Transcript Presentation Title Subhead Title

Utilization of ATC’s, Physician
Extenders, and Other Ancillary
Personnel to promote Orthopedic
Practice Efficiency:
Forrest Pecha MS, ATC, LAT, OTC, CSCS
Director of Clinical Residency and Outreach
St. Luke's Sports Medicine
NATA CEPAT Committee Member
Physician Extender Liaison
Disclosures
• Consultant
• Orthovise LLC
Orthopaedic & Sports Medicine Practice Advisors
• Co-Owner and COO
A Balancing Act
The Business of Healthcare vs. Patient Care
“Healing is an Art,
Medicine is a Science
Healthcare is a Business”
The Business of Healthcare
• Maximize Volume
Quality Assurance
• Maximize Revenue
• Maximize Productivity
• Maximize Efficiency
MINIMIZE EXPENSE
Accreditation
• Maximize Throughput
• Maximize Customer Service
• Maximize Patient Education
• MAXIMIZE MARGIN
Safety Assurance
Physician Extenders
• Agenda:
• Definition of Physician Extender
• Certified Athletic Trainers (AT) as Physician Extenders?
• The Clinic and Financial Value of AT’s as Physician Extenders:
• Improve Clinic Time
• Economic Impacts
• Indirect Financial Impact
• Direct Financial Impact
• Patient and Physician Satisfaction Surveys
• Mid Level Providers in Autonomous and non Autonomous
Roles
• Integrating AT’s and Mid Level Providers in the Orthopedic
Practice
Physician Extenders
•
Webster:
“A health care provider who is not a physician
but who performs medical activities typically
performed by a physician”
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Medical Assistant (MA)
Physician Assistant (PA)/ (OPA)
Nurse (RN, LPN, NP)
Certified Athletic Trainer (ATC/AT)
Clinical Roles of Physician Extenders
• Daily Duties:
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Performing complete physical exams
Taking Patient Histories
Ordering Diagnostic Testing
Presenting findings to physicians
Pre-operative instructions/booking surgeries
Post-operative care
Answering patient phone calls
Teaching administering therapeutic exercises to patients
Casting, splinting and brace fitting
Completing patient paperwork (FLMA/disability)
Understanding of radiological findings
Coding and billing for PM&R codes
Electronic Medical Records training and utilization
Patient medication reconciliation
Scribing for physician dictations
Dictation of patients
Communication with Coaches, Athletes, Parents
Certified Athletic Trainers
• The Many faces of Athletic Trainers
Certified Athletic Trainers
• We have taken the Healthcare team from:
The Sidelines
To your Clinics
Certified Athletic Trainers: As Physician Extenders
• To work under the Guidelines and Direction of
Supervising Physician
• To Evaluate, Treat, Prevent Athletic (orthopedic)
Injuries
• State Practice Acts will Vary
• AT’s highest level of specific MSK education
Certified Athletic Trainers: Education
• Licensed in 47 States
• Recognized by AMA 1990
• 70% have MS or higher
• Medical Based Education Model
(AMA 1993)
• Academic major accredited by
the: Commission on
• AT Education Competencies
Accreditation of Athletic
• Evidence Based Practice
Training Education (CAATE)
• Prevention and Health Promotion
• Nationally Certified by
Independent certifying agency
(BOC)
• Mandatory Continuing
Education (CEU’s)
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Clinical Examination and Diagnosis
Acute Care of Injury and Illness
Therapeutic Interventions
Psychological Strategies & Referral
Healthcare Administration
Professional Development &
Responsibility
www.nata.org
www.bocatc.org
• Source: Athletic Training Competencies 6th Edition
Certified Athletic Trainers
• As Physician Extenders:
• Increase Clinic Efficiency
• Increase Patient Throughput
• Knowledge in Bracing and Casting
• Expertise in Rehab/ Home
Exercise Programs
• Improving Patient Satisfaction
• Administrative Skills to Enhance
Practice Management
Athletic Trainers: Providing Financial Value
• Time, Money, Satisfaction
• Time
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UW – Madison time to task
Time with patients/patient perception
Template physician schedules patient visits
Physician personal time (clinic limits)
• Money - ^ throughput
• AT vs other staff
• AT included into clinical model
• What does this mean $$
• Satisfaction
