Clinic Practice Management Theme Song, Over my Head

2. Clinic Practice ManagementTheme Song, �Over my Head� MAJ Amanda Cuda USAFP 2010

3. Goals and Objectives Officer in Charge = Practice Manager Practice Management Statistics Tools and Definitions Template and Panel Management Resources

4. Who is the Officer in Charge? Personnel Manager Business Manager Practice Manager Senior Military Officer Clinician Medical Director Facilities Overseer Many other potential jobs depending on your environment Babysitter Cheerleader This talk will provide nuts and bolts for the personnel and business management aspect to the OIC position. An OIC does not have to be a physician. Frequently the job of �medical director� is lumped into the OIC position, though it does not have to be.This talk will provide nuts and bolts for the personnel and business management aspect to the OIC position. An OIC does not have to be a physician. Frequently the job of �medical director� is lumped into the OIC position, though it does not have to be.

5. Practice Management Statistics MEPRS DMHRSi FTE�s Coding: 99213 vs 99214 RVU�s Operational Metrics: suggested stats to track We�ll spend the majority of time on RVU�s, coding, FTE�s, and operational metrics.We�ll spend the majority of time on RVU�s, coding, FTE�s, and operational metrics.

6. Why track statistics? They are the tools that guide your decisions. They are the instruments that sell your ideas to your staff, yourself and your boss. They are the facts that protect your clinic and your staff. They are ultimately the measure by which your success or failure will be measured.

7. MEPRS Medical Expense and Performance Reporting System (MEPRS) Local and DoD database of medical expense, workload and manpower http://www.ampo.amedd.army.mil/meprs/index.html Know your Local Staff well The Medical Expense and Performance Reporting System (MEPRS) is a cost management system that accumulates and reports expenses, manpower, and workload performed by the Department of Defense (DoD) fixed military medical and dental treatment facilities. It is the basis for establishing a uniform reporting methodology. This system provides consistent financial and operating performance data to assist managers who are responsible for health care delivery.The Medical Expense and Performance Reporting System (MEPRS) is a cost management system that accumulates and reports expenses, manpower, and workload performed by the Department of Defense (DoD) fixed military medical and dental treatment facilities. It is the basis for establishing a uniform reporting methodology. This system provides consistent financial and operating performance data to assist managers who are responsible for health care delivery.

8. DMHRS-i Defense Medical Human Resources System � internet Internet based database by which the MHS manages and tracks medical human resources http://www.ampo.amedd.army.mil/DMHRSI/index.html The Defense Medical Human Resource System - internet is a web-based Tri-Service decision support system that enables the MHS to manage medical human resources across the enterprise by allowing ready access to essential manpower, personnel, labor cost assignment (MEPRS), education and training and personnel readiness information. The Defense Medical Human Resource System - internet is a web-based Tri-Service decision support system that enables the MHS to manage medical human resources across the enterprise by allowing ready access to essential manpower, personnel, labor cost assignment (MEPRS), education and training and personnel readiness information.

9. DMHRS-I PRINCIPLE #1: Transfer individual accountability for efficient pt care and time keeping to each provider PRINCIPLE #2: Maximize credentialed provider�s RVU generating pt care time, minimize admin and non-RVU generating pt care time

10. DMHRS-i Example

11. B Codes � Outpatient Work Any activity associated with seeing and diagnosing a patient that results in a treatment decision for a patient is considered "patient visit time� Actual time seeing patients in clinic Reviewing LABS, x-rays, Researching Medical care for patients Documenting patient care (i.e., documentation is part of the patient visit whether the provider writes the note immediately after seeing the patient or saves the chart to write the note at the end of the day). (i.e., documentation is part of the patient visit whether the provider writes the note immediately after seeing the patient or saves the chart to write the note at the end of the day).

