians, an average productivity difference of 40.6 percent. The mean annual income projected for the physicians with nurse clinicians was $138,901,
FA7 2 279
HOLMES ET AL.
Table 6. Relative Value Units and Doliar Equivalents* per Eight-hour Day Produced by Each Worker, by Practice Physician Practice
All visits
#1 (with nurse) Relative value ........ 85.89 $ equivalent .......... 533.38
#2 (with nurse) Relative value ........ 67.95 $ equivalent .......... 421.97 #1 (with nurse clinician) Relative value ........ 82.67 $ equivalent .......... 513.38 #2 (with nurse clinician) Relative value ........
Shared Unshared visits visits
Nurse or nurse clinician All Shared Unshared visits visits visits
15A8 96.13
70.41 437.25
17.87 110.97
10.14 62.97
7.73 48.00
48.00 298.08
19.95 123.89
31.12 193.26
17.19 106.75
13.93 86.51
44.02 273.36
38.65 240.02
31.54
195.87
17.03 105.76
14.51 90.11
... 4.46 28.53 32.99 S equivalent .......... ... ... 204.87 27.70 177.17 #3 (with nurse clinician) Relative value ........ 91.59 26.17 43.81 65.42 22.17 21.64 $ equivalent .......... 568.78 162.52 406.26 272.06 137.68 134.38 #4 (with nurse clinician) Relative value ........ 105.33 37.71 67.62 29.46 27.06 2.40 $ equivalent .......... 645.10 234.18 419.92 182.94 168.04 14.90 Based on $6.21 per relative value unit, the average ratio from Table 1.
based on patient visits only; for physicians who had only nurses the annual average was $114,642. The difference represents a 21.2-percent difference in productivity. Considering the combined activities of physician and nurse or physician and nurse clinician reveals an even greater difference in productivity: the projected average annual income for the three physician-nurse clinician teams (neglecting practice 2, which is represented only by a nurse clinician) was $190,970, whereas the projected average income of the physician-nurse teams was $151,150. The difference in these amounts is $39,820, or a 26.3-percent difference in average productivity. Reasons for Productivity Differences The greatest average relative value per visit was generated by the physician-nurse clinician teams in practice 3 and practice 4; their averages were similar even though the amount of independent work by the nurse dinicians in the two practices was quite different. The physician-nurse clinician team in practice 1 generated less average relative value, but this did not appear to result from low productivity by the nurse clinician. Physician 1 received fewer relative value points per visit after he employed the nurse clinician: he delegated to the HEALTH nurse clinician some visits that had previously accounted for a disSERVIRCES proportionate number of his relative value points, and he performed fewer extended examinations, treatment procedures, and special tests. 280 Nevertheless, although the physician's productivity dropped slightly
between the two periods, the productivity of the practice was greater RELATIVE VALUE after the nurse clinician was hired. PRODUCTIVITY The most productive nurse clinicians were those who had the greatest independence in managing patient visits: nurse clinician 3, with the highest average relative value, had her points distributed fairly evenly between visits managed alone and those managed with the physician. Nurse clinician 2, who was second in individual productivity, shared few patient visits with the physician. The nurse clinician in practice 4 had the lowest average relative value per visit among all the nurse clinicians, but practice 4 was the second most productive studied. She and physician 4 managed most visits jointly, and he received relative value points for decisions made during the visits and a portion of the points for the activities he shared with her, which raised his relative value per visit and lowered hers. The nurse in practice 2 was more productive after nurse diician training than before: she averaged 31.1 relative value points per day prior to training and 33.0 after training, due to her changed role in the practice. All of the nurse clinicians generated more relative value in independently managed visits than did the nurses; they also (except in practice 1) generated more relative value in shared visits for history taking, physical examinations, charting, education and counseling, and special testing. All of the nurse clinicians except in practice 1 generated more relative value than the nurses for problem evaluation and treatment determination. The low average relative value generated in this category by nurse clinician 1 was due to the high percentage of well-care visits she managed independently, for which no evaluation and treatment-determination points were assigned. The nurses generally generated more relative value than the nurse clinicians for treatment procedures in both shared and independently managed visits. There were no consistent differences in the average relative values per visit generated by physicians with nurse clinicians and physicians with nurses. Physicians 3 and 4 generated more relative value points in independent visits than did the physicians with nurses; however, physician 1 generated less relative value per independent visit after he added the nurse clinician to his practice. The higher relative value generated by physicians 3 and 4 can be accounted for by the higher percentage of extended and complete initial and return visits they managed and by the fact that both took histories, performed treatment procedures, and gave education and counseling more often. The physicians with nurse clinicians all generated less relative value in shared visits than in independent visits and, with one exception, less relative value in shared visits than did the physicians with nurses. These differences occurred because more patient care tasks were assumed by the nurse clinicians than by the nurses in shared visits.
