Productivity – A Meaningful ModelTuesday June 14, 2016

AAMD 41st Annual Meeting

Levine Cancer Institute, Carolinas Healthcare System

Vicki Reich, AVP

Carolinas HealthCare System Levine Cancer Institute (LCI)

• 2nd (or 3rd) largest non-profit public hospital system in the U.S.• 50 hospitals, 900 locations, 14 Rad Onc sites with the LCI• Approximately 15,000 new cancer cases per year• Awarded a 3 year CoC accreditation with Commendation as an Integrated Network

Cancer Program (INCP)

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Productivity

Webster's: a measure of the efficiency of a person, machine, factory, system, etc. in converting inputs into useful outputs.

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Output per employee

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Objective Reconcile the nuances of Financial Reporting and

Productivity Reporting

Consider the validity of an RVU model vs a Visit Model for Rad Onc

Address nationally accepted Radiation Safety Standards when determining a staffing model

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ASTRO Blue Book

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It is recommended that a minimum of two qualified individuals be present for any routine external beam patient treatments.

Challenges Addressed

Fitting a square peg into a round hole – using an inpatient nursing Productivity model for an outpatient Rad Onc department

Develop RVU methodology and build into Chargemaster

Restate Financial and Productivity ratios for FTE planning and forecasting

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Success Factors/Pre-Requisites

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Build a healthy synergy between clinical and financial stakeholders. Find a Senior Admin champion.

Re-state prior year(s) financials as a baseline for forecasting

Benchmark: ongoing evaluation and revision of model based on changes in service line offerings and/or CMS bundling.

Relevant Outcomes Achieved

Increased awareness of inaccuracy of existing Productivity models

Establish a platform for ongoing dialog and process improvement

Improved accuracy of data within the Chargemaster file

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What is an RVU?

On January 1, 1992 the U. S. government implemented federal resource-based relative value scales (RBRVS) for the payment of physicians

RVUs assign relative values or weights to medical procedures primarily for the purpose of reimbursement of services performed, but also for productivity measurements, cost analysis and benchmarking

RVUs have greatly expanded the possibilities to allow for case complexity and mix analysis, staffing and workload analysis.

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Three components of the Relative Value Unit

Work RVU (wRVU) ≈ 52%*Relative time, effort, and skill needed by a provider in the provision of a procedure

Practice Expense RVU (peRVU) ≈ 44%*Costs associated with maintaining a practice, such as rent, equipment, supplies and staff

Malpractice Expense RVU (mRVU) ≈ 4%*Professional liability insurance

Non-Billable Procedural Inputs

LCI-Morehead

Procedural time analysis for non-billable inputs for

Special Procedures

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Average of 1-4 hours of non-billable inputs by staff

per Special Procedure

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Inputs by staff for Special Procedures

Multiple Areas on single patient

Managing pediatric treatment

Managing inpatient treatment

Multiple radiation oncologists

Treatment Schedule Adjustments

Total Body Pediatric Treatment

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The following services are bundled into the Radiation Therapy codes:

Anesthesia

Skin/Wound Care

Checking of treatment charts, verification of dosage, as needed

Continued patient evaluation, examination, written progress notes, as needed

Nutritional counseling

Pain management

Review & revision of treatment plan

Routine medical management of unrelated problem

Special care of ostomy

Written reports, progress notes , Quality or MU inputs

Follow-up examination and care for 90 days after last treatment

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Resource Allocation Tool

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Inputs accounted for

Facility specific acuity

Model can be expanded

Measurable

Ability to audit

Cancellation Impact Snapshot

% Cancellations

Jan Radonc Facility A 3.1Radonc Facility B 3.07Radonc Facility C 7Radonc Facility D 0.4

FEB Radonc Facility A 6.1Radonc Facility B 3.54Radonc Facility C 6Radonc Facility D 3

Mar Radonc Facility A 4.6Radonc Facility B 3.25Radonc Facility C 9.8Radonc Facility D 1.2

APR Radonc Facility A 3.1Radonc Facility B 2.86Radonc Facility C 10Radonc Facility D 4.5

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Acuity Qualifiers Inpatients- Number of Inpatient Treatments

Anesthesia- # cases requiring anesthesia

Pediatrics- # Pediatric tx procedures

Special Procedures- # HDR, SRS, SBRT, TBI

Xofigo- # Administrations

Radiation Oncologists- # Staffed by location

TX Schedule Adjustments- % No shows, downtime, etc.

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Resource Allocation Snapshot

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Variances

Examples of Variance as related to “Work”

CPT 77412: RVU - 6.79

• Whole brain – 10 min

• Prone breast- 20 minutes

• Pediatric TBI w/ anesthesia- One Hour

• We get paid the same, we get the same one tickmark!

