Hospitals and HealthCare Systems · • ICD 10. Clinical Practice Models. APRNs ... Pros Cons...

Hospitals and HealthCare

Systems

“What you were Not taught in PA

School”

Folusho Ogunfiditimi, DM, MPH, PA-C

Administrative Director, Adult Clinical Services and Advanced Practice Providers

Harper University Hospital/ Hutzel Women’s Hospital

Detroit Medical Center

Tenet Health System

[email protected]

Objectives

• Understand the roles of PA’s

– Recruitment and Retention

– Onboarding and Orientation

– Clinical Practice Models

– Compensation

– Regulatory Standards and Compliance

– Productivity and Provider Enrollment

– Team membership/Physician Collaboration

– Quality, Safety and Patient Satisfaction

Recruitment and Retention

History of Non – Traditionally

Trained Medical Practitioners.

Modern Advanced Practice Providers

1869

1963 1965

1989

1965

From Graduation to Hire

• Average of 90 days

• Graduation-Board Certification – Licensure

• Interviews – Start early

• PA-Intern / Graduate PA

• Job Descriptions

• PA Recruiter

• PA Leader / Director

• Shadow opportunities

• Graduate Physician Assistant is (GPA) is a recently graduated Physician Assistant who has met the academic and State of Michigan practice requirements for certification and Licensure as a Physician Assistant, but who has yet to obtain full organizational credentialing status with the DMC. In accordance with DMC bylaws all licensed physician assistants must undergo organizational credentialing and privileging prior to providing health care services to patients. To this effect the title Physician Assistant - Certified (PA-C) cannot be used until fully credentialed at the DMC and newly graduated PAs, awaiting credentialing will use the title Graduate Physician Assistants.

Credentialing

• Credentialed through Medical Affairs – JC

requirement

• Supervising Physician (employed)

• PA’s must have an NPI and DEA License.

(NPs as well)

• Scope of Practice and Core

Competencies- Every specialty

• OPPE and FPPE

Job request

from

Hospital/Offic

e

HR job

posting

/screening

Recruiting

NP/PA’s

Interviews

Medical

/dept /mlp

office

Job offer

And

acceptanc

e

DMC MG

RecruiterPA/NP

office

Risk MGT

Approval

Approval

Start Date

HR

Process

Start

NP / PA

Training,

EMR/CIS

NP/PA

orientation

Exec Dir.- DMC

MG notification

Final

Credentialin

g Approval

from

Medical

Affairs

Third

Party

Enrollment

and Billing

Medical

Affairs

Temp

Privileges

Approval

Req

Approval

Best Fit and Benefits

• Salaried vs Hourly

• Incentives, RVU based, Bonuses

• CME

• Sign-on Bonus vs. Retention Bonus

• Loan Repayment, Immigration Support

• STD, LTD, Vacation and Sick Leave

• More rigidity, Less flexibility

Onboarding and Orientation

Department Dynamics

• Medicine

– Medicine Service

– Medicine Subspecialties

• Surgery

– General Surgery

– Surgery Subspecialties

• Emergency Medicine

• Ambulatory Care Centers

Team Dynamics

• PA only

• NP only

• PA/NP only

• PA/NP and Residents

• PA/NP, Residents, SW, CM, PT/OT,

Pharmacy

Nursing Model Medical Model

Patient

Integrated Health Care

Medical and Nursing teams,

Advanced Practice Providers, Pharmacy,

Administration etc..

Horizontal continuum of care

GME,

Research,

Productivity,

Quality, and

Compensation

Staffing,

Training,

Governance

Human

Resources

Orientation

• None

• Formal

– 1 to 7days

– System, Hospital, Department, EMR

• Informal

– 30 days to Lifetime

• Checklist

Job request

from

Hospital/Offic

e

HR job

posting

/screening

Recruiting

NP/PA’s

Interviews

Medical

/dept /mlp

office

Job offer

And

acceptanc

e

DMC MG

RecruiterPA/NP

office

Risk MGT

Approval

Approval

Start Date

HR

Process

Start

NP / PA

Training,

EMR/CIS

NP/PA

orientation

Exec Dir.- DMC

MG notification

Final

Credentialin

g Approval

from

Medical

Affairs

Third

Party

Enrollment

and Billing

Medical

Affairs

Temp

Privileges

Approval

Req

Approval

Medicine Roles

• Participate in all aspects and stages of care:

– Front Line: ED, Admissions, Admit H/Ps, Outpt,

Inpt and Intra - Op

–Function in the Middle: keep the dialogue open and

process running smoothly:

• LOS and UR management – Inpt setting

• Follow up visits in outpt settings

• Patient and family education in person and by phone.

