Productivity A Meaningful Model Tuesday June 14, 2016 AAMD 41 st Annual Meeting Levine Cancer Institute, Carolinas Healthcare System Vicki Reich, AVP
Carolinas HealthCare System Levine Cancer Institute (LCI) 2 nd (or 3 rd ) largest non-profit public hospital system in the U.S. 50 hospitals, 900 locations, 14 Rad Onc sites with the LCI Approximately 15,000 new cancer cases per year Awarded a 3 year CoC accreditation with Commendation as an Integrated Network Cancer Program (INCP)
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Productivity Webster's: a measure of the efficiency of a person, machine, factory, system, etc. in converting inputs into useful outputs. Output per employee 3
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Objective Reconcile the nuances of Financial Reporting and Productivity Reporting Consider the validity of an RVU model vs a Visit Model for Rad Onc Address nationally accepted Radiation Safety Standards when determining a staffing model 5
ASTRO Blue Book It is recommended that a minimum of two qualified individuals be present for any routine external beam patient treatments. 6
Challenges Addressed Fitting a square peg into a round hole using an inpatient nursing Productivity model for an outpatient Rad Onc department Develop RVU methodology and build into Chargemaster Restate Financial and Productivity ratios for FTE planning and forecasting 7
Success Factors/Pre-Requisites Build a healthy synergy between clinical and financial stakeholders. Find a Senior Admin champion. Re-state prior year(s) financials as a baseline for forecasting Benchmark: ongoing evaluation and revision of model based on changes in service line offerings and/or CMS bundling. 8
Relevant Outcomes Achieved Increased awareness of inaccuracy of existing Productivity models Establish a platform for ongoing dialog and process improvement Improved accuracy of data within the Chargemaster file 9
What is an RVU? On January 1, 1992 the U. S. government implemented federal resource-based relative value scales (RBRVS) for the payment of physicians RVUs assign relative values or weights to medical procedures primarily for the purpose of reimbursement of services performed, but also for productivity measurements, cost analysis and benchmarking RVUs have greatly expanded the possibilities to allow for case complexity and mix analysis, staffing and workload analysis. 10
Three components of the Relative Value Unit Work RVU (wrvu) 52% *Relative time, effort, and skill needed by a provider in the provision of a procedure Practice Expense RVU (pervu) 44% *Costs associated with maintaining a practice, such as rent, equipment, supplies and staff Malpractice Expense RVU (mrvu) 4% *Professional liability insurance 11
Non-Billable Procedural Inputs Inputs by staff for Special Procedures Multiple Areas on single patient Managing pediatric treatment Managing inpatient treatment Multiple radiation oncologists LCI-Morehead Procedural time analysis for non-billable inputs for Special Procedures = Average of 1-4 hours of non-billable inputs by staff per Special Procedure Treatment Schedule Adjustments 12
Total Body Pediatric Treatment 13
The following services are bundled into the Radiation Therapy codes: Anesthesia Skin/Wound Care Checking of treatment charts, verification of dosage, as needed Continued patient evaluation, examination, written progress notes, as needed Nutritional counseling Pain management Review & revision of treatment plan Routine medical management of unrelated problem Special care of ostomy Written reports, progress notes, Quality or MU inputs Follow-up examination and care for 90 days after last treatment 14
Resource Allocation Tool Inputs accounted for Facility specific acuity Model can be expanded Measurable Ability to audit 15
Cancellation Impact Snapshot % Cancellations Jan Radonc Facility A 3.1 Radonc Facility B 3.07 Radonc Facility C 7 Radonc Facility D 0.4 FEB Radonc Facility A 6.1 Radonc Facility B 3.54 Radonc Facility C 6 Radonc Facility D 3 Mar Radonc Facility A 4.6 Radonc Facility B 3.25 Radonc Facility C 9.8 Radonc Facility D 1.2 APR Radonc Facility A 3.1 Radonc Facility B 2.86 Radonc Facility C 10 Radonc Facility D 4.5 16
Inpatients- Number of Inpatient Treatments Acuity Qualifiers Anesthesia- # cases requiring anesthesia Pediatrics- # Pediatric tx procedures Special Procedures- # HDR, SRS, SBRT, TBI Xofigo- # Administrations Radiation Oncologists- # Staffed by location TX Schedule Adjustments- % No shows, downtime, etc. 17
Resource Allocation Snapshot 18
Variances Examples of Variance as related to Work CPT 77412: RVU - 6.79 Whole brain 10 min Prone breast- 20 minutes Pediatric TBI w/ anesthesia- One Hour We get paid the same, we get the same one tickmark! 19