• Patient perception of AT’s as clinicians
• Physician perception of AT’s as clinicians
AT Clinical Value: Time
Table 1:
AVERAGE TIME SPENT PER TASK
Task
Time on Task (min)
Evaluation
8.2
Presentation to physician
2.3
Assisting physician with patient
7.2
Follow-up & patient education
1.9
Dictation
4.3
Other
1.1
Total
25.1
• 1997 University of Wisconsin –Madison Study
• Evaluated time to task for athletic trainers to do clinical skills
• Compared to patient time spent with MD
• Looked at patient volume if one AT was removed from clinic
UW – Madison Study Results
By removing AT’s MD’s saw a decrease
in patient throughput by 15-30%
* Published Athletic Therapy Today 1997 J. Greene
March 7th through April 29th 2011(8
weeks)
• Clinics = 171 half-day clinics
• Total N = 1542 (athletic trainer, physical therapist, medical
resident, orthopedic fellow/resident, primary care
fellow/resident, medical student)
• Time on Task Study
• Extender Model
• Efficiency & Productivity
* Presented Poster to AMSSM 2012
MD Value Added Activity
Ortho – 10.27 minutes
Case Presentation - 1.89
MD In-Room - 8.38
PCP – 11.4 minutes
Case Presentation – 2.09
MD In-Room – 9.31
40% of orthopedic surgeons spend 9-12 minutes with each patient
25% spend 13-16 minutes with each patient
15% spend 17-20 minutes
Source: Medscape Physician Compensation Report 2011
AT Clinical Value: Time
AT
Non-AT
History/Phys. Exam
8.67
12.57
Case Presentation
1.94
2.36
Patient Education
2.40
1.11
Documentation
4.03
6.23
17.04
22.27
What does an average of 4.3 minutes per patient of documentation mean?
AT Clinical Value: Time
• Time with Patients/ Patient Perception
• Current Emory Study – measure time patient
is with AT vs MD
• Template Physician Schedule
• Emory Throughput study allowed ability to
change appt time
• Dr Nilsson (St Luke’s)
• US/RPV
• Change patient appointment time NPV: 30/20/15
• Physician Personal Time
• Dr Curtin (St Luke’s) limit Sx time
• Measured time out of clinic
• Pre AT finish clinic 7:30 w/ 30+ dictations
AT Clinic Value: Financial Impact
AT vs other PE
•
2006 Emory Sports Medicine Study
• One Year comparative study using MA’s and
AT’s
• Two PCSM, Fellowship Trained, Physicians
• Each MD used an MA for 6 months and an ATC
for 6 months
• Over 6 months 80 full clinic days were
evaluated for each MD using MA’s and AT’s
• Number of patient encounters (visits)
• Billed Charges
• Collections
Emory Study Results
• All variables showed statistical significance for both
Physicians over the three variables (p < .05)
• Physician A saw increase of 17% for patient encounters
• Physician B saw increase of 22% patients encounters
• Physician B daily average patient visits increase from 22.9/day to 27.1/day with ATC
• *Current schedules allow for 32-35 patients/day
• * Submission
to JSH, Poster AOSSM 2011
AT Clinic Value: Financial Impact
AT addition to current staff
• 2008-09 Orthopaedic & Fracture Clinic – Portland OR
• Established Surgeon
• Average daily billings pre AT (3yrs)= $6,605/day
• Average daily billings with AT = $8,076/day
• Increase billed charges of $1,471/day or 18%
• Unpublished data from practice
AT Clinic Value: Financial Impact
AT addition to current staff
• Physician B
• Physician A
• 23% increase in Patient
Volume
• Increase .69 patients/hr
• 2.76 per ½ day
• 4 hr/ ½ day
Yr
tot pt's
Days
pt/dy
pt/hr
2010
908
83
10.9
2.8
Days
pt/dy
Year
2011
tot pt's
1034
75
13.8
• 20% increase in Patient
volume
• Increase 3.7 patients/day
• 6.5 hr/day
• Current clinic template allows for 32
patients/day
2010
# patients
# weeks
pts/day
Wed
878
47
18.7
2011
# patients
# weeks
pts/day
Wed
849
38
22.4
pt/hr
3.45
• Unpublished data from practice
• Started IRB process
Clinic Value: Financial Impact
AT addition to current staff
• Pilot Studies
• Children’s Hospital of Wisconsin 2012
• PCSM clinic supported with 1 AT
• Addition of 2nd AT in clinic
• Increased ~ 5 patients/ ½ day (10/day)
• No change in total clinic time
• Maintained High Patient Satisfaction
• Heartland Orthopedic Specialist 2008
• Addition of AT to existing MD clinic
• AT scribing for dictations, seeing patients
• Increased patient volumes 15 – 20 %
• MD’s clinic finished earlier w/ AT
AT Clinic Value: What does this mean?