– Function as “Closers”: to finish the “health care

deal”;

• Transition of care

Surgical RolePre Operative RoleClinical evaluation to include H/P’s, Diagnostic evaluation,

ancillary study review and medical clearances

Operative RoleFirst and Second AssistRobotic assistanceFacilitating training and education of residents/students

Post Operative RoleDischarge managementPost operative clinical evaluation, participate in the overall

care of patients from presentation onward.Education of patients and families on robotic prostatectomyDevelop and maintain social programs

Challenges

• Communication between APPs and MDs

• Scope of Practice and Supervisory

Agreements

• Employed vs. Non Employed services

• Diversification of Services

• Integration with Academic Medicine

Opportunities

• Provision of continuous services to patients for

MDs

• Quality Metrics

• LOS and Discharge Management

• Utilization and Resource Management

• Billing and Reimbursement

• Core Measures and EMR

• ICD 10

Clinical Practice Models

APRNs (NP, CNM

CRNA)

PAs

Enhanced

Patient

Outcomes

and Patient

Satisfaction

Education, research ,

training , care coordination,

pt.assessment, evaluation, Dx

Tx, Surgical Assist,

Anesthesiology, Pre, Ante

and Post care.

Horizontal Continuum of Care

Types of Clinical Practice

• Ambulatory Practice

– Scribes

– Shared

– Side by Side

– Autonomous

• Inpatient Practice

• InterOperative Practice

• Combined Practice

Scribe Practice

PATIENT

(New and F/U)

PA/NP

Takes H/P

Reports to MD

(May or May not dictate)

MD repeats all the

work of PA/NP and dictates

MD Bills at

100%

Scribe Practice

Pros Cons

• APP learns clinical

practice, dictate etc.

• Acceptable teaching

model for new

graduates

• Physician still has to do

full history and exam

• Double work/single

service/

• Mild incentive for the

MD/poor incentive for the

APP

• Expensive utilization of

Providers.

Shared Practice

Patient

(New and F/U)

PA/NP does complete E/M

service, communicates to MD

and dictates

MD sees patient briefly, and

discuses the MDM of the

Service.

MD bills at 100%

Additional

Patients seen

by MD

Shared Practice

Pros Cons

• Patient seen by two providers.

• Physician does not have to do full exam,

• Good incentive for the Physician

• Billing is done by Physician

• Meets CMS standards

• Good teaching and supervisory provisions

• +/- Access Improvement

• Poor utilization of resources

• Low volume days= low productivity from all providers

• Mild incentive for the APP

Side by Side Practice

PATIENT

(New, +/- F/u)PATIENT

(F/U, +/- New)

MD

(in clinic @ the same time) PA/NP does entire E/M service

MD may see New

patient as a shared visit

PA/NP bills at 85%

if not seen by MD

MD bills for his own

pt....... and may bill for

PA/NP pt....... if seen, at

100%

Constant

Comm

Side by Side PracticePros Cons

• Improved Access

• MD can see New, APP

can see F/U

• Direct access to MD

• Easy conversion to

Shared Practice

• CMS compliance with

billing and supervisory

regulations

• Good incentive for all

providers

• Not always suitable for New or Consults .

• Subject to over booking

• Billing and Reimbursement Limitations: Enrollment, 85%

• Understanding Legal and Compliance rules.

• Administrative Impact-Resources and Space

Autonomous Practice

Pros Cons

• Best model in ideal

setting

• Improves Access for all

patients

• Good incentive

• Downstream Feeders

• Provider is always busy.

• Safety net for last minute

add-Ons

• Productivity justifies

administrative Impact.

