young urologists forum
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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. Changing Patterns of Reimbursement, can your practice adapt?. Paul Brower - PowerPoint PPT PresentationTRANSCRIPT
Young Urologists ForumYoung Urologists Forum
Effectively Managing Practice Economics Effectively Managing Practice Economics and Utilization of Physician Extendersand Utilization of Physician Extenders
Program and Lunch sponsored by the Program and Lunch sponsored by the Young Urologists Committee and Young Urologists Committee and Ortho-McNeil Pharmaceutical, Inc.Ortho-McNeil Pharmaceutical, Inc.
Changing Patterns of Changing Patterns of Reimbursement, can your Reimbursement, can your
practice adapt?practice adapt?
Paul BrowerPaul BrowerCEO Orange County Urology AssociatesCEO Orange County Urology Associates
Fees used in this presentation are based on the Medicare allowables in Fees used in this presentation are based on the Medicare allowables in California. These fees are on the public record and no proprietary California. These fees are on the public record and no proprietary
information is included in this presentation.information is included in this presentation.
Reimbursement HistoryReimbursement History
Began with the creation of the Resource-Based Relative Began with the creation of the Resource-Based Relative Value Scale[RBRVS] by Wm Hsiao in 1988 and adopted by Value Scale[RBRVS] by Wm Hsiao in 1988 and adopted by HICFA as part of the Omnibus Budget Reconciliation Act HICFA as part of the Omnibus Budget Reconciliation Act in1992.in1992.
This allowed a shift to reward “cognitive” skills vs. This allowed a shift to reward “cognitive” skills vs. procedures particularly those performed in the hospital.procedures particularly those performed in the hospital.
The system of CPT codes,DRGs,and RVUs was createdThe system of CPT codes,DRGs,and RVUs was created There have been 3500 corrections and additions since 1992There have been 3500 corrections and additions since 1992 By manipulating the RVUs and place of service there has By manipulating the RVUs and place of service there has
been a successful shift to the office for procedures from the been a successful shift to the office for procedures from the more expensive hospital more expensive hospital
Yotan,YYotan,YJ.Urology,Vol.172,1958-1962,Nov.2004J.Urology,Vol.172,1958-1962,Nov.2004
Between 1995 and 2004 the reimbursement Between 1995 and 2004 the reimbursement for E & M codes increased 51% and surgical for E & M codes increased 51% and surgical fees decreased 28%fees decreased 28%
Reimbursement for office procedures has Reimbursement for office procedures has risen even more than the increase in E & M risen even more than the increase in E & M codescodes
Where we are today?Where we are today?
Medicare has indicated they will reduce Medicare has indicated they will reduce reimbursement an additional 40% over the next 7 reimbursement an additional 40% over the next 7 years. A 5% cut was frozen in 2007,but the freeze years. A 5% cut was frozen in 2007,but the freeze was “paid for” by imaging cuts including a 40% cut was “paid for” by imaging cuts including a 40% cut in reimbursement for transrectal ultrasound in reimbursement for transrectal ultrasound guidance for prostate biopsy.guidance for prostate biopsy.
Most HMO and PPO contracts are quoted as a % of Most HMO and PPO contracts are quoted as a % of Medicare’s fee schedule so this will a have Medicare’s fee schedule so this will a have profound effect on your practice incomeprofound effect on your practice income
Consolidation of Insurers has lead to concentration Consolidation of Insurers has lead to concentration of power in the hands of a few resulting in obscene of power in the hands of a few resulting in obscene profitsprofits
Blue Cross of CA[now Anthem]- $3billionBlue Cross of CA[now Anthem]- $3billion United Health+Pacific Care-$4billionUnited Health+Pacific Care-$4billion
What can we do ?What can we do ? In today’s economic environment we must understand In today’s economic environment we must understand
how and where we make our money.how and where we make our money.
Gone are the days when we could simply come to work, Gone are the days when we could simply come to work, operate, see patients, have someone run our office and operate, see patients, have someone run our office and expect to get paid well each month. expect to get paid well each month.
There has been tremendous pressure on our income in There has been tremendous pressure on our income in the last 5 years. the last 5 years.
Costs associated with running our practices have risen Costs associated with running our practices have risen and reimbursements have fallen.and reimbursements have fallen.