Conclusions
The difference in average daily productivity between the most productive and least productive physician observed was 37.4 relative
FALL 1977
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HOLMES ET AL
value points, or $232 a day. The average daily difference between the least productive nurse and most productive nurse clinician was 25.9 relative value points, or $161 per day. However, this study shows that it is important to compare the productivity of physician-nurse and physician-nurse clinician teams for the best picture of differences in practice productivity: the most productive team produced an average of 36.33 relative value points, or $226 per day, more professional services than did the least productive team. The average relative value productivity of all physician-nurse clinician teams was 128.13 points, higher by 26.3 percent than that of the physician-nurse teams. The use of a relative value schedule to assign values to services yields a different assessment of productivity than that found using a count of patient visits. On average, physician-nurse clinician teams processed 2.5 more patient visits per day, 5.7 percent more than were processed by physician-nurse teams. The 26-percent difference in relative value, however, suggests a mean difference of $166, based on the average of charges estimated by 12 Kansas physicians. The actual dollar equivalent of the relative value scale would of course vary in different parts of the country; it is used here only to illustrate the significance of the productivity differences found in terms of relative value. Ackowledgments. We express our appreciation to the four physicians who made this study possible by allowing us to collect data in their practices and to the nurses and nurse dinicians for their participation; to Ivan Anderson, who made an important contribution to the study by suggesting the use of a relative value schedule; and to Michael Grobe, who did the computer programming for the study.
REFERENCES 1. Holmes, G.C., G. Livingston, and E. Mills. Contribution of a nurse dinician to office practice productivity: Comparison of two solo primary care practices. Health Serv Res 11:21 Spring 1976. 2. Spitzer, W.O., D.L. Sackett, J.C. Sibley, R.S. Roberts, M. Gent, D.J. Kergin, B.C. Hackett, and A. Olynich. The Burlington randomized trial of the nurse practitioner. New Engl J Med 290:251 Jan. 31, 1974. 3. Voltmann, J.D. Jamestown medical clinic system. J Am Med Assoc 234:303 Oct.
20, 1975.
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4. Schiff, D.W., C.H. Fraser, and H.L. Walters. The pediatric nurse practitioner in the office of pediatricians in private practice. Pediatrics 44:62 July 1969. 5. Smith, R.A., J.R. Anderson, and J.T. Okimoto. Increasing physicians' productivity and the hospitalization characteristics of, practices using Medex: A progress report. Northwest Med 70:701 Oct. 1971. 6. Nelson, E.C., A.R. Jacobs, P.E. Breer, and K.G. Johnson. Impact of physician's assistants on patient visits in ambulatory care practices. Ann Intern Med 82:608 May 1975. 7. Yankauer, A., S. Tripp, P. Andrews, and J. Connelly. The cost of training and the income generation potential of pediatric nurse practitioners. Pediatrics 49:878 June 1972. 8. Nelson, E.C., A.R. Jacobs, K. Cordner, and K.G. Johnson. Financial impact of physician assistants on medical practice. New Engl J Med 293:527 Sept. 11, 1975. J.H., H. Wolfe, and K.M. Barker. The use of nurse practitioners in a 9. Merenstein, general practice. Med Care 12:445 May 1974. 10. Pondy, L.R., J.M. Jones, and JA. Braun. The Utilization and Productivity of the Duke Physician Associate. GS.B.A. Paper No. 61. Durham, NC: Duke University Graduate School of Business Administration, 1972.
11. Holmes, G.C. and R. E. Bassett. Primary care nurse clinicians in Kansas: Workingroles, motivation, problems and benefits. J Kans Med Soc 77:553 Dec. 1976. 12. 1966 Relative Value Studies. Topeka, KS: Kansas Medical Society, 1966. 13. Eighth Revision, International Classification of Diseases, Adapted for Use in the United States, Vol. 2. PHS Pub. No. 1693. Washington, DC: U.S. Government Printing Office, 1968. 14.1969 California Relative Value Studies, 5th ed. San Francisco: California Medical Association, 1969.
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clinicians in four primary care practices is described. Relative value points and equivalent dollar values assigned to services provided by professionals yielded a different assessment of productivity than that provided by a count of patient visits. The physician-nurse clinician teams studied were only 6 percent more productive than the physician-nurse teams when productivity was measured by the number of patient visits processed during an 8-hour period but were 26 percent more productive in terms of the value of services they produced per day.
Numerous programs have been established to train nurses and other types of health practitioners to serve as physician extenders. The most important objective of these programs has been to increase the supply of primary care services by relieving physicians of routine health care tasks. It has been assumed that physicians employing these new types of personnel would be freed to concentrate on more complex medical problems and that the volume and comprehensiveness of primary care services produced by the physicians and their practices would be increased. The effect of employing physician extenders on the volume of primary care services produced has been assessed in a number of previous investigations. In an earlier paper based on data from this study [1], it was found that a physician and nurse clinician working together were 31 percent more productive than a physician working with a nurse. Of this difference, 20 percent was directly due to visits managed independently by the nurse clinician. Other investigators have found that introduction of nurse practitioners or physician assistants resulted in an increase in the number of families served [2], in the number of patient visits processed [3-6], and in the net income generated by the practices [7,8]. Two studies, however, found only This research was supported by the Kansas Regional Medical Program. Address communications and requests for reprints to Geraldine C. Holmes, Medical Education Specialist, Department of Medical Education, Bethany Medical Center, 51 North 12th Street, Kansas City, KS 66102. George Livingston is a graduate student in psychology at the University of South Carolina; Elizabeth Mills is a graduate student in the health policy analysis program at Harvard University; Rita E. Bassett is a graduate student in health planning at the University of Pennsylvania. All authors were on the staff of the Kansas Regional Medical Program when this research began.