• Requires well

experienced, confident

APP

• MD may not be present

for complex cases

• Patients may not see MD

on 1st visit

• Requires trust and good

communication between

APP and MD

Autonomous Practice

Patients

(New and F/U)

PA /NP does complete E/M,

dictates and bills at 85%

MD provides indirect

supervision and

available for

consultation

if needed.

MD free to be in

clinic/OR/Procedure.

MD gets downstream

opportunities from

PA/NP

Inpatient Utilization

Pros Cons

• Prompt/

Direct/Consistent Pt.

access.

• Autonomous practice

• MDs gain confidence

in APP

• Good learning

opportunities

• Poor billing /

reimbursement

• Difficult Productivity

measurements

• APPs may be subjected

to “scut” work

• Requires well

experienced, confident

APP

• APP has limited view of

Patients


In- Patient

PA/NP Rounds alone or with team,

writes Progress

notes

Discharges Pt.

MD

Rounds

RVU Formulas

Initial Hosp Visit = 5.82/pt.

Sub Hosp Visit = 2.07/pt.

Inpatient Consult = 3.26/pt.

Ave. 6 pt...... daily = 22.3 RVU

Approx. $550/day

OR Utilization and ROI

Patient

(Operation)

Surgeon

(MD)

First Assist

(PA/NP)

Surgeon Bills at 100% and

PA/NP Bills at 85% of First

Assist Fee =

16% of the Surgeons Fee

If MD fee for VIP = $12,000

PA/NP fee = $1920

Operating Room UtilizationPros Cons

• Improved Revenue

generation: Surgeon fee

and First Assistant fee.

• Develop expertise in OR

• Comfort and Trust with

MD.

• Standardization of

procedures

• Good quality metrics

• Can be monotonous

• Limited view of patient

• Need experienced provider

• Specific language is needed

in GME programs

• Competition with GME

trainees.

Combined UtilizationPros Cons

• Maximum Utilization

• Jack of all Trades

• Experienced flexible provider

• Develop Trust and Confidence with MD APP.

• Maximum Access

• Maximum RVU generation.

• Potential for APP

burn out

• Master of None

• Competency

measurement is

critical

• Commands higher

salary

Combined Practice

In-Patient PracticeAmbulatory Practice

OR Practice

Experienced PA/NP

MD

MD

MD

Recommended Practice Pattern

• PA/NP New Grad (<1yr of clinical experience)– Scribe Practice (not favored)– Shared Practice (ideal for this group)– Side by Side Practice (ideal for fast learner)– Inpatient Utilization (ok for fast learner, but need good orientation),

• PA/NP (1 – 3 yrs. of clinical experience)– Shared Practice – Side by Side Practice– Autonomous Practice– Inpatient Utilization (Ongoing evaluation needed)– OR Utilization (Direct supervision and training required)

• PA/NP (3 - 5yrs of clinical experience)– All practice patterns, Limited direct supervision in OR

• PA/NP (>5 yrs. of clinical experience) – All practices

(Information is based on general limited level 3, 4 and 5 data. Individual providers may exhibit varying degree of competency)

Compensation and Provider

Enrollment

Salary Models

• Salaried – Exempt Employees

• No overtime

• “Moonlighting Opportunity”

• RVU Based compensation

• Incentive laden Salaries

• Productivity and Value provides leverage

• Market Analysis and Adjustments

• 92-96% of the 50-65 percentile

• Critical to Fill positions

Provider Enrollenment

• Medicare and Medicaid

– Provider Enrollment Chain and Ownership

system (PECOS) – internet based

• CAQH

– Council for Affordable Quality Healthcare

– Non profit organization formed by various

trade associations

– Streamline provider credentials with third

party billers

Provider Enrollenment

• Third Party Billing

• Everyone is different

Regulatory Standards and

Compliance

Law vs. Regulation

• Federal laws – Federal agencies and VA

• Stark Laws – Limits on practice delivery

models with physicians

• State Laws vs Organizational Bylaws

• Be aware of laws affecting similar

professions

• Billing and Reimbursement regulations

Physician Certification and

2 Midnight rule

• ACA – Calls for all admissions to be

certified by a Physician

• Verbal tuggle of war between Admitting

Physician and Ordering Physician

• CMS – 2 MN rule – Observation vs

Inpatient Admission

Hospital Billing

• Cost Report

• Employment relationships

• No “Incident too” in hospital based clinics

• Billing opportunties– H/P, daytime and after hours

– Subsequent hospital care

– Consults,

– Procedures

– Surgery

– Discharges

Section 6407 of the ACA established a face-to-

face encounter requirement for certain items of

DME. The law requires that a physician must

document that a physician, nurse

practitioner, physician assistant, or clinical

nurse specialist has had a face-to-face

encounter with the patient. The encounter must

occur within the 6 months before the order is

written for the DME.