12. CALCULATING AMOUNT OF PATIENT CARE HOURS (B CODES) Know the typical RVU workload for a full day of pt care for your clinic. Compare this to the MEDCOM RVU target for your clinic. The clinic template should take into account no-shows, unbooked appts, and still be able to meet or exceed the MEDCOM standard. Teach your providers one of two ways to calculate Patient Care Hours: Ratio: X number of encounters = 1 hour of patient care. Apply this ratio to total number of pts seen for the day. MEDCOM target: total the number of visits needed to exceed the target. Divide this number by 8. Ratio Example: 3 encounters = 1 hour of patient care. Dr. Cuda sees 15 patients today. 15/3 = 5 hours patient care, remainder 3 hours is E or F codes MEDCOM target is 15 RVU/day, typical 99213 = 0.92 RVU/encounter, need 16-17 encounters/day, then divide by 8 hours = 2-3 encounters/ hour.Ratio Example: 3 encounters = 1 hour of patient care. Dr. Cuda sees 15 patients today. 15/3 = 5 hours patient care, remainder 3 hours is E or F codes MEDCOM target is 15 RVU/day, typical 99213 = 0.92 RVU/encounter, need 16-17 encounters/day, then divide by 8 hours = 2-3 encounters/ hour.

13. Non Patient Care Codes (E,F,G) Any activity that involves participation in hospital/clinic support (committees), personnel actions, military training or GME/CME/ research is NON-visit (admin) time. MEDCOM allows for 12% admin (7 hours pt care, 1 hour admin=full 8 hour day) Excessive non-RVU generating pt care typically coded as an E-code or F code

14. DMHRS-i Examples Day with excessive no-shows: provider must not penalize themselves (ratio tends to be easier to apply) New provider: modify template to account for AHLTA, DRAGON training. Still should look productive if coding time correctly. Ratio works the best here. Provider who under-calls their pt care hours: Focus on % patient care � missing MEDCOM stat Slow provider vs. understaffed clinic: choice is between low % patient care hours vs. low RVU/prov/day. For the slow provider, two options: Hold them to the clinic schedule. Takes them 10 hours to do 8 hrs pt care= 8 hrs pt care on DMHRSi. Don�t pay or credit them for the extra 2. Provider who sets own schedule (example ACC). Highlight either the low RVU/pt care number or low % time engaged in pt care in their performance plan. If the MEDCOM RVU standard does not make sense for a clinic (example WTU, SELF) choice is between creating a new, internal standard vs. applying the B code only to the RVU generating pt care time, and reflecting the rest as excessive admin or F-code time.

15. What is a FTE? Full Time Equivalent Helps reflect RVU data more accurately Variations in clinical environment Clinical and non-clinical responsibilities Academic medicine Inpatient, obstetrics, outpatient care

16. Full-Time Equivalent (FTE) A composite of person-hours that equates to one full time employee. It is a measure of the productive hours that an employee works after subtracting out annual leave, sick leave, etc. ������� FTE Value for Calculating Productivity Clinicians = 1 FTE PAs/NPs = .75 FTE

17. Calculating FTE The norm is currently set at 1776-2016 hrs/year (148-168 hrs/month). The FTE is determined: Hours/week at function X 52 weeks/year = FTE 1776-2016 Monthly Conversion factor: one FTE = total actual hours worked/148-168) � ��������� FTE Value for Calculating Productivity Clinicians = 1 FTE PAs/NPs = .75 FTE

18. FTE example PA X works 168 outpatient hours/month 168/168=1 x 0.75 FTE=0.75 FTE/month 8/8=1 x 0.75 FTE=0.75 FTE/day Ave 15 RVU day x 1/0.75=20 RVU/PA FTE/day Doctor X works 168 outpatient hours/month 168/168=1 x 1 FTE=1 FTE month 8/8=1x1 FTE=1 FTE day Ave 15 RVU day x 1=15 RVU/Doc FTE/day Doctor Y works 84 outpatient hours/month 84/168=0.5 x 1FTE = 0.5 FTE month 4/8=0.5 x 1 FTE=0.5 FTE day Ave 15 RVU day x 1/0.5=30 RVU/Doc FTE/day

19. What is a RVU? Relative Value Unit Measurement of the resources required to provide a particular service/procedure Quantifies work that providers do Used by third party payers and HMOs�and us!

