Hospitals and HealthCare Systems
What you were “Not” taught in PA School
Folusho Ogunfiditimi, DM, MPH, PA-C
Director, Mid-Level Provider
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
– Compensation and Provider enrollment
– Clinical Practice Models
– Regulatory Standards and Compliance
– Productivity, Value and Reimbursement
– 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
1869
1965
1989
From Graduation to Hire
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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
Disagree*
Agree
PATIENT CARE
Provides care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness,
treatment of disease and support at the end of life.
Agree
Disagree*
MEDICAL/CLINICAL KNOWLEDGE
Demonstrates knowledge of established and evolving biomedical, clinical, procedural and social sciences, and applies
this knowledge to patient care.
Agree
Disagree*
PRACTICE BASED LEARNING AND IMPROVEMENT
Uses scientific evidence and methods to investigate, evaluate and improve patient care processes.
Agree
Disagree*
INTERPERSONAL & COMMUNICATION SKILLS
Demonstrates interpersonal and communication skills that enable the provider to establish and maintain professional
relationships with patients, families and other members of health care teams and administration
Agree
Disagree*
PROFESSIONALISM
Demonstrates behaviors that reflect a commitment to continuous professional development, ethical practice,
understanding and sensitivity to diversity, and a responsible attitude towards patients, the hospital and the medical
profession
Agree
Disagree*
SYSTEM BASED PRACTICE
Understands the contexts and systems in which health care is provided, and applies this knowledge to improve and
optimize health care
Req
Approval
Job request
from
Hospital/Office
Temp
Privileges
Approval
Approval
Approval
Start Date
HR Process
HR job posting
/screening
Medical
Affairs
PA/NP
office
Interviews
Medical dept
/mlp office
Recruiting
NP/PA’s
Exec Dir.- DMC
MG notification
DMC MG
Recruiter
Job offer
And
acceptance
Risk MGT
NP / PA
Training,
EMR/CIS
Third Party
Enrollment
and Billing
Start
NP/PA
orientation
Final
Credentialing
Approval from
Medical Affairs
Best Fit and Benefits
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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
On boarding and Orientation
Department Dynamics
• Medicine
– Medicine Service
– Medicine Subspecialties
• Surgery
– General Surgery
– Surgery Subspecialties
• Emergency Medicine
• Ambulatory Care Centers
Team Dynamics
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PA only
NP only
PA/NP only
PA/NP and Residents
PA/NP, Residents, SW, CM, PT/OT,
Pharmacy
Horizontal continuum of care
Staffing,
Training,
Governance
GME,
Research,
Nursing Model
Integrated Health Care
Medical and Nursing teams,
Advanced Practice Providers, Pharmacy,
Administration etc..
Medical Model
Productivity,
Quality, and
Compensation
Human
Resources
Patient
Hospital and Health Systems Orientation
• None (rare, in very small hospitals)
• Formal
– 1 to 7days
– System, Hospital, Department, EMR
• Informal
– 30 days to Lifetime
• Checklist
Req
Approval
Job request from
Hospital/Office
Temp
Privileges
Approval
Approval
Approval
Start Date HR
Process
HR job posting
/screening
Medical
Affairs
Interviews
Medical /dept
/mlp office
Recruiting
NP/PA’s
Exec Dir.- DMC MG
notification
DMC MG
Recruiter
Job offer
And
acceptance
PA/NP office
Risk MGT
NP / PA
Training,
EMR/CIS
Third Party
Enrollment and
Billing
Start
NP/PA
orientation
Final
Credentialing
Approval from
Medical Affairs
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.
Develop and maintain social programs
Compensation and Provider Enrollment
Salary Models
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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 Enrollment
• 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 toggle of war between Admitting
Physician and Ordering Physician
• CMS – 2 MN rule – Observation vs.
Inpatient Admission
Hospital and Professional Physician Billing
(Part A and Part B)
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Cost Report
Employment relationships
No “Incident too” in hospital based clinics
Billing opportunities
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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.
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.
Enhanced
Patient
Outcomes
and Patient
Satisfaction
PAs
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
• PA/NP 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
PA/NP
• 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
PA/NP
Side by Side Practice
PATIENT
(New, +/- F/u)
PATIENT
(F/U, +/- New)
MD may see New
patient as a shared visit
MD
(in clinic @ the same time)
PA/NP does entire E/M service
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, PA/NP
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 ImpactResources and Space
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%
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
PA/NP
• MD may not be present
for complex cases
• Patients may not see MD
on 1st visit
• Requires trust and good
communication between
PA/NP and MD
Inpatient Utilization
Pros
• Prompt/
Direct/Consistent Pt.
access.