Productivity, Value, Billing and

Reimbursement

ROI- Scribe Practice

RVU’s=27.75/day

(approx. $685)

MD@ 1150/day

APP @ 440/day

15 pts.. @

1.85 rvu/pt.

APP @ 1 FTE

MD @1 FTE

50% New (2.22 RVUs)

50% Returns (1.48 RVUs)

Amount is based on Level 3 coding

using 2011 Cf of $24.67

ROI- Shared Practice

RVUs=46.25/day

Approx.. $1141/day

MD@ 1150/day

APP @ 440/day

25 pts. @

1.85 rvu/pt.APP @ 1 FTE

MD @ 1 FTE

50% New

50% Returns

40% Increase in RVU with

10 additional patients

ROI – Side by Side Practice

51

• MD @ 1150/day

• APP @ 440/day

• 15 pts. @ 1.97rvu/pt.

• More New, less Return

• 15 Pts. @ 1.72 rvu/pt.

• (More Returns, less new)

MD may see new pt...... as shared

MD Available for Direct

Consultation

MD

APP maintain individual schedule

RVU = 55.4/dayApprox.. $1366/day

ROI - Autonomous Practice

15 Pts. @ 1.82rvu/pt.

(New and F/U)

APP @ 440/day

MD - Run separate

clinic, OR, Research,

etc.

Revenue Generation

dependent on daily

activities.

RVU = 27.38 + MD Approx.. $675 + MD

@85%=$573

ROI - Combined Practice

In-Patient Practice

$550/day

Ambulatory Practice

$625/day

OR Practice

$1920/day

Experienced PA/NP

($440/day)

MD

MD

MD


In- Patient

PA/NP Rounds alone or with team,

writes Progress

notes

Discharges Pt.

MD

Rounds

RVU Formulas

Initial Hosp Visit = 5.82/pt.

Sub Hosp Visit = 2.07/pt.

Inpatient Consult = 3.26/pt.

Ave. 6 pt...... daily = 22.3 RVU

Approx. $550/day

OR Utilization and ROI

Patient

(Operation)

Surgeon

(MD)

First Assist

(PA/NP)

Surgeon Bills at 100% and

PA/NP Bills at 85% of First

Assist Fee =

16% of the Surgeons Fee

If MD fee for VIP = $12,000

PA/NP fee = $1920

Time and Motion Study

Observe and document the time spent by APPs on their daily responsibilities to determine the average amount of time spent on revenue generating and service value added activities.

This data will allow the establishment of Service Value Units (SVUs), which will aid in quantifying an APPs productivity.

Methodology

APPs were randomly selected based on primary location of work. (i.e. Inpatient, Outpatient, Emergency Department and OB)

Use of Personal Digital Assistants (PDAs)

PDAs were pre-populated with Current Procedure Terminology (CPT) coded defined services –(AMA/CPT 2010)

APPs recorded their location and main activity on the PDAs randomly every 15-30 minutes

Results – Inpatient Study

Sample Population:

§ 8 NPs/PAs participated

§ 5 NPs and 3 PAs

§ Departments: Acute Care Surgery (2), General

Surgery (1), Hem/Onc (1), Nephrology (1), Neuro

Surgery (1), Transplant Surgery (2)

§ Collected 25 days of inpatient MLP activity data

§ 23 weekdays (610 data points)

§ 3 weekend days (119 data points)