• How do we measure patient throughput.
• Collections of patient visits
• Downstream revenue of visit
• Paid on Patient RVU’s
• Incident to billing/collections
AT Clinic Value: Collections for Patient Visits
• Methodology
• We Use Medicare rates:
• Build a business plan
• Medicare rates are always transparent
• It is easy to asses where your private payor fees
are as a percentage of Medicare
• It allows us to build a business plan under the
worst case scenario (that we only get reimbursed
100% of Medicare)
AT Clinic Value: Collections for Patient Visits
• What is a patient E/M worth?
• 99213 – $78.54 (2012 Medicare Fee NE)
• 99203 - $137.73 (2012 Medicare Fee NE)
• Assume current new vs established visit ratio is 1 to 4 then your
expected reimbursement for E/M is $88.21per patient (in Medicare
rates)
• One additional patient per day for a provider with three patient
days a week equals an increase in annual collection of
approximately $12,702.24
– 1 pt per day X 3 days a week X 48 weeks a year X $88.21 collected per patient =
$12,702.242 annually
• Two additional patients/day - 3days/wk (6/wk)= $
$25,404.48
AT Clinic Value: Collections for Patient Visits
Collections for each additional E/M per day
$70,000.00
$60,000.00
$50,000.00
$40,000.00
Collections for each additional
E/M per day
$30,000.00
$20,000.00
$10,000.00
$1
2
3
4
• Emory = ^ 4.2 patient/day
• St Luke’s = ^ 3.9 – 5.5 patient/day
• 3 Clinic days/wk
5
AT Clinic Value: Downstream
ASSUMPTIONS
• NPV – RPV = 1-4
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18% Sx
22% MR
26% PT
NPV = $1,028
AT ^ 4 pt’s/day
1 / 4 = NPV
AT = ^ $1,028/day
? day’s clinic/wk
• Math?
Revenue Assumptions
FY10 NPVs
Collections per NPV
NPV to RPV Ratio
9427
218.86
0.71
Collections per RPV
90.88
NPV to Case Ratio
6.08
Average Collections per Case
1,855
FY10 PT Referrals
2492
NPV to PT Referral Ratio
3.78
PT Visits per Referral
7.00
Collections per PT Visit
117.02
Collections per MRI (Man
Care)
733.86
NPV to MRI Ratio
4.56
PE Clinic Value: What does this mean? $$
• In FY 2009, each unique new patient was worth an average
net of $2062.00 to the UW Hospital Department of
Orthopedics and Rehabilitation (Facility Fee)
• In FY 2009, each unique new patient was worth an average
net of $1371.00 to the UW Department of Orthopedics
Physician Practice Group (Professional Fee)
So, Why is Staffing and Workflow Optimization so
Important?