20. RVUs Attempts to measure provider productivity Can be based on per hour work, per clinic session, or per FTE Guides reimbursement RVUs are highly based on documentation and coding May be the �best� way to compare clinics to allocate resources

21. What Drives the RVU? Based on two components Evaluation and Management (E&M) Current Procedural Terminology (CPT) 2008 conversion factor $45.02 =1 RVU 2010 conversion factor $52.20 =1 RVU Technically the RVU Weight is 3 components. 2008 reimbursement rate for ACC or FM clinic = $73.81/RVU with take home = $45.02 39% is decremented for the Military Pay Adjustment (MPA) from standard CMAC rateTechnically the RVU Weight is 3 components. 2008 reimbursement rate for ACC or FM clinic = $73.81/RVU with take home = $45.02 39% is decremented for the Military Pay Adjustment (MPA) from standard CMAC rate

22. Sample Coding Screen (CHCS1)

23. Sample Coding Screen RVU (CHCS1)

24. Sample CPT Coding Screen (AHLTA)

25. Sample E&M Coding Screen (AHLTA)

26. Limitations of RVUs Does not take into consideration the behind the scenes work done outside of the appointment Reviewing reports/records Coordinating care with consultants Documentation based Poor documentation = lower RVUs

27. Importance of RVU�s Low individual and clinic RVU�s are reflective of inaccurate workload capture caused by� Under/misreporting of encounter codes ICD-9/CPT Delayed/lost recording into ADM systems Incorrect reporting of provider time (DMHRSi) �Results in� Understated productivity for providers Missed Third Party billing opportunity Future understaffing for your hospital

28. Coding Differences in E&M coding 3 key factors History Physical examination Decision making Other (education/counseling � if >50%)

29. Coding: RVU Weights Current RVU values for E&M codes. New vs Established: A person who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice in the past 3 years. Inpatient visits will be coded with RWP�s (a whole different talk).Current RVU values for E&M codes. New vs Established: A person who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice in the past 3 years. Inpatient visits will be coded with RWP�s (a whole different talk).

30. The Importance of Coding The more complete the diagnosis (ICD-9) and the more accurate the recording of higher weighted procedures (CPT), the higher the RVU. Indicates providers are: Working at a higher skill level (and documenting it) Seeing sicker patients / identifying more medically necessary office procedures, consults, & referrals Establishing good coding profiles with insurance companies for private practices �after the military�

31. 99213 vs. 99214 National average: 99213=50% 99214=30% 99211/99212=18% 99215=2%

32. 99214 CODING HISTORY HPI 4 points (e.g. position, quality, radiation, severity, timing, modifying factors, assoc sx or signs OR: status of 3 Chronic Stable Dz ROS 2+ areas on (e.g. constitutional, resp, CV, GI, skin, allergy) PMH 1+ or Fam hx or Soc Hx (e.g. tobacco status)

33. 99214 CODING Physical Exam (12 items) 2 X 6 2 bullets from 6 body systems 6 X 2 6 bullets from 2 body systems Must be from approved list of Medicare PE bullets Must relate to area of focus from HPI NOT REQUIRED if meet hx and A/P: criteria

34. 99214 CODING Spend 25+ minutes with patient, AND Spend > 50% on counseling or coordination of care Should document a few sentences describing your efforts, total time spent, and that >50% was on counseling/coordination of care

35. STATISTICS TO CONSIDER % ADS COMPLETED % UTILIZATION of CHCSII % Patient complaints per 1000 patient visits % Patients getting appointments with their PCM % Un-booked Appointments % No-show Appointments