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limited or no gain in productivity following the employment of physician extenders [9,10]. The productivity measure used in most of these studies was the number of patient visits processed in a standard time period. The number of patient visits per unit of time, however, is a fairly insensitive measure of productivity that does not reflect differences in either volume or complexity of services produced. Some visits require more time and skill than others and should consequently be assigned more weight when productivity is assessed. For visits in which two or more practitioners are involved, a count of patients seen does not allow a determination of the respective responsibility of each practitioner for processing the visits. This article describes the results of a study conducted by the staff of the Kansas Regional Medical Program between 1974 and 1976 to examine the effect of nurse clinicans on the productivity of primary care office practices. The nurse clinicians studied were graduates of a program established by the Regional Medical Program in Kansas to train experienced registered nurses for expanded roles in primary care settings [11]. Data for the study were collected in two practices before and shortly after introduction of a nurse clinician, and in two other practices that had employed nurse clinicians for two years. Two measures of productivity were used: the number of patient visits and the value of patient services produced per unit of time. Two researchers timed and coded all services provided to patients by the physicians, nurse clinicians, and nurses. These data were converted into dollar and point values using a modified version of the relative value schedule published by the Kansas Medical Society [12]. This schedule indicates the worth of one procedure relative to any other on the basis of the amount of skill, time, and other resources judged necessary to produce the procedure. The relative value measure of productivity reflects the quantity and complexity of services provided by each practitioner as well as the number of visits produced. This measure more adequately describes the relative contribution of each practitioner to visits that are managed jointly. For all visits the measure permits comparison of the productivity of different types of practitioners, without the assumption that a procedure performed by one type of practitioner is worth more or less than the same procedure performed by a different type of practitioner. The relative value measure of productivity also reveals the economic effect of a practitioner on a practice, allowing estimation of the potential gross income generated by each practitioner.
Methods Comparability of Practices and Patient Populations HEALTH
SERVICES
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270
Three of the practices studied were located in small Kansas towns. The fourth was a suburban practice in the Kansas City metropolitan area. The physician in each practice had been in general or family practice for over 20 years, and the patient demand on each practice
could be described as moderately heavy. The patient population RELATIVE VALUE served by each practice was predominantly white middle or working PRODUCTIVITY class. In each practice the patients seen during the study were fairly evenly divided by sex, except in practice 2, where two-thirds of the patients were female. The patient visits observed during the course of the study were classified according to 15 problem categories and five types of well-care visits. No one practice was extremely deviant from the norm in terms of problems presented. In all practices more acute disorders than chronic disorders were presented in initial office visits, and reevaluations of problems during return visits were about equally divided between acute and chronic conditions. There was some variation in the types of personnel employed by the physicians. Physician 1 and physician 2 were each assisted by an office nurse and two office record keepers during the first observation period. Physician 1, in the second observation period, and physician 3 were each aided by a nurse clinician, an office nurse, and two recordkeeping assistants. Physician 4 employed a nurse clinician, two office nurses, a laboratory technician, and three record-keeping personnel. In practice 2 the same individual was observed as a nurse in the early part of the study and as a nurse clinician later, but in practice 1 the nurse and nurse clinician were different persons. A number of limitations should be noted concerning the beforeand-after comparisons that could be made in practices 1 and 2. In practice 2, posttraining data were available only for the nurse clinician because the physician left the practice after the nurse clinician completed her preceptorship with him and the physician who replaced him did not wish to participate in the study. In practice 1, a substantial increase in malpractice insurance rates during the nurse dinician's training period led to a decision by the physician to discontinue performing surgery that required patients to be hospitalized. This decision apparently reduced the physician's need to delegate responsibility for the care of office patients and undoubtedly affected the nurse dinician's impact on the productivity of the practice. Data Collection Two researchers observed, timed, and coded activities of the physician and nurse or nurse clinician during six data collection periods, each from 9 to 15 consecutive workdays. Timing of activities began when the professional arrived in the office and continued through the working day. All services provided during face-to-face contact with one patient on a given day were defined as a single patient visit. Each visit was identified by the age and sex of the patient, type of visit (initial visit for a problem, return visit for a problem, return visit for a treatment procedure, or a well-care or service visit), and nature of the problem(s) presented. Problems were coded according to 16 general and 103 specific categories based on the ICDA [13]. Time spent in each patient visit was classified using the following activity categories: conversation
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HOLMES ET AL.