AT Clinic Value: RVU production
Productivity Information:
99203 Work RVU 1.42 Total RVU 2.20
99213 Work RVU .97 Total RVU 1.46
• Physician A
• 23% increase in Patient Volume
• Increase .69 patients/hr
• NPV to RPV ratio = 43 - 47%
(2010 & 2011)
• ½ Wk day = 4 hrs
• Patient RVU = 1.16 – 1.18
• ½ Day RVU Increase = 3.2 –
3.26
• ~ 6.4 RVU increase with AT
(.2 FTE)
• Physician B
• 20% increase in Patient
volume
• Increase 3.7 patients/day
• NPV to RPV ratio = 41%
(2010 & 2011)
• 6.5 hr/day
• Patient RVU = 1.15
• ~ 4.3 RVU increase w/ AT
DME Evolution:
“Necessary Evil”
Athletic Trainer: DME Specialist
Goals
-Improve Patient Relations/ Service
-Improve Clinic Efficiency
-Medicare Compliance
-Decrease loss
Tom Koto NATA-HOF
-Increase Revenue
DME Options
1. Stock and Bill (Consignment)
2. Stock and Bill– Hybrid
3. 3rd Party Supplier
a. Prosthetic/Orthotic
b. Medical Supply
4. In House*
Profit Margins
Low Cost/ High Reimbursement
• Hinged or fixed Walking Boot L4386
• ~$36-60
• 2011 MCR Allowable $170.83
• 2012 MCR Allowable $174.93
• Pneumatic hinged or fixed walking boot L4360
• ~$55-75
• 2011 MCR Allowable $312.25
• 2012 MCR Allowable $319.75
• Lace-up ankle brace L1902
• ~$15-25
• 2011 MCR Allowable $90.02
• 2012 MCR Allowable $92.19
• Post-op ROM knee brace w/ drop locks L1832
• ~$110-150
• 2011 MCR Allowable $686.31
• 2012 MCR Allowable $702.08
Profit Margins
Higher Cost/ High Reimbursement
• Lumbar-Sacral Orthoses (LSO) L0631
• ~$155.00
• 2011 MCR Allowable $1106.33
• 2012 MCR Allowable $1132.88
• Custom Osteoarthritis Knee Brace (single hinge)
L1844
• ~$600-800
• 2011 MCR Allowable $1793.16
• 2012 MCR Allowable $1836.19
Potential Clinical Financial Impact
• 2011 DME Billed
$559,604.83
• 2011 DME Collection
$458,096.24
• 2011 DME product cost
$157,686.28
• 2011 DME Profit
$300,409.96
Potential Clinical Financial Impact
• Report from Emory Sports Medicine
• ESMC fiscal year 2007
• 4.5 FTE ~ $130,000
• ESMC fiscal year 2008
• 5.5 FTE ~ $165,000
• ESMC fiscal year 2009
• 6.5 FTE ~ $235,000
• ESMC fiscal year 2010
• 7 FTE ~ $265,000
Skill Sets for AT’s in the Operating Room
•AT can Assist Physician in:
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Prepping and Draping of patients
Identifying and marking anatomical landmarks
Positioning patients
Perform PE under anesthesia
Understanding of instruments
Retracting Tissue
Preparation of ACL grafts
Close and Dress Wounds
Apply post-op dressings
Provide post-op instructions and exercises
Coding and billing for assist services
Benefits of AT’s in the OR: Efficiency
• Unpublished Data
* Emory
• AT’s - prep, drape, position
patients, close wounds
• Prep ACL Grafts15-20
min away from MD time
• ACL surgery approx 50 min
• Can Increase # cases per
day
• Wound closure
• Decrease MD time in OR &
increase time for dictation
etc.