36. Use Statistics to set realistic goals 100% ADS completed by 72 hours after encounter 100% CHCSII utilization Decrease wait time for an appointment to 2 days or less Increase continuity of care to 60-80% Decrease NO-Show/un-booked to less than 2-5% Increase the amount of same day work done by 20% Increase provider, clerk, nursing and patient satisfaction Increase provider productivity to ** pt/day or ** RVU/day Decrease the percentage of your patient population seeking Medical care each month to less than 25%

37. Operational Metrics This is a screen shot of the MEDCOM operational metrics for the Schofield Barracks Acute Care Clinic for FY07. Names have been blocked to protect the innocent. Based on M2 Data. This is a screen shot of the MEDCOM operational metrics for the Schofield Barracks Acute Care Clinic for FY07. Names have been blocked to protect the innocent. Based on M2 Data.

38. This is a screen shot from Red Leg Clinic. Again M2 data.This is a screen shot from Red Leg Clinic. Again M2 data.

39. RVU/FTE/day #pts seen w/ 99213 x RVU value = x #pts seen w/ 99214 x RVU value = y #pts seen w/ 99395 x RVU value = z Add up total RVUs (x+y+z�) Divide total clinic hours reported on DMHRSi by 8 = FTE/day Divide total RVUs by FTE/day Ave 15 RVU day / 0.75 FTE/day = RVU/PA/FTE/day Ave 15 RVU day / 1 FTE/day = 15 RVU/pro/FTE/day Ave 15 RVU day / 0.5 FTE/day = 30 RVU/pro/FTE/day

40. DoD/Health Affairs Goal 18.3 RVUs per provider FTE per 8 hour day 3 patients/hour (99213)=2.76 RVU hour x 8hrs x 1 (168hrs/month) FTE =22.08 RVU per clinician FTE per day 2 patients/hour (99213) and 1 patient/hour (99214) =3.26 RVU hour x 8hrs =26.08 RVU per clinician FTE per day Increase by seeing more patients or documenting more 99214 visits.

41. RVU & FTE Conclusion Meet and exceed MHS Goals Improve coding accuracy Improve documentation Decrease no-shows/cancelled appointments RVUs are not perfect, but they are one of the main metrics we currently implement, track, and compare

42. GWOT Global War On TerrorismReimbursement funds V70.5 deployment code http://www.ampo.amedd.army.mil/gwot/index.html

43. Template Management Template: The delineation of the number and type of patients a provider can see in a day/clinic Scheduling: The availability of a template to be booked with patients

44. Schedules and Templates Understand the standards and performance measures within the Military Health System (MHS) Become familiar with various appointment models Share experiences with the various models

45. TRICARE STANDARDS Acute = 24 hours from time of request Routine = 7 days from time of request Specialty = 30 days from time of request Wellness = 30 days from time of request 30 minutes or less in the provider's waiting room 30 minutes or less travel time to the primary care provider's office

46. General Concepts Patient demographics Demand Variations within the week and seasons Deployments Use historical data Estimate 15 appt/1000 patients/day Appointment System Centralize/decentralize Telephone systems Clinic Flow Admin time ? Population of 6500 pt * 15 appt/1000pt = 97.5 appt/dayPopulation of 6500 pt * 15 appt/1000pt = 97.5 appt/day

47. System Supports PAS/DCA/HCA: Follow Metrics Number seen by PCM and team Number of no-shows by appointment type Number of overflow patients Seen by someone else (AMIC/ACC or ER) Number of T-cons by PCM Coding by PCM Hospitalization Rates by PCM /Team/Clinic Patient Satisfaction Surveys APLSS and ICE Internal Clinic Surveys are good for PI

48. Access and Demand Appointment Availability Appointments must be available at the right time �Running out� is not an option: Plan for Contingencies Don�t be afraid of ROUT, WELL or EST access Convert appointments to SDA/OPAC if unbooked Consider other ways to manage patient needs Demand is typically predictable Structure to plan availability Structure to plan contingencies Structure to plan for special situations Structure to plan for deployments Structure to plan for sick providers Structure to plan for nursing shortages Structure to plan for training missions