HEALTH
SERVICES RESEARCH 272
(to establish rapport), history taking, physical examination, special tests and measures (e.g., less-common tests such as visual acuity, throat cultures, EKG, or drawing blood), charting, treatment procedures, education and counseling, and other (activities not classifiable elsewhere, e.g., preparing the patient or equipment or consulting with a colleague). For each professional in each patient visit, examination steps, procedures and special tests, and diagnostic tests and recommended treatments were also recorded. In some cases the observers were excluded from part or all of a visit. Because application of the relative value formula depends on a record of the time spent in activities within visits, visits for which data were incomplete were excluded from the relative value calculations. Nonvisit activities observed included patient and nonpatient telephone calls; reading charts, laboratory, and x-ray results; reading office correspondence and educational material; writing in patient charts; filling out insurance forms; working on office administration; writing professional papers; consulting with staff; social conversation with staff and patients; performing laboratory tests; preparing equip. ment and rooms; dispensing medication; conversation with the observer; and breaks and waiting periods. These activities were coded using behavior-specific categories that facilitated observation and timing. They were regrouped in functional categories in the subsequent analyses. The observed professionals were also interviewed briefly each day regarding the time they had spent in professional activities outside of office hours, and each staff member of each practice was interviewed to obtain qualitative data about the practice. In each practice the reasons for the study and the observation methods to be employed were explained in advance to the physician and nurse or nurse dinician; they participated out of concern for the objectives of the research and received no payment for their cooperation.
Relative Value Computation The relative value of services provided by each professional observed during patient visits was derived by applying a modified version of the Kansas Medical Society (KMS) relative value schedule [12] to the patient visit time and activity data. Values for services are expressed in points which, as in the California relative value system [14], are presumably based on the prevailing state median charge for identified services. The KMS relative value system does not provide separate values for all of the types of office visits distinguished in this study, nor does it indicate how points should be distributed among activities performed during visits. Therefore 12 general practitioners in Kansas were asked to provide estimates of the relative value of visits not listed in the KMS system and to indicate how the relative value points for all types of visits should be allocated among activities usually performed in the visits. The types of visit activities to which values were separately
Table 1. Relative Value Units and Dollar Equivalents for 14 Types of Primary Care Visits
RELATIVE PRODUCTIVITY
(Mean responses of 12 physician-judges) Dollars
Unit value
Dollar value
3.00
15.08
5.03
3.50
21.04
6.01
7.00 1.00
32.50 6.67
4.64 6.67
history and exam ............................ 1.25
9.38
7.50
14.02
7.01
Visit type
Problem visit 1. Initial problem presentation, limited* history and physical exam ........ ............ 2. Initial problem presentation, extendedt history and physical exam ........ ............ 3. Initial problem presentation, complete* history and physical exam ........ ............ 4. Return for scheduled procedure or test§ ..... .... 5. Return problem visit, limited*
per
unit
6. Return problem visit, extendedt
history and exam ............................ 2.00 7. Return problem visit, complete*
21.46
7.15
.........
1.09
6.32
5.80
............
4.00
27.08
history and exam ............................ 3.00 8. Retum visit for test information .......
Well-care visit 9. Comprehensive general exam .......
10. Limited exam ................................. 2.07
12.46
11. Prenatal or postnatal exam ........
1.85
10.10
6.77 6.02 5.46
12. Well-baby checkup ............................ 1.91
11.50
6.02
............
6.47 13. Insurance, work, school, or camp physical ...... 2.75 17.79 14. Service visitS (e.g., ear piercing or vaccination) .. 0.98 6.38 6.25 * Limited = examination of one or two of nine body areas or systems. t Extended = examination of three to six of nine body areas or systems. * Complete = examination of seven or more of nine body areas or systems. § Points for the visit do not indude the value of the test or procedure performed.
assigned were social conversation to establish rapport, history taking, physical examination, evaluating the problem and prescribing treatment, charting, and patient education and counseling. The responses of the physician-judges were averaged to produce the required values for visits and activities within visits. The average values assigned are presented in Table 1 for each type of visit; values for activities within visits are shown in Table 2 (p. 274). Table 1 also shows the average charge estimated by the physician-judges and the resulting dollar value per relative value unit for each visit type. The relative values shown in Tables 1 and 2, plus other values from the KMS schedule, were used to compute the relative value generated by each professional in the visits and activities observed, as follows: 5
RI'1 = Ve + V,p + Via + E Wa [t.a/(t,a + tia)] a=1 where RV, = the relative value generated by practitioner i in a visit V. = the relative value assigned for evaluating the problem FALL and prescribing treatment (this quantity was always as- 1977 signed to the physician in shared visits and was set at 273 zero when i represented a nurse or nurse clinician)
HOLMES ET AL.
Table 2. Relative Values of Activities Within Visits (Mean responses of 12 physician-judges) Visit
type*
A
Conver- History Physical Evaluation, Charting Euain sation exam prescription coseling
1....... 3.00 0.22 0.94 2 ...... 3.50 0.20 1.19 3 ...... 7.00 2.50 0.41 4 ...... 1.00 ... 0.12 5 ...... 1.25 0.09 0.30 6 ...... 2.00 0.12 0.52 7 ...... 3.00 0.83 0.21 8 ...... 1.09 ... 0.14 9 ...... 4.00 1.47 0.24 10 ...... 2.07 0.19 0.64 11 ...... 1.85 0.13 0.42 12 ...... 1.91 0.48 0.12 13 ...... 2.75 0.17 0.85 14 ...... 0.98 0.14 ... * See Table 1 for visit description.
0.64 0.86
1.87 ...
0.49
0.48 0.81 ...