We are “piece workers” and the only thing we have to We are “piece workers” and the only thing we have to sell is our timesell is our time
We get paid for the number of widgets we produce and We get paid for the number of widgets we produce and this is hard to leveragethis is hard to leverage
If you don’t understand where you make your money If you don’t understand where you make your money you can’t possibly maximize your production and you can’t possibly maximize your production and income per unit of time spentincome per unit of time spent
What we look at for our practice What we look at for our practice benchmarkingbenchmarking
OfficeOfficePatient Counts: New patients,Return visits,# days seeing Patient Counts: New patients,Return visits,# days seeing patients,#procedures done,ratio of procedures per patient patients,#procedures done,ratio of procedures per patient visit,procedures that require a procedure visit,procedures that require a procedure room[vas,bx,utc,cysto]room[vas,bx,utc,cysto]Collections total and average per patient visit[always use Collections total and average per patient visit[always use collections not billings]collections not billings]Coding:level and ratio for each MD and compared to the Coding:level and ratio for each MD and compared to the groupgroup
HospitalHospital# Consultations# Consultations# OR Cases# OR Cases# Case as Assistant# Case as Assistant# Long Cases[> 2 1/2 hrs]# Long Cases[> 2 1/2 hrs]Ratio of OR cases patient[Total, New]Ratio of OR cases patient[Total, New]Collections from the OR and HospitalCollections from the OR and Hospital
OCUA for 2005OCUA for 2005
9 MDs9 MDs 1 new assoc. doing the laparoscopy and building 1 new assoc. doing the laparoscopy and building
his practice[#9]his practice[#9] 2 specializing in female and incontinence[#4,500]2 specializing in female and incontinence[#4,500] 1 male infertility specialist[#400]1 male infertility specialist[#400] 1 CEO,seeing patients 1/2 time[#100]1 CEO,seeing patients 1/2 time[#100]
Approximate revenues per Approximate revenues per partnerpartner
0%
10%20%30%40%50%60%70%80%90%
100%
% of maximum collections
1
2
4
8
100
200
400
500
900
Office Patient VisitsOffice Patient Visits
0
500
1000
1500
2000
2500
3000
3500
total pts
1248100200400500900
OR CasesOR Cases
0
50
100
150
200
250
# cases
1248100200400500900
% Total Collections-OR% Total Collections-OR
0%
5%
10%
15%
20%
25%
30%
% collections OR
1248100200400500900
Income from surgery versus Income from surgery versus office encounteroffice encounter
0
200
400
600
800
1000
1200
income/pt income/case
1248100200400500900
OCUA 2006 StatsOCUA 2006 Stats
6,323 New Patients6,323 New Patients 17,803 Return Visits 17,803 Return Visits 24,126 MD - patient encounters24,126 MD - patient encounters 2,000 Surgical Cases2,000 Surgical Cases 13,200 Office Procedures13,200 Office Procedures 9 MDs [1new associate and 1 working 1/2 time]9 MDs [1new associate and 1 working 1/2 time]
Collections 2006Collections 2006
Office Patients VisitsOffice Patients Visits 31%31% Office ProceduresOffice Procedures 39%39% SurgerySurgery 16%16% Other[supplies,meds]Other[supplies,meds] 13%13%
Comparative FeesComparative Fees
1986*1986* 20072007TURPTURP $2000$2000 $923$923Rad.NephRad.Neph $3000$3000 $1452$1452Lap Rad NephLap Rad Neph $1536$1536Rad.CystectomyRad.Cystectomy $4000$4000 $2185$2185Ureteroscopy,laserUreteroscopy,laser $488$488ESLESL $2500$2500 $639$639Rad PxRad Px $3500$3500 $1635$1635
PathologyPathologyProstate bxProstate bx
$144/specimen$144/specimenCytologyCytology $95$95
*Balance Billing allowed then and not now*Balance Billing allowed then and not now
Office FeesOffice Fees
20072007 Office consult[99244] Office consult[99244] $223$223 Return Visit[99213]Return Visit[99213] $76$76 Cystoscopy[52000]Cystoscopy[52000] $283$283 Vasectomy[55250]Vasectomy[55250] $742$742 TUMT[53850]TUMT[53850] $5214$5214 BT<0.5cm[52224]BT<0.5cm[52224] $1992$1992 Prostate Biopsy[55700]Prostate Biopsy[55700] $335$335 Prostate US[76872]Prostate US[76872] $176$176 Video UrodynamicsVideo Urodynamics $800-1000$800-1000 Renal US[76770]Renal US[76770] $168$168
Value of Your Time
0
1000
2000
3000
4000
5000
6000
Inco
me
Pe
r H
ou
r ($
)
Another Day in the Office - 03/08/2007
CPT # $/ Visit TotalNew Patient 99244 5 $233 $1,165
Return Visit 99213 17 $49 $833
Biopsy Discussion 99215 1 $113 $113
Cystoscopy 52000 3 $283 $849
Vasectomy 55250 1 $750 $750
PVR 51798 10 $25 $250
ProstateUS/ BX 76872 1 $738 $7387694255700
TOTAL $4,698
Cystectomy 51596 1 $2,657Radical PX 55842 2 $3,270
Who had more fun?
