Measuring Provider Performance: The Anti-Gaming Commission

Transcription

1 Measuring Provider Performance: The Anti-Gaming Commission Presented by: Frank D. Cohen, MBB, MPA Director of Analytics Doctors Management 4/25/2016 1

2 Why Measure Performance? Because a medical practice is a business Providers are responsible for generating revenue and consuming resources Performance indicators can be tied directly to profitability 4/25/2016 2

3 Performance Metrics Financial (revenue and expense) Resource consumption (RBRVS) Compensatory measures Productivity Compliance (related to RUC time) Volumetric Acuity 4/25/2016 3

4 Internal Data Requirements Volume by doc Gross charges (fee * frequency) Revenue Compensation Hours that define 1 FTE RVUs (work, PE and total) Expenses (direct and fixed) 4/25/2016 4

5 External Resources RBRVS and GAF reference data sets Harvard/RUC Time Study National Average Salary Data (optional) 4/25/2016 5

6 Non-Physician providers Is data available by NPP provider? Incident-to or not incident-to? Do NPPs share in the bonus distribution? How are supervising docs accounted? Where does NPP data end up? 4/25/2016 6

7 Mastering RBRVS 4/25/2016 7

8 What is a Resource Based Relative Value Scale? The RBRVS is a relative value scale that is based upon the consumption of resources, not a measurement of costs. Developed by the Cambridge Health Education Group. Adopted by HCFA in 1992 as the official methodology for determining the physician component of the Medicare Fee Schedule Values are adjusted by geographic factors, based on the market location of the Medicare carrier 4/25/2016 8

9 Uses of the Relative Value Scale Developing fees for new and existing practices Cost Accounting Resource Allocation Physician compensation issues Productivity studies Break even and profit/loss analysis Managed care contract analysis PMPM capitation cost analysis 4/25/2016 9

10 Understanding the RBRVS Model Relative Value Unit (RVU) The standard unit of measurement in the RBRVS Assign a value for consumption of resources for a service or procedure (event) Geographic Adjustment Factor (GAF) Made up Geographic Practice Cost Indices (GPCI) Used to adjust the value regionally for cost variances Conversion Factor (CF) Used to convert an RVU to a fee 4/25/

11 Relative Value Components Work Related (RVU_WK) Measures the time and effort required by the provider to deliver the specified service Practice Expense Related (RVU_PE) Measures the costs associated with the performance of the procedure Malpractice Expense Related (RVU_MP) Adjusts for Educational offset Considers risk factors 4/25/

12 Work Related RVU Based on two components Time Pre-service Intra-service Face to Face time for non-surgical Skin to Skin time for surgical procedures Post-service Intensity Physical effort and skill Mental effort and judgment Stress from iatrogenic risk Tied to intra-service time 4/25/

13 Practice Expense RVU Top-down approach Developed specialty-specific cost pools Allocated to individual services Practice expense by hour Total non-physician payroll (including fringe benefits) Administrative payroll (including fringes for non-clinical staff) Office and facility expenses (rent, depreciation, utilities) Medical supplies (disposable supplies, i.e., drugs, x-ray films) Medical equipment (lease, rental, depreciation) All other expenses (L&P, accounting, consulting) Estimated total hours by specialty (Harvard/RUC) Allocation of specialty-specific estimates of cost to procedures performed by that specialty 4/25/

14 Geographic Adjustment Factor Locations based upon intermediary market area Made up of Geographic Practice Cost Indices (GPCI) Work Related GPCI (GAF WK ) Measures work value by region No value is less than 1.00 (1.50 for Alaska) Practice Expense Related (GAF PE ) Adjusts for regional costs, i.e., rent, salaries, etc. Malpractice Expense Related (GAF MP ) Measures cost of malpractice by region 4/25/

15 Location, Location, Location Non-Facility Procedure done within the physician s office or extension of their office Practice expense is greater, therefore Reimbursement amount is greater Facility Procedure done in a facility other than the physician s office Practice expense is less, therefore Reimbursement amount is less Designation only affects the practice expense RVU Not all procedures have both values Only indication is on CMS 1500 form (Box 24b) 4/25/

