tennessee primary care association august 17, 2016 · cash and cash position increasingly important...

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Considerations for Improving Health Center

Operations

Presented by Michael Holton

Holton Healthcare Consulting, Inc.

Raleigh, NC

[email protected]

www.holtonhealthcare.com

Tennessee Primary Care Association

August 17, 2016

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I. Welcome & Introductions 9:00am

II. Executive Management Overview of

Revenue Cycle as Basis for Operations 9:15am

III. The Impact of Budgeting, Data and

Accountability on Ops Improvements 10:15am

Lunch 11:30 am

IV. Costing for Understanding Provider

Staffing and Services 12:15pm

V. Other Influences on Productivity & Efficiencies

Incentive-Based Compensation

Data Driven Decisions

Other 2:30pm

VI. Discussion 3:00pm

VII. Next Steps & Adjourn 3:30pm

mailto:[email protected]

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How can Executive Management better understand and manage the billing and revenue cycle function.

What are KPIs and how can Executive Management use them to assure that efforts in billing and collections are productive, efficient and meet organizational goals.

Discuss relationships of volume, revenues and expenses to each other.

What is the future if we dont focus on continuous process improvement?

How does productivity affect the bottom line, both directly and indirectly?

Using data to determine our current status and future goals.

Executive Management Overview of the Revenue Cycle as a Basis for Operations

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Revenue cycle performance in healthcare is particularly challenging due to:

The complex nature of services to be billed;

The complex specifications for billing practices;

The number of varied employees that contribute to the process;

The systems and tools used to capture and process billing information;

and,

The unending variation that occurs in each of these dimensions.

Revenue Cycle Management: A Life Cycle

Approach for Performance Measurement and System Justification

2010 Health Information and Management System Society (HIMSS)

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Todays healthcare revenue cycle remains as complex as ever.

Growing need for high performance with changing environment

Cash and cash position increasingly important

Need for results-driven organizations

Working towards goals of ideal outcomes oversight and standards for: Finance Department clean audit; timely reporting; viable operation

Service Providers expectation of high quality services and productivity

Administration federal measures; compliance; board and management performance; community perception; patient satisfaction

Billing???????? Revenue cycle performance????????

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What is the Revenue Cycle?

Appointment

Scheduling

Registration/CertificationPatient Reception

Patient Clinical Visit

Service Delivery

Documentation &

Coding

Charge Processing/C heck Out

Patient Statement &

Claim ProductionClaims & Patient Payments

Processing

Denied Claims

Management

Accounts Receivable

Management and

Collections

The

Revenue

Cycle

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What are some things Executive Management Should Know About the Revenue Cycle?

Billing Issues

Front office competency directly affects billing success

Accurate information and the verification process is key

Training there is frequently high turnover of front desk staff; and thus making

sure that all staff understand their responsibilities is crucial

Eligibility verification explore all internet and system options

Proper completion and entry of registration information is key

Feedback loop with the billing department must be established so that front

desk staff understand the impact of their actions. Oftentimes the best form for

the communication is a facilitated peer-to-peer interaction

Operational Issues

Must know services you offer, plans you accept, operational structure

Excessive wait times can result from slow patient processing

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Billing Issues

Billing cannot fix provider coding issues, but may be able to identify them

Billing may be able to fix some of the front end issues on the previous slide,

but it is more efficient to reduce errors

Your practice management/EMR system cannot correct errors, but it can

minimize them through edit checks and restriction of inputs

Nowadays, completion of the electronic record by providers can affect claims

filing, patient statements and revenue maximization

Patient statements should be mailed monthly. Should be an

acknowledgment or approval that this is done each month. Should

include a contact name and phone number for questions.

Claims should be sent no less that once weekly, more often if a larger

health center. Are you currently receiving any notice each time they are

sent?

Should receive a report showing number of claims sent by payer

Report should show the value of the claims sent, with FQHC Medicare and PPS valued at their cost rates.

Must have a collections strategy for both patients and claims.

Management needs to be sure this is followed. Might want to include

an installment plan system for patients.

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Denial Management Denial management is the process of understanding and monitoring the

denial of claims billed to third parties (e.g. Medicaid, Medicare, privateinsurance).

The objective of denial management is to understand the reasons whyclaims are being denied, and use this information to identify the rootcause of the denial in the billing system, and then correct the underlyingdeficiency.

How is denial management often accomplished? Periodic review of explanation of benefit statements received Appropriate denial information being captured by the practice management system

Things Executive Management Should Know About the

Back End of the Revenue Cycle

How Can Executive Management Better Understand the Billing Process?

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Why Document the Revenue Cycle? Training of new staff is much more effective.

Measuring staff performance is easier when responsibilities are clearly identified.

It is an opportunity to improve systems that may result in more dollars, better productivity and patient satisfaction

Why is Documenting the Revenue Cycle Important to Executive Management? Leadership involves setting clear direction and expectations related to

job performance.

Executive Management will gain an in-depth understanding of the revenue cycle through a documentation exercise.

Reviewing the revenue cycle should include looking at:

Front desk and Appointments

Registration

Exam room (by provider)

Cashier/Appointment scheduling/ Check-out

Billing

Patient Statement & Claims Production

Claims & Patient Payments Processing

Denied Claims Management

Accounts Receivable Management & Collections

FrontOffice

BackOffice

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Consider process flow (or work flow) mapping for documenting the revenue cycle..

Why? One of the fastest ways to lower errors, increase productivity and improve patient service

Flow charts are easy-to-understand diagrams showing how steps in a process fit together. This makes them useful tools for communicating how processes work, and for clearly documenting how particular jobs within the revenue cycle are accomplished.

The act of mapping a process in flow chart format helps everyone clarify their understanding of the process, and identify where the process can be improved.

A flow chart can therefore be used to: Define and analyze processes;

Build a step-by-step picture of the process for analysis, discussion, or communication; and

Define, standardize or find areas for improvement in a process

Also, by conveying the information or processes in a step-by-step flow, you can then concentrate more intently on each individual step, without feeling overwhelmed by the bigger picture.

The process will help reconcile what you think is happening vs. what is actually happening

Documentation of the Revenue Cycle

Patient Registers

Claims sent to payor (non-capitation)

Denials Investigated and Corrected

Patient Seen By Provider

Provider Completes Encounter Form

Patient Released at Front Desk

Claim Report Prepared

Encounter Form Processed

Remittance Received with Payment

Billing Department Reconciles and Posts

Resubmission of Denied Claims

Month Ending Journal Entries Posted

In any sequential process, problems at the beginning flow downstream. To understand these processes, it is necessary to understand cycle time (how long it takes to get done) vs. process time (how long it takes to do an individual step)

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1. Choose a Process Decide what you want to improve. It might be the entire revenue cycle or only a part of it (i.e., registration). Best bet are processes which are time consuming, error prone, and/or critical to success.

2. Assemble a Team - should include staff from the lowest to highest levels directly involved in the operation. Must have an approval process for recommended changes to the work flow in order to be effective.

3. Map out the Way Work is Currently Done diagram each step showing decisions and/or process actions and other important aspects of the current work. This can be accomplished with interviews of staff, having them share documents and other steps needed to accomplish tasks. It is often easier to sketch out individual tasks first, the go back and fill-in the details.

4. Identify Problem Areas areas where staff feel there are current major issues that need addressing, i.e., patient satisfaction, waste or significant delays. If too many, use 80/20 rule: work on 20% of the areas that cause 80% of the problems.

5. Brainstorm Solutions What changes can be introduced to the process to

improve problem areas identified. Hopefully, there is consensus among

those affected.

6. Action Steps - change the flow to establish a set of action steps that

need accomplishing before the process can be modified.

7. Assign Responsibilites assign staff responsibilities for each action step

and set deadlines for completion.

8. Create a Master Plan Summarize responsibility for actions and

deadlines. Distribute plan to participants to make certain it accurately

reflects decisions.

9. Follow Through

Meet every two weeks for progress reports and interaction

If needed, hold another brainstorming session

Adjust master plan when and where appropriate

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Executive Management Needs Key Performance Indicators (KPI) for the Revenue Cycle Function

If you do not measure it, you cannot manage it. --W. Edwards Deming

He is regarded as having had more impact upon Japanese manufacturing and business than any other individual not of Japanese heritage.

What is a Key Performance Indicator?

Numerical Factor

Used to quantitatively measure performance

Activities, volumes, etc.

