Advanced Practice Providers - APPs in Oncology

Advanced practice providers (APPs) are a key component to effective team-based care, but what is it that our APP team-members can do in an oncology practice? Join the Co-hosts of the APP podcast series, Todd Pickard (MD Anderson Cancer Center) and Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guests Wendy Vogel (BroadcastMed/APSHO)) and Tammy Triglianos (University of North Carolina Basnight Cancer Hospital), as they highlight the services and examples of what APPs in oncology can do, their role as an APP in team-based care, if and how they bill for their services, and how they are reimbursed. 

Speaker Disclosures:
Stephanie Williams: Consultant or Advisory Role – CVS Caremark
Tammy Triglianos: Consulting or Advisory Role – Pfizer
Todd Pickard: No relationships to disclose
Wendy Vogel: No relationships to disclose 

Resources:
Podcast: Advanced Practice Providers - APPs 101: What and Who Are Advanced Practice Providers (APPs)?

Podcast: Advanced Practice Providers – An APP’s Scope of Practice

Advanced Practice Providers - APPs 101: Physicians Assistants (PAs) and Advanced Practice Registered Nurses (APRNS) in Oncology

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TRANSCRIPT

The disclosures for guests on this podcast can be found in the show notes.

Dr. Stephanie Williams: Hello, everyone, and welcome back to the ASCO Education podcast, and our fourth episode of the Advanced Practice Providers series. I'm Dr. Stephanie Williams, a medical oncologist, and your co-host for the series, along with physician assistant Todd Pickard. We’d also like to introduce you to our guest panelists today. Returning guest, Wendy Vogel, along with Tammy Triglianos. We’ll take a moment to let them introduce themselves, starting with Wendy.

Wendy Vogel: Hi. Thanks so much for having me today. I'm Wendy Vogel. I'm an oncology nurse practitioner by trade, and I am the Executive Director of APSHO, the Advanced Practitioner Society for Hematology and Oncology. And thanks for having me here today. I'm really excited to be here.

 Dr. Stephanie Williams: Tammy.

 Tammy Triglianos: Hi, everyone. Thank you for having me. And I'm excited to join this group for our conversation today. I'm Tammy Triglianos. I am a certified oncology nurse practitioner practicing in North Carolina. My career has been dedicated to caring for oncology patients, even starting out as a nursing assistant and then as a registered nurse practicing in a variety of settings. I've been a nurse practitioner for almost 20 years now, with the past 15 specializing in GI medical oncology.

 Dr. Stephanie Williams: Thank you.

 Todd Pickard: Thanks, everybody, for being here today.

 Dr. Stephanie Williams: In today's episode, we will be highlighting the services and examples of what advanced practice providers in oncology can do and describing if and how they bill for their services and how they are reimbursed.

 So let's get started. Wendy and Tammy, I'm starting in my clinic, 8:30 in the morning. We have a full panel of patients, patients who just need reassessment, chemotherapy prescribed, reevaluation, bone marrow biopsies, test results. How do we work together to see, as a team, these particular patients, or in other words, what can you do to help me through my days as an oncology practitioner?

 Wendy Vogel: Wow, that’s a great question to just jump right in and start with. I’m excited to talk about that. Well, I think that, you know, as we always are talking about our team approach, we would look at that schedule. And hopefully, the AP and you have their own schedule so that we're able to divide and conquer and be able to accomplish that schedule, see all the patients in the most efficient manner possible. Hopefully, I've looked at all my patients beforehand and see if there's anything that I need to collaborate with you on. Looking at our labs, you know, maybe scans, talking about any changes in plans that we might anticipate together, and so on.  

Tammy, would you do the same?

 Tammy Triglianos: Yeah, I’d like to echo your point, Wendy. Having independent schedules, I think, makes for a more efficient workflow in the clinic. And in my practice we have a team meeting with our clinical pharmacist, physician, myself, and our nurse navigator, and review last week’s and even prep for the upcoming week, trying to anticipate and make sure people are set up and orders are in, and we're prepared for the week to come. Day of, as you know, can get pretty hectic. But since we've done a lot of that prep work, I think it makes for the unknowns that pop up in clinic easier to connect with each other, with my physician and other team members.

