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]
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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
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
Inpatient Utilization
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
Inpatient Utilization
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)
Results – Inpatient Study
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
Results – Inpatient Study
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%
Collection of Physiological Data
1%
Research Visit Documentation
3%
Student Precepting2%
Collection of Physiological Data
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
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