Business processes

Financial assets

Functional groups

The revenue cycle

Source: BearingPoint, Key Performance Indictors

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KPI Introduction

http://en.wikipedia.org/wiki/Manufacturinghttp://en.wikipedia.org/wiki/Business

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Report entitled Revenue Cycle Management: A Life Cycle Approach for Performance Measurement and System Justification.

Addresses revenue cycle issues and establishes performance measures and best practice standards in the following areas:

Upstream Scheduling; patient access; pre-authorization/verification and financial counseling.

Midstream Case management; charge capture/documentation; charge description master maintenance (fee schedule) and Health Information Management.

Downstream Billing/claim submission; cashiering/refunds/adjustments; 3rd

party follow-up/processing/payment posting; customer service and collections/outsourcing

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Healthcare Information and Management

Systems Society (HIMSS)

A comprehensive strategy to transform the revenue cycle by helping leaders Measure performance, Apply evidence-based practices for improvement, and Perform to the highest standards.

Addresses revenue cycle standards in four areas: Patient Access

Revenue Integrity

Claims Adjudication

Management

KPIs have been developed for each area

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Healthcare Financial Management

Association (HFMA) MAP Initiative

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Reviewed the HFMA and HIMSS measures and standards Many apply to hospitals Some measures are very sophisticated, such that data may not be available to

health centers Includes services or functions health centers either dont provide or do not

provide intensively enough for establishing KPIs or standards, i.e., case management, pre-authorizations, etc.

Suggest KPIs in the same four areas as HFMA: Patient Access Revenue Integrity Claims Adjudication Management

Health centers should determine additional KPIs as applicable to individual revenue cycle management issues.

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How About Revenue Cycle Key Performance

Indicators (KPI) for FQHCs?

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Some Suggested Key Performance Indicators for

FQHCs

Patient Access Front Office Performance

Key Performance Indicator HIMSS Measure

HFMA Measure

Registration Error Ratio - -

Insurance Eligibility Verification Rate 98%

Point of Service Cash Collected 65%

Returned Mail Percentage < 5%

Medicaid Eligibility Screening -uninsureds

100%

Medicaid Eligibility Screening Medicare Onlys

100%

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FQHCs

Revenue Integrity


HFMA Measure

Days to Posting of Charges 85%

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FQHCs

Management


HFMAMeasure

Days in AR by Insurance Payer

Days in AR - Patients

Bad Debt - % of Net Revenue

Front Office Cash Collections % to Patient Net Revenue

Case Mix Net Revenue vs. Collections/Payer Type/Visit

Billing Managers sometimes communicate in a foreign language.

There is no Billing Manager school for FQHCs.

Need to expand the Billing Managers responsibility to include management of the revenue cycle.

Have regular meetings with Billing Manager and get more details about things not understood. Ask for acronyms to be explained.

The Billing Managers primary responsibility is to figure ways to get paid, sometimes irresponsibly or without proper knowledge.

Have the Billing Manager participate in any state-wide efforts with billing networks or other billing managers

Should consider having Billing Manager attend seminars, workshops and webinars sponsored by the National Association of Community Health Centers and your states Primary Care Association.

Be certain to have a succession plan for your billing managers position. Do not simply assume that having an assistant position will necessarily assure continuing operations.

Hold the Billing Manager accountable based on KPIs. All Executive Management staff should be involved, not just Supervisor.

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Sufficient service/patient demand

Provider supply and availability that reasonably match

demand for services

Operating infrastructure (e.g., staff, practice

management system) and processes that facilitate

moving patients efficiently through the system

Volume Revenues Expenses.theyre related.

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Meeting mission, vision & values

Providing the maximum number of services to the maximum number of patients in service population while staying financially viable and building reserves

Patients, services, quality, mission, revenue, cost, regulatory requirements and financial health all combine in a delicate balance. Problems in one area can easily upset the delicate balance.

Environmental pressures are threatening the CHCs delicate balance. Health reform will increase competition for patients who have a

payment source (e.g. Medicaid, private insurance), with the potential to erode an FQHCs -

Payor mix Patient base

Because of health reform, Federal and state governments are taking a new look at the health care financing system, potentially impacting FQHCs - Reimbursement rates

Subsidies for uncompensated care

Primary Care Medical Home

Accountable Care Organizations

The cost of providing healthcare services are increasing. Health centers are trying to improve provider productivity at

varying levels of success.

OPERATIONAL MANAGEMENT OF A CHC THE REALITY

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Benchmarking often describes comparing health center performance to national averages or medians

Meeting or beating the national average does not necessarily mean success Because of the delicate balance, a center could meet or exceed benchmarks in

one area but still not have successful overall performance. For example, a health center could have average provider productivity, but because of payormix and/or grant support it could still lose money

What is most important is to determine budget needs, establish plans that best address those needs, and then monitor achievement or lack of achievement, adjusting course if possible.

A centers best benchmark is itself. Performance vs. prior periods is more important than vs. a peer group

Executive management must be in charge of health center operations

Health center management must perform detailed, systematic analyses to

understand operations and how they affect productivity and performance.

Anecdotal information, assumptions, or the way weve always done

things, will give a misleading picture of how a health center functions and

what needs to change to improve performance.

Various tools are available to measure operational performance in each

health center department.

Once management understands its operations, it can begin to develop

effective solutions for improvement.

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Internal Benchmarks Establishing the Annual Operating Budget

Preparation of a carefully constructed annual operating budget allows

management to anticipate and prepare for financial success in the coming

year.

Projecting a budget begins with the determination of assumptions

(internal and external) and a projection of what level of visit volume is

needed to generate sufficient revenues for:

1. Breakeven with anticipated expenses

2. Generation of additional monies to establish sufficient cash reserves

3. Additional profits to cover:

a. Replacement of fixed assets

b. New or expanded services or sites

c. Bonuses/Incentives for providers and other staff

d. Other investments or arrangements

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Projected Visit Report

ABC Health Center - Budgeted Visit Report

Employee Position

Medical

FTE

Average

Visits Site A Site B Site C

Total

Budgeted

Visits

Dr. S. Smith Internist/Medical Dir. 0.4 4,302 1,721 1,721

Dr. B. Scott Pediatrics 1.0 4,056 4,056 4,056

Dr. P. Lee Pediatrics 1.0 2,500 2,500 2,500

Dr. H. Grafton Internist 1.0 3,935 3,935 3,935

Dr. A. Rosen Internist 1.0 4,202 2,101 2,101 4,202

Dr. L. Hanks Geriatrics 1.0 3,815 3,815 3,815

Dr. J. Diaz Internist 1.0 4,200 4,200 4,200

Ann Ramondo Nurse Practitioner 1.0 2,059 2,059 2,059

Leslie Arnold Nurse Practitioner 1.0 2,364 2,364 2,364

Rosa Ferraro Nurse Practitioner 1.0 2,628 2,628 2,628

Total 9.4 10,480 8,400 12,600 31,480

Average Annual Visits Per Full Time Equivalent Provider = 3,349

Payor Mix:

Changes in economy resulting in changes in payor mix

Implementation of Medicaid Managed Care, Child Health

Programs, Family Health Programs

Age of community

Changes in policy, (i.e., welfare reform, State programs -

uncompensated care)


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New Sites and/or Services:

Opening/Closing of a site

Consider whether a new site will shift visits from an

existing site.

Adding new services/departments


Revenue Projection

Patient Services Revenue Projections :

Site A Site B Site C Total

Visits 10,480 8,400 12,600 31,480

Revenue

Patient Services Revenue

Medicaid 451,084$ 239,400$ 399,000$ 1,089,484

Medicaid Managed Care 41,040 63,000 94,500 198,540

Medicare 125,325 63,000 157,500 345,825

Self-Pay 13,470 22,050 22,050 57,570

Other Third Party 29,925 31,500 55,125 116,550

Total Patient Services Revenue 660,844 418,950 728,175 1,807,969

How were determinations made about revenue per visit?

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Bottom Line

Site A Site B Site C Total

Visits 10,480 8,400 12,600 31,480 Revenue

Total Patient Services Revenue 660,844 418,950 728,175 1,807,969

Grants & Contracts 468,150 318,364 521,546 1,308,060

Wraparound 39,670 62,636 93,954 196,260

Interest Income 1,000 500 1,250 2,750

Miscellaneous 855 746 300 1,901

Total Revenues 1,170,519$ 801,196$ 1,345,225$ 3,316,940$

Expenses

Salaries

Direct 375,000 230,000 368,000 973,000

Fringe Benefit 90,000 55,200 88,320 233,520

Supplies 94,800 74,000 114,510 283,310

Total Direct Expenses 726,438 492,796 774,248 1,993,482

Total Indirect Expenses 454,438 297,789 559,691 1,311,918

Total Expenses 1,180,876 790,585 1,333,939 3,305,400

Income (Loss) (10,357)$ 10,611$ 11,286$ 11,540$

Is the $11,540 bottom line enough to meet annual goals?