 Todd Pickard: I agree. I think the great thing about how physicians and APPs work in teams is that the team can decide what's best. I have done everything from having my own independent template so that I have patients that I'm responsible for to a general template where the physician and I just divide and conquer at the beginning of clinic, and we say, “Okay, you see these patients, I'll see these patients, and we'll back each other up if we need to.” All the way to seeing every single patient along with the physician when we are seeing a lot of news and consults, very complex, very acutely ill patients. And we basically just work as a team the entire day on everything.

 So it's really interesting about the conversation that I think we'll end up doing today is the “what” versus “how.” What APPs do is– really, honestly, APPs can do anything and everything unless a state scope of practice or an institution's policy specifically says they can't. That's the good news is that we pretty much can do everything but the “how,” that's a really interesting question because a lot of different things come into play. Position preferences, which could be influenced by their own personal experience or their own personal preferences of style versus, you know, having a misunderstanding of what APPs can and can't do. Then there's the institutional policies and the state scope of practices that come into play. So I think this where we’ll end up spending some time today.

 And, you know, Stephanie, maybe we could start the conversation with you a little bit around physician preferences and what your experience has been, and some of the things that you’ve noted around the physicians as part of this team.

 Dr. Stephanie Williams: I’ve worked with APPs, both inpatient and outpatient, and I think it is very important to have that team-based approach. Patients really appreciate that, knowing that there is always a provider, someone there that they can turn to. And I think that’s one of the great things about APPs is they always seem to be there for patients to turn to and for our nurses to turn to, to get help too. Both our clinic nurses, our infusion nurses, and our inpatient nurses really appreciate having that extra clinical provider available to them. I think as a physician, during my day, what I would like to see is us getting through our panels of patients, whether we’re together, which is not as efficient as if we’re independently seeing patients, but also help with things like procedures that need to be done on patients, phone calls at the end of the day, peer-to-peer reviews in order to get either medications or tests done for our particular patients. Filling out forms, no one likes doing that. No one likes filling out disability forms or other insurance forms, but those are all things that we all need help with in terms of doing. Ordering consults, seeing new patients together. I work in the transplant field, so they’re complicated patients, so it actually is very helpful to have, to see a patient with your advanced practice provider so that you can come up with a treatment plan together that you know you can then follow throughout the course of hopefully that patient's treatment and recovery. Chemotherapy orders is another place that we need, that can be very valuable, whether it's the initial chemotherapy order, which were usually the physician or pharmacist initiated, but those follow-up chemotherapy appointments or problems in the infusion clinic are also helpful areas.

 There are some physicians, though, who want to have an APP simply as their scribe, to follow them around in clinic and to then begin whatever orders they feel is appropriate for that particular patient. That is not the most efficient way to see patients, particularly when you have a large panel of patients that you have to see.

 Wendy Vogel: Exactly. It really isn't. I will just tag off something you said about the AP being the scribe. That's probably one of the most expensive scribes that a physician could employ, and what a better use of our time is to not be a scribe. You know, there are other people who could really efficiently be a scribe better than the AP, and the AP could actually be seeing patients and gaining reimbursement for the practice.

 Tammy Triglianos: An additional comment on team-based care. I work with a physician where we alternate visits, and I think that has really worked well in establishing a relationship with patients. We both have very high touch points with the patients, very involved, and patients feel like there's that team that's always available because always one of us is usually available.

Dr. Stephanie Williams: How long did it take you all, all three of you, to develop that relationship with your physician colleagues to work tightly in a team?

Todd Pickard: That's really a great question, Stephanie, because I think one of the strengths of the relationship is that level of trust and comfort and not really to view it as a hierarchical relationship, but really a team. We're there for each other. And you know, that depends, you know, there’s personalities involved, people’s previous experience, you know. If you've only had great experiences with APPs, probably trust them right away. If you've had difficult relationships with APPs or teams that didn't work well, it may take longer. I'd say the best approach is for both the APP and the physician to really look at this as, “How can we accomplish our work together that provides the best quality and the highest level of safety for our patients?” And really just set the expectations of ‘this is a trusting relationship where we work together, we support each other, and we're willing to talk about where the limits of our knowledge are. And for both of us, that's when we get consultations with other folks, and so we just approach it from this perspective.’ And of course, you know,over time, that just strengthens and grows. And when you have a really good, strong, trusting relationship, that's where the real power of the team comes into play.