16 Calculating The Total RVU Adding the components without adjusting by GAF results in a geographically neutral total RVU. RVUwk + RVUpe + RVUmp = RVUtu Factoring the GAF results in a geographically adjusted total RVU First, factor each RVU component by the corresponding GAF component and then get the sum of the products, as follows: RVUtot = (RVUwk * GPCIwk) + (RVUpe * GPCIpe) + (RVUmp * GPCImp) 4/25/

17 GAF and RVU Sample Values Geographic Adjustment Factors Work component: Practice Expense component: Malpractice component: RVU components are as follows: Work component: 2.00 Current non-facility practice expense component 1.51 Current facility practice expense component 0.74 Malpractice component: /25/

18 Sample Non-Facility RVU Calculations (RVU WK * GAF WK ) + (RVU PENF * GAF PE ) + (RVU MP * GAF MP ) OR (2.00 * 1.000) + (1.51 *.946) + (.10 * 1.268) OR and this equals: To obtain the approximate Medicare fee amount, multiply the RVUTOT times the CF as follows: * $ = $ /25/

19 Sample Facility RVU Calculations (RVU WK * GAF WK ) + (RVU PEF * GAF PE ) + (RVU MP * GAF MP ) OR (2.00 * 1.000) * 0.946) + (.10 * 1.268) OR and this equals: To obtain the approximate Medicare fee amount, multiply the RVU TOT times the CF as follows: * $ = $ (vs ) 4/25/

20 Medicare and Sequestration There is a 2% reduction in the allowable, But only for payment to the practice, not the patient For example Allowed amount = $100 Practice paid 80% of $98 = $78.40 Patient pays 20% of $100 = $20 Practice gets $98.40 Medicare saves 2% ($1.60) 4/25/

21 Building the Impact Analysis Old Adjusted Non-Facility Medicare New Adjusted Non-Facility Medicare Old Non- Facility Expected New Non- Facility Expected Extended Non- Facility HCPCS Description Non- Facility Count Allowable Allowable Payment Payment Non- Facility Delta Delta Total Delta Impact Fna w/o image 1 $ $ $ $ $0.00 $0.00 $0.00 -$ Drainage of skin abscess 9 $ $ $94.40 $92.51 $0.00 $0.00 $0.00 -$ Drainage of skin abscess 10 $ $ $ $ $0.00 $0.00 $0.00 -$ Drainage of pilonidal cyst 2 $ $ $ $ $0.00 $0.00 $0.00 -$ Drainage of pilonidal cyst 1 $ $ $ $ $0.00 $0.00 $0.00 -$ Remove foreign body 3 $ $ $ $ $0.00 $0.00 $0.00 -$ Remove foreign body 3 $ $ $ $ $0.00 $0.00 $0.00 -$ Drainage of hematoma/fluid 2 $ $ $ $ $0.00 $0.00 $0.00 -$ Puncture drainage of lesion 4 $ $ $ $ $0.00 $0.00 $0.00 -$ Complex drainage wound 3 $ $ $ $ $0.00 $0.00 $0.00 -$ Debride infected skin 6 $55.00 $55.00 $44.00 $43.12 $0.00 $0.00 $0.00 -$ DEBRIDE SKIN/TISSUE 7 $ $ $95.95 $94.03 $0.00 $0.00 $0.00 -$ Deb musc/fascia 20 sq cm/< 9 $ $ $ $ $0.00 $0.00 $0.00 -$ Biopsy skin lesion 1 $ $ $84.93 $83.23 $0.00 $0.00 $0.00 -$ Removal of skin tags 4 $89.70 $89.70 $71.76 $70.32 $0.00 $0.00 $0.00 -$ Shave skin lesion 1 $99.40 $99.40 $79.52 $77.93 $0.00 $0.00 $0.00 -$ Exc tr-ext b9+marg 0.5 < cm 4 $ $ $ $98.95 $0.00 $0.00 $0.00 -$ Exc tr-ext b9+marg cm 30 $ $ $ $ $0.00 $0.00 $0.00 -$ /25/