Cash Reserves at 2-3 months of operating expenses

2 months of $3,305,400 = $ 550,900

Assume equipment depreciation of $50,000 year

Salary increases of 3% will require $75,550 (includes fringe)

Why Might the $11,540 Not Be Enough?

Assumptions for Bottom Line Needs

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Assume building of cash reserves to 60 days over three year

period:

$ 550,900 3 years = $ 185,000/year

Equipment Replacement $ 50,000/ year

Salary increases $ 75,550/next year

Bottom Line Needs = $ 310,550

Current Generation ( 11,540)

Addl Revenue Needs =$ 299,010

Why Might the $11,540 Not Be Enough?

Assumptions for Bottom Line Needs

Addl Revenue Needs $ 299,010

Patient Services Revenue $1,807,969

Wraparound Revenue 196,260

Total Patient Revenue $ 2,004,219

Visits 31,480

Revenue/Visit $ 63.67

Additional Revenue Needs $ 299,010 = 4,696

Revenue/Visit 63.67 Addl Visit

Needs

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Additional Visit Needs 4,696

Original visit projection 31,480

Total Visit Needs for Budget 36,176

Provider FTEs 9.4

New Visit Goal per Provider 3,850

Previous Budget 3,348

Increase 502

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STEP 1

We Must Set our Productivity Goals!

What Level of Productivity can we Realistically Expect to Achieve?

Step 2: Setting Goals for Productivity

The goal for the outcome of the productivity equation should be to maximize the fill rate

If our goal is to see 21 patients per day within a 7-hour clinical time, then the equation calculates as:

21 net result = Filled appointment slots of 21 X 20% (Net No Show Rate ) = 26 filled slots/day X 230 days in clinic = 4830 Visits/FTE

21 per day equates to 3 patients seen per hour

220 X 7 hours/day = 1,540 hours patient time

4,620 1,540 = 3 patients/hour

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21 Patient Visits Per Day or 4,620/FTE/Year

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The goal for the outcome of the productivity equation should be to maximize the fill rate

If our goal is to see 24 patients per day within a 8-hour clinical time, then the equation calculates as:

24 net result = Filled appointment slots of 21 X 20% (Net No Show Rate ) = 29 filled slots/day X 230 days in clinic = 5,520 Visits/FTE

24 per day equates to 3 patients seen per hour

230 X 8 hours/day = 1,840 hours patient time

5,520 1,840 = 3 patients/hour

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24 Patient Visits Per Day or 5,520/FTE/Year

Productivity targets must be clearly communicated and understood by all

parties

Providers, support staff, schedulers, other administrative staff

This includes discussing what happens to the volume when there are no-

shows, schedules are changed without approval, etc.

Productivity includes scheduler productivity as well

The center should establish guidelines for numbers of appointments scheduled by each scheduler just in the same way the center would establish provider

productivity targets

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STEP 2

DATA THAT HELPS PRODUCTIVITY

SYSTEMS

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No Shows by Provider

Walk Ins by Provider

Unfilled appointment slots by Provider

3rd next available appointment by Provider

Patient cycle time

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Consider no shows as anything that disrupts the appointment schedule:

Patients who simply do not show for their appointment with no notice

Patients who call either the evening before or the day of their appointment and cancel

Data Collection & Reporting

Must be calculated daily (Monday, Tuesday, etc.) Must be by provider

If your result is a percentage, what are you using as a denominator?

Filled appointment slots for the day, or

Available appointment slots for the day

Provider Monday Tuesday Wed Thurs Fri Average

Provider 1

22.2% 22.4 18.5 17.8 18.4 19.9

Provider2

20.4% 17.8 18.1 17.9 15.9 18.0

Provider 3

21.9% 21.8 23.4 20.8 24.2 22.4

Provider4

15.5% 14.6 18.4 13.6 15.3 15.5

Provider 5

21.6% 22.0 13.7 23.6 22.3 20.6

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Consider walk-ins as anything that disrupts the

appointment schedule:

Patients who simply show for their appointment with no notice

Patients who call either the evening before or the day of their appointment are worked-in.


Must be calculated daily (Monday, Tuesday, etc.)

Must be by provider

If your result is a percentage, what are you using as a denominator?

Filled appointment slots for the day, or

Available appointment slots for the day


Provider 1

2.2% 8.4 8.5 7.8 1.4 5.7

Provider2

10.4% 7.8 8.1 7.9 5.9 8.0

Provider 3

2.9% 2.6 3.8 7.8 6.2 4.7

Provider4

7.5% 6.6 7.4 5.6 8.3 7.1

Provider 5

5.6% 4.0 6.7 7.6 3.3 5.4

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Provider 1

20.0% 14.0 10.0 10.0 17.0 14.2

Provider2

10.0% 10.0 10.0 10.0 10.0 10.0

Provider 3

19.0% 19.2 19.6 13.0 18.0 3.6

Provider4

8.0% 8.0 11.0 8.0 7.0 8.4

Provider 5

16.0% 18.0 7.0 16.0 19.0 15.2

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Must determine what constitutes a full schedule for

each provider.

How many hours of clinical time are established for each work day? 7 hours? 8 hours?

How many slots are considered a full schedule for an hour of patient time? 2? 3? 4?

How many patient visits do you want to have at days end? 16? 21? 24?



Must be by provider

Will your PMS give you the data? If not, then what is involved in counting it manually?

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Provider 1 Provider 2 Provider 3 Provider 4 Provider 5

2/1 4 8 4 2 5

2/2 5 10 4 9 5

2/3 5 9 5 4 4

2/4 2 3 3 3 7

2/7 6 3 2 2 6

2/8 1 11 2 11 8

2/9 7 8 4 10 4

2/10 3 5 3 4 4

2/11 5 5 3 6 5

2/14 0 6 2 5 3

2/15 3 4 2 4 7

2/16 6 0 4 3 4

2/17 4 5 5 6 6

2/18 5 3 4 6 6

Totals 56 80 47 75 74

% Unfilled/Day 19% 27.2% 16% 25.5% 25%

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Defined as average length of time in days between the day a patients makes a request for an appointment with a [provider] and the third available appointment for a new patient physical, routine exam or return visit exam.

Health centers should understand the implications of this measure typically, full patient demand means the 3rd next available appointment is about two weeks

Source: Institute for Healthcare Improvement (www.ihi.org)

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2/1 2 1 4 2 5

2/2 3 1 4 1 5

2/3 Same 1 5 4 4

2/4 2 1 3 3 1

2/7 4 Same 2 2 2

2/8 4 Same 2 1 1

2/9 3 Same 4 1 3

2/10 2 Same 3 1 3

2/11 1 1 3 3 2

2/14 Same 1 2 3 2

2/15 3 1 2 2 1

2/16 2 Same 4 1 2

2/17 4 3 5 3 4

2/18 5 2 4 2 1

2/21 1 1 1 1 2

2/22 1 Same 1 2 1

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Consider time patient arrives at reception until they

check out and leave the health center:

Data needs to be captured at each health center site

Should not count those only arriving for prescriptions or refills or for taking labs, or should count separately



Should be totaled for month and an average determined by patient

Some EHRs now have time stamps for this purpose. May want to start simply by only measuring arrival and departure

times.

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Site 1 Site 2 Site 3 Site 4 Site 5

2/1 95 80 125 75 78

2/2 110 70 110 65 80

2/3 90 105 105 67 85

2/4 125 90 110 58 90

2/7 85 85 95 70 95

2/8 115 88 125 75 80

2/9 99 110 130 55 75

2/10 89 68 115 45 78

2/11 120 100 110 50 84

2/14 100 75 120 80 75

2/15 95 78 125 50 80

2/16 90 80 100 40 66

2/17 100 95 105 45 70

2/18 110 100 110 55 85

2/21 75 65 120 65 58

Average 105 86 114 60 74

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Elements/Milestones in Patient Cycle

Patient Arrival

Registration arrival

Registration complete

Move to exam room

Vitals/specimen taken &

patient ready for provider

Interaction with Provider

Provider-Patient interaction

complete

Move to check out

Check out complete

Patient departure

*Initial Focus if Concept is New to Your Health Center

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Cycle times per health center site should be given to Practice Improvement committee

Goal should be to bring recommendations to the CEO for changes that would increase efficiencies

Consider a Nurse manager in the back office at each health center that would be utilized as a traffic cop

Primary responsibility would be to keep exam rooms full at all times.