UltrasoundUltrasound
In office US is a very good way to leverage your In office US is a very good way to leverage your timetime
US tech comes to the office on regular basis and US tech comes to the office on regular basis and performs renal,scrotal,penile,color doppler studiesperforms renal,scrotal,penile,color doppler studies
Most Urologists are already doing their own US of Most Urologists are already doing their own US of the prostatethe prostate
AdvantagesAdvantages Does not require dedicated spaceDoes not require dedicated space Cost of equipment nominal compared to other Cost of equipment nominal compared to other
imagingimaging Personnel costs are limited[pay per procedure]Personnel costs are limited[pay per procedure] Enhanced patient service and satisfactionEnhanced patient service and satisfaction Does not require separate contracting with Does not require separate contracting with
radiologistradiologist
US Codes and FeesUS Codes and FeesCPT CodeCPT Code DescriptionDescription FeeFee•5179851798 PVRPVR $21$21•7677076770 Retroperitoneal[complete]Retroperitoneal[complete] $142$142•7677576775 Retroperitoneal[limited]Retroperitoneal[limited] $127$127•7685676856 Pelvic[complete]Pelvic[complete] $122$122•7685776857 Pelvic[limited]Pelvic[limited] $110$110•7687276872 Prostate-Transrectal[Bx supervision]Prostate-Transrectal[Bx supervision] $147$147•7694276942 Guidance for biopsyGuidance for biopsy $189$189•5570055700 Biopsy prostateBiopsy prostate $145$145•7687376873 Prostate Vol. BrachyRxProstate Vol. BrachyRx $195$195•7687076870 Scrotal & ContentsScrotal & Contents $120$120•9397693976 Duplex Scan[limited]Duplex Scan[limited] $305$305•9398093980 Duplex Scan-penileDuplex Scan-penile $232$232
PathologyPathology
Must be very careful of the structure to avoid Stark Must be very careful of the structure to avoid Stark issues;must own the equipment,own or lease the issues;must own the equipment,own or lease the space,formal contract with the pathologist.space,formal contract with the pathologist.
Bill global fee and split collections per contract with the Bill global fee and split collections per contract with the pathologistpathologist
Requires limited dedicated space and funds for Requires limited dedicated space and funds for equipment:200 sq.ft,$80-$100,000equipment:200 sq.ft,$80-$100,000
We are only doing 2 tests tissue histopathology,urine We are only doing 2 tests tissue histopathology,urine cytologycytology
Medicare feesMedicare fees• CPTCPT DescriptionDescription Fee Fee
• 8830588305 Surgical Path[gross & micro] Surgical Path[gross & micro]$143/core 88108$143/core 88108 Urine Cytology Urine Cytology
$95$95
PATHOLOGY LABPATHOLOGY LAB
CTCT
Must lease or purchase the equipment[new or Must lease or purchase the equipment[new or refurbished].Start up costs $300-$600,000refurbished].Start up costs $300-$600,000
Must have contractual arrangement with Must have contractual arrangement with radiologist to interpret [on the premises or via radiologist to interpret [on the premises or via PACs system].Bill separately or global. PACs system].Bill separately or global.
Requires CT tech and MD to inject contrastRequires CT tech and MD to inject contrast Dedicated Dedicated
space,construction,inspection,licensespace,construction,inspection,license Certificate of Need[CON]Certificate of Need[CON] Pre-certification for proceduresPre-certification for procedures Radiologists and some payors resisting this at Radiologists and some payors resisting this at
the state and federal levelsthe state and federal levels
CT Pro forma *CT Pro forma * RevenueRevenue CT Patients per dayCT Patients per day 66 Days per monthDays per month 20.7520.75 Rev/pt- Abd/pelvis Rev/pt- Abd/pelvis $835[may be $835[may be
considerably less]considerably less]with & without contrastwith & without contrast
Total RevenueTotal Revenue $1,248,252$1,248,252
ExpensesExpenses Equipment leaseEquipment lease $85,000$85,000 Service contractService contract $65,000$65,000 Technologist[SOCA]Technologist[SOCA] $85,000$85,000 Radiologist[16% of global[Radiologist[16% of global[ $200,000$200,000 Medical suppliesMedical supplies $10,000$10,000 Misc[rent,utilities]Misc[rent,utilities] $20,000$20,000 TotalTotal $465,000$465,000
Potential Cash FlowPotential Cash Flow $783,252$783,252
* Hypothetical Pro forma from Neusoft Imaging Systems * Hypothetical Pro forma from Neusoft Imaging Systems Solutions[modified by PAB]Solutions[modified by PAB]
How can you adapt ?How can you adapt ? Office is the center for income and expenses-keep it busy. Have Office is the center for income and expenses-keep it busy. Have
the space,equipment,staff to be maximally efficient with your the space,equipment,staff to be maximally efficient with your timetime
