Young Urologists Forum

1. Young Urologists Forum Effectively Managing Practice Economics and Utilization of Physician Extenders Program and Lunch sponsored by the Young Urologists Committee and Ortho-McNeil Pharmaceutical, Inc.

2. Changing Patterns of Reimbursement, can your practice adapt? Paul Brower CEO Orange County Urology Associates Fees used in this presentation are based on the Medicare allowables in California. These fees are on the public record and no proprietary information is included in this presentation.

3. Reimbursement History Began with the creation of the Resource-Based Relative Value Scale[RBRVS] by Wm Hsiao in 1988 and adopted by HICFA as part of the Omnibus Budget Reconciliation Act in1992. This allowed a shift to reward “cognitive” skills vs. procedures particularly those performed in the hospital. The system of CPT codes,DRGs,and RVUs was created There have been 3500 corrections and additions since 1992 By manipulating the RVUs and place of service there has been a successful shift to the office for procedures from the more expensive hospital

4. Yotan,YJ.Urology,Vol.172,1958-1962,Nov.2004 Between 1995 and 2004 the reimbursement for E & M codes increased 51% and surgical fees decreased 28% Reimbursement for office procedures has risen even more than the increase in E & M codes

5. Where we are today? Medicare has indicated they will reduce reimbursement an additional 40% over the next 7 years. A 5% cut was frozen in 2007,but the freeze was “paid for” by imaging cuts including a 40% cut in reimbursement for transrectal ultrasound guidance for prostate biopsy. Most HMO and PPO contracts are quoted as a % of Medicare’s fee schedule so this will a have profound effect on your practice income Consolidation of Insurers has lead to concentration of power in the hands of a few resulting in obscene profits Blue Cross of CA[now Anthem]- $3billion United Health+Pacific Care-$4billion

6. What can we do ? In today’s economic environment we must understand how and where we make our money. Gone are the days when we could simply come to work, operate, see patients, have someone run our office and expect to get paid well each month. There has been tremendous pressure on our income in the last 5 years. Costs associated with running our practices have risen and reimbursements have fallen. We are “piece workers” and the only thing we have to sell is our time We get paid for the number of widgets we produce and this is hard to leverage If you don’t understand where you make your money you can’t possibly maximize your production and income per unit of time spent

7. What we look at for our practice benchmarking Office Patient Counts: New patients,Return visits,# days seeing patients,#procedures done,ratio of procedures per patient visit,procedures that require a procedure room[vas,bx,utc,cysto] Collections total and average per patient visit[always use collections not billings] Coding:level and ratio for each MD and compared to the group Hospital # Consultations # OR Cases # Case as Assistant # Long Cases[> 2 1/2 hrs] Ratio of OR cases patient[Total, New] Collections from the OR and Hospital

8. OCUA for 2005 9 MDs 1 new assoc. doing the laparoscopy and building his practice[#9] 2 specializing in female and incontinence[#4,500] 1 male infertility specialist[#400] 1 CEO,seeing patients 1/2 time[#100]

9. Approximate revenues per partner

10. Office Patient Visits

11. OR Cases

12. % Total Collections-OR

13. Income from surgery versus office encounter

14. OCUA 2006 Stats 6,323 New Patients 17,803 Return Visits 24,126 MD - patient encounters 2,000 Surgical Cases 13,200 Office Procedures 9 MDs [1new associate and 1 working 1/2 time]

15. Collections 2006 Office Patients Visits 31% Office Procedures 39% Surgery 16% Other[supplies,meds] 13%

16. Comparative Fees 1986* 2007 TURP $2000 $923 Rad.Neph $3000 $1452 Lap Rad Neph $1536 Rad.Cystectomy $4000 $2185 Ureteroscopy,laser $488 ESL $2500 $639 Rad Px $3500 $1635 Pathology Prostate bx $144/specimen Cytology $95 *Balance Billing allowed then and not now

17. Office Fees 2007 Office consult[99244] $223 Return Visit[99213] $76 Cystoscopy[52000] $283 Vasectomy[55250] $742 TUMT[53850] $5214 BT<0.5cm[52224] $1992 Prostate Biopsy[55700] $335 Prostate US[76872] $176 Video Urodynamics $800-1000 Renal US[76770] $168

