In Brief: In a team-based care model, all members of the physician-led team play an integral role in providing patient care.
By 2035 the number of Americans with cardiovascular disease (CVD) will rise to more than 130 million. This increased demand will double the total cost of care for CVD, with the price tag exceeding $1 trillion annually.
To manage costs, payers are likely to increase pressure on health systems and providers to deliver more targeted, personalized care across a patient’s life span, with an emphasis on timely access and high-quality care and outcomes.
February is American Heart Month, and this article explores several factors contributing to the current shortage of cardiology providers and encourages cardiovascular (CV) program leaders to consider team-based care models a strategic imperative.
Cardiology Workforce Pressure Points
Many cardiology practices across the country are experiencing demand levels that push appointment wait time far beyond recommended benchmarks. The aging CV workforce, the ongoing impact of provider burnout, an insufficient number of practicing cardiologists, and increasing subspecialization are all key factors contributing to a misalignment of CV providers and the demand for care. Healthcare leaders need to address these current workforce trends to avoid further deterioration of patient access over the next decade.
Aging Workforce
More than a quarter of cardiologists in the US are over the age of 61, and more than 60% are over the age of 55. Cardiology has a very high on-call burden across all subspecialties, and in addition to on-call demand, procedural subspecialties experience the physical demand of standing for long hours in interventional labs wearing heavy lead aprons. While many cardiologists work well into their seventies, there is often a slowdown period several years prior to fully retiring, in which cardiologists transition to a reduced clinical schedule over the span of a decade.
Provider Burnout
Provider burnout was an issue before COVID-19; the pandemic only amplified the problem. A survey conducted by the American College of Cardiology (ACC) noted that self-reported burnout was at 20% among cardiologists prior to the pandemic and nearly doubled to 38% at its peak. The additional stress experienced by the cardiology workforce may accelerate retirement and initiate more pre-retirement slowdowns.
Supply Deficit
As demand for CV care continues to climb, the US is projecting a shortfall of new cardiologists entering the workforce. Estimates of the severity of this shortfall vary but represent an alarming number, especially given that even a one-for-one replacement would be inadequate to meet demand. Additionally, as more early-career cardiologists gravitate toward higher-population cities, the limited availability of cardiologists is disproportionately impacting rural and underserved communities.
Subspecialization
A growing number of cardiology fellows now pursue additional subspecialty training, which may reduce access to general cardiology care. Several factors are driving this increased subspecialization:
- Rapidly advancing therapies and technology are creating the need for cardiologists to narrow their field of practice to remain current and maintain technical skills.
- Advances in minimally invasive, catheter-based therapies require a greater amount of time in interventional labs, reducing the amount of available clinic time.
- Despite the widespread emergence of value-based care models, many cardiology compensation plans are still predominantly constructed around RVU-based productivity, driving a trend toward procedural specialties rather than the E&M-based services provided by general cardiologists.
Team-Based Care as a Solution
While several factors are contributing to a current shortage of cardiology providers, CV program leaders should consider team-based care models a strategic imperative. Team-based care is a strategic redistribution of work among members of a practice team. In this model, all members of the physician-led team play an integral role in providing patient care.
While there are some considerations for variations in licensing and practice across states, a nurse practitioner (NP) or physician assistant (PA) can provide the equivalent of a full-time physician managing established and post-discharge patients in an ambulatory clinic. This does not require an independent practice model for the advanced practice provider (APP) team. Rather it is a thoughtfully defined partnership between two to four cardiologists and an APP practicing at the top of their license.
In addition to expanding patient access, a well-designed, team-based care model can also improve care coordination and patient engagement.
Evidence-Based Care Pathways Drive Care Coordination
In highly effective team-based care models, ambulatory APP encounters are managed through care pathways. These pathways are established collaboratively with the cardiology members of the care team for specific patient populations. Examples include heart failure, coronary artery disease, atrial fibrillation, and posthospital or postprocedural care.
The care pathways will designate time frames for follow-up visits, including which provider the patient should see and at what time intervals, as well as basic care management protocols for the specific patient population.
The Team-Based Care “Pod”
To successfully optimize access and continuity of care in this model, APP FTEs must be fully dedicated to the ambulatory clinic and partnered with a small group of two to four cardiologists. Often these “pods” are designed around subspecialities (interventional cardiology, EP, general cardiology, etc.). Each cardiologist participates in the design of the care pathways for the APP member of the pod and supports the consistent use of the pathways for their patients. This helps ensure the success of the APP as they see and manage patients from the cardiologists’ panels.
Role-specific responsibilities and job descriptions should guide work distribution among the team and ensure each provider is working at the top of their license. Figure 1 provides an example of delineating shared goals and clear roles for patient care in the team-based care model. Onboarding and training new team members is important to ensure each provider understands their role in caring for patients and how they interact with other members of the care team.
Importantly, the APP is assuming a full clinic schedule with established and posthospital discharge patients and must be given the same level of support as a cardiologist. An example is provided in figure 2, but there are many hybrid options to designing FTE composition and allocation for the cardiology team-based care model.
Scheduling Templates Drive Appropriate Care with the Appropriate Provider
Clinic scheduling templates are a critical component of success in the team-based care model. Well-designed templates ensure that patients are seen at the right time by the right provider, and that cardiologists and APPs are fully utilized and operating at the top of license.
Clinic schedules should be open and available for scheduling a minimum of six months in advance, and ideally for one year. Templates and scheduling rules should be straightforward, clear, and consistent for schedulers.
- Each cardiologist should have dedicated new patient appointment slots each day to achieve a goal of three to five days for time to new patient appointment.
- APP schedules should be fully utilized for established patients with slots reserved daily to accommodate post-discharge patients, based on historical demand in the practice.
Value Proposition
Successful team-based care models can be financially sustainable. Figure 3 provides an example of a daily APP clinic schedule using 30-minute visit templates. Partnered in a pod with three cardiologists, the APP can function as a full-time provider with a schedule that accommodates approximately 3,200 visits annually* as illustrated below. Often E&M billing can fully support the cost of the APP FTE. And for each of the three cardiologists, this may net up to 1,000 open slots annually for new patients, making the team-based care model a financially sustainable means to expand access, grow patient panel size, and better manage patient outcomes.
Implementing Team-Based Care Models
Establishing team-based care models is a creative and cost-effective way to address the multitude of provider workforce and patient access challenges CV programs are currently facing. When implemented effectively, a well-designed team-based care model improves care coordination and patient engagement, increases patient access to care, and allows each provider to work at the top of their licensure. Utilizing evidence-based care pathways and clearly delineating clinical responsibilities will foster collaboration among team members and ultimately drive success.
Edited by: Matt Maslin
Published February 15, 2023