49. Appointment Models Traditional Model Carve-out Model Wave/Modified-Wave Open and Advanced Access Model Acute Care Access

50. Traditional Model Acute care is added onto full schedules Loads most of today�s work for tomorrow � Creates backlog/wait list (good and bad) 4 week backlog for appointments is common Contributed to increase in Acute Care Centers Patients and Providers familiar with model NO-SHOW rate Can be up to 20% for EST and ROUT appointments WELL appointments may actually be higher NO-SHOW rates Difficult to cancel clinics Most Clinics can plan using demand (typical distribution) ACUT 20-40% ROUT 20% EST 20-40% WELL 20%

51. Traditional Model Easiest to understand for central booking No contingency when appointments run out Patients showing up late creates a problem Clinic wait time for patients is low Provider sees a fixed number of patients every day Doesn�t allow for extended visits (unmodified) Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003. Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003.

52. Carve-out Model Holding a specified number of appointments for acute care �Specified number� - guess work Difficulty in handling the non-urgent patient who needs to be seen in the next few days - steal from tomorrow? Backlog/Wait list

53. Carve Out Model Standard booking Acutes are attractive for Providers to use for 1 week or 2-3 day follow up Acute access for entire clinic can be degraded by nibbling Doesn�t allow patients to be early or late Wait time in clinic is shorter Provider may see fewer patients Downtime is attractive to Providers Doesn�t allow for extended visits Least efficient of options for Provider and Nursing time Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003. Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003.

54. Wave/Modified-Wave Wave All patients for AM or PM show at up at the same time First come, first serve Not patient friendly Modified-Wave Load the front end of each hour, leave open slots to catch up Advantages: minimizes physician downtime allows physicians more control of their use of time patient wait is not as long as with the wave Pitfalls: filling catch-up time slots with acutes patient selection (new patients, difficult patients or patients with complications)

55. Wave Model Book 2 appointments for every 30 minutes 1st patient to show up is seen first Allows patients to be early or late Wait time in clinic may be longer Allows Provider to see large number of patients (q15 min) Doesn�t allow for extended visits (unmodified) Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003. Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003.

56. Modified Wave Model Book long and short appt at top of hour Book short appt at 15 after Book long appt at 30 after End of hour is catch up time for Provider Allows patients to be early or late Wait time in clinic will be longer Allows for Extended appts Difficult to communicate with central booking One sicker acute patient can throw off entire half-day Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003. Zazove, P. Clinic scheduling and access. Clinics in Family Practice. 5:4. Dec 2003.

57. Advanced (Open) Access Model Patients are offered appointments on the day they call regardless of the reason for the visit Providers start each day with 70-80% of their schedule open �Do today�s work today�

58. Advanced Access Advanced Access describes open access with pure same day scheduling (SDA) or blend EST and SDA (OPAC) Need for EST appointments is recognized under OPAC plan Number of EST appointments is practice dependant These EST appointments are intended for PCM only appointments Easy to plan for surges and demand but overflow may happen Needs a fall back contingency plan for heavy utilization periods

59. Advanced Access: SDA Model Advantages: Reduces waiting times Less backlog Better outcomes: DM, clinician satisfaction, decreased ER use, better PM care NO-SHOW rate is less than 5% Easy to cancel appointments Pitfalls: Patients and Providers variably familiar with model Doesn�t allow for acute follow up � 1 week, 2 weeks, etc. Bergeson, S. and J. Dean. A Systems Approach to Patient-Centered Care. JAMA. 296:23. 20 Dec 2006Bergeson, S. and J. Dean. A Systems Approach to Patient-Centered Care. JAMA. 296:23. 20 Dec 2006

60. Advanced Access Scheduling: SDA Model All Patients who call are seen that day PCM unavailable, patient still seen Could combine with Wave or Modified Wave to book 4 appointments per hour vs. 3. No pre-positioning of Medical Record No Nursing pre-planning Phone line intensive Has potential to become overwhelmed Beware of un-booked appointments Provides no assurance of acute follow up Murray, M. and D. Berwick. Advanced access, reducing waiting and delays in primary care. JAMA. 289:8. 26 Feb 2003. Murray, M. and D. Berwick. Advanced access, reducing waiting and delays in primary care. JAMA. 289:8. 26 Feb 2003.