0.24 OA1 0.68 ... 1.18 0.49
0.22 0.36 0.53 ... ...
0.58
0.58 0.95
... ... ...
...
...
...
0.27 0.30 0.67 0.21 0.13 0.20 0.29 0.20 0.47 0.27 0.19 0.19 0.37 0.28
0.44 0.47
0.74
0.67 0.27 0.39 0.46 0.75 0.64 0.48 0.53 0.54 OA1 0.56
Vip = the value of any treatment procedures performed by practitioner i during a visit V = the value of any spedal tests and measures performed by practitioner i during a visit a = 1, . . . , 6, representing the types of activities (other than treatment procedures and special tests) within visits for which time was recorded and relative value weights were assigned ta= time spent by practitioner i in activity a during a visit tja = time spent by practitioner j in activity a during a visit Wa = the relative value weight (from Table 2) assigned to activity a
HEALTH RSEARCH
274
A computer program was designed to assign visits to relative value classes on the basis of type of visit or primary problem presented and on the extensiveness of the physical examination steps performed in the visits; the program also selected the appropriate relative value weights for visit activities and computed the relative value totals for each practitioner. The output of this program was then used to calculate the average relative value per visit, the projected relative value per time period, and the projected potential dollar income per time period for each practitioner (computed using the average dollar value per relative value unit for all visit types). Independently performed direct care activities were emphasized in assigning relative value units and in calculating potential dollar values generated. For example, no relative value points were allocated to a practitioner for assisting during examination of a patient, assisting with a procedure, consulting with a colleague, or observing during a
visit.
of Data Collection and Analysis Procedures RELATIVE The projected dollar amounts found for each practice may not VALUE reflect the actual income these practices generated. The KMS relative PRODUCTIVITY value schedule, published in 1966, is not used in all Kansas practices. The office visit rates in the schedule are similar to rates charged in many Kansas practices, but the definitions of patient visits used in this study do not necessarily conform to the definitions used in these practices for billing purposes. Dollar amounts are given only for Limitations
comparison, to emphasize differences in productivity in a way that is easily understood. Allocation of relative value points on the basis of time spent in various activities ignores possible differences in productivity due to differences in the speed with which professionals performed similar tasks. Another limitation is that office personnel not observed in this study were sometimes involved in completing patient visits (measuring vital signs, for example). Such services constituted part of a patient visit and accounted for some relative value, but they were not induded in the calculations. Thus the relative value totals assigned to observed practitioners in such cases were somewhat inflated.
Results Differences in Workday and Role Variations in workday among the persons observed reflect role differences related to individual and practice productivity. The average time spent by all three types of professionals in and outside the office
Table 3. Average Workday and Distribution of Office Time Physician Activity Activity
nurse With With_nurs #1 #2*
#1
8.20 8.69 2.36 1.86 5.84 6.83
9.50 7.58 0.20 0 9.50 7.38
8.53 8.51 8.13 8.15 3.64 1.49 0.63 2.11 4.89 7.02 7.50 6.04
55.9 54.4 8.2 1.0 0.3 0.2 3.1 10.3 5.4 3.9 5.5 10.2 6.7 2.9
18.5 27.1 6.3 3.6 2.3 0.7 8.1 4.5 2.6 0.8 6.7 7.8 36.4 1.6 0.4 0.7 9.7 9.3 0 0.7 4.8 12.6 1.5 27.4 2.8 3.2
62.3 35.7 479 40.7 1.1 3.2 15.3 1.5 1.1 0.7 0.4 0.7 4.7 15.8 9.3 18.0 0.4 2.3 6.3 2.2 5.1 17.0 4.0 6.7 1.8 0.5 1.1 IA 3.0 0.1 2.5 0.6 5.6 3.7 2.4 5.9 1.6 3.1 0.9 5.7 3.6 9.2 1.1 5.0 5.2 7.1 6.3 8.5 4.5 1.7 2.6 3.2
dinician
Total working day, hr. 9.33 10.03 7.77 Outside office, hr ...... 2.83 4.91 1.83 5.94 ... 6.50 5.12 In office, hr ... Patient visits, % of office time ............... 64.2 57.0 63.3 1.6 1.6 5.6 Telephone, patients, % . Conversation, patients, % ... 2.5 0.5 2.5 Charting, % ................ 5.7 11.1 6.2 1.6 Telephone about patients, % . 2.1 2.3 8.5 Conversation, staff, % ....... 4.9 7.7 1.4 Administration, % .......... 32 3.7 OA lab tests, % ............... 0.7 0 Equipment upkeep, % ...... 0.2 OA 0.1 1.0 0.4 Study, % ..................0. 7.1 Breaks and personal, % .... 4.3 4.5 4.5 2.8 6 Transit and other, % .....4. 2.4 Time with observer, % ..... 42 3A * Before nurse dlinician joined practice.