20. Ultrasound In office US is a very good way to leverage your time US tech comes to the office on regular basis and performs renal,scrotal,penile,color doppler studies Most Urologists are already doing their own US of the prostate Advantages Does not require dedicated space Cost of equipment nominal compared to other imaging Personnel costs are limited[pay per procedure] Enhanced patient service and satisfaction Does not require separate contracting with radiologist

21. US Codes and Fees CPT Code Description Fee 51798 PVR $21 76770 Retroperitoneal[complete] $142 76775 Retroperitoneal[limited] $127 76856 Pelvic[complete] $122 76857 Pelvic[limited] $110 76872 Prostate-Transrectal[Bx supervision] $147 76942 Guidance for biopsy $189 55700 Biopsy prostate $145 76873 Prostate Vol. BrachyRx $195 76870 Scrotal & Contents $120 93976 Duplex Scan[limited] $305 93980 Duplex Scan-penile $232

22. Pathology Must be very careful of the structure to avoid Stark issues;must own the equipment,own or lease the space,formal contract with the pathologist. Bill global fee and split collections per contract with the pathologist Requires limited dedicated space and funds for equipment:200 sq.ft,$80-$100,000 We are only doing 2 tests tissue histopathology,urine cytology Medicare fees CPT Description Fee 88305 Surgical Path[gross & micro] $143/core 88108 Urine Cytology $95

23. PATHOLOGY LAB

24. CT Must lease or purchase the equipment[new or refurbished].Start up costs $300-$600,000 Must have contractual arrangement with radiologist to interpret [on the premises or via PACs system].Bill separately or global. Requires CT tech and MD to inject contrast Dedicated space,construction,inspection,license Certificate of Need[CON] Pre-certification for procedures Radiologists and some payors resisting this at the state and federal levels

25. CT Pro forma * Revenue CT Patients per day 6 Days per month 20.75 Rev/pt- Abd/pelvis $835[may be considerably less] with & without contrast Total Revenue $1,248,252 Expenses Equipment lease $85,000 Service contract $65,000 Technologist[SOCA] $85,000 Radiologist[16% of global[ $200,000 Medical supplies $10,000 Misc[rent,utilities] $20,000 Total $465,000 Potential Cash Flow $783,252 * Hypothetical Pro forma from Neusoft Imaging Systems Solutions[modified by PAB]

26. How can you adapt ? Office is the center for income and expenses-keep it busy. Have the space,equipment,staff to be maximally efficient with your time Build a grid based on 1/2 day blocks-don’t violate your office block to go to the OR[it costs you lots of money]. Use block time Develop ancillary sources of income US,Lithotripsy,CT,Pathology,IMRT,Incontinence Center Built 15,000 sq. ft. office with 23 exam/procedure rooms,pathology lab,research,color doppler US,2 urodynamic rooms,C-arm and flouro table Must finds ways to leverage your time Little things matter: Communicate by email, assign hospitals rounds,whomever is in the hospital sees all of the patients there,who ever lives closest stops in the AM Review the schedule weekly,look for conflicts,openings,inefficiencies Try to use RNFA or retired surgeons to assist,utilize surgical blocks

27. Working smarter and being more productive Designing your office This is where you make your money and where your fixed costs are Our new office:15,000 sq. ft 23 exam and procedure rooms;2 urodynamics,nurse visit room,fluoroscopy,Clinical Research,Pathology Lab 7 MDs and 2 PAs working simultaneously Designed to never have to defer a procedure or delay seeing patients Location Primary office should be geocentric to the primary hospitals served Satellite offices-utilize them only if they bring in patients that would go to someone else if you weren’t there. They are expensive and inefficient

28. Size Really Does Matter Group Size Minimum # MDs - 6 Maximum - None [the larger the group the more potential problems with governance and personalities] Large groups have access to capital for wholly owned ancillary services-lithotripters,laser,CT,IMRT Fixed Costs Most practice costs are fixed[rent,staff] They don’t go away when you aren’t there 6 MDs -3 or 4 working in the office all of the time Critical mass is required for capital expenses and overhead Recruiting Large groups have been successful,small practices have not Fellowship trained MDs want larger groups Large groups can support the sub specialist with patient referrals and financial subsidies

