Hospitals and HealthCare Systems

What you were “

Not”

taught in PA School Folusho Ogunfiditimi, DM, MPH, PA-C Director, Mid-Level Provider Harper University Hospital/ Hutzel Women’s Hospital Detroit Medical Center Tenet Health System [email protected]

Objectives

• Understand the roles of PA’s

– Recruitment and Retention – Onboarding and Orientation – Compensation and Provider enrollment – Clinical Practice Models – Regulatory Standards and Compliance – Productivity, Value and Reimbursement – Team membership/Physician Collaboration – Quality, Safety and Patient Satisfaction

Recruitment and Retention

History of Non – Traditionally Trained Medical Practitioners.

Modern Advanced Practice Providers

1965 1963 1989 1869 1965

From Graduation to Hire

• Average of 90 days • Graduation-Board Certification – Licensure • Interviews – Start early • PA-Intern / Graduate PA • Job Descriptions • PA Recruiter • PA Leader / Director • Shadow opportunities

• Graduate Physician Assistant is (GPA) is a recently graduated Physician Assistant

who has met the academic and State of Michigan practice requirements for certification and Licensure as a Physician Assistant, but who has yet to obtain full organizational credentialing status with the DMC.

In accordance with DMC bylaws all licensed physician assistants must undergo organizational credentialing and privileging prior to providing health care services to patients. To this effect the title Physician Assistant Certified (PA-C) cannot be used until fully credentialed at the DMC and newly graduated PAs, awaiting credentialing will use the title Graduate Physician Assistants.

Credentialing

• Credentialed through Medical Affairs – JC requirement • Supervising Physician (employed) • PA’s must have an NPI and DEA License. (NPs as well) • Scope of Practice and Core Competencies- Every specialty • OPPE and FPPE

Agree Agree Disagree* Disagree* Agree Disagree* PATIENT CARE

Provides care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease and support at the end of life.

MEDICAL/CLINICAL KNOWLEDGE

Demonstrates knowledge of established and evolving biomedical, clinical, procedural and social sciences, and applies this knowledge to patient care.

PRACTICE BASED LEARNING AND IMPROVEMENT

Uses scientific evidence and methods to investigate, evaluate and improve patient care processes.

Agree Disagree* INTERPERSONAL & COMMUNICATION SKILLS

Demonstrates interpersonal and communication skills that enable the provider to establish and maintain professional relationships with patients, families and other members of health care teams and administration

Agree Disagree* Agree Disagree* PROFESSIONALISM

Demonstrates behaviors that reflect a commitment to continuous professional development, ethical practice, understanding and sensitivity to diversity, and a responsible attitude towards patients, the hospital and the medical profession

SYSTEM BASED PRACTICE

Understands the contexts and systems in which health care is provided, and applies this knowledge to improve and optimize health care

Job request from Hospital/Office

Req Approval

HR job posting /screening Temp Privileges Approval Approval Medical Affairs PA/NP office Recruiting NP/PA’s Exec Dir.- DMC MG notification DMC MG Recruiter Interviews Medical dept /mlp office Job offer And acceptance Approval Start Date HR Process Risk MGT Start NP/PA orientation NP / PA Training, EMR/CIS Third Party Enrollment and Billing Final Credentialing Approval from Medical Affairs

Best Fit and Benefits

• Salaried vs. Hourly • Incentives, RVU based, Bonuses • CME • Sign-on Bonus vs. Retention Bonus • Loan Repayment, Immigration Support • STD, LTD, Vacation and Sick Leave • More rigidity, Less flexibility

On boarding and Orientation

Department Dynamics

• Medicine

– Medicine Service – Medicine Subspecialties

• Surgery

– General Surgery – Surgery Subspecialties

• Emergency Medicine • Ambulatory Care Centers

Team Dynamics

• PA only • NP only • PA/NP only • PA/NP and Residents • PA/NP, Residents, SW, CM, PT/OT, Pharmacy

Staffing, Training, Governance

Horizontal continuum of care

GME, Research, Nursing Model Integrated Health Care

Medical and Nursing teams, Advanced Practice Providers, Pharmacy, Administration etc..

