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Higher Practice Skill Mix May Not Be What the Doctor Ordered

“Practicing at the top of your license” and “upskilling your workforce”are two popular healthcare buzz phrases right now. As account-hungry consultants breathlessly will tell you, when medical professionals spend their time doing the things that they’re trained to do and quit wasting their time on things lesser-skilled people or machines can do, good things happen. Quality and productivity go up, costs go down and everyone’s a winner under value-based reimbursement models.  

Well, maybe not. Maybe you can get more done by hiring smart albeit cheap labor who’ll work hard.

Premier, the healthcare group purchasing organization that endeavors to call itself a “leading healthcare improvement company,” recently published a white paper that talked about the skill mix at primary care practices and how that skill mix drives the productivity of the practices. 

Like all vendor-produced white papers, most of the 10-page Premier white paper, Ready, Risk, Reword: Optimizing Primary Care Model Design to Improve Performance, is written to sell you something—in this case, it’s Premier’s services to revamp physician practices to compete in tomorrow’s healthcare market.

But, there is some interesting data in the white paper that should give physician practices pause today before they start chanting “practice at the top of our license” and “upskill our workforce.”

Analyzing 2018 data from 257 family medicine and primary-care medical practices, Premier found that the practices that had a lower-skilled workforce actually were more productive than practices that had a higher-skilled workforce. 

The 257 practices had a total of 885 doctors and 1,445 clinical support staff members. Premier defined clinical support staff members as medical assistants (MAs), registered nurses (RNs) and licensed practical nurses (LPNs). Of the practices:

  • 54 percent used MAs AND RNs OR LPNs
  • 24 percent used MAs AND RNs AND LPNs
  • 22 percent used MAs only with NO RNs OR LPNs

As it turns out, the physician practices that employed MAs only with no RNs or LPNs were as productive if not more productive than the other practices that employed RNs, LPNs or both.

Premier measured the practices’ productivity by wRVUs, or “work relative value units.” Per Premier, wRVUs are a measure of “how much effort the provider puts into the service that was billed.” In short, the MA-only practices do more for less as they presumably pay MAs less than they would RNs or LPNs.

Further, physician practices that use RNs and LPNs and presumably pay them more without doing more are unnecessarily driving up healthcare costs.

“While many of these practices are still largely fee-for-service based from a revenue perspective, it is safe to assume that unless the higher skill mix models are leveraging staff working at the top of their license, they may be contributing to a higher cost of care,” Premier said.

Point being, as long as FFS continues to be the dominant payment model, you’re wasting your time and everyone else’s money by upskilling your workforce because RNs and LPNs won’t be doing anything that only they know how to do like counseling patients about their health and coordinating their care.

Healthcare is a business just like any other business. Overpaying highly-skilled workers for the tasks that lesser-skilled workers or machines can do is bad for any business, including healthcare.

That applies to RNs and LPNs who hear the footsteps of MAs creeping up behind them just as much as it applies to physicians who hear the footsteps of physician assistants and nurse practitioners. 

To learn more on this topic, please read “Should Doctors Make Less Money?” on 

Thank you.

About the 4sight Health Author
David Burda News Editor & Columnist

Dave is 4sight Health’s biggest news junkie, resident journalist and healthcare historian. He began covering healthcare in 1983 and hasn’t stopped since. Dave writes his own column, “Burda on Health,” for us, contributes weekly blog posts, and manages our weekly e-newsletter and weekly podcast, 4sight Friday and 4sight Roundup. Dave believes that healthcare is a business like any other business, and customers—patients—are king. If you do what’s right for patients, good business results will follow. Follow Burda on Twitter @DavidRBurda and on LinkedIn.