29. Office vs OR Office is where you make your money-85% for OCUA Office procedures are the economic kicker The $ penalty for the OR is lost income of 1/3 to 20x per unit of time Don’t stop operating but organize your time Use block time Don’t schedule cases in the middle of the day Office days are office days-don’t leave Rotate days in the hospital[rounds,operate,call] Economic Death Assisting- getting paid $175 for 1/2 day in the OR Track assists and compensate your partners Try not to use associates [use RNFA,retired surgeons]

30. Conclusions Do Internal Bench Marking at least annually The majority of income comes from the office [85% for OCUA] The system rewards those that stay in the office seeing patients and doing procedures Group size is critical to survive in the future A Minimum size is required to keep the office busy,support ancillary services,afford capital expenditures,take economic risk You must develop ancillary services and learn to leverage your time

31. Physician Assistant Gordon R Gluckman,MD Residency Director Northwest Metropolitan Urology Associates Rosiland Franklin Phycisian Assistant Program

32. Physician Assistant Background Navy corpsmen trained in Vietnam with considerable medical treatment Shortage of primary care physicians Duke University - 1965 Director – Dr. Eugene Stead Based on fast-track WWII physician training

33. Physician Assistant Current Education Typical Applicant Bachelor’s degree 4 years of experience Extremely Competitive Nurses, EMTs, Paramedics Females>Males

34. Physician Assistant Practicing PAs Graduate of Accredited program Must pass National Certification Exam “C” 62% females Final Degree 44% Bachelor’s 35% Master’s

35. Physician Assistant Areas of Practice Family/General medicine(27%) General Internal medicine(7%) General Pediatrics(3%) OB/GYN (2%) Surgery/Surgical specialties (25%) Emergency medicine (10%) Internal medicine specialty (11%) Dermatology (3%)

36. Physician Assistant Why Hire?? Shift physician workload Handling routine office visit, rounds, call Less time in office Flexibility Cost Effectiveness For every dollar generated by PA 28 cents cost to employer Physician-PA team concept

37. Northwest Metropolitan Urology Associates 16000 patient visits 4500 hospital consults 4000 hospital patient rounds 2500 post operative visits

38. Northwest Metropolitan Urology Associates 150 nephrectomies/laparoscopic 400 TURP’s/Lasers 200 open/robotic prostatectomies 700 TRUS/BX 400 Urodynamics

39. Northwest Metropolitan Urology Associates Physician Assistant Hospital rounds Consults OR assistant Calls Help in office

40. Northwest Metropolitan Urology Associates One year residency Lectures/OR/rounds/office Two programs in the country

41. Physican Extenders James C. Ulchaker MD FACS Co-Director Prostate Center Glickman Urological and Kidney Institute Cleveland Clinic Foundation

42. What are APN’s? Master’s prepared registered nurses Current certification Certificate of authority from OBN Certificate to prescribe Function in collaboration with physicians to provide mid-level care Mid-level provider Can see pts independently; no need for protocols, standard order sets No need for physician to see pts; co-sign charts. Must be available by some form of telecommunication Mid-level provider Can see pts independently; no need for protocols, standard order sets No need for physician to see pts; co-sign charts. Must be available by some form of telecommunication

43. Titles of APN’s Nurse Practitioners (CRNP) Certified Nurse Midwives (CNM) Clinical Nurse Specialists (CNS) Certified Registered Nurse Anesthetists* (CRNA)

44. Standard Care Arrangement Required for CRNP,CNS,CNM (ORC) Formal document of collaborative relationship Must be kept on site Reviewed and signed annually Must be kept current Signed at time of hire Originals kept in APN office Signed by dept chair, section heads; must be reviewed in dept mtg We send letter to OBM annually listing all APN’s and collaborating physicians to help ensure compliance with OBMSigned at time of hire Originals kept in APN office Signed by dept chair, section heads; must be reviewed in dept mtg We send letter to OBM annually listing all APN’s and collaborating physicians to help ensure compliance with OBM

45. APN Core Privileges Patient assessment: History & physical Develop plan of care: ordering diagnostic tests & therapies medication management with CTP Implement/ re-evaluate plan of care: perform diagnostic tests as per privileging Can request special privileges based upon practice, knowledge & skill Evaluated by collaborating MD thru QM process: chance to sit down, discuss practice, need for addtl trainign etc; ways to increase practiceCan request special privileges based upon practice, knowledge & skill Evaluated by collaborating MD thru QM process: chance to sit down, discuss practice, need for addtl trainign etc; ways to increase practice