• Autonomous practice
• MDs gain confidence
in PA/NP
• Good learning
opportunities
Cons
• Poor billing /
reimbursement
• Difficult Productivity
measurements
• PA/NP may be subjected
to “scut” work
• Requires well
experienced, confident
PA/NP
• PA/NP 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
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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 .
• Maximum Access
• Maximum RVU
generation.
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Cons
Potential for PA/NP
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)
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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)
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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)
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
APP @ 1 FTE
APP @
440/day
25 pts. @
1.85 rvu/pt.
50% New
50% Returns
MD@
1150/day
RVUs=46.25/day
Approx.. $1141/day
MD @ 1 FTE
40% Increase in RVU with
10 additional patients
ROI – Side by Side Practice
• 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
APP
maintain
individual
schedule
MD
• APP @
440/day
• MD @
1150/day
RVU = 55.4/day
Approx.. $1366/day
50
ROI - Autonomous Practice
15 Pts. @ 1.82rvu/pt.
(New and F/U)
MD - Run separate
clinic, OR, Research,
etc.
Revenue Generation
dependent on daily
activities.
RVU = 27.38 + MD
Approx.. $675 + MD
@85%=$573
APP @ 440/day
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
ROI - Combined Practice
Ambulatory Practice
$625/day
In-Patient Practice
$550/day
OR Practice
$1920/day
Experienced PA/NP
($440/day)
MD
MD
MD
Results – Inpatient Study
Business Meeting
Collection of
1%
Physiological Data
2%
Special Reports
Telephone
3%
Consultation by NPP
3%
Analysis of Clinical
Data
Service Value
8%
Team
35.12%
Conferences
16%
Lunch meeting
0.27%
Other
3.29%
Cafeteria
3%
Other Revenue
Generating Activities
1%
Other Service Value
Activities
3%
Subsequent
Hospital Care
34%
Discharge
Management
16%
Admission H/P
Procedure
4%
Documentation Procedures Post Op Care
3%
3%
1%
Charts for each area can be seen in the Appendix
Revenue Generating
61.59%
Results – Inpatient Study
IP Activities
Revenue Service
Occurrences Generating Value
Subsequent Hospital Care
Discharge Management
Admission H/P
Post Op Care
245
116
30
22
x
x
x
x
Procedures
21
x
Procedure Documentation
Other Revenue Generating
Activities
Team Conferences
Analysis of Clinical Data
Telephone Consultation by NPP
Special Reports
Collection of Physiological Data
Business Meeting Council or
Committee
Other Service Value Activities
6
x
9
114
55
25
24
12
x
7
19
CPT 2010 Code
99231 - 99233
99238 - 99239
99221 - 99223
99024
Based on procedure
code
Based on procedure
code
x
x
x
x
x
99366
99090
98966 - 98968
99080
99091
x
x
N/A
Results – Outpatient Study
Service Value
38.23%
Collection of
Physiological Data
1%
Telephone
Consultation Patient Follow-Up
4%
Collection of
Student Precepting
Physiological Data
2%
1%
Research Visit
Documentation
3%
Team Conference
4%
Other Service Value
Activities
2%
Revenue Generating
59.04%
Analysis of Clinical
Data
18%
Outpatient Visit
32%
Outpatient FollowUp
11%
Other
1%
Other
2.73%
Personal Time
1%
Cafeteria
1%
Other Revenue
Generating Activities
0.39%
Procedure
2%
Procedure
Documentation
6%
General
Documentation
8%
Statistical Analysis
Outpatient Percent of Time
Spent on RVU Activities
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%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
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%
IP
OP
30.00%
ED
20.00%
OB
10.00%
0.00%
Revenue Generating
Service Value
Other
Employee (PA) Engagement and Physician
Collaboration
Engagement Opportunties
• Hospital committee participation
– From P/T to Medical Executive committee
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•
Utilization Resource committee
Volunteer opportunities
Physician Champion
PA’s know about PA’s….. etc.
Be Visible – Do not presume that others
know
Strategic Initiatives
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•
•
•
•
•
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 achieve maximum Patient
Access, satisfaction and maintain quality measures
Questions