• Teach Post-op
instructions, brace/splint
fit and application
• Patient Education &
increase Pt satisfaction
* University Orthopedics
2006 (Atlanta GA)
• Showed with AT support in OR
– MD’s able to increase 1
surgical case/day
* SUNY Downstate
Department of Orthopedics
• Showed with AT support as
part of OR team, patient
turnover time in the OR
decreased by about 50%
• AT consents, transports, positions,
drapes, preps, braces postoperatively and performed minor 2nd
assist (SUNY DMC has orthopedic
residency program)
Benefits of AT’s in the OR: Possible Collections
• Need to have AT credentialed to work in OR
• As duel credential, can bill as first assist in
OR similar to a PA or NP
• AS modifier: Non Surgeon Assist
• Can bill for managed care INS contracts
• If denied can appeal
• Re submit bill including:
• CMS guidelines for surgeries allowing assist
• OTC Certification
• Job Description for OTC or OT-SC
• AT Education & BOC Cert
• May need to change NPI provider information
• ATC – Surgical Assist
• Cannot bill Medicare or Medicaid
• Collection rates vary per insurance carrier
Benefits of AT’s in the OR – Direct Revenue
OR Billing number for OTC/ATC's
ATC
Yr
St
Billed amount
Billing
period
Collections
% collections
Units
Billed
Adjustable $$
KM
2008-09
GA
$437,813.00
12 mo
$42,766.00
9%
KM
2007-08
GA
$353,229.00
12 mo
$59,090.00
17%
168
$333,544.33
KM
2006-07
GA
$247,315.50
12 mo
$44,689.68
18%
158
$161,610.00
KM
2004-04
GA
$293,958.50
12 mo
$51,704.07
18%
218
$301,482.57
CK
2007-08
GA
$204,416.25
12 mo
$51,814.81
25%
452*
$144,363.31
*Includes clinical billings
JS
2007-08
TX
$102,303.00
12 mo
$25,467.00
25%
198
$75,864.00
HG
2007-08
CT
$236,768.00
12 mo
$52,134.00
22%
212
$128,594.00
PH
2008-09
OR
6 mo
$3,064.93
24%
126
$3,124.27
SM
2008-09
GA
10 Mo
$30,125.78
14%*
402
$140,968.51
$12,649.40
$216,872.10
*Starting in new practice
PM
2008-09
CO
$9,480.00
www.emorysportsmedicine.org
4 Mo
$2,084.00
22%
14
AT Clinic Value: Financial Impact
Billing under/with MD
• PM&R Usable Clinic Billing Codes
• 97110/97530: Therapeutic Exercise (15 min of education for one parameter of
strength, balance, endurance, ROM, and functional activity)
• 97116: Crutch training or gait training (training in the manner or style of walking or
assistance of walking)
• 97760: Orthotic fitting and training upper or lower extremities (fitting and training of a
patient to use an orthotic device or splint (brace) to facilitate stability or function)
• 97750: Physical Prof tests/ measurements, 15 min. (KT 1000, Biodex, Strength
testing)
• 99211: Non physician patient visit
• Can be used in conjunction with Thera X code
• Reimbursements will vary with states and INS contracts
• If no Reimbursement = (+) Patient satisfaction
Collections with AT services
• Collections very among States and INS
• Emory Atlanta GA
• 5 yrs data
• Collections ~35% ($12,000 – $16,000/ AT)
• University of Wisconsin – Madison
• Collections ~ 52%
• St Luke’s Health System - Boise ID
• Collections ~ 33%
• Heartland Orthopedic Specialist – Alexandria MN
• Collections ~ 68% (2009 – 2011)
• Bellin Health Systems – Green Bay WI
• Collections ~ 59.6%
Collections with AT services
Row Labels
97110
97116
97530
97750
97760
97762
99211
Grand Total
Values
Chrgs
$ 5,016.00
$
156.00
$ 1,012.00
$ 27,216.00
$ 15,617.00
$
249.00
$ 2,508.00
$ 51,774.00
Contr. Adj.
Pt Pmts
$
69.00
$
4.00
$
15.00
$
194.00
$
158.00
$
3.00
$
50.00
$
493.00
Net Pmts
$ 2,443.00
$
122.29
$
448.18
$ 6,604.03
$ 5,406.79
$
76.91
$
805.69
$ 15,906.89
Collections with AT services: Intangibles
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Incident to: vs Patient throughput
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• Intangibles
• AT’s can provide
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Outreach, marketing
Clinic Relationship building, clinic AT – traditional AT
Knowledge in Bracing and Casting
Expertise in Rehab/Home Ex Program
Intangible Work Ethic
Administrative Skills = enhance practice management
AT Clinic Value: Patient Satisfaction
• 2009 Emory Patient Perception Study
• Double Blinded
• New Patients randomly Chosen
• Orthopaedic Resident vs.