Medical Model Human Resources Productivity, Quality, and Compensation Patient

Hospital and Health Systems Orientation

• None

(rare, in very small hospitals)

• Formal

– 1 to 7days – System, Hospital, Department, EMR

• Informal

– 30 days to Lifetime

• Checklist

Job request from Hospital/Office

Req Approval

Temp Privileges Approval Approval HR job posting /screening Medical Affairs PA/NP office Recruiting NP/PA’s Exec Dir.- DMC MG notification DMC MG Recruiter Interviews Medical /dept /mlp office Job offer And acceptance Approval Start Date HR Process Risk MGT Start NP/PA orientation NP / PA Training, EMR/CIS Third Party Enrollment and Billing Final Credentialing Approval from Medical Affairs

Medicine Roles

• Participate in all aspects and stages of care:

– Front Line: ED, Admissions, Admit H/Ps, Outpt, Inpt and Intra - Op – Function in the Middle: keep the dialogue open and process running smoothly: • LOS and UR management – Inpt setting • Follow up visits in outpt settings • Patient and family education in person and by phone.

– Function as “Closers”: to finish the “health care deal”; • Transition of care

Surgical Role

 Pre Operative Role  Clinical evaluation to include H/P’s, Diagnostic evaluation, ancillary study review and medical clearances  Operative Role  First and Second Assist  Robotic assistance  Facilitating training and education of residents/students  Post Operative Role  Discharge management  Post operative clinical evaluation, participate in the overall care of patients from presentation onward.

 Develop and maintain social programs

Compensation and Provider Enrollment

Salary Models

• Salaried – Exempt Employees • No overtime • “Moonlighting Opportunity” • RVU Based compensation • Incentive laden Salaries • Productivity and Value provides leverage • Market Analysis and Adjustments • 92-96% of the 50-65 percentile • Critical to Fill positions

Provider Enrollenment

• Medicare and Medicaid

– Provider Enrollment Chain and Ownership system (PECOS) – internet based

• CAQH

– Council for Affordable Quality Healthcare – Non profit organization formed by various trade associations – Streamline provider credentials with third party billers

Provider Enrollment

• Third Party Billing • Everyone is different

Regulatory Standards and Compliance

Law vs. Regulation

• Federal laws – Federal agencies and VA • Stark Laws – Limits on practice delivery models with physicians • State Laws vs. Organizational Bylaws • Be aware of laws affecting similar professions • Billing and Reimbursement regulations

Physician Certification and 2 Midnight rule

• ACA – Calls for all admissions to be certified by a Physician • Verbal toggle of war between Admitting Physician and Ordering Physician • CMS – 2 MN rule – Observation vs. Inpatient Admission

Hospital and Professional Physician Billing (Part A and Part B)

• Cost Report • Employment relationships • No “Incident too” in hospital based clinics • Billing opportunities – H/P, daytime and after hours – Subsequent hospital care – Consults, – Procedures – Surgery – Discharges

Section 6407 of the ACA established a face-to-face encounter requirement for

certain items of DME.

The law requires that a physician must document that a physician, nurse practitioner, physician assistant, or clinical nurse specialist

has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME.

Clinical Practice Models

Horizontal Continuum of Care

APRNs (NP, CNM CRNA)

Education, research , training , care coordination, pt.assessment, evaluation, Dx Tx, Surgical Assist, Anesthesiology, Pre, Ante and Post care.

PAs Enhanced Patient Outcomes and Patient Satisfaction

Types of Clinical Practice

• Ambulatory Practice – Scribes – Shared – Side by Side – Autonomous • Inpatient Practice • Interoperative Practice • Combined Practice

Scribe Practice

PATIENT (New and F/U) PA/NP Takes H/P Reports to MD (May or May not dictate) MD repeats all the work of PA/NP and dictates MD Bills at 100%

Scribe Practice Pros

• PA/NP learns clinical practice, dictate etc.

• Acceptable teaching model for new graduates

Cons

• Physician still has to do full history and exam • Double work/single service/ • Mild incentive for the MD/poor incentive for the PA/NP • Expensive utilization of Providers.

Shared Practice

Patient (New and F/U) PA/NP does complete E/M service, communicates to MD and dictates Additional Patients seen by MD MD sees patient briefly, and discuses the MDM of the Service. MD bills at 100%

Shared Practice Pros

• Patient seen by two providers. • Physician does not have to do full exam, • Good incentive for the Physician • Billing is done by Physician • Meets CMS standards • Good teaching and supervisory provisions

Cons

• +/- Access Improvement • Poor utilization of resources • Low volume days= low productivity from all providers • Mild incentive for the PA/NP

Side by Side Practice

PATIENT (F/U, +/- New) MD may see New patient as a shared visit PATIENT (New, +/- F/u) PA/NP does entire E/M service PA/NP bills at 85% if not seen by MD MD (in clinic @ the same time) Constant Comm MD bills for his own pt....... and may bill for PA/NP pt....... if seen, at 100%

Side by Side Practice Pros

• Improved Access • MD can see New, PA/NP can see F/U • Direct access to MD • Easy conversion to Shared Practice • CMS compliance with billing and supervisory regulations • Good incentive for all providers

Cons

• Not always suitable for New or Consults .