Nurse clinician#4 #2 #3
Nurse #1* #2*
With nurse
#1
#3
#4
1.9 0.6 0.9
0
4A 42 3.0
4.0 7.5 3.8
1.0 0.8
HOLMES ET AL.
and the distribution of their office time on a typical workday are shown in Table 3. (Note that in tables and in the text, physician 1 and nurse 1 constitute practice 1, physician 2 and nurse 2 constitute practice 2, and so on. Physician 1 and nurse clinician 1 constitute practice 1 at a later period of the study.) Relatively few differences were found among the physicians in the general use of professional time. All of the physicians spent over half of their time in the office seeing patients, and there were no uniform differences between physicians with and without nurse clinicians in the time spent in any office activity. Minor differences in time spent in conversation with staff, on the telephone with patients, or in other activities appeared to result from physician preferences rather than from presence or absence of a nurse clinician. Physician 1 spent about 34 minutes less time in the office per day after addition of the nurse clinician. However, the other physicians working with nurse clinicians did not spent less time in the office than the physicians with nurses. All of the physicians with nurse clinicians had shorter total workdays than the physicians without nurse clinicians. For physicians 1 and 4, some shortening of the workday resulted from the nurse clinicians' making some hospital, home, and nursing home
visits. There were significant role differences between the nurses and nurse clinicians in the practices observed. All of the nurse clinicians spent more of their office time in patient visits than did the nurses. The nurse clinicians spent from 35.7 to 62.3 percent of their day in patient visits, whereas the two nurses spent 18.5 and 27.1 percent of their time with patients. The nurse clinicians also spent more time studying and less in -upkeep of equipment and office than did the nurses. Other differences in the workdays of the nurses and nurse clinicians resulted from task assignments and work conditions specific to each practice. Nurse clinician 3 spent more of her time than did the others in telephone calls to patients because she was given the task of reporting laboratory test results as they became available. Nurse clinicians 2 and 4 often worked on patient records when patients were not present. Nurse clinician 2 spent a relatively high percentage of her time consulting with other staff members, particularly with the physician, regarding visits she was managing. Nurse 1 was the primary bookkeeper for the practice and consequently spent a large part of her day in office business and administration. In practice 2 a substantial part of the nurse's time was spent waiting for patients to arrive or for duties to be assigned to her. The nurse clinicians averaged less time per day in the office than the nurses, but their workdays were equivalent to those of the nurses since they spent time in hospital, home, and nursing home visits, study at home, patient telephone calls, and consultations outside the office. HEALTH Nurse clinicians 1, 2, and 4 reported spending between 1.13 and 2.22 SERVICES RESEARCH hours per day in hospital, home, and nursing home visits; only in practice 2 did a nurse report any time spent in home visits. The practices differed in the independence with which physicians 276
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HOLMES ET AL.
and nurse clinicians managed patient visits. Physician 1 was assisted by the nurse clinician in over half of the visits he processed, whereas physician 3 and his nurse clinician worked more independently of one another. Nurse clinician 2 managed many more visits independently than she managed with the physician. Nurse clinician 4 managed few visits independently but assisted the physician in a large number of visits. Table 4 shows that the nurse clinicians independently managed more complex types of problems and spent more time in most aspects of both shared and independent visits than did the nurses. The nurses managed few evaluations and reevaluations of problems by themselves; most of the visits they managed independently involved procedures such as injections or ultrasound therapy. Nurse clinicians 2 and 3 independently managed a significant number of evaluations and reevaluations of chronic and acute conditions; the visits managed alone by nurse clinician 1 were most often well-care visits. Within both shared and independent visits, the nurse clinicians generally spent more time in history taking, physical examination, special tests, charting, and education and counseling than did the nurses. The physicians in these practices managed similar types of visits. After he hired the nurse clinician, physician 1 managed a smaller number of well-care requests than he had before because he delegated many of these visits to his nurse clinician. For the physicians with nurse clinicians, there were few differences in distribution of problems managed alone and with the nurse clinician. The exception was physician 3, who handled well-care visits with the nurse clinician more often than by himself. The distribution of physician time within visits was quite similar, but the physicians with nurse clinicians spent less time per visit, on average, than the physicians without nurse
clinicans. Number of Patient Visits Table 5 shows the projected numbers of patient visits that could be processed by the professionals in this study in an 8-hour day and a 240-day workyear, based on the observed output of the practices. The three physicians with nurse clinicians processed an average of 5.3 more visits per day, or 14.7 percent more than physicians working with nurses. Nurse 2 saw the largest number of patients with the physician before she was trained as a nurse clinician, and she saw the largest number independently after training. The nurse in practice 1 saw fewer patients than any of the nurse clinicians. However, the patient visit data do not reflect the full productivity differences among the nurse clinicians and nurses or among the physicians. The relative value of services provided during visits reveals a greater difference in productivity than is shown by the number of visits managed. HEALTH
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Differences in
Productivity
The differences in the productivity of individual physicians, nurses, and nurse clinicians studied are shown in relative value units and gross
Table 5. Projected Visits per Day and per Year That Could be Processed at Observed Rates of Work Visits per 8-hr day
Visits per 240-day yr
38.3 33.7
9192 8088
Physician with nurse clinician #1, all visits ................... 40.9 #1, shared visits ............... 22.1 #1, unshared visits ............. 18.8 #3, all visits ................... 42.5 #3, shared visits ............... 14.3 #3, unshared visits ............. 28.2 #4, all visits . -.........-.-.-.-.-.... .40.5 #4, shared visits ............... 17.5 #4, unshared visits ............. 23.0
9816 5 304 4512 10200 3 432 6768 9720 4200 5520
Personnel Physician with nurse #1* (all visits) .................