Wendy Vogel: I like what you said about trusting. You know, the AP has to trust in the physician to be able to go and ask questions and to be mentored, and vice versa, too. I think we play to each other's strengths. If my strength is talking about hospice to a patient that needs to change trajectory of course, then maybe that's what I do better. And there are other things that another team member would do better, but feeling comfortable and saying, “You know, this is what I do good,” or, “Hey, I need help with this. I don't do this as well as I would like to.”

Dr. Stephanie Williams: Tammy, anything? You said you work with one physician. How did that develop? 

Tammy Triglianos: Right now, that's my current setup because of volumes, but I have worked with a team of physicians as well, which, when you're an APP working with a team of three, four plus physicians, that can kind of get a little bit tricky, people fighting for your time. I think being in parallel clinics has helped establish our trusting relationship because all day long, you're with that person navigating care together. We've been together probably 14 years, so that's really dipping back into my memory bank of the beginning of our time together. But I think it's what Wendy was talking about is just approaching each other with questions or, “Hey, why did you do that?” Or “Help me understand this.” And I think our approach to each other wasn't, “Why did you do that?” But, “Help me understand your thoughts on this.” Or “Can I talk through this with you to make sure I'm on the right page.” And how that response came back, then I think that has helped develop a trusting relationship. 

Dr. Stephanie Williams: You both bring up excellent points because there still exists that power gradient between the physician, the advanced practice provider, and a staff nurse or an infusion nurse. And it's really important to overcome that so that people are comfortable in terms of taking care of the patient, to give the patient the best possible care that there is.

Todd Pickard: Yeah, I mean, I think this is a great time to really just highlight the fact that there's a lot of misinformation and misunderstanding out there around APPs, what they can, what they can't do, what they will, what they won't do. In some corners, there's this fear that APPs will go rogue, and that will harm patients. And really, that is an irrational fear because when we are trained, we are trained very clearly about when you reach your own limits, that you are required and obligated as part of your professional practice to find that support, find those resources, get consultations, work with your team to understand so that you serve the patient. And I think it's really important that folks remember that with this respect and trust and accountability, because asking for help is not a failure. Asking for help shows a successful dynamic within a team so that the entirety of the team brings to bear their expertise, their knowledge, their skills, and their judgment. And when the team doesn't know what to do, that's when you’ve got to reach out to your consults and your other resources. So I think that's an important thing to remind everybody is that we're all here trying to do the same work, and it doesn't do any good if you spend a lot of time wondering, “What's Todd up to today?” So I think it's important to realize and for us to kind of dispel those kinds of myths.

Wendy Vogel: I think, despite a social media post by one of our well-known medical associations that will remain unnamed, we don't think that healthcare is a game. We are absolutely serious about this, and we love taking care of our oncology patients. This is something that we're trained to do and that we want to work together as a team. Great thoughts, Todd.

Dr. Stephanie Williams: In terms of actual practice in the states that you're at, are there any restrictions, either statewide, institution-wise, on what you can and can't do?

Tammy Triglianos: I think a big topic that comes up a lot is signing treatment plans or antineoplastic treatment plans. And I don't know across the states, but in my state, that is not a state restriction. But not allowing APPs to sign antineoplastic treatment plans is more of an institutional restriction, and that varies. Recently, I was able to work with a team of people to update our policy to allow APPs to sign antineoplastic treatment plans and how it works at my institution, they go through a privileging process, so essentially it's an opt-in privilege. So, APPs can obtain approval to sign treatment plans, and it is restricted to cycle two and after. So the treatment plan initiation and signing the first cycle is done by the physician, and APP can place the treatment plan and get it teed up. But it actually is signed by a physician for cycle one, and then an APP is now allowed to sign beyond cycle one. We have a few guidelines like they have to be in their subspecialty practice and be manipulating treatment plans that are cosigned by the physician initially and have certain subspecialty training. So, yeah, I'm excited about this update to allow APPs to practice to the top of their license. 

Todd Pickard: Stephanie, this is such an important concept and one that we have hit upon in all of our podcasts. And really, the limits of APPs outside of physician preferences are really state laws and institutional policies. And so, the answer to your question is ‘yes, and it depends on where you are’. So, for example– Tammy gave an example of what's going on in her institution. In my institution, all chemotherapy plans must have a double signature, whether it's initiated by a physician or a pharmacist, or an APP, and that's a safety and quality check. And so everybody just needs to understand, again, limits generally are only in state laws and institutional policies rather than what APPs are trained to do or what folks will reimburse for. And so, really, that's where you have to do the most detailed examination is: what state are you in and what does your institution or your practice say?