• Subject to over booking • Billing and Reimbursement Limitations: Enrollment, 85% • Understanding Legal and Compliance rules.

• Administrative Impact Resources and Space

Autonomous Practice

MD provides indirect supervision and available for consultation if needed.

MD free to be in clinic/OR/Procedure.

MD gets downstream opportunities from PA/NP Patients (New and F/U) PA /NP does complete E/M, dictates and bills at 85%

Autonomous Practice Pros

• Best model in ideal setting • Improves Access for all patients • Good incentive • Downstream Feeders • Provider is always busy.

• Safety net for last minute add-Ons • Productivity justifies administrative Impact .

Cons

• Requires well experienced, confident PA/NP • MD may not be present for complex cases • Patients may not see MD on 1 st visit • Requires trust and good communication between PA/NP and MD

Inpatient Utilization Pros

• Prompt/ Direct/Consistent Pt. access.

• Autonomous practice • MDs gain confidence in PA/NP • Good learning opportunities

Cons

• Poor billing / reimbursement • Difficult Productivity measurements • PA/NP may be subjected to “scut” work • Requires well experienced, confident PA/NP • PA/NP has limited view of patients

Inpatient Utilization

PA/NP Rounds alone or with team, writes Progress notes Discharges Pt. In- Patient

RVU Formulas Initial Hosp Visit = 5.82/pt.

Sub Hosp Visit = 2.07/pt.

Inpatient Consult = 3.26/pt.

MD Rounds

Ave. 6 pt...... daily = 22.3 RVU Approx. $550/day

OR Utilization and ROI

Patient (Operation) Surgeon (MD) First Assist (PA/NP) Surgeon Bills at 100% and PA/NP Bills at 85% of First Assist Fee = 16% of the Surgeons Fee

If MD fee for VIP = $12,000 PA/NP fee = $1920

Operating Room Utilization Pros

• Improved Revenue generation: Surgeon fee and First Assistant fee.

• Develop expertise in OR • Comfort and Trust with MD.

• Standardization of procedures • Good quality metrics

Cons

• Can be monotonous • Limited view of patient • Need experienced provider • Specific language is needed in GME programs • Competition with GME trainees.

Combined Utilization Pros

• Maximum Utilization • Jack of all Trades • Experienced flexible provider • Develop Trust and Confidence with MD .

• Maximum Access • Maximum RVU generation.

Cons

• Potential for PA/NP burn out • Master of None • Competency measurement is critical • Commands higher salary

Combined Practice Ambulatory Practice In-Patient Practice OR Practice Experienced PA/NP MD MD MD

Recommended Practice Pattern

• • • •

PA/NP New Grad (<1yr of clinical experience)

– Scribe Practice (not favored) – Shared Practice (ideal for this group) – Side by Side Practice (ideal for fast learner) – Inpatient Utilization (ok for fast learner, but need good orientation),

PA/NP (1 – 3 yrs. of clinical experience)

– Shared Practice – Side by Side Practice – Autonomous Practice – Inpatient Utilization (Ongoing evaluation needed) – OR Utilization (Direct supervision and training required)

PA/NP (3 - 5yrs of clinical experience)

– All practice patterns, Limited direct supervision in OR

PA/NP (>5 yrs. of clinical experience)

– All practices

Productivity, Value, Billing and Reimbursement

ROI- Scribe Practice APP @ 1 FTE 50% New (2.22 RVUs) 50% Returns (1.48 RVUs)

APP @ 440/day MD@ 1150/day 15 pts.. @ 1.85 rvu/pt.

MD @1 FTE

RVU’s=27.75/day (approx. $685)

Amount is based on Level 3 coding using 2011 Cf of $24.67

ROI- Shared Practice APP @ 1 FTE

APP @ 440/day MD@ 25 pts. @ 1.85 rvu/pt.

1150/day

MD @ 1 FTE 50% New 50% Returns 40% Increase in RVU with 10 additional patients RVUs=46.25/day

Approx.. $1141/day

ROI – Side by Side Practice

• 15 Pts. @ 1.72 rvu/pt.

• (More Returns, less new) MD may see new pt...... as shared MD Available for Direct Consultation • 15 pts. @ 1.97rvu/pt.

• More New, less Return APP maintain individual schedule MD • APP @ 440/day • MD @ 1150/day

RVU = 55.4/day

Approx.. $1366/day 50

ROI - Autonomous Practice

15 Pts. @ 1.82rvu/pt.

(New and F/U) MD - Run separate clinic, OR, Research, etc. Revenue Generation dependent on daily activities.