Build a grid based on 1/2 day blocks-don’t violate your office 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 block to go to the OR[it costs you lots of money]. Use block time
Develop ancillary sources of income Develop ancillary sources of income US,Lithotripsy,CT,Pathology,IMRT,Incontinence Center US,Lithotripsy,CT,Pathology,IMRT,Incontinence Center
Built 15,000 sq. ft. office with 23 exam/procedure Built 15,000 sq. ft. office with 23 exam/procedure rooms,pathology lab,research,color doppler US,2 urodynamic rooms,pathology lab,research,color doppler US,2 urodynamic rooms,C-arm and flouro tablerooms,C-arm and flouro table
Must finds ways to leverage your timeMust finds ways to leverage your time Little things matter:Little things matter:
• Communicate by email, assign hospitals rounds,whomever is in the Communicate by email, assign hospitals rounds,whomever is in the hospital sees all of the patients there,who ever lives closest stops in hospital sees all of the patients there,who ever lives closest stops in the AMthe AM
• Review the schedule weekly,look for Review the schedule weekly,look for conflicts,openings,inefficienciesconflicts,openings,inefficiencies
• Try to use RNFA or retired surgeons to assist,utilize surgical blocksTry to use RNFA or retired surgeons to assist,utilize surgical blocks
Working smarter and being more productiveWorking smarter and being more productive
Designing your officeDesigning your officeThis is where you make your money and where your fixed This is where you make your money and where your fixed
costs arecosts areOur new office:15,000 sq. ftOur new office:15,000 sq. ft23 exam and procedure rooms;2 urodynamics,nurse 23 exam and procedure rooms;2 urodynamics,nurse
visit room,fluoroscopy,Clinical Research,Pathology visit room,fluoroscopy,Clinical Research,Pathology LabLab
7 MDs and 2 PAs working simultaneously7 MDs and 2 PAs working simultaneouslyDesigned to never have to defer a procedure or delay Designed to never have to defer a procedure or delay
seeing seeing patientspatients LocationLocation
Primary office should be geocentric to the primary hospitals Primary office should be geocentric to the primary hospitals served served
Satellite offices-utilize them only if they bring in patients Satellite offices-utilize them only if they bring in patients that that would would go to someone else if you weren’t there. go to someone else if you weren’t there. They They are expensive and inefficientare expensive and inefficient
Size Really Does MatterSize Really Does Matter Group SizeGroup Size
Minimum # MDs - 6Minimum # MDs - 6
Maximum - None [the larger the group the more potential Maximum - None [the larger the group the more potential problems with governance and personalities]problems with governance and personalities]
Large groups have access to capital for wholly owned Large groups have access to capital for wholly owned ancillary services-lithotripters,laser,CT,IMRTancillary services-lithotripters,laser,CT,IMRT
Fixed CostsFixed CostsMost practice costs are fixed[rent,staff]Most practice costs are fixed[rent,staff]
They don’t go away when you aren’t thereThey don’t go away when you aren’t there
6 MDs -3 or 4 working in the office all of the time6 MDs -3 or 4 working in the office all of the time
Critical mass is required for capital expenses and overheadCritical mass is required for capital expenses and overhead RecruitingRecruiting
Large groups have been successful,small practices Large groups have been successful,small practices have have notnot
Fellowship trained MDs want larger groupsFellowship trained MDs want larger groups
Large groups can support the sub specialist with Large groups can support the sub specialist with patient patient referrals and financial subsidiesreferrals and financial subsidies
Office vs OROffice vs OR
Office is where you make your money-85% for OCUAOffice is where you make your money-85% for OCUA Office procedures are the economic kickerOffice procedures are the economic kicker The $ penalty for the OR is lost income of 1/3 to 20x per The $ penalty for the OR is lost income of 1/3 to 20x per
unit of timeunit of time Don’t stop operatingDon’t stop operating but organize your time but organize your time Use block timeUse block time Don’t schedule cases in the middle of the dayDon’t schedule cases in the middle of the day Office days are office days-don’t leaveOffice days are office days-don’t leave Rotate days in the hospital[rounds,operate,call]Rotate days in the hospital[rounds,operate,call] Economic DeathEconomic Death