46. Why hire an APN? Promote access Cost effective provider Focus on prevention & wellness, patient education, promotion of compliance Enhance revenue Continuity of care Facilitate physician productivity Mid-level provider Determinig need for APN Access: shorter wait times; increased pt satisfaction. Look at pt demand Less costly than MD; ability to bill for services Focus on prevention, education, counselling, continuity of care: better outcomes Enhance revenue Facilitates physician productivity: allows physician to see more complex, challenging pts; perform proceduresMid-level provider Determinig need for APN Access: shorter wait times; increased pt satisfaction. Look at pt demand Less costly than MD; ability to bill for services Focus on prevention, education, counselling, continuity of care: better outcomes Enhance revenue Facilitates physician productivity: allows physician to see more complex, challenging pts; perform procedures

47. Optimal Use of APN’s Outpatient Setting Established patients Pre-op assessments Post-op visits Inpatient Setting Patient evaluation Facilitate discharge planning Promote patient satisfaction Outpatient: New, urgents Chronically ill pts for follow up, acute visit Education & counselling Pre-op evaluations for procedures Anticoagulation mgmt Follow ups for services in global period Need own schedule, own pts to see; not merely to w/u pts for MD Inpatients: Daily evaluation; order diagnostic tests & therapies Discharge planning & coordination of care; education Timely response to pt needs: higher pt satisfaction Outpatient: New, urgents Chronically ill pts for follow up, acute visit Education & counselling Pre-op evaluations for procedures Anticoagulation mgmt Follow ups for services in global period Need own schedule, own pts to see; not merely to w/u pts for MD Inpatients: Daily evaluation; order diagnostic tests & therapies Discharge planning & coordination of care; education Timely response to pt needs: higher pt satisfaction

48. Reimbursement of APN’s Independent Incident to Shared service in hospital setting Independent: news, urgent visits, education & counselling, group visits Incident to Shared vistis: hospital or HOPSIndependent: news, urgent visits, education & counselling, group visits Incident to Shared vistis: hospital or HOPS

49. Facilitating APN Reimbursement Provider enrollment packet Medicare Medicaid BWC Masterfile form PIF for managed care enrollment Processed once privileging is complete Treat as physician. Admin to ensure that provider enrollment & PIF packet is completed; processed after Privileging complete. Can then open own schedule and begin billing Treat as physician. Admin to ensure that provider enrollment & PIF packet is completed; processed after Privileging complete. Can then open own schedule and begin billing

50. Measuring APN Value Patient Satisfaction: QDM Requires EPIC provider number & billing number Requires APN to have own schedule Patient Outcomes LOS, discharge times, re-admit rates, compliance with standards of care QDM: own schedule. Submitted to QDM once provider number and billing number assigned Outcomes: looking at APN outcomes in internal medicine pts; important for pay for perfromance Focus on education, coordination & counseling: leads to better outcomes QDM: own schedule. Submitted to QDM once provider number and billing number assigned Outcomes: looking at APN outcomes in internal medicine pts; important for pay for perfromance Focus on education, coordination & counseling: leads to better outcomes

51. Measuring APN Value Productivity Number of visits Encounter types (Clarity) Billed charges RVU’s Impact on physician practice Various methods available Now focusing on number of visits; can also look at other indicators Epic: visits Epicare encounters: appointment, office visit, phone call, med refill, orders only etcVarious methods available Now focusing on number of visits; can also look at other indicators Epic: visits Epicare encounters: appointment, office visit, phone call, med refill, orders only etc

52. What is a Physician Assistant? Physician Assistants are health care professionals licensed to practice medicine with physician supervision. PAs are educated in the medical model designed to complement physician training. (www.aapa.org)

53. Physician Assistants: Conduct physical exams Diagnose and treat illnesses Order and interpret tests Counsel on preventive health care Assist in surgery And in 49 states, write prescriptions As of May 17, 2006, Ohio passed legislation enabling PA’s to have RX authority.

