Presentation is loading. Please wait.

Presentation is loading. Please wait.

Utilization of ATC’s, Physician Extenders, and Other Ancillary Personnel to promote Orthopedic Practice Efficiency: Forrest Pecha MS, ATC, LAT, OTC, CSCS.

Similar presentations

Presentation on theme: "Utilization of ATC’s, Physician Extenders, and Other Ancillary Personnel to promote Orthopedic Practice Efficiency: Forrest Pecha MS, ATC, LAT, OTC, CSCS."— Presentation transcript:

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

Download ppt "Utilization of ATC’s, Physician Extenders, and Other Ancillary Personnel to promote Orthopedic Practice Efficiency: Forrest Pecha MS, ATC, LAT, OTC, CSCS."

Similar presentations

Ads by Google