#2* (all visits)
.................
Nurse #1, shared visits .............. #1*, unshared visits ............
6.0
#2*, shared visits .............. #2*, unshared visits ............
23.9
6.1
9.5
Nurse clinician #1, shared visits ............... 22.1 6.1 #1, unshared visits ............. 2A #2, shared visits ............... #2, unshared visits ............. 10.1 #3, shared visits ............... 14.3 7.7 #3, unshared visits ............. #4, shared visits ............... 17.5 #4, unshared visits ............. 1.2 * Before nurse clinician joined practice.
VALUE PRODUCTIVITY
1 440 1464 5 736 2280 5 304 1464
576 2 424
3432 1 848
4200 288
dollar amounts in Table 6 (p. 280). Relative value projections for each subject were based on mean values per visit and the projected number of visits per 8-hour day; the projected dollar amounts were calculated as $6.21 per relative value unit, the average of the ratios shown in Table 1. The productivity of the physicians for a projected 8-hour day ranged from 68 to 105 relative value units ($422-$654); the productivity of the nurses and nurse dinicians ranged from 17.9 to 43.8 relative value units per day ($109-$272). Based on a 240-day workyear, the projected average annual gross amount generated was $51,345 for the four nurse clinicians and $36,508 for the nurses-$14,837 more per year for the nurse dinicians, an average productivity difference of 40.6 percent. The mean annual income projected for the physicians with nurse clinicians was $138,901,
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Table 6. Relative Value Units and Doliar Equivalents* per Eight-hour Day Produced by Each Worker, by Practice Physician Practice
All visits
#1 (with nurse) Relative value ........ 85.89 $ equivalent .......... 533.38
#2 (with nurse) Relative value ........ 67.95 $ equivalent .......... 421.97 #1 (with nurse clinician) Relative value ........ 82.67 $ equivalent .......... 513.38 #2 (with nurse clinician) Relative value ........
Shared Unshared visits visits
Nurse or nurse clinician All Shared Unshared visits visits visits
15A8 96.13
70.41 437.25
17.87 110.97
10.14 62.97
7.73 48.00
48.00 298.08
19.95 123.89
31.12 193.26
17.19 106.75
13.93 86.51
44.02 273.36
38.65 240.02
31.54
195.87
17.03 105.76
14.51 90.11
... 4.46 28.53 32.99 S equivalent .......... ... ... 204.87 27.70 177.17 #3 (with nurse clinician) Relative value ........ 91.59 26.17 43.81 65.42 22.17 21.64 $ equivalent .......... 568.78 162.52 406.26 272.06 137.68 134.38 #4 (with nurse clinician) Relative value ........ 105.33 37.71 67.62 29.46 27.06 2.40 $ equivalent .......... 645.10 234.18 419.92 182.94 168.04 14.90 Based on $6.21 per relative value unit, the average ratio from Table 1.
based on patient visits only; for physicians who had only nurses the annual average was $114,642. The difference represents a 21.2-percent difference in productivity. Considering the combined activities of physician and nurse or physician and nurse clinician reveals an even greater difference in productivity: the projected average annual income for the three physician-nurse clinician teams (neglecting practice 2, which is represented only by a nurse clinician) was $190,970, whereas the projected average income of the physician-nurse teams was $151,150. The difference in these amounts is $39,820, or a 26.3-percent difference in average productivity. Reasons for Productivity Differences The greatest average relative value per visit was generated by the physician-nurse clinician teams in practice 3 and practice 4; their averages were similar even though the amount of independent work by the nurse dinicians in the two practices was quite different. The physician-nurse clinician team in practice 1 generated less average relative value, but this did not appear to result from low productivity by the nurse clinician. Physician 1 received fewer relative value points per visit after he employed the nurse clinician: he delegated to the HEALTH nurse clinician some visits that had previously accounted for a disSERVIRCES proportionate number of his relative value points, and he performed fewer extended examinations, treatment procedures, and special tests. 280 Nevertheless, although the physician's productivity dropped slightly
between the two periods, the productivity of the practice was greater RELATIVE VALUE after the nurse clinician was hired. PRODUCTIVITY The most productive nurse clinicians were those who had the greatest independence in managing patient visits: nurse clinician 3, with the highest average relative value, had her points distributed fairly evenly between visits managed alone and those managed with the physician. Nurse clinician 2, who was second in individual productivity, shared few patient visits with the physician. The nurse clinician in practice 4 had the lowest average relative value per visit among all the nurse clinicians, but practice 4 was the second most productive studied. She and physician 4 managed most visits jointly, and he received relative value points for decisions made during the visits and a portion of the points for the activities he shared with her, which raised his relative value per visit and lowered hers. The nurse in practice 2 was more productive after nurse diician training than before: she averaged 31.1 relative value points per day prior to training and 33.0 after training, due to her changed role in the practice. All of the nurse clinicians generated more relative value in independently managed visits than did the nurses; they also (except in practice 1) generated more relative value in shared visits for history taking, physical examinations, charting, education and counseling, and special testing. All of the nurse clinicians except in practice 1 generated more relative value than the nurses for problem evaluation and treatment determination. The low average relative value generated in this category by nurse clinician 1 was due to the high percentage of well-care visits she managed independently, for which no evaluation and treatment-determination points were assigned. The nurses generally generated more relative value than the nurse clinicians for treatment procedures in both shared and independently managed visits. There were no consistent differences in the average relative values per visit generated by physicians with nurse clinicians and physicians with nurses. Physicians 3 and 4 generated more relative value points in independent visits than did the physicians with nurses; however, physician 1 generated less relative value per independent visit after he added the nurse clinician to his practice. The higher relative value generated by physicians 3 and 4 can be accounted for by the higher percentage of extended and complete initial and return visits they managed and by the fact that both took histories, performed treatment procedures, and gave education and counseling more often. The physicians with nurse clinicians all generated less relative value in shared visits than in independent visits and, with one exception, less relative value in shared visits than did the physicians with nurses. These differences occurred because more patient care tasks were assumed by the nurse clinicians than by the nurses in shared visits.