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BMI Nursing Time Impact of PUTS Level I Level II Level III Level IV Level V D/C Instruction/Pt Education - Basic Education/Case Mgmt/Interview 16-30 mins* D/C Instruction/Pt Education - Mod Cerumen Removal Communication with Outside Agencies Extensive Data Gathering/Chief Complaint Drug Response Testing Coordination of Care for HR OB patients Dressing Change-Complex (wet-to-dry) Education/Case Mgmt/Interview <15 Forms Completion - Simple Education/Case D/C Instruction/Pt Education Education/Case mins* (BTL, School PE) Mgmt/Interview 31-45 mins* - Ext. (new med) Mgmt/Interview > 60 mins* Social History Forms Completion - Extensive Dental Varnishing (non Head Circumference Extensive/Complete (College) Medicaid) Emergency Care Medication Administration - Education/Case Provider Assistance - Complex Height/Length PO, Rectal Mgmt/Interview 46-60 mins* Procedures Medication Screening RN Walk-in Triage Assessment (taking no meds) Medication Reconciliation In and Out Catheterization (pt seen that day) Pain Screening (not OB History - Initial currently in pain) OB History Update Completion Social History Partial Pain Assessment Orthostatic Blood Pressures Vitals Past Medical History - Initial Completion/Update Oxygen Administration Provider Assistance - Routine Peak Flow Meter Weight Procedures Assessment Pulse Oximetry Provider Assistance - Mod Complex Procedures Staple/Suture Removal Pulse Oximetry Post Exercise Referral (Specialty, Radiology) Spec Need Requiring Spec Facility Resources TB Test Check - Positive Result 21
Non-Billable Clinical Staff Procedures Weekly Patient Under Treatment Visits PUTS Visits 6 months annualized Radonc Facility A 1493 2986 Radonc Facility B 1161 2322 Radonc Facility C 781 1562 Radonc Facility D 1065 2130 TOTALS 9000
CPT 2014 with AMA RVU s 23
Bundling, Packaging, Edits Packaging is about payment there is one payment for everything packaged but we still report all codes. Bundling is about coding NCCI Edits define bundling. Bundled codes are not reported, but sometimes a modifier can be added to bypass an edit. Modifier 0=not allowed Column 1 Deletion Date *=no data 1=allowed 9=not applicable 77295 77014 20070101 * 0 77295 77280 19960101 * 0 77295 77285 19960101 * 0 77295 77290 19960101 * 0 77295 77300 20160101 20160101 9 77295 77305 20010401 20141231 0 77295 77306 20150101 * 0 77295 77307 20150101 * 0 77295 77310 20010401 20141231 0 77295 77315 20010401 20141231 0 77334 77332 19960101 * 1 77334 77333 19960101 * 1 77334 77336 20031001 * 1 24
Bundled Codes 77300 w/ 3D 4.0 per plan # CPT 77300 PER ENCOUNTER DIAGNOSIS # ENCOUNTERS MIN MAX MEAN 174 Malignant neoplasm of female breast 226 1 25 4.238938053 162 Malignant neoplasm of trachea bronchus and lung 147 2 19 4.897959184 198 Secondary malignant neoplasm of other specified sites 76 1 30 5.973684211 233 Carcinoma in situ of breast and genitourinary system 44 1 8 3.181818182 154 Malignant neoplasm of rectum rectosigmoid junction and anus 31 2 12 3.580645161 180 Malignant neoplasm of cervix uteri 19 1 4 1.789473684 185 Malignant neoplasm of prostate 19 1 10 3 197 Secondary malignant neoplasm of respiratory and digestive systems 14 2 24 7.285714286 188 Malignant neoplasm of bladder 10 2 4 3.7 191 Malignant neoplasm of brain 10 2 18 4.4 196 Secondary and unspecified malignant neoplasm of lymph nodes 10 2 6 3.3 182 Malignant neoplasm of body of uterus 9 1 8 2.333333333 157 Malignant neoplasm of pancreas 8 2 4 3.5 150 Malignant neoplasm of esophagus 6 1 6 3.666666667 225 Benign neoplasm of brain and other parts of nervous system 6 5 6 5.5 153 Malignant neoplasm of colon 5 2 8 4.2 25
Bundling: Lose the code, but DON T lose the RVU s! Previous 77295 = 9.0 77300 = 1.22 x 4 = 4.88 New RVU for 77295 = 13.88 Previously 77301 = 46.12 77290 = 12.52 New RVU for 77301 = 58.64 ** Check with Finance to see if the charge also needs to change! 26
Setting Dosimetry up to Succeed almost perfect! 27
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Gains Through Process Enhanced relationship with finance Mutual learning Establishment of Rad Onc productivity task force Restated historical and current budgets More effective projections for future budgets especially with bundled/packaged procedures 29
Next Steps Evaluation of the performance for next year Development of Prospective Staffing Tools Tools that mine data from Time Planner or Treatment Schedule in the future and calculates number of FTE s needed for scheduled volume 30
Acknowledgements Tomain Murphy and Donna Royster, my team! Directors at 2 of our sites Stephen Andrew, Director, Productivity Team 31
Discussion & Questions 32