Measuring Productivity of Midlevel Providers Could Benefit Oncologists

Data from ASCO's Workforce Study indicates a pending shortage of between 2,350 and 3,800 oncologists by the year 2020. That could be cause for concern.

Data from the American Society of Clinical Oncology’s (ASCO) Workforce Study indicates a pending shortage of between 2,350 and 3,800 oncologists by the year 2020. That could be cause for concern. A new productivity tool, however, developed by the National Comprehensive Cancer Network (NCCN), may help measure the productivity of mid-level oncology providers—including nurse practitioners (NPs) and physician assistants (PAs)—as a way of extending an oncologist’s time and capacity.

“I think this is beginning to scratch the surface of how we can use NPs and PAs in a way that, hopefully, will help with the predicted future shortage of oncologists,” said F. Marc Stewart, Fred Hutchinson Cancer Research Center, who co-authored a pilot study that assessed NCCN’s productivity tool. “Being able to understand exactly how much activity a particular NP or PA does, overall, is important.”

A New Tool

The new NCCN tool is an online survey that includes questions regarding work characteristics, allocation of time and labor, and productivity. Jennifer Hinkel, MSc, manager, Business Insights at NCCN, was lead author of the pilot study. She said the metrics used in the study were the numbers of patients that mid-level providers saw in a half-day clinic, including new and returning patients. The reason for using a survey tool, Hinkel said, is that mid-level providers do not necessarily bill for their services separately from the physicians with whom they partner.

“This was a convenience sample,” Hinkel noted, “so I’m not sure that you can generalize [the results] to say that this is what all mid-levels in oncology do. We’re in the initial stages of going back and combining this study with another study NCCN previously conducted on physician productivity (, where we’ll aim to look at the productivity of the physician, and then their productivity when they’re working with mid-levels, and then the productivity of mid-levels alone.”

Stewart said he hopes the follow-up survey will provide data on the productivity of a particular PA/physician team or NP/physician team and analyze the components of that productivity. Questions he hopes to see answered include, “How much does the NP or PA practice independently of the physician?,” “How frequently do they partner with the physician?” and, “What seems to be the best model or mix?” Finding answers to these questions will help investigators resolve a larger question: “Do you get more productivity when the NP or PA is working almost completely independent, or is productivity enhanced when the physician can move very quickly through a clinic with the assistance of a NP or PA?”

The information garnered from these surveys, Hinkel said, will be of great assistance for many oncologists who are currently unsure about the role that mid-level providers can play. “Some oncologists really aren’t familiar with the scope of practice for NPs and PAs, and sometimes they’re not used to their full capacity. There’s some confusion out there about the various roles NPs and PAs can play and how they can be fully integrated into a practice.”

Quality Counts, Too

After reviewing the study, Lee Igel, PhD, assistant professor at New York University, said that the NCCN tool may not measure productivity as much as it measures the number of patients seen. His concern is that efficiency is only one-half of the productivity equation. The real question, he said, is “How effective are these mid-level providers?”

“Efficiency without effectiveness is almost meaningless,” Igel said. “It’s like going to Starbucks. They figured out how to move people through, but at the end of the day, it turns out their coffee isn’t as good as they hoped it would be and the sandwiches are less than stellar. So, they’re very efficient but not effective.”

Igel suggested there is an opportunity here, even a responsibility, for community oncologists to take a leadership role by stepping up and coordinating the care of their patients. “It doesn’t matter if it’s a primary care doctor or an oncologist. Patients want someone who can tell them what they need to do next and how they should manage their care. So, this becomes a great opportunity.”

Igel outlined a three-step process. First, oncologists must acknowledge and accept both the responsibility and the opportunity. Next, they need to identify the strengths and weaknesses of their staff—“Where do they fit best? What can they contribute?—and lastly, they need to institute a feedback program. This is where the physician identifies what he or she wants to get out of the effort and reassesses where the practice is in relation to those goals 6 months or a year down the road.

Igel indicated that setting goals was an essential part of the process. “Did you put the right people in place?” Igel asked, rhetorically. “You can’t go willy-nilly into this kind of thing. If you don’t first set the goals for what you want to achieve and then measure them over time, how will you know where you’re going and when you’ve gotten there? If you’ve gotten there?”

Ed Rabinowitz is a veteran healthcare writer and reporter. He welcomes comments at

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