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Nursing Time Impact of PUTS

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Level I Level II Level III Level IV Level V

BMID/C Instruction/Pt Education - Basic

D/C Instruction/Pt Education -Mod Cerumen Removal

Communication with Outside Agencies Extensive

Data Gathering/Chief Complaint

Education/Case Mgmt/Interview 16 - 30 mins* Drug Response Testing

Coordination of Care for HR OB patients

Dressing Change-Complex (wet-to-dry)

Education/Case Mgmt/Interview <15 mins*

Forms Completion - Simple (BTL, School PE)

Education/Case Mgmt/Interview 31 - 45 mins*

D/C Instruction/Pt Education - Ext. (new med)

Education/Case Mgmt/Interview > 60 mins*

Head CircumferenceSocial History Extensive/Complete

Forms Completion - Extensive (College)

Dental Varnishing (non Medicaid) Emergency Care

Height/LengthMedication Administration -PO, Rectal

Education/Case Mgmt/Interview 46 - 60 mins*

Provider Assistance - Complex Procedures

Medication Screening (taking no meds) Medication Reconciliation In and Out Catheterization

RN Walk-in Triage Assessment (pt seen that day)

Pain Screening (not currently in pain) OB History Update

OB History - Initial Completion

Social History Partial Pain Assessment Orthostatic Blood Pressures

VitalsPast Medical History - Initial Completion/Update Oxygen Administration

WeightProvider Assistance - Routine Procedures

Peak Flow Meter Assessment

Pulse OximetryProvider Assistance - Mod Complex Procedures

Staple/Suture RemovalPulse Oximetry Post ExerciseReferral (Specialty, Radiology)Spec Need Requiring Spec Facility ResourcesTB Test Check - Positive Result

Non-Billable Clinical Staff Procedures

Weekly Patient Under Treatment Visits

PUTS Visits 6 months annualized

Radonc Facility A 1493 2986

Radonc Facility B 1161 2322

Radonc Facility C 781 1562

Radonc Facility D 1065 2130

TOTALS 9000

CPT 2014 with AMA RVU’s

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Bundling, Packaging, Edits

Packaging is about payment – there is one payment for everything packaged but we still report all codes.

Bundling is about coding – NCCI Edits define bundling. Bundled codes are not reported, but sometimes a modifier can be added to bypass an edit.

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Column 1Deletion Date*=no data

Modifier0=not allowed1=allowed9=not applicable

77295 77014 20070101 * 077295 77280 19960101 * 077295 77285 19960101 * 077295 77290 19960101 * 077295 77300 20160101 20160101 977295 77305 20010401 20141231 077295 77306 20150101 * 077295 77307 20150101 * 077295 77310 20010401 20141231 077295 77315 20010401 20141231 077334 77332 19960101 * 177334 77333 19960101 * 177334 77336 20031001 * 1

Bundled Codes – 77300 w/ 3D – 4.0 per plan# CPT 77300 PER ENCOUNTER

DIAGNOSIS# ENCOUNTERS MIN MAX MEAN

174 Malignant neoplasm of female breast 226 1 25 4.238938053

162 Malignant neoplasm of trachea bronchus and lung 147 2 19 4.897959184

198 Secondary malignant neoplasm of other specified sites 76 1 30 5.973684211

233 Carcinoma in situ of breast and genitourinary system 44 1 8 3.181818182

154 Malignant neoplasm of rectum rectosigmoid junction and anus 31 2 12 3.580645161

180 Malignant neoplasm of cervix uteri 19 1 4 1.789473684

185 Malignant neoplasm of prostate 19 1 10 3

197 Secondary malignant neoplasm of respiratory and digestive systems 14 2 24 7.285714286

188 Malignant neoplasm of bladder 10 2 4 3.7

191 Malignant neoplasm of brain 10 2 18 4.4

196 Secondary and unspecified malignant neoplasm of lymph nodes 10 2 6 3.3

182 Malignant neoplasm of body of uterus 9 1 8 2.333333333

157 Malignant neoplasm of pancreas 8 2 4 3.5

150 Malignant neoplasm of esophagus 6 1 6 3.666666667

225 Benign neoplasm of brain and other parts of nervous system 6 5 6 5.5153 Malignant neoplasm of colon 5 2 8 4.2

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Bundling: Lose the code, but DON’T lose the RVU’s!

• Previous 77295 = 9.077300 = 1.22 x 4 = 4.88New RVU for 77295 = 13.88

• Previously 77301 = 46.1277290 = 12.52

New RVU for 77301 = 58.64

** Check with Finance to see if the charge also needs to change!

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Setting Dosimetry up to Succeed –almost perfect!

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Gains Through Process

Enhanced relationship with finance

• Mutual learning

Establishment of Rad Onc productivity task force

Restated historical and current budgets

More effective projections for future budgets especially with bundled/packaged procedures

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Next Steps

Evaluation of the performance for next year

Development of Prospective Staffing Tools

• Tools that mine data from Time Planner or Treatment Schedule in the future and calculates number of FTE’s needed for scheduled volume

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Acknowledgements

Tomain Murphy and Donna Royster, my team! Directors at 2 of our sites

Stephen Andrew, Director, Productivity Team

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Discussion & Questions

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