22 Factoring for Modifiers A modifier is used to alter or enhance the manner in which a procedure or service is performed or delivered A modifier does not change the description Two major modifier categories: Those that affect the reimbursement (26, 50, 51, 82, etc.) Also affect the value of the RVU Those that don t affect the reimbursement (24, 25, 59, etc.) Do not affect the value of the RVU If a modifier changes the reimbursement, it should also change the value of the RVU using the same ratio. 4/25/

23 Check Which Component to Adjust Work RVU should be adjusted only for modifiers that affect physician work effort Practice expense RVU should be adjusted for procedures that affect fixed and variable expense Be careful not to factor RVUs for modifiers that reflect productivity variances -62, -80, AS, etc. 4/25/

24 For Example... Modifier 80 (Assistant Surgeon) pays at 16% of allowable charge Should the RVU value be reduced to 16%? Yes, if you are paying the physician No, if you are the physician Modifier 50 (bi-lateral procedure) pays at 150% (sometimes). Should the RVU value be increased? Yes, but only the work RVU 4/25/

25 What is the Conversion Factor? The Conversion Factor (CF) is a dollar amount that is multiplied by the RVU to convert the RVU value into a fee. For CY 2011, for Medicare, it was For CY 2012, for Medicare, it was For CY 2013, for Medicare, it was For CY 2014, for Medicare, it is For Q3 Q4 2015, for Medicare, it was For 2016, for Medicare, it is be used to measure individual and group values within an existing fee schedule. 4/25/

26 What is the CF Used For? To profile/benchmark the fee schedule To verify Medicare reimbursement To establish fees for new procedures To re-price existing fees that are aberrant To benchmark cost and collection metrics 4/25/

27 Calculating the Conversion Factor To obtain the approximate CF for any procedure, you need the current fee and the assigned RVU value Divide the fee by the adjusted total RVU If the fee is $617 and the RVU is : Fee / RVU TOT = CF OR $617 / = /25/

28 Categorical Distribution - Major CF values should be calculated by Major Code Categories (at least!) Surgery Radiology Pathology Medicine (exc ) E/M HCPCS II A0000 Z9999 Tracking End with F or T 4/25/

29 Visualize Data Distribution Distribution Normality Outliers Variability Confidence Intervals Shape 4/25/

30 Analyze CF by Category Compare CF values by category Look for low levels (1.5 * Medicare) Look for higher levels (4 * Medicare) Look for outliers (above 10 * Medicare) 4/25/

31 Understand Variance and Distribution Interval graphs help us bet a visual understanding of the distribution of ranges around a central measurement Note the different between pathology CF values and E/M CF values 4/25/

32 Calculating RVUs When Absent For Medicare Divided the MFS allowable by the MFS conversion factor Using time Calculate the minutes per RVU Divide the number of minutes for the procedure by minutes per RVU 4/25/

33 Example No RVUs Medicare allowable MFS = $545 CF = Estimated RVU = 545/ = Time RVU Components Work = 53% * = 8.06 PE = 44% * = 6.70 MP = 3% * = 0.46 Minutes per WRVU = 25.5 Procedure time = 41 minutes RVU = 41/25.5 = 1.6 4/25/

34 What RVUs are NOT! RVUs do NOT measure productivity An RVU is a measure of consumption of a resource All providers have an expense associated within the practice Every wrvu can be attributed/associated back to provider expense If the doc gets paid $250,000 and reports 5,000 WRVUs, then every WRVU reported consumes $50 of resource If you add the direct expenses for the doc (i.e., $100k), then resource per unit is higher (i.e., $70 per WRVU) Distribute additional expense, and it grows even more 4/25/

35 So, Why Productivity? Let s say we have a practice with 4 physicians Doc 1 is energetic, motivated and experienced and can see 41 patients a day Doc 2 is motivated, but new and takes longer to see a patient, seeing 26 per day Doc 3 is tired and old and plods along seeing a dozen or so patients a day Doc 4 is status quo; steady as she goes for 35 patients a day; day in and day out Should all four get paid the same? 4/25/

