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 Co-Owner and COO 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 Maximize Revenue Maximize Productivity Maximize Efficiency Maximize Throughput Maximize Customer Service Maximize Patient Education MAXIMIZE MARGIN Quality Assurance MINIMIZE EXPENSE Accreditation 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” Medical Assistant (MA) Physician Assistant (PA)/ (OPA) Nurse (RN, LPN, NP) Certified Athletic Trainer (ATC/AT)

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

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 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) www.nata.org www.bocatc.org 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

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 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 PCP – 11.4 minutes Case Presentation - 1.89 Case Presentation – 2.09 MD In-Room - 8.38 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 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 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

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 Emory = ^ 4.2 patient/day St Luke’s = ^ 3.9 – 5.5 patient/day 3 Clinic days/wk

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?

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: 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 post-operatively 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%   2007-08 $353,229.00 $59,090.00 17% 168 $333,544.33 2006-07 $247,315.50 $44,689.68 18% 158 $161,610.00 2004-04 $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 www.emorysportsmedicine.org

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

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

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 Knowledge compared to MD 8.14 8.18 AT MD Knowledge compared to MD 8.14 8.18 Knowledge in field 7.46 7.51 Highest level Ed. * 7.45 8.16 Questions answered 8.46 8.56 Efficiently managed care 8.83 8.67 Professional Manner 9.50 9.27 Strong Comm. Skills 9.45 9.22 Overall Satisfaction 9.02 8.95 * 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 1 2 3 4 5 6 7 8 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 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 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 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: 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! Bones of PA DJO Global Joe Greene ATC Many Others Boise ID