Conclusions
The difference in average daily productivity between the most productive and least productive physician observed was 37.4 relative
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value points, or $232 a day. The average daily difference between the least productive nurse and most productive nurse clinician was 25.9 relative value points, or $161 per day. However, this study shows that it is important to compare the productivity of physician-nurse and physician-nurse clinician teams for the best picture of differences in practice productivity: the most productive team produced an average of 36.33 relative value points, or $226 per day, more professional services than did the least productive team. The average relative value productivity of all physician-nurse clinician teams was 128.13 points, higher by 26.3 percent than that of the physician-nurse teams. The use of a relative value schedule to assign values to services yields a different assessment of productivity than that found using a count of patient visits. On average, physician-nurse clinician teams processed 2.5 more patient visits per day, 5.7 percent more than were processed by physician-nurse teams. The 26-percent difference in relative value, however, suggests a mean difference of $166, based on the average of charges estimated by 12 Kansas physicians. The actual dollar equivalent of the relative value scale would of course vary in different parts of the country; it is used here only to illustrate the significance of the productivity differences found in terms of relative value. Ackowledgments. We express our appreciation to the four physicians who made this study possible by allowing us to collect data in their practices and to the nurses and nurse dinicians for their participation; to Ivan Anderson, who made an important contribution to the study by suggesting the use of a relative value schedule; and to Michael Grobe, who did the computer programming for the study.
REFERENCES 1. Holmes, G.C., G. Livingston, and E. Mills. Contribution of a nurse dinician to office practice productivity: Comparison of two solo primary care practices. Health Serv Res 11:21 Spring 1976. 2. Spitzer, W.O., D.L. Sackett, J.C. Sibley, R.S. Roberts, M. Gent, D.J. Kergin, B.C. Hackett, and A. Olynich. The Burlington randomized trial of the nurse practitioner. New Engl J Med 290:251 Jan. 31, 1974. 3. Voltmann, J.D. Jamestown medical clinic system. J Am Med Assoc 234:303 Oct.
20, 1975.
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4. Schiff, D.W., C.H. Fraser, and H.L. Walters. The pediatric nurse practitioner in the office of pediatricians in private practice. Pediatrics 44:62 July 1969. 5. Smith, R.A., J.R. Anderson, and J.T. Okimoto. Increasing physicians' productivity and the hospitalization characteristics of, practices using Medex: A progress report. Northwest Med 70:701 Oct. 1971. 6. Nelson, E.C., A.R. Jacobs, P.E. Breer, and K.G. Johnson. Impact of physician's assistants on patient visits in ambulatory care practices. Ann Intern Med 82:608 May 1975. 7. Yankauer, A., S. Tripp, P. Andrews, and J. Connelly. The cost of training and the income generation potential of pediatric nurse practitioners. Pediatrics 49:878 June 1972. 8. Nelson, E.C., A.R. Jacobs, K. Cordner, and K.G. Johnson. Financial impact of physician assistants on medical practice. New Engl J Med 293:527 Sept. 11, 1975. J.H., H. Wolfe, and K.M. Barker. The use of nurse practitioners in a 9. Merenstein, general practice. Med Care 12:445 May 1974. 10. Pondy, L.R., J.M. Jones, and JA. Braun. The Utilization and Productivity of the Duke Physician Associate. GS.B.A. Paper No. 61. Durham, NC: Duke University Graduate School of Business Administration, 1972.
11. Holmes, G.C. and R. E. Bassett. Primary care nurse clinicians in Kansas: Workingroles, motivation, problems and benefits. J Kans Med Soc 77:553 Dec. 1976. 12. 1966 Relative Value Studies. Topeka, KS: Kansas Medical Society, 1966. 13. Eighth Revision, International Classification of Diseases, Adapted for Use in the United States, Vol. 2. PHS Pub. No. 1693. Washington, DC: U.S. Government Printing Office, 1968. 14.1969 California Relative Value Studies, 5th ed. San Francisco: California Medical Association, 1969.
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