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Forrest Pecha MS, ATC, LAT, OTC, CSCS Director of Clinical Residency and Outreach

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.

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Forrest Pecha MS, ATC, LAT, OTC, CSCS Director of Clinical Residency and Outreach

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  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 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) 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

  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 • 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 – 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

  17. AT Clinical Value: Time 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 ImpactAT 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 32-35 patients/day • * Submission to JSH, Poster AOSSM 2011

  21. AT Clinic Value: Financial ImpactAT 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

  22. 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 AT Clinic Value: Financial ImpactAT addition to current staff

  23. Clinic Value: Financial ImpactAT 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) • 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

  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 • 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 $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?

  30. 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 AT Clinic Value: RVU productionProductivity Information:99203   Work RVU 1.42  Total RVU 2.20  99213   Work RVU .97    Total RVU 1.46 

  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 • ~$110-150 • 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 $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

  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 www.emorysportsmedicine.org

  42. AT Clinic Value: Financial ImpactBilling 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 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

  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

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