61. Advanced Access: OPAC Model Allows practice flow to dictate demand Easy to cancel clinics Less pre-booked appointments Provider Satisfaction � run your own schedule Must have support to see extra patients Provider must be engaged in schedule Shortens patient waiting time for appointments Less NO-SHOW appointments than Traditional Access Typical Template EST 20-40% ACUT 60-80% Open Access PCM Driven - allows provider to affect template Allows for daily Provider Driven decisions about care Takes Provider away from seeing patients Allows Providers to potentially degrade acute care access Larsen, R. Open Access Implementation Manual. Advanced Access Coordinator. Tricare Europe. 2 May 2003. Larsen, R. Open Access Implementation Manual. Advanced Access Coordinator. Tricare Europe. 2 May 2003.

62. Advanced Access: OPAC Model All Patients calling for appointments are seen or booked May combine with Wave or Modified Wave Partial pre-positioning of Medical Record Partial Nursing pre-planning Allows patient to book future appointments Minimizes unused availability Best method to meet acute and chronic need Patient offered choice, SDA vs. PCM appt. Maximizes PCM booking Larsen, R. Open Access Implementation Manual. Advanced Access Coordinator. Tricare Europe. 2 May 2003. Larsen, R. Open Access Implementation Manual. Advanced Access Coordinator. Tricare Europe. 2 May 2003.

63. Acute Access Study demand day-by-day Highest acute demand - Monday, Tuesday and Friday Highest routine demand also on these days Active management of Acute access is important Plan for contingencies Sick Provider Lack of nursing support High demand months: Dec-Feb Local concerns : Reservists and NG soldiers Summer /Holiday understaffing for Providers Schedule Providers or template to meet demand More Acutes on Mondays and Fridays or after Holiday

64. Acute Access: MOD Assign one or two Providers to acute care only Effectively establishes an �Acute Minor Illness Clinic� within practice Does not support PCM ownership of acute care for panel Does not support PCM awareness of acute care for panel Can be overwhelmed if not properly staffed Provider is taken away from managing their panel while providing acute care for everyone Nursing �intensive� tasking Labs, IVs, Nebulizer treatments Nursing support will need to be higher for these providers What happens when MOD is sick?

65. Acute Access: Contingency Plans All Contingencies depend on Team-oriented Practice Book Acute Care Early Open up 0700-0800 time for 4 appointments per PCM or designated provider, booked the night before Book Acute Care through lunch Open up 1200-1300 time for 4 appointments per PCM for their patients or designated Provider Book Acute Care in PM Open up 1600-1700 time for 4 appointments per PCM for their patients or designated Provider Make PCM aware and work patient in during existing clinic Triage over phone: Triage RN and/or PCM TCON PCM ownership vs. being a designated Provider

66. An Example: TMC Mostly acute/same day issues High no-show rate for booked appointments Change appointment types to acute and established and varied the percentage based on the day using wave/modified wave Created memo for TRICARE explaining why no routine appointment slots

67. An Example: Procedure Clinics Need 1-2 monthly for every procedure-credentialed provider Minimize filling with �fluff� Cryotherapy should be done at time of visit Minor Biopsies � 1 site, can usually be done at visit Save for meaningful Procedures Encourage PCM self-scheduling or fill by demand Avoid scheduling on Monday or Friday: minimizes Acute Access conflict Maintain standard of access Wait lists should be avoided If procedure cannot be performed in 30 days, recommend referral to specialty care