Assisting- getting paid $175 for 1/2 day in the ORAssisting- getting paid $175 for 1/2 day in the ORTrack assists and compensate your partners Track assists and compensate your partners Try not to use associates [use RNFA,retired surgeonsTry not to use associates [use RNFA,retired surgeons]]
ConclusionsConclusions
Do Internal Bench Marking at least annuallyDo Internal Bench Marking at least annually The majority of income comes from the office The majority of income comes from the office
[85% for OCUA][85% for OCUA] The system rewards those that stay in the The system rewards those that stay in the
office seeing patients and doing proceduresoffice seeing patients and doing procedures Group size is critical to survive in the futureGroup size is critical to survive in the future
A Minimum size is required to keep the A Minimum size is required to keep the office busy,support ancillary office busy,support ancillary services,afford capital expenditures,take services,afford capital expenditures,take economic riskeconomic riskYou must develop ancillary services and You must develop ancillary services and learn to leverage your timelearn to leverage your time
Physician AssistantPhysician AssistantGordon R Gluckman,MDGordon R Gluckman,MD
Residency DirectorResidency DirectorNorthwest Metropolitan Urology AssociatesNorthwest Metropolitan Urology Associates
Rosiland Franklin Phycisian Assistant ProgramRosiland Franklin Phycisian Assistant Program
PhysicianPhysician Assistant Assistant
BackgroundBackground• Navy corpsmen trained in Vietnam with Navy corpsmen trained in Vietnam with
considerable medical treatmentconsiderable medical treatment• Shortage of primary care physiciansShortage of primary care physicians• Duke University - 1965Duke University - 1965
Director – Dr. Eugene SteadDirector – Dr. Eugene Stead Based on fast-track WWII physician trainingBased on fast-track WWII physician training
Physician AssistantPhysician Assistant
Current EducationCurrent Education• Typical ApplicantTypical Applicant
Bachelor’s degreeBachelor’s degree 4 years of experience4 years of experience Extremely CompetitiveExtremely Competitive Nurses, EMTs, ParamedicsNurses, EMTs, Paramedics Females>MalesFemales>Males
Physician AssistantPhysician Assistant
Practicing PAsPracticing PAs• Graduate of Accredited programGraduate of Accredited program• Must pass National Certification Exam Must pass National Certification Exam
“C”“C”• 62% females62% females• Final DegreeFinal Degree
44% Bachelor’s44% Bachelor’s 35% Master’s35% Master’s
Physician AssistantPhysician Assistant
Areas of PracticeAreas of Practice• Family/General medicine(27%)Family/General medicine(27%)• General Internal medicine(7%)General Internal medicine(7%)• General Pediatrics(3%)General Pediatrics(3%)• OB/GYN (2%)OB/GYN (2%)• Surgery/Surgical specialties (25%)Surgery/Surgical specialties (25%)• Emergency medicine (10%)Emergency medicine (10%)• Internal medicine specialty (11%)Internal medicine specialty (11%)• Dermatology (3%)Dermatology (3%)
Physician AssistantPhysician Assistant
Why Hire??Why Hire??• Shift physician workloadShift physician workload
Handling routine office visit, rounds, callHandling routine office visit, rounds, call Less time in officeLess time in office
• FlexibilityFlexibility• Cost EffectivenessCost Effectiveness
For every dollar generated by PA 28 cents For every dollar generated by PA 28 cents cost to employercost to employer
• Physician-PA team conceptPhysician-PA team concept
Northwest Metropolitan Urology Northwest Metropolitan Urology AssociatesAssociates
16000 patient visits16000 patient visits
4500 hospital consults4500 hospital consults
4000 hospital patient rounds4000 hospital patient rounds
2500 post operative visits2500 post operative visits
Northwest Metropolitan Urology Northwest Metropolitan Urology AssociatesAssociates
150 nephrectomies/laparoscopic150 nephrectomies/laparoscopic 400 TURP’s/Lasers400 TURP’s/Lasers 200 open/robotic prostatectomies200 open/robotic prostatectomies 700 TRUS/BX700 TRUS/BX 400 Urodynamics400 Urodynamics
Northwest Metropolitan Urology Northwest Metropolitan Urology AssociatesAssociates
Physician AssistantPhysician Assistant• Hospital roundsHospital rounds• ConsultsConsults• OR assistantOR assistant• CallsCalls• Help in officeHelp in office
Northwest Metropolitan Urology Northwest Metropolitan Urology AssociatesAssociates
One year residencyOne year residency
Lectures/OR/rounds/officeLectures/OR/rounds/office
Two programs in the countryTwo programs in the country
Physican ExtendersPhysican Extenders
James C. Ulchaker MD FACSJames C. Ulchaker MD FACSCo-Director Prostate CenterCo-Director Prostate Center
Glickman Urological and Kidney InstituteGlickman Urological and Kidney InstituteCleveland Clinic FoundationCleveland Clinic Foundation
What are APN’s?What are APN’s?