36 When do RVUs Measure Productivity? Only when used to create ratios of consumption to revenue For pure productivity, use expenses. To estimate based on resource consumption, use RVUs Take revenue as a percent of total revenue and divide by expense (or PE RVU) as a percent of total Performance focuses on work effort while productivity focuses on financial markers 4/25/

37 So, Why Work RVUs? Work RVUs are based upon a more concise research model i.e. RASCH estimate Work RVUs are not subject to political infighting over the BNA or other budgetary issues Work RVUs have been relational from the start Work RVUs measure the amount of time and effort expended by a doc to provide a service or procedure Without doing time-motion studies, it s the best we got! 4/25/

38 Assumptions Work RVUs accurately (or approximately) equate to time and effort expended by the provider Work RVUs, as a relative model, accurately (or approximately) measure the resources consumed by the provider The practice is dynamically unstable with respect to financial and performance attributes (shift happens!). Chaos is an inherent attribute within any productivity- or volumetric-based compensation model Patient volume, payer mix, contract rates, collections, regulations, payer confusion, etc. 4/25/

39 Physician Performance Time and FTEs 4/25/

40 Calculate Charges and Utilization Provider ID Specialty Charges Revenue 66 GE $ 1,293,108 $ 584, GE $ 1,442,264 $ 604, GR $ 414,329 $ 178, IM $ 977,002 $ 570, IM $ 676,290 $ 376, PM $ 1,469,113 $ 531, PM $ 1,329,581 $ 432, RH $ 501,122 $ 295,581 8 RH $ 1,537,184 $ 766,420 $ 9,639,993 $ 4,340,209 First, for each provider. calculate the total charges and reported total revenue It is critical that the revenue is accurate or you can lose physician confidence in the process 4/25/

41 Calculate Collection Amounts Provider ID Specialty Charges Revenue Collection Percent 66 GE $ 1,293,108 $ 584, % 95 GE $ 1,442,264 $ 604, % 794 GR $ 414,329 $ 178, % 13 IM $ 977,002 $ 570, % 1249 IM $ 676,290 $ 376, % 71 PM $ 1,469,113 $ 531, % 1056 PM $ 1,329,581 $ 432, % 1025 RH $ 501,122 $ 295, % 8 RH $ 1,537,184 $ 766, % $ 9,639,993 $ 4,340,209 Collection is calculated by dividing Revenue by Charges Major variances should be investigated Coding errors, payer mix, doesn t go along with the program Note variances both between and within specialties 4/25/

42 Calculating Spread Cost Normally includes overhead expenses Facility, general staff, excess capacity, etc. Allocation can be made several ways Equally amongst all providers Total RVU values Practice Expense RVU values Gross Charges Revenue Each has pros and cons that need to be considered 4/25/

43 Equally Distributed Spread Cost Provider ID Specialty Spread Cost Direct Expense Total Expense 66 GE $ 69,947 $ 634,082 $ 704, GE $ 69,947 $ 634,082 $ 704, GR $ 69,947 $ 197,579 $ 267, IM $ 69,947 $ 215,675 $ 285, IM $ 69,947 $ 215,675 $ 285, PM $ 69,947 $ 328,764 $ 398, PM $ 69,947 $ 328,764 $ 398, RH $ 69,947 $ 288,011 $ 357,958 8 RH $ 69,947 $ 288,011 $ 357,958 $ 629,521 $ 3,130,643 $ 3,760,164 Take total expenses (less direct expenses) and divide by the number of providers This type of model would works best with groups with high degree of homogeneity 4/25/

44 RVU Distributed Spread Cost Provider ID Specialty Spread Cost Direct Expense 66 GE $ 75,899 $ 634, GE $ 77,695 $ 634, GR $ 21,717 $ 197, IM $ 78,265 $ 215, IM $ 49,515 $ 215, PM $ 110,724 $ 328, PM $ 84,842 $ 328, RH $ 26,770 $ 288,011 8 RH $ 104,094 $ 288,011 $ 629,521 $ 3,130,643 Take total expenses (less direct expenses) and divide by total RVUs Here, the cost per RVU for the spread cost was $6.28 since most charges were allocated to direct expenses Multiply cost per RVU times total RVUs per provider 4/25/