Subsequent Hospital Care

34%

Discharge Management

16%

Admission H/P4%

Post Op Care3%

Procedures3%

Procedure Documentation

1%

Other Revenue Generating Activities

1%

Cafeteria3%

Lunch meeting0.27%

Team Conferences

16%

Analysis of Clinical Data8%

Telephone Consultation by NPP

3%

Special Reports3%

Collection of Physiological Data

2%

Business Meeting1%

Other Service Value Activities

3%

Other3.29%

Service Value35.12%

Revenue Generating61.59%

Charts for each area can be seen in the Appendix


IP Activities Occurrences

Revenue

Generating

Service

Value CPT 2010 Code

Subsequent Hospital Care 245 x 99231 - 99233

Discharge Management 116 x 99238 - 99239

Admission H/P 30 x 99221 - 99223

Post Op Care 22 x 99024

Procedures 21 x

Based on procedure

code

Procedure Documentation 6 x

Based on procedure

code

Other Revenue Generating

Activities 9 x

Team Conferences 114 x 99366

Analysis of Clinical Data 55 x 99090

Telephone Consultation by NPP 25 x 98966 - 98968

Special Reports 24 x 99080

Collection of Physiological Data 12 x 99091

Business Meeting Council or

Committee 7 x N/A

Other Service Value Activities 19 x

Results – Outpatient Study

Outpatient Visit32%

Outpatient Follow-Up

11%

General Documentation

8%Procedure

Documentation6%

Procedure2%

Other Revenue Generating Activities

0.39%

Cafeteria1%

Personal Time1%

Other1%

Analysis of Clinical Data18%

Team Conference4%

Telephone Consultation -

Patient Follow-Up4%


1%

Research Visit Documentation

3%

Student Precepting2%


1%Other Service Value

Activities2%

Service Value38.23%

Revenue Generating59.04%

Other2.73%

Statistical Analysis

Compared surgical and medicine departments (inpatient

and outpatient combined)

No difference found between surgical department activities

(p = 0.205)

Medicine departments are different (p<0.05)

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%

Inpatient Percent of Time Spent on RVU Activities

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%

Outpatient Percent of Time Spent on RVU Activities

Medicine Department Surgical Department

Summary of Results

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Revenue Generating Service Value Other

IP

OP

ED

OB

Comparison of Activity Categories

Simple Buisness Plan – Outpatient

• 36 hrs. of pt. contact / week. (1 FTE)

• @ 30min slots =14 pts./day, X 5 days = 72

pts. / wk.

• 5 wks. vacation and 5 days of CME time.

• 46 wk. /year = 3312 pts.

• 14pts/day (1.72) (5) (46) = 5538 RVU/yr

– Or $194,000 (@$35/RVU)

• @ 60% RVU generation = 3322 RVU/yr.

– Or $116,000 (approx salary + benefit) 64

Employee (PA) Engagement

and Physician Collaboration

Engagement Opportunties

• Hospital committee participation

– From P/T to Medical Executive committee

• Utilization Resource committee

• Volunteer opportunities

• Physician Champion

• PA’s know about PA’s….. etc.

• Be Visible – Do not presume that others

know

Strategic Initiatives

• PCMH

• Ambulatory Care centers

• Centers of Excellence

• Service Line development

• Less Inpatient – More Outpatient

• Transition of Care

Quality, Safety and Patient

Satisfaction

Quality and Safety

• 2015 – Reimbursement tied to value not

volume (1-2% penalty)

• Quality Metrics

– Discharge Management

– Morbidity and Mortality

– Core Measures – AMI, HF, Pneumonia,

Stroke and SCIP

Patient Satisfaction

• HCAPS

– Hospital Consumer Survey of Healthcare

Providers and systems

– 6 Domains –Pain, Communication, Nursing,

Hospitals systems

– 1 domain – dedicated to Physicians/Providers

– NPI used to run reports

Summary

• PA’s are extremely well positioned

– Organizational and Patient Throughput

– Transition of Inpatient care to Acute care

Management

– Transition of Care

– Productivity tools

– Advocacy to Improve Laws

– ACA, Medicaid Expansion –

– Ideas are needed to acieved maximum Patient

Access, satisfaction and maintain quality measures

Questions

Hospitals and HealthCare Systems · • ICD 10. Clinical Practice Models. APRNs ... Pros Cons...

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