54. Physician Assistant Demographics: There are just over 59,000 individuals who practice full-time as physician assistants. 59% female; 41% male 41 years old The average PA has been in practice as a PA 9.1 years (AAPA 2005 census)

55. Physician Assistant Demographics: AT THE CLEVELAND CLINIC: Over 140 PA’s employed at CCF Average years of clinical experience: 13yrs Average years of employment: 8yrs Range from 1yr to 32yrs

56. Demographics at CCF:

57. Division of Surgery

58. Physician Assistant in The Work Place 43.3% work in a solo physician or group practice 11.6% in a rural clinic, community health center, or freestanding urgent care or surgical facility 34.5% in a hospital Less than 1% work in a nursing home or long-term care facility (AAPA 2004 Annual PA Census Survey)

59. Physician Assistant On The Job: Perform invasive procedures: 43.6% Precept PA students: 38.3% Educate other providers: 36.6% Assist in surgery: 26.6% Precept other students: 26.5% Make decisions about procurement: 24.6% Perform quality assurance: 22.2% Supervise other clinical staff: 20.2% 100% or respondents provide direct patient care (AAPA 2004 Annual Census Survey)

60. Methods of measuring productivity: Average number of visits per unit of time Charges generated Increased physician activity Number of office visits or procedures Overhead reduction Time spent per patient visit

61. Lori B. Lerner, MD Assistant Professor of Surgery Chief, Section of Urology White River Junction VAMC Dartmouth Medical School White River Junction, VT

62. White River VAMC 27 NP’s and PA’s employed by the hospital Surgical Service 3 in General Surgery One each in GU, Vascular, Ortho Approx 50% of primary care clinics staffed by PA’s and NP’s

63. Urology Service 2 attendings, 1 senior level resident and one NP Since losing our intern 8 yrs ago, we have had a PA or NP Daily rounds and half day clinic, pre-operative history and physicals, prostate biopsies, in-patient consults, discharge planning, pt phone calls, prescription renewals

64. Surgical Service 3 PA’s 40 hour work week Daily rounds, discharges, assist in the OR, H & P’s, post operative orders and post-op checks No assigned clinic patients, but they attend and assist When 80 hr work week was instituted, PA’s began overnite call

65. Salary Range Very wide range depending on provider experience, yrs at the VA NP: $45,520-83,927 PA: $43,731-82,446 With yearly raises in the VA system, some providers are above this range

66. Contact Information:Physician Assistants http://www.clinicianreviews.com/index.asp?ArticleType=SiteSpec&page=body/PAorganizations.htm American Academy of Physician Assistants http://www.aapa.org http://www.healthecareers.com/site_templates/AAPA/index.asp?aff=AAPA&SPLD=AAPA American Association of Surgical Physician Assistants http://www.aaspa.com/SurgInfo.asp E-mail: aaspa@aaspa.com PMB 201 4267 NW Federal HighwayJensen Beach, FL 34957 888.882.2772 772.388.3457 (fax)

67. Contact Information:Physician Assistants http://www.paworld.net/ http://www.advancedpracticejobs.com/ http://www.medhunters.com/jobs/healthcare.allied.pa.urology-pa.2519.html http://www.careermd.com/newsletters/ currentnewsletters/CareerPA_1.htm

68. Contact Information:Nurse Practioners http://www.clinicianreviews.com/index.asp?ArticleType=SiteSpec&page=body/NPorganizations.htm State NP organizations American Academy of NPs PO Box 12846 Austin, TX 78711 512.276.5906 http://www.aanp.org   American College of NPs 1111 19th St NW, Ste 404 Washington, DC 20036 202.659.2190 E-mail: acnp@acnpweb.org 

69. Contact Information:Nurse Practioners National Association of Pediatric NPs 20 Brace Rd, Ste 200 Cherry Hill, NJ 08034 877.662.7627 http://www.napnap.org National Conference of Gerontological NPs 4824 Edgemoor Ln Bethesda, MD 20814 301.654.3776 http://www.ncgnp.org

70. Effectively Managing Practice Economics and Utilization of Physician Extenders Young Urologists Committee Kevin Spear MD Chair

71. What was the reason you hired a physician extender?

72. How long did it take for you to hire a physician extender?

73. What resources did you utilize to assist you in the hiring process?

74. Was the hiring process difficult?

75. How did you formulate the salary and benefit package?

76. Was credentialing difficult?

77. How do you utilize your physician extender?

78. How do your patients perceive the physician extender?

79. Was your initial plan different than your current utilization plan?

80. How do you supervise and assure quality control?

81. Are there any liability concerns?

82. What were the trials and tribulations of the physician extender process?

83. Do you have any recommendations for physicians to consider when hiring a physician extender?