45 Calculating P/L per Provider Provider ID Specialty Charges Spread Cost Direct Expense Total Expense Profit / Loss 66 GE $ 1,293,108 $ 75,899 $ 634,082 $ 709,981 $ (125,149) 95 GE $ 1,442,264 $ 77,695 $ 634,082 $ 711,777 $ (107,115) 794 GR $ 414,329 $ 21,717 $ 197,579 $ 219,296 $ (40,813) 13 IM $ 977,002 $ 78,265 $ 215,675 $ 293,940 $ 276, IM $ 676,290 $ 49,515 $ 215,675 $ 265,190 $ 110, PM $ 1,469,113 $ 110,724 $ 328,764 $ 439,488 $ 92, PM $ 1,329,581 $ 84,842 $ 328,764 $ 413,606 $ 18, RH $ 501,122 $ 26,770 $ 288,011 $ 314,781 $ (19,200) 8 RH $ 1,537,184 $ 104,094 $ 288,011 $ 392,105 $ 374,315 $ 9,639,993 $ 629,521 $ 3,130,643 $ 3,760,164 $ 580,045 Add direct expense for each provider to spread cost to get total expense Be careful with direct expenses when dealing with drugs and other supplies Revenue minus total expense equals profit/loss 4/25/

46 Time and FTEs Alternative Performance Metrics 4/25/

47 Harvard/RUC/CMS Time Data Began with time assignments in 1989 under the original RBRVS study through Harvard School of Public Health AMA picked it up and added thousands of procedures to the list CMS creates time estimates for those several hundred remaining with out existing estimates In total, nearly 8,000 procedures are assigned a value of minutes that are used to create the work RVU 4/25/

48 RUC Time Exemplar Cpt code Pre Eva lua tion T ime Pre Positioning time Pre Se rvice Scrub Dre ss W a it tim Me dia n Intra Se rvice T ime Imme dia te post Se rvice time Follow-up post Se rvice T ime T ota l time /25/

49 Step 1 Define 1 FTE HAM AND EGGS A day's work for a chicken A lifetime commitment for a pig. 4/25/

50 Defining a Full Time Equivalent In every practice, there needs to be some way to equate a full time equivalent provider to time and/or work effort Dr. Speedup, Dr. Slowdown, Dr. Broke, Dr. I m outa here! Hours, number of patient encounters, etc. MGMA, FPSC, etc. Assume using work hours Multiply total hours per period by 60 minutes Divide total minutes by minutes per work RVU 2080 hours (124,800 mins.) define 1 FTE Divide minutes by minutes per work RVU (i.e., 24.5) 124,800 / 24.5 = 5,094/year (424 /month) Calculate 95% confidence interval Use average (or median) for homogeneous group of docs 4/25/

51 Examples of Minutes per Work RVU Number of Hours for FTE Lower wrvu Bound Upper wrvu Bound Specialty Description Minutes per wrvu Average wrvu 79 Addiction Medicine ,080 3, , , Allergy/Immunology ,080 2, , , Anesthesiology ,080 4, , , Audiologist (ind. billing) ,080 2, , , Cardiac Electrophysiology ,080 3, , , Cardiac Surgery ,080 4, , , Cardiovascular Disease ,080 3, , , Certified Nurse Midwife ,080 4, , , Chiropractic ,080 3, , , Clinical Nurse Specialist ,080 3, , , Clinical Psychologist ,080 3, , , Colorectal Surgery ,080 4, , , Critical Care (intensivists) ,080 4, , , To calculate WRVU range, divide mean RVU per FTE by lower bound for upper bound of WRVU and by upper bound for lower bound of wrvu 4/25/

52 Calculating RVUs When Absent For Medicare Divided the MFS allowable by the MFS conversion factor Using time Calculate the minutes per RVU Divide the number of minutes for the procedure by minutes per RVU 4/25/