Must coordinate with front office, nurses and providers.

Must listen to providers about their needs in developing a productive environment

Doesnt mean they need more nurses Must consider keeping them focused on seeing patients

Step 3

WE MUST ESTABLISH A PRODUCTIVE ENVIRONMENT

FOR OUR PROVIDERS!

Delivery of Patient Service

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Patient Arrives in

Clinical Area From

Registration

Have Exam Room

Cleaned and

Prepped for Next

Visit

Call for Medical

Chart

Medical Record

Available?*

Ancillary

Service

Needed?

Provider

Ready?

Exam Room

Prepared?

Patient Checkout/

Billing Office

*Health Centers with

Electronic Medical Records

eliminate this question.

Patient Exam

YES

NO

YES

NOYES

Patient Waits

Patient Routed to

Ancillary Department

NO

YES

Objective - To prepare facilities and patients for a productive visit with a provider as quickly as possible

Clinical support staff (e.g. nurses, medical assistants) impact patient flow and provider productivity. They should:

Understand and perform their job functions (e.g., retrieve and prepare patients

in a timely manner, prepare exam rooms, maintain exam room supply

inventory);

Have supervision who monitors performance and resolves issues that

negatively influence performance;

Be organized in a workable staffing model (i.e., nurses versus MAs) that has

a sufficient complement. There is not a right staffing model instead health centers tend to equalize the cost of

these staff by the skill level mix (i.e. CHCs with a nurse staffing model tend to have less clinical support staff per provider).

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Role of Providers in Increasing

Productivity

Objective - To provide the highest possible quality of care to the maximum

number of patients

Providers should:

Direct questions/comments/requests regarding appointment scheduling to the

appropriate manager, not the staff person who performs the function.

Discuss schedule changes with the Chief Medical Officer as soon as possible (and

secure approval, as appropriate).

Arrive at work at least 15 minutes before their first appointment each day (everyone

needs prep time).

Resist the natural tendency to treat all the conditions of medically complex patients

who have been noncompliant (e.g., repeat no-shows) during a single visit.

Establish a protocol to identify and then reschedule noncompliant patients.

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Providers should:

Minimize time devoted to non-patient care activities

Occasions requiring long travel times (e.g., between care

sites) during the middle of the day; Consider

benefit/disadvantages of such schedules

Administrative time

Time off during peak volume cycles

Consistently document care, at least sufficiently to support

selected diagnostic and procedure codes, before each patient is

discharged.

Maintain an ongoing dialogue with support staff regarding ways to

increase the teams collective productivity.

Share impediments to increased productivity with management

and jointly conclude ways to eliminate them.

MANAGEMENT

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Management will be most effective when they enable, not dictate, increased productivity

(EVENTUALLY) Implement Incentive compensation

Will encourage increased provider productivity Will not remove operational impediments that suppress it Make start the conversation about, or make the providers

stakeholders in, removing obstacles to productivity

Operating processes that are clearly defined, thoroughly understood and consistently carried out are key

Keep key operating data, i.e., 3rd next available appointment by provider, no shows, walk-ins, patient satisfaction, etc.

ROLE OF MANAGEMENT IN INCREASING

PROVIDER PRODUCTIVITY

Monitoring staff conformity with defined processes is required to ensure continued compliance.

Measure process time

Measure patient cycle time

Identify bottlenecks

Review exam room utilization

Review patient satisfaction surveys

Directly observe patient flow

Identify space needs of operations

Review health center space layout

Establish provider schedules and appointment scheduling

Create a continuous feedback loop that informs ALL parties.

Oftentimes the best forum for communication is facilitated peer-to-peer interaction.

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STEP 4

Utilizing The Appointment Scheduling System to Assure Productivity Levels

Management Must Be Involved in Our Appointment Scheduling System

Step 3: Implementing a Productivity Program

There is a direct relationship between the appointment schedule and the number of visits done at the health center

In turn, this will be reflected in the financial and mission performance of the health center

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The Schedule is either a facilitator of, or an obstacle to access &

productivity

The Schedule is owned by the health center.

The Schedule is a proxy measure for efficiency of resources

Resources including human resources, fixed assets, supplies, etc.

When the schedule is well-designed and adhered to, it will assist patients

in obtaining the health care services they need

Staff will be clear on how to handle patients requests for appointments

Patient satisfaction with the process will be high

The schedule will help regulate the input of patients into the operations of the health center and assist in speeding patient flow

78

When the schedule is not well designed, patients cannot

access the center when they need to

Providers have full schedules, yet productivity is not

optimal

The health center may be experiencing financial or

other difficulties

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The final template is a product of trial and error. Must adjust for

Net No Shows.

Ideally, each providers appointment template will be based on their

individual experience with no shows and walk-ins.

Aim is toward maximal productivity on the part of providers along

with ease of accommodating patients in slots

Must test the fact that schedules can be completely filled with

desired number of full slots. If not, then must analyze unfilled

appointment slots and 3rd next available appointment data. There

must be an alignment between number of providers and demand.

80

81

For a 24 visit schedule, assume providers work 8 am to 12 pm, and 1 pm to 5 pm Monday through Friday (or in a 21 visit schedule, maybe 9 am to 12pm and 1pm to 5pm.

Provider has 2 exam rooms available for work. Appointments for problems and follow-ups are scheduled

every 15 minutes, across more than one room Physicals are given 2 slots, and are limited to two per

session, one in each room, other room is blocked during this time

The new patient, physical and procedure slots are not restricted if 3rd next available appointments are less than 8 days or if there are consistently unfilled appointment slots based on the data.

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Scheduling staff should make every attempt to schedule the next available appointment that meets patient specifications.

Practice management system should have an built in algorithm that facilitates the identification of next available slots.

On a regular basis, the front office manager and/or business manager should:

Review and monitor the scheduling of patient visits;

Check that appointments are being double/triple-booked, as appropriate; and

Review the impact of special requests on appointment scheduling (e.g., unanticipated provider schedule changes).

Schedulers should fill the full days schedule.

Dont stop scheduling appointments early.

Use same-day appointment to fill open and cancelled appointment slots.

82

Conclude provider schedules (i.e., availability) and

scheduling templates (i.e., standard time slots by

provider for each appointment type) as policy

Deviation from this policy should require the Chief Medical Officers or CEOs approval

Dont put Schedulers in the unenviable position of debating scheduling issues with providers

Ultimately, the schedule belongs to the center, not

the provider

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To keep the schedule simple, a health center should try to limit the types of appointments as much as possible

Physicals (new patients and existing patients) are usually the longest types (30 minutes)

Problem Visits -- new and existing patients (15 minutes)

Urgent Care Visits new and existing patients (15 minutes)

Follow Up Visits (15 minutes)

Procedures (if your center does them) (15-30 minutes)

Using these set appointment types will also encourage the utilization of the slots for all kinds of patients on a daily basis those who call in, recall visits at the providers behest, walk-ins, etc.

Limiting appointments by type, i.e., physicals, new patients, can be a barrier to care.

84

85

Pros

Able to calculate no-show rates by visit type easily (e.g., HIV visits)

Helps regulate supply of visits to certain types of care, like

procedures, the HIV example, etc.

Cons

Too much detail can cause the wrong appointment type to be chosen

May unnecessarily restrict access to care

If the specific appointment type is not available for 4 months, should a patient really be kept waiting, especially if other appointment types of the same length are going unfilled?

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Consider Staggering Staff/Provider Hours

The schedule will not work well if the health center opens the front desk at 8:00 a.m. it needs to open at 7:30 or 7:45 to be viable

Support staff also must be in the center ready to work.may need to stagger hours

The provider must also arrive no later than 7:45 everyone needs time to get the day started and to be prepared

86

Lunch hour has been provided for in these examples It will always happen that patients run over time, and support staff

will need to adjust accordingly

Managers have to adjust staffing schedules on the fly in order to maintain services

Closing time is also in this example Staffing properly by staggering starting and ending times of staff will

allow for individuals to be available to serve the patients as they

present

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Providers have other things to do that are incident to their direct patient

care

Review of laboratory reports

Writing case reports for other physicians

Phoning Patients for questions, lab results, etc.

Some centers provide set-aside administrative time for these activities (not

recommended)

The most productive providers do this work between patients, around lunch

time, after-hours, etc.