Master’s prepared registered nursesMaster’s prepared registered nurses Current certificationCurrent certification Certificate of authority from OBNCertificate of authority from OBN Certificate to prescribeCertificate to prescribe Function in collaboration with Function in collaboration with
physicians to provide mid-level carephysicians to provide mid-level care
Titles of APN’sTitles of APN’s
Nurse Practitioners (CRNP)Nurse Practitioners (CRNP) Certified Nurse Midwives (CNM)Certified Nurse Midwives (CNM) Clinical Nurse Specialists (CNS)Clinical Nurse Specialists (CNS) Certified Registered Nurse Certified Registered Nurse
Anesthetists* (CRNA)Anesthetists* (CRNA)
Standard Care ArrangementStandard Care Arrangement Required for CRNP,CNS,CNM (ORC)Required for CRNP,CNS,CNM (ORC)
Formal document of collaborative Formal document of collaborative relationship relationship
Must be kept on siteMust be kept on site
Reviewed and signed annuallyReviewed and signed annually
Must be kept currentMust be kept current
APN Core PrivilegesAPN Core Privileges
Patient assessment: History & Patient assessment: History & physicalphysical
Develop plan of care: Develop plan of care: • ordering diagnostic tests & therapiesordering diagnostic tests & therapies• medication management with CTP medication management with CTP
Implement/ re-evaluate plan of care:Implement/ re-evaluate plan of care:• perform diagnostic tests as per perform diagnostic tests as per
privilegingprivileging
Why hire an APN?Why hire an APN?
Promote accessPromote access Cost effective providerCost effective provider Focus on prevention & wellness, Focus on prevention & wellness,
patient education, promotion of patient education, promotion of compliancecompliance
Enhance revenueEnhance revenue Continuity of careContinuity of care Facilitate physician productivityFacilitate physician productivity
Optimal Use of APN’s Optimal Use of APN’s Outpatient SettingOutpatient Setting Established patientsEstablished patients Pre-op assessmentsPre-op assessments Post-op visitsPost-op visits
Inpatient SettingInpatient Setting Patient evaluationPatient evaluation Facilitate discharge planningFacilitate discharge planning Promote patient satisfaction Promote patient satisfaction
Reimbursement of APN’sReimbursement of APN’s
IndependentIndependent
Incident toIncident to
Shared service in hospital settingShared service in hospital setting
Facilitating APN Facilitating APN ReimbursementReimbursement
• Provider enrollment packetProvider enrollment packet MedicareMedicare MedicaidMedicaid BWCBWC Masterfile formMasterfile form
• PIF for managed care enrollmentPIF for managed care enrollment
• Processed once privileging is completeProcessed once privileging is complete
Measuring APN ValueMeasuring APN Value
Patient Satisfaction: QDMPatient Satisfaction: QDM• Requires EPIC provider number & billing Requires EPIC provider number & billing
numbernumber• Requires APN to have own scheduleRequires APN to have own schedule
Patient OutcomesPatient Outcomes
• LOS, discharge times, re-admit rates, LOS, discharge times, re-admit rates, compliance with standards of care compliance with standards of care
Measuring APN ValueMeasuring APN Value
ProductivityProductivity• Number of visitsNumber of visits• Encounter types (Clarity)Encounter types (Clarity)• Billed chargesBilled charges• RVU’sRVU’s• Impact on physician practiceImpact on physician practice
What is a Physician Assistant?What is a Physician Assistant?
Physician Assistants are health care professionals Physician Assistants are health care professionals licensed to practice medicine with physician licensed to practice medicine with physician supervision. PAs are educated in the medical supervision. PAs are educated in the medical model designed to complement physician model designed to complement physician training.training.((www.aapa.orgwww.aapa.org))
According to the American Association of Physician Assistants’ web site:
Physician Assistants:Physician Assistants:
Conduct physical examsConduct physical exams Diagnose and treat illnessesDiagnose and treat illnesses Order and interpret testsOrder and interpret tests Counsel on preventive health careCounsel on preventive health care Assist in surgeryAssist in surgery And in 49 states, write prescriptionsAnd in 49 states, write prescriptions As of May 17, 2006, Ohio passed legislation As of May 17, 2006, Ohio passed legislation
enabling PA’s to have RX authority.enabling PA’s to have RX authority.
Physician Assistant Physician Assistant Demographics:Demographics:
There are just over 59,000 individuals who There are just over 59,000 individuals who practice full-time as physician assistants. practice full-time as physician assistants.
