young urologists forum

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


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


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%)


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


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


Physician AssistantPhysician Assistant• Hospital roundsHospital rounds• ConsultsConsults• OR assistantOR assistant• CallsCalls• Help in officeHelp in office


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?

young urologists forum

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