53 Other FTE Methods By provider Looking only at those procedures that provider reports Applicable for sub-specialties in highly specialized facilities By specialty When data cannot be collected by provider, can aggregate by specialty By Department Can include multiple sub-specialties and is applicable in larger practices and teaching facilities By budgetary requirements Calculating necessary revenue by expense and converting to work RVUs 4/25/

54 Step 2 Compensatory Mechanism Man is a gaming animal. He must always be trying to get the better in something or other. [Charles Lamb, ] 4/25/

55 Collection per RVU Can vary greatly between docs Huge point of contention i.e. I m not involved in collection so shouldn t be penalized for it Establishes a baseline, not a benchmark Based on historical activity so no down side for the doc Bad payer mix? Poor collection activity? Bad billing practices? No problem! Conducted in 12 month rolling average No month can effect more than 8.33% of total 4/25/

56 Defining Collection Actual amount collected amount during the data period Because of payer instability, it is difficult to align to charges and/or billing Adjustments should be considered since these reverse revenue for the practice 4/25/

57 Summary Stats for Collect/WRVU 24 month run Normal distribution Mean and median approximately equal 95% CI calculated Lower = Upper = Other statistics within acceptable range 4/25/

58 Visualize Revenue Statistics Control chart indicates that, with one exception, collection per WRVU reporting is in control, meaning the variation from month to month is reasonable and expected Run chart of collection per WRVU indicates that there aren t any significant patterns to note, such as clustering, trends or oscillation 4/25/

59 Why? Control chart indicates that collection per wrvu reporting trends to out of control, meaning the variation from month to month is due to something other than normal or expected variation (noise). 4/25/

60 Step 3 - Measuring productivity 4/25/

61 Calculating Work and Total RVUs Provider ID Specialty Modifier Factored Total RVU Total Work RVU 66 GE 12, , GE 16, , GR 5, , IM 9, , IM 8, , PM 13, , PM 14, , RH 6, , RH 12, , , , Lower Range 5, , Lower Quartile 8, , Mean 11, , Median 12, , Upper Quartile 13, , Upper Range 16, , Be sure to factor total RVUs based on modifier relationships Determine ahead of time whether to adjust geographically If comparing to national or other data, consider using geographically neutral values Work RVUs can be used to look at FTE relationships Here, the median is 5,803 and the mean is 6,438 This only works for same-specialty genus 4/25/

62 Calculating Work to Total RVUs Provider ID Specialty Total Work RVU Work to Total RVUs 66 GE 7, GE 10, GR 4, IM 4, IM 5, PM 5, PM 9, RH 4, RH 5, , Lower Range 4, Lower Quartile 4, Mean 6, Median 5, Upper Quartile 7, Upper Range 10, Standard Deviation 2, Because work RVUs are related to provider costs, which is primarily salary, work RVUs present less actual cost than practice expense RVUs Procedures with higher work to total RVU ratios may be more profitable Physicians that are paid on work RVUs earn more reporting procedures that have higher work RVU ratio Some docs know how to game the system 4/25/

63 Defining Financial Productivity The relationship between what goes in the bucket and what comes out of the bucket Revenue measures only left side Income but not expense Expenses only measure the right side Productivity is NOT: Revenues alone Expenses or costs alone Work effort alone (RVUs) 4/25/

64 Measuring Productivity Measures the clinical productivity of the provider Ratio of Revenue to Resources Uses either RVUs or true expenses Eliminates FTE consideration Defensible benchmark Works well in academic settings Agnostic to non-clinical work Need buy-in by all concerned parties Data sets, revenue components, methodologies, etc. 4/25/