Meetings also take valuable time

These should be scheduled as often as possible in the morning, the evening, and over lunchtime

88

Costing for Understanding Provider

Staffing and Services

89

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Description Worksheet Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Provider 6 Provider 7 Provider 8 Provider 9 Totals

Provider Cost

Salary/Contract Amount A 112,500 120,008 101,999 100,000 100,000 100,000 100,000 115,000 104,000 953,507

Fringe Benefits B 20,813 22,201 18,870 18,500 18,500 18,500 18,500 21,275 19,240 176,399

Nursing Salary & Fringe Allocation C 60,577 96,924 72,693 121,155 121,155 121,155 121,155 121,155 121,155 957,122

Medical Supplies D 14,582 14,489 6,406 15,809 14,318 13,340 6,150 12,416 19,016 116,524

Allocation of Space Costs E 5,602 8,963 6,722 11,204 11,204 11,204 11,204 11,204 11,204 88,510

Other Direct Costs F 5,529 8,846 6,634 11,057 11,057 11,057 11,057 11,057 11,057 87,352

2,379,414

Share of Overhead Costs G 77,984 124,775 93,581 155,969 155,969 155,969 155,969 155,969 155,969 1,232,154

Total Provider Costs 297,587 396,206 306,905 433,693 432,203 431,224 424,034 448,075 441,640 3,611,568

Analysis

Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Provider 6 Provider 7 Provider 8 Provider 9 Totals

Provider FTE 0.50 0.80 0.60 1.00 1.00 1.00 1.00 1.00 1.00 7.90

Appointments Slots 18/Day X 220 X FTE 1,980 3,168 2,376 3,960 3,960 3,960 3,960 3,960 3,960 31,284

Cost Per Appointment Slot 150.30 125.07 129.17 109.52 109.14 108.90 107.08 113.15 111.53 115.44

Visits 1,878 1,866 825 2,036 1,844 1,718 792 1,599 2,449 15,007

Unfilled Slots 102 1,302 1,551 1,924 2,116 2,242 3,168 2,361 1,511 16,277

Annual Cost of Unfilled Slots 15,330 162,835 200,341 210,714 230,945 244,143 339,227 267,148 168,515 1,839,197

Unfilled Slots @ Revenue/Visit 14,851 189,571 225,826 280,134 308,090 326,435 461,261 343,762 220,002 2,369,931

Lost Opportunity Dollars 4,209,128

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Affordable Provider Cost at Current Fill Level

Total Provider Cost 3,611,568

Filled Slots % of Total Slots Available

15,007 31,284 = 48.00%

Affordable Provider Cost 1,733,553

Average Cost Per FTE Provider

or $ 3,567,130 7.9 FTEs = 451,535

Number of FTEs supported by Current

Provider Productivity 3.84

Current Provider Visits Per FTE 1,900

Required Level Per FTE at Affordable Level 3,960

Monday Tuesday Wednesday Thursday Friday Saturday Totals Monday Tuesday Wednesday Thursday Friday Totals

Provider 1 0 19 19 19 56

Provider 2 26 26 26 26 26 130 0

Provider 3 23 17 19 59 0

Provider 4 26 26 26 26 26 130 0

Provider 5 26 26 26 78 26 26 52

Provider 6 0 26 26 26 26 26 130

Provider 7 26 26 26 26 26 130 0

Provider 8 26 26 26 26 26 130 0

Provider 9 14 28 26 16 84 28 28

Totals 167 175 52 149 52 0 741 45 45 52 45 52 266

Site One

Provider Template Slots

Site Two

Provider Template Slots

Is Your Schedule Designed Such That it Produces Desired Results?

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Total Weekly Slots Available

MD's (totals for 1 week X 44 weeks) 10,780

Mid-Levels (totals for 1 week X 44 weeks) 33,528

Totals 44,308

Analysis Actual Variance

Ann'zed Visits From Actual

Available Slots X 12 Months = Annual Visits 44,308

X No Show Rate of 35% 15,508

Net Billable Visits from Current Schedule 28,800 15,601 13,199

X Average Collections Per Visit of $145.00 = $4,176,000 $2,262,145 $1,913,855

Excess

% No Show % Fill Rate Revenue Cost (Loss)

Date Day of Week # Providers 8-12noon 12-1pm 1-5pm Totals 8-12noon 12-1pm 1-5pm Totals

Site One - Monday's

1/4/2016 Monday 5.00 43 13 46 102 33 9 35 77 24.5% 78.46% 11,211.20 12,863.50 (1,652.30)

1/11/2016 Monday 5.00 42 15 41 98 32 15 36 83 15.3% 75.38% 12,084.80 12,863.50 (778.70)

1/25/2016 Monday 4.33 31 18 44 93 25 11 33 69 25.8% 82.61% 10,046.40 11,139.79 (1,093.39)

Totals Site One - Monday's 116 46 131 293 90 35 104 229 21.8% 33,342.40 36,866.79 (3,524.39)

Site One - Tuesday's

1/5/2016 Tuesday 3.00 21 19 24 64 21 18 20 59 7.8% 88.89% 8,590.40 7,718.10 872.30

1/12/2016 Tuesday 3.00 16 9 26 51 12 8 22 42 17.6% 70.83% 6,115.20 7,718.10 (1,602.90)

1/19/2016 Tuesday 4.33 19 20 22 61 18 14 19 51 16.4% 58.70% 7,425.60 11,139.79 (3,714.19)

1/26/2016 Tuesday 3.00 11 17 16 44 7 15 14 36 18.2% 61.11% 5,241.60 7,718.10 (2,476.50)

Totals Site One - Tuesday's 67 65 88 220 58 55 75 188 14.5% 27,372.80 34,294.09 (6,921.29)

Site One - Wednesday's

1/6/2016 Wednesday 5.00 32 7 35 74 25 6 31 62 16.2% 61.67% 9,027.20 12,863.50 (3,836.30)

1/13/2016 Wednesday 4.00 26 3 30 59 16 2 28 46 22.0% 61.46% 6,697.60 10,290.80 (3,593.20)

1/20/2016 Wednesday 5.00 43 9 40 92 37 8 37 82 10.9% 76.67% 11,939.20 12,863.50 (924.30)

1/27/2016 Wednesday 5.00 28 6 35 69 22 4 34 60 13.0% 57.50% 8,736.00 12,863.50 (4,127.50)

Totals Site One - Wednesday's 129 25 140 294 100 20 130 250 15.0% 36,400.00 48,881.30 (12,481.30)

# of Patients Scheduled

# of Patients Seen

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January 2016 Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Provider 6 Provider 7 Provider 8 Provider 9 Totals

Number Scheduled

Mondays 54 61 41 37 51 51 47 25 60 427

Tuesdays 56 59 53 47 57 71 50 21 95 509

Wednesdays 53 53 56 9 21 0 50 28 72 342

Thursdays 17 55 69 64 67 47 48 34 51 452

Fridays 32 54 55 0 25 0 50 22 67 305

212 282 274 157 221 169 245 130 345 2035

Number Kept (or Seen)

Mondays 40 36 27 27 34 35 34 23 40 296

Tuesdays 44 41 38 24 37 41 22 17 64 328

Wednesdays 41 33 29 7 18 0 39 26 42 235

Thursdays 13 46 40 40 46 25 35 25 31 301

Fridays 32 44 39 0 19 0 37 17 43 231

170 200 173 98 154 101 167 108 220 1391

% Not Kept (or No Show %)

Mondays 0.259 0.410 0.341 0.270 0.333 0.314 0.277 0.080 0.333 0.307

Tuesdays 0.214 0.305 0.283 0.489 0.351 0.423 0.560 0.190 0.326 0.356

Wednesdays 0.226 0.377 0.482 0.000 0.143 0.000 0.220 0.071 0.417 0.313

Thursdays 0.235 0.164 0.420 0.375 0.313 0.468 0.271 0.265 0.392 0.334

Fridays 0.000 0.185 0.291 0.000 0.240 0.000 0.260 0.227 0.358 0.243

Provider

Slots Available Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Provider 6 Provider 7 Provider 8 Provider 9 Totals