Generally speaking, most states allow teams at the local level to kind of figure out what they want to do. Sometimes they'll limit a certain medication, like a schedule II drug or a certain other medication. Institutions sometimes do the same thing. But the good news is, if it's not explicit in state law, you can change institutional policy and physician preference all day long. 

Wendy, what's your experience been? 

Wendy Vogel: Oh, I totally agree. I think it's important for APs to know who's setting the institutional policies and for physicians to know this as well because it may be someone who is not familiar with what the AP role could really be. What do they know about the advanced practitioner? We mentioned that earlier. But I think it also brings up a very important gap that we've seen in oncology, is what's the training of the AP to be able to write anti-cancer therapy orders, and it's a wide variety. There are very few, for instance, nurse practitioner oncology certification or graduate programs. Most of us are trained in a generalist level as a family nurse practitioner. PAs, as you said before on this podcast, you are trained at a generalist level, and we get a lot of our specialty education on the job or through other advanced education. So we're coming into this at all different levels: brand new APs, brand new to oncology APs, and we've seen a gap at the educational level across the US is not the same. 

One of the things that APSHO has done to relieve this, and I'm so excited to be able to share with you guys, is we've just recently launched the APSHO Cancer Therapy Prescribing Course. This, I think, will set the benchmark that we've just talked about and bridge this gap, and allow APs to really practice to the top of their licensure, as Tammy mentioned earlier. It's a very comprehensive online, self-paced course providing that advanced education to prescribe cancer therapies and to manage that hem/onc patient throughout the treatment trajectory. It does not just include the cancer therapies but other things we need to know as APs, like: what kind of drugs do we give with the cancer therapies, what are the standards of care, what do we do in clinical trials? And so just all this that we need to know, and I hope this will bridge that gap, if you will, for this education. 

Dr. Stephanie Williams: Excellent points. I think it also requires physician education to know and understand what advanced practice providers can do. And I think an advantage to our younger generation physicians is that they are now growing up in institutions where APPs are normal, as opposed to older physicians like myself, where we really do have to learn what can be done and what can't be done so that we can trust what everyone is doing there.

Todd Pickard: Are we normal? Yes. But what you really mean is that we're present. It's really about interprofessional education, and I think there's a lot of importance of that concept. If we're going to be delivering care in teams, we should be trained in teams so that you grow up side by side and so that way it does seem normal. I'm working in a team; where's the social worker? Where's the APP? You know, where’s the pharmacist? Because that’s how you trained, and that’s how we really deliver care. That’s the honest truth. No man or no woman is an island in medicine. We all work in teams, whether we recognize that or not. And so I think it’s great when you hear about folks that are actually training side by side because it just dispels some of this anxiety, some of these misconceptions, and you’re just used to the team being around, and it’s like, “Okay, where’s my team?” And then it doesn’t become unusual. It’s just normal.

Wendy Vogel: Yeah, we’re all sitting here nodding our heads together. You all can’t see us, but we’re all nodding. So, Stephanie, I really want to know, how do you educate your colleagues who might not be as receptive to the idea of an advanced practitioner writing cancer therapy orders?

Dr. Stephanie Williams: I have to tell you, it’s difficult sometimes, Wendy, or it has been difficult in the past. The problem becomes not so much a “do you know what you're doing,” problem is how does the reimbursement - I hate to say this – how does reimbursement figure into all this? If I let an APP see half of my patients, who gets that money? And then the other thing is just how do I efficiently use an APP? And we are trying, and  ASCO through the Clinical Practice Committee, to try to get out there and reach out to practices, particularly rural practices, to help them understand the role and the value of advanced practice providers. And I think it's going to be a reach-out effort, leading by example, showing people that this is the way we can do it and we have to do it this way because we need practitioners out there to take care of patients.

Todd Pickard: I want us to all pause here because what you just talked about is critically important. And we all know this is part of medicine, whether we like it or not. But reimbursement, how we get paid, and productivity, how we are recognized for what we do, are concepts that sometimes get mixed up. So when you're talking about reimbursement, APPs are reimbursed just like physicians for everything that we do. Depending on who's paying the bill, they may reduce that reimbursement. So CMS reduces generally to 85% of the physician fees. Medicaid is all over the place, depending on your state and the third-party payers, like the commercial insurance, that's based on whatever you've negotiated in your contract. Sometimes it's a little, and sometimes it's the same. So APPs get reimbursed, period. What level they get reimbursed compared to the physician’s reimbursement is really up to a lot of different factors. 

