RHC/CAH Provider Productivity

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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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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).


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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.


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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.


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Productivity Metrics

Key Performance Indicators

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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


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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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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?


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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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Hospital-based provider productivity examples:

• Emergency Department

• Hospitalists

• Anesthesia


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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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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).


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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

[email protected]

Corina Schoenke, CPA

Partner, Wipfli Health Care Practice 414.259.6730

[email protected]

Documents

RHC/CAH Provider Productivity