65 The Bucket Brigade Provider ID Specialty Percent Charges Percent Revenue Percent Total RVU Percent Work RVU Percent Expense 66 GE 13.41% 13.47% 12.56% 12.96% 18.72% 95 GE 14.96% 13.93% 16.10% 18.61% 18.72% 794 GR 4.30% 4.11% 5.77% 7.26% 7.11% 13 IM 10.13% 13.14% 9.81% 8.12% 7.60% 1249 IM 7.02% 8.66% 8.74% 9.27% 7.60% 71 PM 15.24% 12.25% 13.14% 10.01% 10.60% 1056 PM 13.79% 9.96% 14.86% 16.23% 10.60% 1025 RH 5.20% 6.81% 6.16% 7.42% 9.52% 8 RH 15.95% 17.66% 12.86% 10.10% 9.52% For each provider, calculate charges, expenses and revenue as a percent of total for the practice 4/25/

66 RVU-based Productivity Provider ID Specialty Percent Revenue Percent Total RVU Percent Expense RVU Productivity Ratio 66 GE 13.47% 12.56% 18.72% GE 13.93% 16.10% 18.72% GR 4.11% 5.77% 7.11% IM 13.14% 9.81% 7.60% IM 8.66% 8.74% 7.60% PM 12.25% 13.14% 10.60% PM 9.96% 14.86% 10.60% RH 6.81% 6.16% 9.52% RH 17.66% 12.86% 9.52% 1.37 Calculate revenue by provider as a percent of all revenue for the practice Calculate total RVU by provider as a percent of total RVU for the practice Divide Percent Revenue by Percent RVU and calculate productivity This only works when the majority of codes have RVUs associated 4/25/

67 Expense-based Productivity Provider ID Specialty Percent Revenue Percent Total RVU Percent Expense RVU Productivity Ratio Expense Productivity Ratio 66 GE 13.47% 12.56% 18.72% GE 13.93% 16.10% 18.72% GR 4.11% 5.77% 7.11% IM 13.14% 9.81% 7.60% IM 8.66% 8.74% 7.60% PM 12.25% 13.14% 10.60% PM 9.96% 14.86% 10.60% RH 6.81% 6.16% 9.52% RH 17.66% 12.86% 9.52% Calculate revenue by provider as a percent of all revenue Calculate total expense by provider as a percent of total RVU Divide Percent Revenue by Percent expense The accuracy of expense productivity is directly proportional to the accuracy of the expense data entered 4/25/

68 Tic-Toc-Tic-Toc While We re in the Neighborhood 4/25/

69 Assessed Time Calculations Provider ID Specialty E/M Time Non-E/M Time Pre-Service Time Intra- Service Time Post- Service Time Total Time 66 GE 2,283 1, ,913 1,014 3, GE 4,030 1,180 1,134 2,724 1,348 5, GR 2, , , IM 1, , , IM 2, , , PM 1,021 1, , , PM 3,531 1,742 1,116 2,629 1,528 5, RH 1, , ,911 8 RH 489 1, , ,344 18,912 8,314 5,706 14,135 7,192 27,231 Total Time is a large element of compliance risk assessment OIG looks at times in excess of 2 times FMV, or 4,000+ hours E/M time can be used to validate suspected up-coding of E/M levels Total time can be used to estimate FTE-based work effort Mean time is 2,360 assessed hours 4/25/

70 Time-based Financial Calculations Provider ID Specialty Charge per Hour - Practice Charge per Hour - National Collection per Hour Cost per hour 66 GE $ $ $ $ GE $ $ $ $ GR $ $ $ $ IM $ $ $ $ IM $ $ $ $ PM $ $ $ $ PM $ $ $ $ RH $ $ $ $ RH $ $ $ $ Charge per hour is useful in accrual models for estimating revenue for physicians using antiquated PM systems Collection per hour is useful for negotiating per-diem relationships and administrative duties Cost per hour is useful as a mechanism for benchmarking and tracking physician-related expenses 4/25/

71 Procedural/Efficiency Studies Provider ID Specialty Procedures per Hour - Practice Procedures per Hour - National Minutes per Procedure - Practice Minutes per Procedure - National 66 GE GE GR IM IM PM PM RH RH Efficiency can be measured by comparing the number of procedures per hour and minute per procedure for each provider Compared against other providers in same specialty and peer groups via national average Question anomalies, such as the difference between the PM docs 4/25/

72 Follow Up Contact information Frank Cohen Toolbox Library=>Toolboxes Password to Unzip: /25/