59% female; 41% male59% female; 41% male 41 years old41 years old The average PA has been in practice as a PA 9.1 The average PA has been in practice as a PA 9.1
years years (AAPA 2005 census)(AAPA 2005 census)
Physician Assistant Physician Assistant Demographics:Demographics:
AT THE CLEVELAND CLINIC:AT THE CLEVELAND CLINIC:
• Over 140 PA’s employed at CCFOver 140 PA’s employed at CCF
• Average years of clinical experience: Average years of clinical experience: 13yrs13yrs
• Average years of employment: 8yrsAverage years of employment: 8yrs Range from 1yr to 32yrsRange from 1yr to 32yrs
Demographics at CCF:Demographics at CCF:
PA's PER DIVISIONTotal of 142 PA's
(Updated 4/04/07)
Surgery (45%)
Medicine (26%)
Neuroscience Institute (11%)
Anesthesiology (5%)
Cancer Center (6%)
R M P ' s (7%)
Division of SurgeryDivision of Surgery
PA's by Department in Division of SurgeryTotal of 64 PA's
(Updated 4/04/07)Director - 1 (2%)
Breast Center - 2 (3%)
Beachw ood OB-GYN - 1 (1%)
CardioThoracic - 7 (11%)
Colorectal Surgery - 6 (9%)
General Surgery - 4 (6%)
Orthopaedics - 15 (23%)
Plastics - 5 (8%)
Transplant Center - 4 (6%)
Urological Institute - 8 (13%)
Vascular Surgery - 4 (5%)
ASC (PAT) - 8 (13%)
Physician Assistant in The Work Physician Assistant in The Work PlacePlace
43.3% work in a solo physician or group practice43.3% work in a solo physician or group practice 11.6% in a rural clinic, community health center, 11.6% in a rural clinic, community health center,
or freestanding urgent care or surgical facilityor freestanding urgent care or surgical facility 34.5% in a hospital34.5% in a hospital Less than 1% work in a nursing home or long-Less than 1% work in a nursing home or long-
term care facilityterm care facility
(AAPA 2004 Annual PA Census Survey)(AAPA 2004 Annual PA Census Survey)
Physician Assistant On The Physician Assistant On The Job:Job:
Perform invasive procedures: 43.6%Perform invasive procedures: 43.6% Precept PA students: 38.3%Precept PA students: 38.3% Educate other providers: 36.6%Educate other providers: 36.6% Assist in surgery: 26.6%Assist in surgery: 26.6% Precept other students: 26.5%Precept other students: 26.5% Make decisions about procurement: 24.6%Make decisions about procurement: 24.6% Perform quality assurance: 22.2%Perform quality assurance: 22.2% Supervise other clinical staff: 20.2%Supervise other clinical staff: 20.2% 100% or respondents provide direct patient care100% or respondents provide direct patient care (AAPA 2004 Annual Census Survey)(AAPA 2004 Annual Census Survey)
Methods of measuring Methods of measuring productivity:productivity:
Average number of visits per unit of timeAverage number of visits per unit of time Charges generatedCharges generated Increased physician activityIncreased physician activity Number of office visits or proceduresNumber of office visits or procedures Overhead reductionOverhead reduction Time spent per patient visitTime spent per patient visit
Lori B. Lerner, MDLori B. Lerner, MD
Assistant Professor of Assistant Professor of SurgerySurgery
Chief, Section of UrologyChief, Section of Urology
White River Junction White River Junction VAMCVAMC
Dartmouth Medical SchoolDartmouth Medical School
White River Junction, VTWhite River Junction, VT
White River VAMCWhite River VAMC
27 NP’s and PA’s employed by the 27 NP’s and PA’s employed by the hospitalhospital
Surgical ServiceSurgical Service• 3 in General Surgery3 in General Surgery• One each in GU, Vascular, OrthoOne each in GU, Vascular, Ortho
Approx 50% of primary care clinics Approx 50% of primary care clinics staffed by PA’s and NP’sstaffed by PA’s and NP’s
Urology ServiceUrology Service
2 attendings, 1 senior level resident 2 attendings, 1 senior level resident and one NPand one NP
Since losing our intern 8 yrs ago, we Since losing our intern 8 yrs ago, we have had a PA or NPhave had a PA or NP
Daily rounds and half day clinic, pre-Daily rounds and half day clinic, pre-operative history and physicals, operative history and physicals, prostate biopsies, in-patient consults, prostate biopsies, in-patient consults, discharge planning, pt phone calls, discharge planning, pt phone calls, prescription renewalsprescription renewals
Surgical ServiceSurgical Service
3 PA’s3 PA’s 40 hour work week40 hour work week Daily rounds, discharges, assist in Daily rounds, discharges, assist in
the OR, H & P’s, post operative the OR, H & P’s, post operative orders and post-op checksorders and post-op checks
No assigned clinic patients, but they No assigned clinic patients, but they attend and assistattend and assist
When 80 hr work week was When 80 hr work week was instituted, PA’s began overnite callinstituted, PA’s began overnite call
