Hospitals and HealthCare Systems What you were Not taught in PA School

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 fogunfid@dmc.org

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 1965 1963 1965 1869 1989

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 Req Approval HR job posting /screening Recruiting NP/PA s Interviews Medical /dept /mlp office Temp Privileges Approval Approval Medical Affairs PA/NP office Exec Dir.- DMC MG notification DMC MG Recruiter Job offer And acceptanc e Approval Start Date HR Process Risk MGT Start NP / PA Training, EMR/CIS Third Party Enrollment and Billing NP/PA orientation Final Credentialin g Approval from Medical Affairs

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

Staffing, Training, Governance Horizontal continuum of care GME, Research, Nursing Model Integrated Health Care Medical and Nursing teams, Advanced Practice Providers, Pharmacy, Administration etc.. Medical Model Human Resources Productivity, Quality, and Compensation Patient

Orientation None Formal 1 to 7days System, Hospital, Department, EMR Informal 30 days to Lifetime Checklist

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 Role Pre Operative Role Clinical evaluation to include H/P s, Diagnostic evaluation, ancillary study review and medical clearances Operative Role First and Second Assist Robotic assistance Facilitating training and education of residents/students Post Operative Role Discharge management Post operative clinical evaluation, participate in the overall care of patients from presentation onward. Education of patients and families on robotic prostatectomy Develop 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

Horizontal Continuum of Care APRNs (NP, CNM CRNA) Education, research, training, care coordination, pt.assessment, evaluation, Dx Tx, Surgical Assist, Anesthesiology, Pre, Ante and Post care. PAs Enhanced Patient Outcomes and Patient Satisfaction

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 APP learns clinical practice, dictate etc. Acceptable teaching model for new graduates Cons 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) Additional Patients seen by MD 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%

Shared Practice Pros 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 Cons +/- Access Improvement Poor utilization of resources Low volume days= low productivity from all providers Mild incentive for the APP

Side by Side Practice PATIENT (F/U, +/- New) PATIENT (New, +/- F/u) MD may see New patient as a shared visit PA/NP does entire E/M service MD (in clinic @ the same time) Constant Comm 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%

Side by Side Practice Pros 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 Cons 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 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. Cons Requires well experienced, confident APP MD may not be present for complex cases Patients may not see MD on 1 st visit Requires trust and good communication between APP and MD

Autonomous Practice 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 Patients (New and F/U) PA /NP does complete E/M, dictates and bills at 85%

Inpatient Utilization Pros Prompt/ Direct/Consistent Pt. access. Autonomous practice MDs gain confidence in APP Good learning opportunities Cons 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 PA/NP Rounds alone or with team, writes Progress notes Discharges Pt. MD Rounds In- Patient 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 Utilization Pros Improved Revenue generation: Surgeon fee and First Assistant fee. Develop expertise in OR Comfort and Trust with MD. Standardization of procedures Good quality metrics Cons Can be monotonous Limited view of patient Need experienced provider Specific language is needed in GME programs Competition with GME trainees.

Combined Utilization Pros Maximum Utilization Jack of all Trades Experienced flexible provider Develop Trust and Confidence with MD APP. Maximum Access Maximum RVU generation. Cons Potential for APP burn out Master of None Competency measurement is critical Commands higher salary

Combined Practice Ambulatory Practice In-Patient 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-toface 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 50% New (2.22 RVUs) 50% Returns (1.48 RVUs) APP @ 440/day 15 pts.. @ 1.85 rvu/pt. APP @ 1 FTE MD@ 1150/day MD @1 FTE RVU s=27.75/day (approx. $685) Amount is based on Level 3 coding using 2011 Cf of $24.67

ROI- Shared Practice 25 pts. @ APP @ 1 FTE APP @ 440/day 1.85 rvu/pt. 50% New 50% Returns MD@ 1150/day MD @ 1 FTE RVUs=46.25/day Approx.. $1141/day 40% Increase in RVU with 10 additional patients

ROI Side by Side Practice 15 Pts. @ 1.72 rvu/pt. (More Returns, less new) MD may see new pt... as shared MD Available for Direct Consultation 15 pts. @ 1.97rvu/pt. More New, less Return APP maintain individual schedule MD APP @ 440/day MD @ 1150/day RVU = 55.4/day Approx.. $1366/day 51

ROI - Autonomous Practice MD - Run separate clinic, OR, Research, etc. Revenue Generation dependent on daily activities. 15 Pts. @ 1.82rvu/pt. (New and F/U) APP @ 440/day RVU = 27.38 + MD Approx.. $675 + MD @85%=$573

ROI - Combined Practice Ambulatory Practice $625/day In-Patient Practice $550/day OR Practice $1920/day Experienced PA/NP ($440/day) MD MD MD

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)

Collection of Physiological Data 2% Telephone Consultation by NPP 3% Service Value 35.12% Other 3.29% Results Inpatient Study Lunch meeting 0.27% Cafeteria 3% Analysis of Clinical Data 8% Other Revenue Generating Activities 1% Business Meeting 1% Special Reports 3% Team Conferences 16% Procedure Documentation 1% Procedures 3% Charts for each area can be seen in the Appendix Subsequent Hospital Care 34% Discharge Management 16% Admission H/P 4% Post Op Care 3% Other Service Value Activities 3% Revenue Generating 61.59%

IP Activities Results Inpatient Study 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 Based on procedure Procedures 21 x code Based on procedure code Procedure Documentation 6 x 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

Service Value 38.23% Collection of Physiological Data Team Conference 4% Other 2.73% Results Outpatient Study 1% Telephone Consultation - Patient Follow-Up 4% Other 1% Personal Time 1% Cafeteria 1% Student Precepting 2% Research Visit Documentation 3% Analysis of Clinical Data 18% Other Revenue Generating Activities 0.39% Collection of Physiological Data 1% Procedure 2% Outpatient Visit 32% Procedure Documentation 6% Other Service Value Activities 2% Revenue Generating 59.04% Outpatient Follow- Up 11% General Documentation 8%

Statistical Analysis 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Inpatient Percent of Time Spent on RVU Activities 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Outpatient Percent of Time Spent on RVU Activities Medicine Department Surgical Department 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)

Summary of Results Comparison of Activity Categories 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% IP OP ED OB 10.00% 0.00% Revenue Generating Service Value Other

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