Mondays 78 78 78 54 78 67 68 74 79 654

Tuesdays 93 86 84 64 90 72 52 83 98 722

Wednesdays 99 96 100 14 96 0 100 97 75 677

Thursdays 26 104 104 98 104 40 104 104 84 768

Fridays 52 104 104 0 104 0 104 104 112 684

348 468 470 230 472 179 428 462 448 3505

Number Scheduled

Mondays 54 61 41 37 51 51 47 25 60 427

Tuesdays 56 59 53 47 57 71 50 21 95 509

Wednesdays 53 53 56 9 21 0 50 28 72 342

Thursdays 17 55 69 64 67 47 48 34 51 452

Fridays 32 54 55 0 25 0 50 22 67 305

212 282 274 157 221 169 245 130 345 2035

Fill Quotient

Mondays 0.692 0.782 0.526 0.685 0.654 0.761 0.691 0.338 0.759 0.653

Tuesdays 0.602 0.686 0.631 0.734 0.633 0.986 0.962 0.253 0.969 0.705

Wednesdays 0.535 0.552 0.560 0.000 0.219 0.000 0.500 0.289 0.960 0.505

Thursdays 0.654 0.529 0.663 0.653 0.644 1.175 0.462 0.327 0.607 0.589

Fridays 0.615 0.519 0.529 0.000 0.240 0.000 0.481 0.212 0.598 0.446

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January February 1/2 March Totals Annualized

Analysis

At 90% Fill rate and: 3,155 2,823 1,672 7,650 36,720

If No Show Rate were 30% 2,208 1,976 1,171 5,355 25,704

Difference from Actual Visits 817 711 393 1,921 9,221

$ Value @ $145.60/Visit $118,977 $103,567 $57,154 $279,698 $1,342,548


Difference from Actual Visits 1,133 994 560 2,686 12,893

$ Value @ $145.60/Visit $164,907 $144,674 $81,501 $391,082 $1,877,192

At 80% Fill rate and: 2,804 2,510 1,486 6,800 32,640



$ Value @ $145.60/Visit $83,254 $71,594 $38,217 $193,066 $926,715



$ Value @ $145.60/Visit $124,080 $108,134 $59,859 $292,074 $1,401,953

At 70% Fill rate and: 2,454 2,196 1,301 5,950 28,560

If No Show Rate were 30% 1,717 1,537 910 4,165 19,992

Difference from Actual Visits 326 272 132 731 3,507

$ Value @ $145.60/Visit 47,466 39,622 19,280 106,368 510,567

0



$ Value @ $145.60/Visit 83,254 71,594 38,217 193,066 926,715

Current Fill Rate = 58% 64% 67% 62%

At Current Fill rate and: 2,035 2,002 1,236 5,273 25,310



$ Value @ $145.60/Visit $4,950 $19,802 $12,667 $37,419 $179,611



$ Value @ $145.60/Visit $34,507 $49,067 $30,722 $114,296 $548,621

Actual Patients Seen 1,391 1,265 778 3,434 16,483

2016

99

Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Totals

Physician Physician Physician FNP PA

4 hours admin. time per provider

4 hours X 44 weeks (220 days 5 days) 176 176 141 176 176 845

Patient Visits - 4 hours admin X 12

visits 528 528 422 528 528 2,534

Cost Per Appointment Slot Unfilled 126.66 126.91 130.03 121.79 121.05 125.09

Total Cost of Administrative Time 66,876 67,009 54,873 64,303 63,914 316,977

Loss Revenue at $ 100/visit 52,800 52,800 42,200 52,800 52,800 253,400

Total Financial Impact of Adminstrative Allowance 119,676 119,809 97,073 117,103 116,714 570,377

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Adj to 100%

Net Net # of Days # of Days Avg. Days FTE Days

Provider Name FTE Total Hrs. Holiday Vacation Sick CME Other Worked FTE Worked In Yr/FTE Off Off

Provider 1 0.06 132.50 18.00 114.50 0.06 14 17 2 35

Provider 2 1.00 2,080.00 88.50 137.50 97.00 38.00 8.00 1,711.00 0.82 214 260 46 46

Provider 3 0.28 583.00 24.00 9.00 10.00 540.00 0.26 68 73 5 19

Provider 4 1.00 2,080.00 96.00 211.00 104.50 16.00 1,652.50 0.79 207 260 53 53

Provider 5 1.00 2,080.00 89.25 150.00 21.00 18.50 1,801.25 0.87 225 260 35 35

Provider 6 0.82 1,696.00 95.50 112.50 107.00 16.00 1,365.00 0.66 171 212 41 51

Provider 7 0.11 224.00 8.00 8.00 208.00 0.10 26 28 2 19

Provider 8 0.51 1,064.00 32.00 80.00 4.50 947.50 0.46 118 133 15 28

Provider 9 0.28 584.00 24.00 4.00 556.00 0.27 70 73 4 12

Totals and Averages 5.06 10,523.50 457.25 730.00 323.00 59.00 58.50 8,895.75 4.28 124 146 23 33

Analysis of Provider Time Off

# of Work Days in Year = 260.00

Avg.Work Days off Per Provider 33.00

Avg Work Days Per Provider 227.00

Outliers

Provider 2 46

Provider 4 53

Provider 5 35

Provider 6 51

Cost of Excess Days

53 Days X Avg Provider Cost/Day of $ 1758 = $93,190

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Excess

% No Show % Fill Rate Revenue Cost (Loss)

Date Day of Week # Providers 5-6pm 6-7pm 7-8pm Totals 5-6pm 6-7pm 7-8pm Totals

Site One

1/4/2016 Monday 2.00 5 8 0 13 4 6 0 10 23.1% 65.00% 1,456.00 1,979.00 (523.00)

1/5/2016 Tuesday 2.00 7 6 0 13 5 4 0 9 30.8% 65.00% 1,310.40 1,979.00 (668.60)

1/7/2016 Thursday 1.00 3 1 0 4 3 1 0 4 0.0% 40.00% 582.40 989.50 (407.10)

1/11/2016 Monday 2.00 5 7 0 12 3 6 0 9 25.0% 60.00% 1,310.40 1,979.00 (668.60)

1/12/2016 Tuesday 2.00 8 6 0 14 5 6 0 11 21.4% 70.00% 1,601.60 1,979.00 (377.40)

1/14/2016 Thursday 1.00 3 3 0 6 2 2 0 4 33.3% 60.00% 582.40 989.50 (407.10)

1/19/2016 Tuesday 1.00 4 3 0 7 2 2 0 4 42.9% 70.00% 582.40 989.50 (407.10)

1/21/2016 Thursday 1.00 3 3 0 6 3 2 0 5 16.7% 60.00% 728.00 989.50 (261.50)

1/25/2016 Monday 2.00 5 6 0 11 5 4 0 9 18.2% 55.00% 1,310.40 1,979.00 (668.60)

1/26/2016 Tuesday 3.00 8 5 0 13 7 4 0 11 15.4% 43.33% 1,601.60 2,968.50 (1,366.90)

1/28/2016 Thursday 1.00 5 5 0 10 5 3 0 8 20.0% 100.00% 1,164.80 989.50 175.30

Totals Site One - January 2016 56 53 0 109 44 40 0 84 22.9% 12,230.40 17,811.00 (5,580.60)

Late Hours

# of Patients Scheduled

Late Hours

# of Patients Seen

Central Office

Patient Services & Other Revenue Visits Rate/Visit Net Revenue Visits Rate/Visit Net Revenue Revenue Visits Net Revenue

Medicare 609 83.52 50,864 628 83.52 52,451 1,237 103,314

Medicare Managed Care 517 83.52 43,180 232 83.52 19,377 749 62,556

Medicaid 1,508 99.62 150,227 396 99.62 39,450 1,904 189,676

Medicaid Managed Care 835 99.62 83,183 232 99.62 23,112 1,067 106,295

Private Insurance/Other 729 76.30 55,623 425 76.30 32,428 1,154 88,050

Self-Pay @ 200% or Above 0 58.08 0 0 58.08 0 0 0

Self-Pay Below 200% 2,882 12.00 34,584 1,656 12.00 19,872 4,538 54,456

Federal Grant Funds 1,110,331 1,110,331

Other Revenue 80,777 80,777

Total Revenue 7,080 417,660 3,569 186,688 1,191,108 10,649 1,795,456

Allocation of CO Revenues 1,036,633 154,475 (1,191,108) 0

Revenue After Allocation of CO 1,454,293 341,163 0 1,795,456

Expenses Personnel

Total Salaries Cost 475,701 213,810 373,171 1,062,682

Fringe Benefits 122,303 54,971 95,942 273,216

Total Personnel Cost 598,004 268,781 469,113 1,335,898

Contract Expenses 54,612 9,566 127,178 191,356

Supplies 36,827 6,562 12,208 55,597

Total Other Expenses 48,445 48,589 120,998 218,032

Total Operating Expenses 737,888 333,498 729,497 1,800,883

Allocation of Central Office Costs 503,353 226,144 (729,497)