Salary RangeSalary Range
Very wide range depending on Very wide range depending on provider experience, yrs at the VAprovider experience, yrs at the VA
NP: $45,520-83,927 NP: $45,520-83,927 PA: $43,731-82,446 PA: $43,731-82,446 With yearly raises in the VA system, With yearly raises in the VA system,
some providers are above this rangesome providers are above this range
Contact Information:Contact Information:Physician AssistantsPhysician Assistants
http://www.clinicianreviews.com/index.asp?http://www.clinicianreviews.com/index.asp?ArticleType=SiteSpec&page=body/ArticleType=SiteSpec&page=body/PAorganizations.htmPAorganizations.htm
American Academy of Physician AssistantsAmerican Academy of Physician Assistants• http://www.aapa.orghttp://www.aapa.org• http://www.healthecareers.com/site_templates/AAPA/http://www.healthecareers.com/site_templates/AAPA/
index.asp?aff=AAPA&SPLD=AAPAindex.asp?aff=AAPA&SPLD=AAPA American Association of Surgical Physician AssistantsAmerican Association of Surgical Physician Assistants
• http://www.aaspa.com/SurgInfo.asphttp://www.aaspa.com/SurgInfo.asp• E-mail: [email protected]: [email protected]• PMB 201 4267 NW Federal HighwayPMB 201 4267 NW Federal Highway
Jensen Beach, FL 34957Jensen Beach, FL 34957• 888.882.2772888.882.2772• 772.388.3457 (fax)772.388.3457 (fax)
Contact Information:Contact Information:Physician AssistantsPhysician Assistants
http://www.paworld.net/http://www.paworld.net/ http://www.advancedpracticejobs.com/http://www.advancedpracticejobs.com/ http://www.medhunters.com/jobs/http://www.medhunters.com/jobs/
healthcare.allied.pa.urology-pa.2519.htmlhealthcare.allied.pa.urology-pa.2519.html http://www.careermd.com/newsletters/http://www.careermd.com/newsletters/
currentnewsletters/CareerPA_1.htmcurrentnewsletters/CareerPA_1.htm
Contact Information:Contact Information:Nurse PractionersNurse Practioners
http://www.clinicianreviews.com/index.asp?Articlehttp://www.clinicianreviews.com/index.asp?ArticleType=SiteSpec&page=body/NPorganizations.htmType=SiteSpec&page=body/NPorganizations.htm• State NP organizationsState NP organizations
American Academy of NPsAmerican Academy of NPs• PO Box 12846 PO Box 12846
Austin, TX 78711 Austin, TX 78711 512.276.5906 512.276.5906
• http://www.aanp.org http://www.aanp.org American College of NPsAmerican College of NPs
• 1111 19th St NW, Ste 404 1111 19th St NW, Ste 404 Washington, DC 20036 Washington, DC 20036 202.659.2190 202.659.2190
• E-mail: [email protected]: [email protected]
Contact Information:Contact Information:Nurse PractionersNurse Practioners
National Association of Pediatric NPsNational Association of Pediatric NPs • 20 Brace Rd, Ste 200 20 Brace Rd, Ste 200
Cherry Hill, NJ 08034 Cherry Hill, NJ 08034 877.662.7627 877.662.7627
• http://www.napnap.orghttp://www.napnap.org National Conference of National Conference of
Gerontological NPsGerontological NPs• 4824 Edgemoor Ln 4824 Edgemoor Ln
Bethesda, MD 20814 Bethesda, MD 20814 301.654.3776 301.654.3776
• http://www.ncgnp.orghttp://www.ncgnp.org
Effectively Managing Effectively Managing Practice Economics and Practice Economics and Utilization of Physician Utilization of Physician
ExtendersExtenders
Young Urologists CommitteeYoung Urologists Committee
Kevin Spear MD ChairKevin Spear MD Chair
What was the reason What was the reason you hired a physician you hired a physician
extender?extender?
How long did it take for How long did it take for you to hire a physician you to hire a physician
extender?extender?
What resources did you What resources did you utilize to assist you in the utilize to assist you in the
hiring process?hiring process?
Was the hiring process Was the hiring process difficult?difficult?
How did you formulate How did you formulate the salary and benefit the salary and benefit
package?package?
Was credentialing Was credentialing difficult?difficult?
How do you utilize your How do you utilize your physician extender?physician extender?
How do your patients How do your patients perceive the physician perceive the physician
extender?extender?
Was your initial plan Was your initial plan different than your current different than your current
utilization plan?utilization plan?
How do you supervise How do you supervise and assure quality and assure quality
control?control?
Are there any liability Are there any liability concerns?concerns?
What were the trials and What were the trials and tribulations of the physician tribulations of the physician
extender process?extender process?
Do you have any Do you have any recommendations for recommendations for physicians to consider physicians to consider
when hiring a physician when hiring a physician extender?extender?