1. 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

2. Disclosures Consultant Orthovise LLC Co-Owner and COO
Orthopaedic & Sports Medicine Practice Advisors
Co-Owner and COO

3. A Balancing Act The Business of Healthcare vs. Patient Care
“Healing is an Art,
Medicine is a Science
Healthcare is a Business”

4. The Business of Healthcare
Maximize Volume
Maximize Revenue
Maximize Productivity
Maximize Efficiency
Maximize Throughput
Maximize Customer Service
Maximize Patient Education
MAXIMIZE MARGIN
Quality Assurance
MINIMIZE EXPENSE
Accreditation
Safety Assurance

5. 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

6. Physician Extenders
Webster:
“A health care provider who is not a physician but who performs medical activities typically performed by a physician”
Medical Assistant (MA)
Physician Assistant (PA)/ (OPA)
Nurse (RN, LPN, NP)
Certified Athletic Trainer (ATC/AT)

7. Clinical Roles of Physician Extenders
Daily Duties:
•         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

8. Certified Athletic Trainers
The Many faces of Athletic Trainers

9. Certified Athletic Trainers
We have taken the Healthcare team from:
The Sidelines
To your Clinics

10. 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

11. Certified Athletic Trainers: Education
Licensed in 47 States
70% have MS or higher
Academic major accredited by the: Commission on Accreditation of Athletic Training Education (CAATE)
Nationally Certified by Independent certifying agency (BOC)
Mandatory Continuing Education (CEU’s)
Recognized by AMA 1990
Medical Based Education Model (AMA 1993)
AT Education Competencies
Evidence Based Practice
Prevention and Health Promotion
Clinical Examination and Diagnosis
Acute Care of Injury and Illness
Therapeutic Interventions
Psychological Strategies & Referral
Healthcare Administration
Professional Development & Responsibility
Source: Athletic Training Competencies 6th Edition

12. 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

13. Athletic Trainers: Providing Financial Value
Time, Money, Satisfaction
Time
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

14. 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

15. 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

16. MD Value Added Activity
Ortho – minutes PCP – 11.4 minutes
Case Presentation Case Presentation – 2.09
MD In-Room MD In-Room – 9.31
40% of orthopedic surgeons spend 9-12 minutes with each patient
25% spend minutes with each patient
15% spend minutes
Source: Medscape Physician Compensation Report 2011

17. AT Clinical Value: Time
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?

18. 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

19. 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

20. 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 patients/day
* Submission to JSH, Poster AOSSM 2011

21. AT Clinic Value: Financial Impact AT addition to current staff
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

22. AT Clinic Value: Financial Impact AT addition to current staff
Physician A
23% increase in Patient Volume
Increase .69 patients/hr
2.76 per ½ day
4 hr/ ½ day
Physician B
20% increase in Patient volume
Increase 3.7 patients/day
6.5 hr/day
Current clinic template allows for 32 patients/day
Unpublished data from practice
Started IRB process Yr
tot pt's
Days
pt/dy
pt/hr
2010
908 83
10.9
2.8
2010
# patients
# weeks
pts/day
Wed
878 47
18.7
Year
tot pt's
Days
pt/dy
pt/hr
2011
1034 75
13.8
3.45
2011
# patients
# weeks
pts/day
Wed
849 38
22.4

23. 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

24. 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

25. 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)

26. AT Clinic Value: Collections for Patient Visits
What is a patient E/M worth?
99213 – $78.54 (2012 Medicare Fee NE)
$ (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, annually
Two additional patients/day - 3days/wk (6/wk)= $ $25,404.48

27. AT Clinic Value: Collections for Patient Visits
Emory = ^ 4.2 patient/day
St Luke’s = ^ 3.9 – 5.5 patient/day
3 Clinic days/wk

28. AT Clinic Value: Downstream
ASSUMPTIONS
Revenue Assumptions
FY10 NPVs
9427
Collections per NPV
218.86
NPV to RPV Ratio
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
NPV – RPV = 1-4
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?