Total Cost of Operations Per Site 1,241,241 559,642 0 1,800,883

Revenues Over (Under) Expenses 213,052 (218,479) (5,427)

TotalsSite One Site Two

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0

100

200

300

400

500

600

700

800

8 - 9am 9 -10am

10 -11am

11 -12pm

12 -1pm

1pm -2pm

2pm -3pm

3pm -4pm

4pm -5pm

5pm -6pm

Number of Answered Calls

Answered Calls January

Answered Calls February

Answered Calls March

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

8 - 9am 9 - 10am 10 -11am 11 -12pm

12 - 1pm 1pm -2pm

2pm -3pm

3pm -4pm

4pm -5pm

5pm -6pm

% of Answered Calls Versus Time of day

January

February

March

0

50

100

150

200

250

300

8 - 9am 9 - 10am 10 -11am

11 -12pm

12 - 1pm 1pm -2pm

2pm -3pm

3pm -4pm

4pm -5pm

5pm -6pm

Number of Unanswered Calls

Unanswered Calls January

Unanswered Calls February

Unanswered Calls March

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

8 - 9am 9 - 10am 10 -11am 11 - 12pm 12 - 1pm 1pm -2pm

2pm -3pm

3pm -4pm

4pm -5pm

5pm -6pm

% of Unanswered Calls Versus Time of day

January

February

March

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STEP 5

Are We Meeting Our Goals?

We Must Continue to Monitor Progress Using Data to Evaluate

We Must Make Adjustments When Results Arent Meeting Our Goals

Step 4: Evaluation and Review

Monthly Monthly Variance YTD YTD Variance

Budget Actual Over(Under) Budget Actual Over(Under)

Billiable Patient Visits

Site/Provider #1

Medicare 50 35 (15) 600 650 50

Medicaid 150 134 (16) 1,800 1,820 20

Private Insurance 30 33 3 360 350 (10)

Self-Pay Patients 110 125 15 1,320 1,400 80

Other 10 14 4 120 110 (10)

Total for Site/Provider #1 350 341 (9) 4,200 4,330 130

Site/Provider #2

Medicare 55 50 (5) 660 625 (35)

Medicaid 165 160 (5) 1,980 2,080 100

Private Insurance 35 40 5 420 450 30

Self-Pay Patients 105 110 5 1,260 1,330 70

Other 10 11 1 120 95 (25)

Total for Site/Provider #2 370 371 1 4,440 4,580 140

Total for All Sites/Providers

Medicare 530 540 10 6,360 6,400 40

Medicaid 1,550 1,675 125 18,600 17,900 (700)

Private Insurance 400 410 10 4,800 4,650 (150)

Self-Pay Patients 1,350 1,440 90 16,200 17,500 1,300

Other 200 190 (10) 2,400 2,150 (250) Total for All Providers 4,030 4,255 225 48,360 48,600 240

Walk-ins 20% 25% 5% 20% 26% 6%

No Shows 30% 40% 10% 30% 42% 12%

New Patients

Medicare 6 3 (3) 72 61 (11)

Medicaid 45 38 (7) 540 490 (50)

Private Insurance 3 1 (2) 36 30 (6)

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2/1 4 8 4 2 5

2/2 5 10 4 9 5

2/3 5 9 5 4 4

2/4 2 3 3 3 7

2/7 6 3 2 2 6

2/8 1 11 2 11 8

2/9 7 8 4 10 4

2/10 3 5 3 4 4

2/11 5 5 3 6 5

2/14 0 6 2 5 3

2/15 3 4 2 4 7

2/16 6 0 4 3 4

2/17 4 5 5 6 6

2/18 5 3 4 6 6

Totals 56 80 47 75 74

% Unfilled/Day 19% 27.2% 16% 25.5% 25%


Provider 1

20.0% 14.0 10.0 10.0 17.0 14.2

Provider2

10.0% 10.0 10.0 10.0 10.0 10.0

Provider 3

19.0% 19.2 19.6 13.0 18.0 3.6

Provider4

8.0% 8.0 11.0 8.0 7.0 8.4

Provider 5

16.0% 18.0 7.0 16.0 19.0 15.2

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110

111

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Is your health center environment

structured in a way that ensures the

highest

effectiveness and efficiencies?

What are the components of successful health centers

culture that support an incentive compensation

system?

Accountability

Goal Setting

Provider focused

Productive environment

Incentive Compensation

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Transparency Providers and staff have to understand how the system works, and

how their job duties contribute to the overall performance of the center

Also must know how much they can potentially earn either in dollars, or percent of salary

Customization An incentive system has to be designed to fit the centers

operations

Must have an adequate reporting system on progress or lack there of.

Size of the Center The system should be proportional and realistic

A center with a budget of $5 million probably cannot support a total package of incentives worth $500K it is out of scale with the centers operations

WHAT MAKES AN INCENTIVE SYSTEM WORK?

MAKING INCENTIVES MEANINGFUL

Amount of the incentive

Target incentive compensation must be large enough to be a

meaningful incentive

May mean limiting participants

Linked directly to performance

Incentives cannot be pennies from heaven

Established around distinct criteria

A center should have requirements for participation in the

incentive program

Who participates if everyone gets incentive comp regardless

of individual performance, is there any true incentive?

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POTENTIAL PARTICIPATION CRITERIA

Minimum FTE requirement

e.g., 50% FTE minimum

Minimum length of service, and/or prorated based on length of

service during the year being incentivized

e.g., must be employed minimum of 6 months in the year, then

prorated to actual length of service

Employment status on date of payment

Must be an employee in good standing on the date of payment

Cannot be in a performance plan or on probation

Establishing an incentive system can be a culture change

Providers and staff may have chosen to work in a CHC because of

a (perceived) lack of focus on accountability; may be accustomed

to this type environment

Personnel may consider a helping culture to be more to their

liking

e.g., an example center where 50% of the provider team said

they didnt want incentive compensation, because it would

change the workplace too much

They preferred an environment where the most productive

physician noted that she voluntarily works extra shifts to

assist her colleagues who have children and family

obligations, and the team didnt want to upset that kind of

dynamic

CENTER CULTURE

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A center must develop a system that works within the environment

that exists at the center in terms of its finances, culture, and

operations

Incentive systems ultimately call into question every operating

tenet that the center has

Changes the way the center views teamwork, cost

containment, roles and responsibilities, outreach, customer

service, etc.

With the alignment of goals, expect that outspoken members of the

team will question the activities of coworkers, including senior

leaders, who become more accountable to the rest of the team as to

how their jobs impact the centers performance

IMPLEMENTING AN INCENTIVE SYSTEM

Provider Incentive Funding and

Participation

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Provider eligibility Participation should be based on a minimumFTE standard.

New Hires - providers should be on staff for one quarter prior to

participation to allow providers time to familiarize themselves with

the program and to build up a patient panel.

Threshold - The distribution of the funding for each component is

distributed among participating providers based on the performance

standards set by the organization. Performance standards are set by

determining acceptable minimum thresholds.

Weight of Component Each component carries a percentage

weight that determines the value of each component when

calculating the overall performance rating of a provider.

FACTORS TO CONSIDER PRIOR TO IMPLEMENTATION

Budget Neutral Approach Minimum or baseline productivity should

balance budget revenue expectations

Ability to Fund Incentive Pool Must have dollars set aside to pay

incentives.

Quality Importance A zero score on quality should have the result of

no incentive/bonus payments

FTE Definition Providers and management must agree on the FTE

definition used to determine productivity.

Agreement on Services to be Included The service areas should be

agreed upon between management and providers that will be used to

assign units for productivity.

Factors to consider prior to plan implementation

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Linking performance to incentive compensation could be executed in the following manner:

A. Risk

1) Cost of living adjustment at 3% to fund the pool

B. Opportunity-Based Increase

1) Group productivity incentive at 20% of net collections over standard

INCENTIVE POOL FUNDING

A. Risk

In lieu of annual salary increases for providers, the cost of living adjustment

can be utilized to fund the incentive compensation plan.