RVU = 27.38 + MD

Approx.. $675 + MD

@85%=$573

APP @ 440/day

Inpatient Utilization

PA/NP Rounds alone or with team, writes Progress notes Discharges Pt. In- Patient

RVU Formulas Initial Hosp Visit = 5.82/pt.

Sub Hosp Visit = 2.07/pt.

Inpatient Consult = 3.26/pt.

MD Rounds

Ave. 6 pt...... daily = 22.3 RVU Approx. $550/day

OR Utilization and ROI

Patient (Operation) Surgeon (MD) First Assist (PA/NP) Surgeon Bills at 100% and PA/NP Bills at 85% of First Assist Fee = 16% of the Surgeons Fee

If MD fee for VIP = $12,000 PA/NP fee = $1920

ROI - Combined Practice Ambulatory Practice $625/day In-Patient Practice $550/day Experienced PA/NP ($440/day) OR Practice $1920/day MD MD MD

Results – Inpatient Study

Collection of Physiological Data 2% Telephone Consultation by NPP 3% Special Reports 3% Analysis of Clinical

Service Value 35.12%

Data 8% Lunch meeting 0.27% Business Meeting 1% Team Conferences 16%

Other 3.29%

Cafeteria 3% Other Revenue Generating Activities 1% Procedure Documentation 1% Procedures 3% Subsequent Hospital Care 34% Discharge Management 16% Admission H/P 4% Post Op Care 3% Other Service Value Activities 3%

Revenue Generating 61.59%

Charts for each area can be seen in the Appendix

Results – Inpatient Study IP Activities

Subsequent Hospital Care Discharge Management Admission H/P Post Op Care Procedures Procedure Documentation Other Revenue Generating Activities Team Conferences Analysis of Clinical Data Telephone Consultation by NPP Special Reports Collection of Physiological Data Business Meeting Council or Committee Other Service Value Activities

Occurrences Revenue Generating Service Value

245 116 30 22 x x x x 21 6 x x

CPT 2010 Code

99231 - 99233 99238 - 99239 99221 - 99223 99024 Based on procedure code Based on procedure code 9 114 55 25 24 12 7 19 x x x x x x x x 99366 99090 98966 - 98968 99080 99091 N/A

Results – Outpatient Study Service Value 38.23%

Collection of Physiological Data 1% Telephone Consultation Patient Follow-Up 4% Student Precepting 2% Research Visit Documentation 3% Team Conference 4% Other 1% Collection of Physiological Data 1% Analysis of Clinical Data 18% Other Service Value Activities 2% Outpatient Visit 32%

Revenue Generating 59.04%

Outpatient Follow Up 11%

Other 2.73%

Personal Time 1% Cafeteria 1% Other Revenue Generating Activities 0.39% Procedure 2% Procedure Documentation 6% General Documentation 8%

Statistical Analysis

80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0%

Inpatient Percent of Time Spent on RVU Activities

80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0%

Outpatient Percent of Time Spent on RVU Activities

Medicine Department Surgical Department    Compared surgical and medicine departments (inpatient and outpatient combined) No difference found between surgical department activities (p = 0.205) Medicine departments are different (p<0.05)

Summary of Results Comparison of Activity Categories

70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% Revenue Generating Service Value Other IP OP ED OB

Employee (PA) Engagement and Physician Collaboration

Engagement Opportunties

• Hospital committee participation

– From P/T to Medical Executive committee

• Utilization Resource committee • Volunteer opportunities • Physician Champion • PA’s know about PA’s….. etc.

• Be Visible – Do not presume that others know

Strategic Initiatives

• PCMH • Ambulatory Care centers • Centers of Excellence • Service Line development • Less Inpatient – More Outpatient • Transition of Care

Quality, Safety and Patient Satisfaction

Quality and Safety

• 2015 – Reimbursement tied to value not volume (1-2% penalty) • Quality Metrics

– Discharge Management – Morbidity and Mortality – Core Measures – AMI, HF, Pneumonia, Stroke and SCIP

Patient Satisfaction

• HCAPS

– Hospital Consumer Survey of Healthcare Providers and systems – 6 Domains –Pain, Communication, Nursing, Hospitals systems – 1 domain – dedicated to Physicians/Providers – NPI used to run reports

Summary

• PA’s are extremely well positioned – Organizational and Patient Throughput – Transition of Inpatient care to Acute care Management – Transition of Care – Productivity tools – Advocacy to Improve Laws – ACA, Medicaid Expansion – Ideas are needed to achieve maximum Patient Access, satisfaction and maintain quality measures

Questions