Mind the (Productivity) Gap

By  |  July 19, 2018 | 

So out in the varied land of hospital medicine, I have noticed something that I have no clear explanation for. It turns out there is often a gap in productivity between that of NP/PA providers and physicians. The range of the gap varies wildly – I just got off the phone with a HM group leader who has observed a 50% difference to a smaller gap of perhaps 10%. In my very rough and unscientific analysis, I routinely see a 15-20% gap.

But I simply don’t understand why this gap exists. The physical time to see and examine a patient, coordinate care with consultants and case managers, discuss the plan of care with family, write a note and bill is the same regardless of experience or credentials behind a name.

Or is it?

Does the more robust education and training of physicians force them to be more efficient? Do we focus so much on “safety” of NP/PA providers that we fail to train them to be efficient? Is there a lack of experience at the outset of their careers compared with that of a physician? Is there a double standard?

When I ask about the source or impacts on the gap, I receive a variety of replies: NP/PAs can’t “handle the volume”. NP/PAs are “early career” and don’t have the experience.

There is often a perception as well to “protect” the NP/PAs. They “spend more time” with patients and families. They “take longer to document”.

Whatever the root cause, this gap has an important impact on two main areas.

First, any economic advantages of deploying NP/PA providers can easily melt away without similar levels of patient volume, though the acuity of patients need not be similar. Optimization simply requires similar productivity.

And secondly, the lack of parity can create cultural conflicts breeding what I call “the secret ingredient” – resentment. If physician providers routinely see more patients than NP/PAs, yet NP/PAs want to have similar input into the practice, this can create a disparity. And disparities create friction. And friction creates instability. And instability means providers leave for other practices. Which leads to hiring less experienced people. Which may expand the gap.

So how do we address this and prevent existing gaps from expanding? I have a few takeaway points:

  • NP/PA providers should be onboarded and trained in three discrete arenas: hospital-specific processes, independent medical judgement in the patient population they are caring for and efficiency.
  • Don’t just accept a gap. Research why it exists and ways it can be addressed.
  • Analysis of the financial costs of this gap should be analyzed and factored in to decisions about NP/PA optimization.

How do you “mind the gap” in your HMG?


  1. Andrea Childress July 23, 2018 at 11:51 am - Reply

    Tracy – I appreciate there should be no gap in terms of our abilities and training, however, there is one big reason – equitability. NP/PA’s are paid roughly half of that of MD’s – it is completely demeaning and frustrating to carry out the exact same responsibilities, RVU’s, carry same responsibility/liability and yet receive half the salary for the same work. I am not suggesting that NP/PA’s be paid equal given the education difference and 15% Medicare reimbursement difference (which may be going away in the future), but if there is going to be that big of a divide then a census differential is only fair. The other option is same work and increased salaries for NP/PA with maybe 15-20% differential on salary.

    The about would apply for a seasoned NP/PA. I do see a big difference with a new grad – they are not yet equipped to handle the same load for obvious reasons – that is where the difference in training comes in.

    • Rekha Umoh July 30, 2018 at 12:38 pm - Reply

      Well Said.!

  2. PHILLIP July 25, 2018 at 10:54 pm - Reply

    I work has a hospitalist NP for which I was trained for as an acute care Nurse Practitioner. I work in a group of primarily physicians I carry an equal work load of patients. I do spend more time working to see these patients than my coworkers because my documentation is much more thorough, I’m complaint with hospital policies over meaningful use of the electronic media record and have higher RAFF scores than my MD colleagues. I know these as my medic group tracks then all closely. I also work with an MD group that is very supportive and understands my role and I also understand my role and we appropriately interact with each other as colleagues when necessary, allowing efficiency. some NP colleges deal with micro managing colleagues and also policies from government as well as institutional that slow our work..
    This issue isnt as easy as 1 2. or 3 . and I see the same work load for way less $$

  3. Dan D. July 30, 2018 at 12:07 pm - Reply

    It’s difficult to draw any meaningful conclusions from a “very rough and unscientific analysis.” It does perhaps suggest that the issue may be deserving of a more scientific analysis to determine ‘if’ there really is a difference in productivity, quality of care, outcomes, etc. Only then can a meaningful, non-anecdotal and maybe a more objective, less emotional discussion take place.

  4. Mary Monastesse July 31, 2018 at 8:08 am - Reply

    As an NP in a busy urban clinic working alongside MDs, PAs, and NPs, I will match my productivity against my colleagues’ productivity and come out on top. I would like to see an actual study that supports your view. Two things you fail to consider: 1) NP work in many states is subject to physician oversight. My documentation must support my diagnoses and treatment plan and therefore must be complete and crystal clear. Physicians have no such worry. My documentation takes extra time. Despite this, I’m pretty fast. And don’t make nearly the same salary as the MDs I work with. 2) I see the same acuity of patients as my colleagues. Given that many are quite complex, I need to consult an MD an average of 2 times a day. This takes time.

Leave A Comment

About the Author: Tracy Cardin

Tracy Cardin
Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations. In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.


Related Posts

By  | November 12, 2018 |  0
I do not loathe him, actually. As you might have heard, Atul Gawande will be running the big health concern comprised of Amazon, JP Morgan, and Berkshire Hathaway. How in heavens name he was able to pump out another tome in The New Yorker, a sharp one at that, boggles my mind. If you do not […]
By  | October 16, 2018 |  0
By: Rich Bottner, PA-C and Victoria Valencia, MPH You submit an issue to your Event Reporting System and never hear back. You discuss the need for institutional improvement with your colleagues around the water cooler, but few things seem to change. Sound familiar? Instead of passively waiting for quality improvement to happen in hospitals, organizations […]
By  | October 2, 2018 |  0
On behalf of SHM’s Practice Analysis Committee, I’m delighted to announce that the 2018 State of Hospital Medicine Report is now available! This year’s report may be the most representative yet regarding the current state of hospital medicine. Of the survey’s 569 respondent groups: 52% are employed by hospitals or health systems 25% are employed […]