68. An Example: PAP Clinics Need 1-2 monthly for every provider Nursing planning required for PAP Clinic 20-30 minute visits Easy to template, difficult to cancel Easy to plan for Provider shortages EX: during Active Duty Provider under-lap in Summer, No PAP Clinics PPF � Provider Palatability Factor Doesn�t Support PCM Ownership of PAP appointments

69. Schedules & Template Conclusion Aggressive management of templates and scheduling is critical to managing access Several appointment models are available to the clinic manager Creating templates/schedules that maximize clinic efficiency is one of the most important aspects of clinic operations Direct impact on RVU/FTE numbers

70. Panel Size Normally 1050-1200 Due to staffing, other requirements, etc. Tricare ideal: 1500 VA: 1088/1.0 FTE 789/1.0 FTE mid-level provider Panel size of 1500 = estimated 22.5 appt/day

71. Empanelment Watch for Over Empanelled Providers Doesn�t matter what scheduling method used, Demand >> Supply Means can�t see all their patients Being a good or patient-friendly doctor does not equal being asked to do more Watch �Popular� M.D. panels harder than others Requests for movement to new PCM = Who will MD give up? Middle Level Providers Ancillary support Acute Care and Routine Access to assist Physicians Uncomplicated patients Visits should be staffed with PCM Watch their empanelment hard or don�t empanel them

72. PCM Ownership Reinforce PCM at every visit Providers, Nursing, Clerical, Phone Staff need to support this mission New PCM Proactively engage more chronically ill Easier to do from beginning for PCM Verification of patient information at every visit Clerks, checked by nursing, verified by Provider POC is PCM � reinforced through systems and Providers Less demand for inappropriate follow-up Telephone management assistance: T-con management by PCM is standard

73. Resources AAFP FPM: www.aafp.org/fpm USAFP www.usafp.org Mentors Department Chief Healthcare Administrator Tricare www.tricare.osd.mil Resource Management

74. Questions?

75. References Easter, Deborah. Utilization Management Coordinator, MCXP-RMD-MC. 10Jul2002. Johnston, Sarah E., Newton, Warren P. Resource-based Relative Value Units: A Primer for Academic Physicians. Family Medicine, March 2002. Performance Plan Between Deputy Secretary of Defense and Assistant Secretary of Defense (Health Affairs) FY 2003-2007. 08Aug2002. Henley, Douglas E. Coding Better for Better Reimbursement. Family Practice Management � Jan 2003. CPT Mary Reed LTC(P) Telita Crosland MAJ Paul Crum MAJ Matt Fandre

76. How are RVUs Calculated? Physician Work RVU Time, effort, intensity required on physician�s part Practice Expense RVU Direct and indirect expenses to perform services/procedures Non-physician labor, supplies, equipment, utilities Malpractice Expense RVU Intent is to apply a heavier weight to those specialties with higher malpractice costs

77. Ambulatory Data Bases Family Medicine Productivity Visits 25 visits per day (AMA, others) 92 visits per week (AAFP) 125 visits per week (AMA) 3995 visits per year RVUs (work) 17.5 per day 2.2 RVU per hour seeing patients 3980 Mean Annual Appts (25th % - 3221; 75th % - 4568) (25th % - 3221; 75th % - 4568)

78. Other factors GPCI Geographical Practice Cost Index Conversion Factor Nationally uniform Converts RVUs into payment amount

79. How does one calculate a payment from RVUs (civilian market)? RVU Physician Work x GPCI for Physician Work + RVU Practice Expense x GPCI for Practice Expense + RVU Malpractice Expense x GPCI for Malpractice Expense = Total RVUs X Conversion Factor = Payment amount

80. In MHS Environment No Practice Expense No Malpractice Expense RVU = RVU Physician Work More slides at end detailing RVU calculations�More slides at end detailing RVU calculations�

81. Civilian Sector

82. In MHS

83. 99213 vs. 99214 National average: 99213=50% 99214=30% 99211/99212=18% 99215=2%