29. PE Clinic Value: What does this mean? $$
In FY 2009, each unique new patient was worth an average net of $ to the UW Hospital Department of Orthopedics and Rehabilitation (Facility Fee)
In FY 2009, each unique new patient was worth an average net of $ to the UW Department of Orthopedics Physician Practice Group (Professional Fee)
So, Why is Staffing and Workflow Optimization so Important?

30. AT Clinic Value: RVU production Productivity Information: 99203   Work RVU 1.42  Total RVU 2.20     Work RVU .97    Total RVU 1.46 
Physician A
23% increase in Patient Volume
Increase .69 patients/hr
NPV to RPV ratio = % (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

31. DME Evolution: “Necessary Evil”

32. Athletic Trainer: DME Specialist
Goals
-Improve Patient Relations/ Service
-Improve Clinic Efficiency
-Medicare Compliance
-Decrease loss
Tom Koto NATA-HOF
-Increase Revenue

33. 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*

34. 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 $92.19
Post-op ROM knee brace w/ drop locks L1832 ~$
2011 MCR Allowable $686.31
2012 MCR Allowable $702.08

35. Profit Margins Higher Cost/ High Reimbursement
Lumbar-Sacral Orthoses (LSO) L0631
~$155.00
2011 MCR Allowable $
2012 MCR Allowable $
Custom Osteoarthritis Knee Brace (single hinge) L1844 ~$
2011 MCR Allowable $
2012 MCR Allowable $

36. 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

37. 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

38. Skill Sets for AT’s in the Operating Room
AT can Assist Physician in:
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

39. 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 post-operatively and performed minor 2nd assist (SUNY DMC has orthopedic residency program)

40. 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

41. 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 GA
$437,813.00
12 mo
$42,766.00 9%
$353,229.00
$59,090.00
17%
168
$333,544.33
$247,315.50
$44,689.68
18%
158
$161,610.00
$293,958.50
$51,704.07
218
$301,482.57 CK
$204,416.25
$51,814.81
25%
452*
$144,363.31
*Includes clinical billings JS TX
$102,303.00
$25,467.00
198
$75,864.00 HG CT
$236,768.00
$52,134.00
22%
212
$128,594.00 PH OR
$12,649.40
6 mo
$3,064.93
24%
126
$3,124.27 SM
$216,872.10
10 Mo
$30,125.78
14%*
402
$140,968.51
*Starting in new practice PM CO
$9,480.00
4 Mo
$2,084.00 14

42. 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

43. 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%

44. Collections with AT services

45. Collections with AT services: Intangibles
Incident to: vs Patient throughput -
Intangibles
AT’s can provide
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

46. 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

47. Survey Results Knowledge compared to MD 8.14 8.18
AT MD
Knowledge compared to MD
Knowledge in field
Highest level Ed. *
Questions answered
Efficiently managed care
Professional Manner
Strong Comm. Skills
Overall Satisfaction
* Statistical Difference in Q #3
Highest level of education you think this clinician has attained:
High School Associates Degree Bachelors Degree Masters Degree Doctoral Degree

48. 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
0-1 not at all;
2-3 minimal;
4-5 Adequate;
7-8 Very Well;
9-10 Exceptional

49. 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

50. 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

51. Mid Level Providers: UW Health
Direct Collections and Downstream Revenue by Provider, May, 2011
Calendar Year 2009 Retrospective Analysis
Case 1 : Non-Autonomous Utilization
PA in Joint Service. Sees all patients in conjunction with MD
Collections : $
2 new patients, 6 established patients
Downstream revenue on unique new patients : $
Case 2 : Autonomous Utilization
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

52. 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

53. Mid Level and AT integration
Clinic Considerations:
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

54. Thank you!
Bones of PA
DJO Global
Joe Greene ATC
Many Others
Boise ID