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RHC/CAH Provider Productivity
Friday, August 23, 2019
Jeff Bramschreiber, CPAHealth Care Partner
Corina Schoenke, CPAHealth Care Partner
• Provider Staffing Requirements in the RHC Setting
• Productivity Metrics
• Financial Impact of RHC Provider Productivity
• CAH Productivity Examples
• Summary/Questions
Session Agenda
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Provider Staffing Requirements in the RHC Setting
Medicare Regulations
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Provider Staffing Requirements
30.1 - RHC Staffing Requirements (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)
In addition to the location requirements, an RHC must:
• Employ an NP or PA; and
• Have an NP, PA, or CNM working at the clinic at least 50 percent of the time
the clinic is operating as an RHC.
The employment may be full or part time, and is evidenced by a W-2 form from
the RHC. If another entity such as a hospital has 100 percent ownership of the
RHC, the W-2 form can be from that entity as long as all the non-physician
practitioners employed in the RHC receive their W-2 from this owner.
Source: CMS Publication 100-02, Chapter 13
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Provider Staffing Requirements
30.1 - RHC Staffing Requirements (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)
As of July 1, 2014, RHCs may contract with non-physician practitioners (PAs,
NPs, CNM, CPs or CSWs) if at least one NP or PA is employed by the RHC
(subject to the waiver provision for existing RHCs set forth at section
1861(aa)(7) of the Act).
Source: CMS Publication 100-02, Chapter 13
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Provider Staffing Requirements
30.1 - RHC Staffing Requirements (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)
An RHC practitioner is a physician, NP, PA, CNM, CP, or CSW. At least one of
these practitioners must be present in the RHC and available to furnish patient
care at all times the RHC is in operation. A clinic that is open solely to address
administrative matters or to provide shelter from inclement weather is not
considered to be in operation during this period and is not subject to the staffing
requirements.
Source: CMS Publication 100-02, Chapter 13
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Provider Staffing Requirements
30.1 - RHC Staffing Requirements (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)
An NP, PA, or CNM must be available to furnish patient care at least 50 percent
of the time that the RHC is open to provide patient care. This requirement can be
fulfilled through any combination of NPs, PAs, or CNMs as long as the total is at
least 50 percent of the time the RHC is open to provide patient care. Only the
time that an NP, PA, or CNM spends in the RHC, or the time spent directly
furnishing patient care in another location as an RHC practitioner, is counted
towards the 50 percent time.
Source: CMS Publication 100-02, Chapter 13
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Productivity Metrics
Key Performance Indicators
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Productivity Metrics
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Provider Productivity:
Physician work Relative Value Units per
provider FTE.
Separate by physicians and non-
physician practitioners.
Benchmark data available from Medical
Group Management Association
(MGMA) and various other sources.
0
1,000
2,000
3,000
4,000
5,000
6,000
wRVUs per Provider FTE
CY2015 CY2016
Productivity Metrics
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Provider Productivity:
Patient Visits per provider FTE.
Separate by physicians and non-
physician practitioners.
RHC-specific data available on Medicare cost report.
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
Patient Visits per FTE
CY2012 CY2013 CY2014
CY2015 CY2016
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Productivity Metrics
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If provider encounters per FTE are lower than State, Regional, and/or National averages:
• Are FTEs accurate?
• Are encounters accurate?
• Are there barriers to achieving higher productivity?
• Are providers rewarded for higher productivity?
Productivity Metrics
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Non-physician practitioner
productivity comparisons
may reveal differences from physician productivity.
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Financial Impact of RHC Provider Productivity
Sample Illustration
Productivity Impact Illustration
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Key Data and Assumptions for Analysis
• Baseline data (RHC Medicare Cost report)
• Not currently meeting productivity standards
• Assumed overall costs not impacted by additional encounters
• Assumed to increase productivity by 2 patients per day (420 per year)
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Productivity Impact Illustration
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PRODUCTIVITY IMPACT ILLUSTRATION Current Improved
Total Allowable Cost 2,559,000$ 2,559,000$
Actual Encounters 13,000 13,420
Medicare Productivity Minimum (Adjusted) Encounters 13,328 13,328
Total Allowable Cost per Actual Encounter 197$ 191$
Total Allowable Cost per Adjusted Encounter 192$ 192$
Medicare Encounters (25%) 3,250 3,355
Medicaid Encounters (20%) 2,600 2,684
All Other Encounters (55%) 7,150 7,381
Total Actual Encounters 13,000 13,420
Medicare Reimbursement (Encounters x Allowable Cost per Encounter) 624,000$ 639,750$
Medicaid Reimbursement (@ Medicare AIR) 499,200 511,800
All Other Reimbursement (@ $150 per encounter) 1,072,500 1,107,150
Total Reimbursement 2,195,700$ 2,258,700$
Reimbursement Increase for 420 additional patients (2 per day) 63,000$
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CAH Provider Productivity
Productivity Metrics for Hospital-Based Providers
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CAH Provider Productivity
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Hospital-based provider productivity examples:
• Emergency Department
• Hospitalists
• Anesthesia
CAH Provider Productivity
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Emergency Department:
• Physician median wRVUs vary greatly from < 6,000 wRVUs in non-metro areas to > 7,000 wRVUs in metro areas.
• 3.5 to 4.5 wRVUs per clinical hour worked is not unreasonable.
• Physician Assistant (primary/urgent care) median approximately 3,600 wRVUs.
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CAH Provider Productivity
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Hospitalists:
• Hospitalist (family medicine) median of approximately 4,500 wRVUs annually; slightly lower for internal medicine hospitalists.
• 2.0 to 3.0 wRVUs per clinical hour worked is not unreasonable.
• Limited data on nurse practitioner hospitalists suggesting substantially lower productivity (median of 1,700 wRVUs).
CAH Provider Productivity
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Anesthesia - CRNA:
• Anesthesia productivity metrics include American Society of Anesthesiologist (ASA) Relative Value Guide.
• ASA units consist of base units, time units (15-minute increments) and may also include modifiers for patient severity.
• Anesthesiologist (MD) median is approximately 12,000 ASA units annually; professional charges of about $1.5M.
• CRNA median is approximately 5,300 ASA units annually; professional charges of about $500,000.
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CAH Financial/Productivity
Hospital Financial /Productivity Metrics
CAH Financial/Productivity
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Critical Access Hospital financial/productivity examples:
• Salaries per Discharge: $4,286
• FTEs per Occupied Bed: 4.94 FTEs
• Staff Hours per Discharge: 145.3 hours
• Hospital Length of Stay: 4.9 days
(2017 median data for All Critical Access Hospitals, as reported by Optum.)
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• RHCs have stringent practitioner staffing requirements
• Various metrics can be used to measure provider productivity
• CAHs often employ/contract practitioners in areas such as ED, inpatient/hospitalist, and anesthesia
• Productivity changes can substantially impact financial performance
Summary
More
Questions?
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Today’s Presenters
Jeff Bramschreiber, CPA
Partner, Wipfli Health Care Practice 920.662.2822
Corina Schoenke, CPA
Partner, Wipfli Health Care Practice 414.259.6730
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