But productivity, I think that's the thing that we really get hung up on is, well,who's going to get credit for this work? And guess what? The beauty of that is you get to decide. Every practice, every institution makes up those rules. And so, you know, the take-home message here is, don't confuse reimbursement with productivity. Reimbursement is a lot of external factors that are either statutory, or they're contractually negotiated. But productivity is an internal accounting, and you can use team-based metrics. Who's to stop you from saying ‘we reward and recognize both the physician and the APP in these teams.’ They both get credit, and they both get productivity measurements and recognition. And so I think that's where we really need to drive home the message is it's not about setting each other up as competitors. It's redesigning our internal productivity measures so that it's collaborative and that all the work that's being done by the entire team is being recognized and rewarded.

Wendy Vogel: A lot of what we do, as Stephanie referred to earlier, is not reimbursable. All those peer-to-peer reviews, we don't get paid for that. None of us do. Calling patients back, liaisoning with the nursing staff, and answering their questions through the triage line, so much of that is vital to supporting a practice, and you can't do it without all that, but it doesn't appear on the bean counter's metric sheet. So how do we do that? I don't have the answer to that.

Tammy Triglianos: Yeah, and I think in oncology/hematology, there's a lot of frequent touch points in between provider visits, and that doesn't equate to money, but equates to high-quality care, to have access to skilled providers to help manage all the complications, and, you know,in between stuff that happens between provider visits.

Dr. Stephanie Williams: Wendy, there have been changes now in terms of who can enroll and write treatment orders for patients on cancer clinical trials. Could you go over those changes with us and how APPs can now fully participate in this process?

Wendy Vogel: So there were some recent changes to CTEP and then now allowing APs to sign clinical trial orders. This is huge because it really makes the process of getting patients their drugs in the infusion suite much quicker. We don't have to track down a physician to sign those clinical trial orders. The AP can do that. And so this process is made much smoother. I think we'll see a lot of other cooperative groups and institutions follow suit with this. And I think this was a real demonstration of the AP's quality of care and the safety of AP prescribing and being able to have this privilege.

Todd Pickard: Well, this has been a fascinating conversation today, and I would like everybody to have a final say. What’s your take-home message today about what APPs can and can't do. And Tammy, we'll start with you. 

Tammy Triglianos: Thank you. This was a great conversation today. Happy to be a part of it. Know that APPs with supportive, appropriate training, and, you know, I just have to shout out to Wendy and APSHO for the chemo prescribing course. I think this is huge for bridging a gap. Lots of education programs don't have oncology subspecialty, and this is such a comprehensive course that bridges a gap that I think will be huge. And I hope every oncology cancer center adopts, incorporating this to elevate the education and offer some subspecialty education to our oncology APPs. Kudos for all the team-based care and physician and APP teams out there that are really working hard to care for our cancer patients.

Todd Pickard: Wendy, what are some of your final thoughts?

Wendy Vogel: I have to agree with Tammy. I'm really excited about the APSHO Cancer Therapy Prescribing Course. I think that we can, together as a team, really make a difference in cancer care, playing to each other's strengths, and I think that would be my takeaway is: how can we better play to each other's strengths?

Todd Pickard: Stephanie, what about some of your final thoughts?

Dr. Stephanie Williams: I think working with APPs is critical to the success of any medical practice and to any physician who takes care of patients.

Todd Pickard: Well, I appreciate all the insights. And just as a reminder, APPs and physicians, generally speaking, can decide whatever they want that is best for the practice, best for their patients, and delivers high-quality and safe care. Just be aware of your state regulations and find those institutional policies that are holding you back. Good news on the institutional policies - you can change them just like you can change your productivity metrics and models. So the good word is APPs and physicians can work in amazing teams, and we have all the power at our disposal to do so. 

Well, I want to thank you to my co-host, Dr. Williams, along with Wendy and Tammy, for joining our discussion today and sharing all of your experience and highlights into the services that APPs can deliver. It's clear that APPs and physicians working together in teams are vital to a strong and efficient delivery of our team-based care. 

Well, until our next episode, thanks, everybody, and take care.

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