Athletic Training Resident
• Patients blinded to care givers
professional qualifications
• Care Givers unaware of which patients
were receiving survey
• Paper being written
Survey Results
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Knowledge compared to MD
Knowledge in field
Highest level Ed. *
Questions answered
Efficiently managed care
Professional Manner
Strong Comm. Skills
Overall Satisfaction
AT
8.14
7.46
7.45
8.46
8.83
9.50
9.45
9.02
MD
8.18
7.51
8.16
8.56
8.67
9.27
9.22
8.95
* Statistical
Difference in Q #3
• Highest level of education you think this clinician has attained:
• High School
•
1
2
Associates Degree
3
4
Bachelors Degree
5
6
Masters Degree
7
8
Doctoral Degree
9
10
AT Clinic Value: Physician Satisfaction
• Current Survey sent to Physicians:
• Evaluating the skills and satisfaction of hiring a
Residency trained AT
• 25/35 Physicians have hired both RTAT & non RTAT
• Current total of 35 surveys
• Scale 0-10
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0-1 not at all;
2-3 minimal;
4-5 Adequate;
7-8 Very Well;
9-10 Exceptional
Survey Results
• Evaluating the Skills of a Residency Trained Athletic Trainer (RTAT)
• 0-1 not at all; 2-3 minimal; 4-5 Adequate; 7-8 Very Well; 9-10 Exceptional
• How Prepared do you feel a RTAT is to be integrated into your clinic
• = 8.74
• Comparing Clinical skills of RTAT to non Residency Trained AT
• = 7.88
• Comparing MSK skills of RTAT to entry level PA or NP
• = 8.0
• Comparing the clinical skills of RTAT to MA’s
• = 9.17
Survey Results
• Evaluating the Satisfaction of a Residency Trained Athletic Trainer (RTAT)
• 0-1 not at all; 2-3 minimal; 4-5 Adequate; 7-8 Very Well; 9-10 Exceptional
• Extent to which you feel patient satisfaction has improved having a RTAT in
your practice
• = 7.9
• Extent to which your quality of life has improved (more specific MD time with
patients, clinics running on time, more work completed during clinic time)
having a RTAT in your practice
• = 8.5
• Extent to which your clinic has benefited (^ clinical efficiency, patient flow,
patient volume) having RTAT vs. other physician extenders
• = 8.1
• Your Overall Satisfaction with utilizing a RTAT as a physician extender
• = 9.05
Mid Level Providers: UW Health
• Direct Collections and Downstream Revenue by Provider,
May, 2011
• Calendar Year 2009 Retrospective Analysis
Case 1 : Non-Autonomous Utilization
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PA in Joint Service. Sees all patients in conjunction with MD
Collections : $1106.00
2 new patients, 6 established patients
Downstream revenue on unique new patients : $7214.00
Case 2 : Autonomous Utilization
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PA in Trauma Service and Orthopedic Urgent Care
Sees nearly all patients autonomously
Collections : $72,272.00
270 new patients, 104 established patients
Downstream revenue on unique new patients : $1,139,534.00
Mid Level and AT integration
- Mid-level’s function as autonomously and independently as
possible.
•
•
Collections and downstream revenue are maximized
Minimize occurrence of two billable providers seeing the same patient.
- Athletic trainers/residents/fellows see patients concurrently
with physician and in the global period post surgery.
- Mid-level’s maximize procedures, function in OR as assists,
and in orthopedic urgent care roles
- Athletic trainers used to allow for traditional mid-level roles to
shift
AAOE Newsletter Article: Using Athletic Trainers with Mid-Level Providers to Add Clinical and Financial Value to an
Orthopaedic Practice. November, 2011.
Joseph J. Greene MS ATC
Mid Level and AT integration
• Clinic Considerations:
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Clinic Patient Volume
Surgical Case Load
Billing Considerations
Practice Structure:
• Ortho Residency, Fellow, PE utilization (MA,RN)
• Need For Autonomous clinic
• Discussion:
• AT Only Practice Example
• Mid Level Practice Example
• AT & Mid Level Practice Example
Thank you!
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Bones of PA
DJO Global
Joe Greene ATC
Many Others
Boise ID