Total Providers 2015 Annual Base Salary $800,000

Expected 2015 Cost of Living Adjustment (3%) $24,000*

Total Providers 2016 Base Salary $800,000

Expected 2016 COLA (3%) $24,000

2016 Incentive Pool Funding $48,000


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B. Opportunity-Based Increase

Step One: Calculate Total Productivity

Current Target FTEs Annual Visits Annual Visits

Physician Standard Billable Visits 20 4,000 4,200

Mid-level Standard Billable Visits 10 2,400 2,500

(Billable visits count after provider has worked for six months)

Note: Target visits is approximately 5% above current productivity


B. Opportunity-Based Increase (continued)

Step Two: Calculation of Incremental Visits

Visit Total

FTEs Target Visits

Physicians 20 4,200 84,000

Mid-levels 10 2,500 25,000

Total Visits 109,000

Target Quarterly Visits (109,000/4) 27,250

Billable Visits for Quarter (actual) 29,250

Incremental Visits (Actual Target) 2,000


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B. Opportunity-Based Increase (continued)

Step Three: Calculate an average collection per visit using current billable visits

Evaluation of Collections:

Cash Collected for Quarter: $1,112,500

330 Grant Quarterly Allocation 350,000

Total Collections $1,462,500

Current Billable Visits for Quarter 29,250

Average Collection Per Visit ($1,462,500/29,250) $50.00

Incremental Visit Collections ($50 X 2,000) $100,000

Funding of the Pool ($100,000 X 20%) $20,000


Incentive Plan Structure

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Goals should be carefully chosen to balance conflicting

priorities, such as encouraging improvement in

provider efficiency and effectiveness while maintaining

a high level of quality of care. Categories of goals

could include:

Productivity

Patient Satisfaction

Quality of Care

Contribution to the Organization

COMPONENTS OF A PROVIDER PERFORMANCE

MONITORING PROCESS

Productivity is a key measure of provider performance. Increasing productivity can:

Maximize patient throughput Realize additional revenue Increase a health centers capacity to meet the needs of the

community

The most effective way to evaluate provider productivity is to use visits to measure financial contribution, and Relative Value Units (RVUs) to measure service contribution.

PROVIDER PRODUCTIVITY

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Providers (both physicians and mid-levels) can be evaluated against benchmarks appropriate for each provider level. Sample quarterly benchmarks are as follows:

Score Standing Score Quarterly Visits per FTE

Exceeds Expectations 4 1,200

Meets Expectations 3 1,000

Needs Improvement 2 850

Does Not Meet Expectations 1 < 750

Based on this example, a provider with 700 visits per FTE would score a 2 (Needs Improvement). Productivity is calculated utilizing billable visits. It is therefore imperative that provider coding patterns are monitored.

PROVIDER PRODUCTIVITY SCORING

Patient satisfaction is critical to maintaining and/orincreasing market share. Efforts to increase productivityand efficiency should enhance rather than mitigate patientsatisfaction. Providers who strive to meet their patientsexpectations should be acknowledged and rewarded.

It is extremely important to extract provider satisfactionfrom the patients overall health center experience.Therefore, factors beyond the providers control, such ashealth center amenities, waiting times not associated withprovider efficiency, front office staff performance, etc.,should not be included in the evaluation instrument.

PATIENT SATISFACTION

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The following issues could be included when selecting goals relating topatient satisfaction:

Medical care received

Ability to communicate treatment/medicine requirements, etc.

Listening and addressing questions/concerns

People Skills

The best way to gather this information is to use a provider-specific patient

satisfaction questionnaire. This questionnaire would be stand for all

providers and can be distributed to patients on a quarterly or on-going

basis.

PATIENT SATISFACTION

1. Do you feel your provider listened and understood your concern(s)?

Not at all ____ Somewhat____ Well____ Very Well____ Does Not

Apply______

2. How well did your provider meet your primary medical needs?

Poor ____ Fair ____ Good____ Excellent ____ Does Not

Apply______

3. How complete was your provider in explaining your condition and treatment

options?

Poor ____ Fair ____ Good ____ Excellent ____ Does Not

Apply_____

4. Would you recommend your physician/provider to family and friends?

Not at all ____ Maybe ____ Likely ____ Absolutely ____ Does Not

Apply_____

PATIENT SATISFACTION QUESTIONNAIRE SAMPLE

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Evaluating a providers performance regarding patient satisfaction can beaccomplished by collecting the completed questionnaires and calculating the totalnumber of points realized by each provider divided by the total possible points.

For example:

How interested is your physician/provider in you and your medical problem(s)?

Not at all ___ Somewhat___ Interested___Very Interested___Does Not Apply ___

Points (0) (1) (2) (3) (0)

Suppose twenty patients completed a 5-question questionnaire for Provider A,resulting in a total of 200 points out of a possible 300 (66.7%).

PATIENT SATISFACTION SCORING

Each of the survey questions will be totaled using the same methodology toderive an overall score as follows:

Score Standing % of Total Point Targets Score

Exceeds Expectations 70% 4

Meets Expectations 60% 3

Needs Improvement 50% 2

Does Not Meet Expectations < 50% 1

Based on this scoring system, Provider A having received a score of 62.5%

would receive a score of 3.

PATIENT SATISFACTION SCORING

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Quality of Care is a tenet of any healthcare organization and is a central component ofprovider responsibility. Providers should be held accountable to provide the highestquality of care to his/her patients. Quality of Care can be measured on many levels.Categories could include:

Prevention/Primary Care

Immunizations/Vaccinations

Vision and Hearing Screening

Cholesterol Screening

Annual Pap Smear

Condition/Disease Specific

Asthma Management (Adult and Pediatric)

Diabetes Management

Hypertension Management

QUALITY OF CARE

Documentation

Accurate Documentation of Medical Record

Match Between ICD-9 and CPT Codes

Up-to-date Problem List

Providers and Management must work together to pre-

determine the specific quality goals within each category as

well as benchmarks that should be used to evaluate the

providers with respect to the achievement of such goals.

QUALITY OF CARE

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Quality of Care can be measured on a PASS/FAIL score. An overall Pass/Fail score for each participating provider

will be assigned based on results from the selected measures.

Because the overall evaluation of participating providers is a weightedaverage of the four component scores, the Pass/Fail score for Quality ofCare must be assigned a numeric value. The Pass/Fail results will be linkedto a numeric score as follows:

Pass/Fail Result Numeric ScorePass 4Fail 1

QUALITY OF CARE SCORING

Providers play an important role in improving operations by ensuring continuity of and access to care, and by actively participating in their communities. These activities often go beyond the job description and should be encouraged and rewarded.

Contribution to the organization/community can be measured in many ways, including the following: Participation in internal and external committees Participation in marketing, outreach and community service

activities which enhance the health centers exposure Participates in teaching, mentoring or research activities either

internal and or external Maintenance of CME requirements Maintenance of academic appointments, participation in teaching

programs, participation in research

CONTRIBUTION TO THE ORGANIZATION/COMMUNITY

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A providers contribution to the organization/community can be evaluated by collecting the completed questionnaires and calculating the total number of points realized by each provider divided by the total possible points.

Example

Response scores for questions may vary. Suppose using a ten question form, Provider A has a total score of 20 points out of a total possible score of 30 points, or 66.7% of total possible points.

% of Total Possible

Score Standing Points Targets Score

Exceeds Expectations 75% 4

Meets Expectations 65% 3

Needs Improvement 55% 2

Does Not Meet Expectations < 55% 1

Based on this scoring system, Provider A would have received a score of 3.

CONTRIBUTION TO THE ORGANIZATION/COMMUNITY

SCORING

The Provider Performance Monitoring Process will utilize benchmarks to

score three of the four components. The benchmarks for these components

are linked to the following numeric scoring range:

4=Exceeds Expectations

3=Meets Expectations

2=Needs Improvement

1=Does Not Meet Expectations

The Quality of Care results of Pass or Fail are assigned an automatic

numeric score of 4 or 1, respectively.

OVERALL SCORING

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The overall score of the providers results is determinedby the weight distribution of each component. In theexample below, the sample organization chose todistribute the overall score in the following manner:

Provider Productivity 40%

Quality of Care 30%

Patient Satisfaction 20%

Contribution to the Organization 10%

Total 100%

OVERALL SCORING

Weighted

Component Score Weight Score

Provider Productivity 2 35% .7

Quality of Care 4 25% 1.0

Patient Satisfaction 3 20% .6

Contribution to the Organization 3 20% .6

Weighted Summary Score 100% 2.9

To calculate a total weighted summary score, multiply each component

score by its respective weight and then sum the totals. Below is the

weighted summary score for a sample provider:

OVERALL SCORING

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Compare the total weighted scores amongst providers to determine their

percentage of the incentive compensation pool

Overall Scoring/Payment

Total Weighted

Points

% of Points/ Incentive

Comp Pool

Incentive Comp

Earned

Provider A 2.1 13% 6,334$

Provider B 3.4 20% 9,744$

Provider C 3.6 22% 10,718$

Provider D 1.6 10% 4,872$ Failed quality

Provider E 2.9 17% 8,282$

Provider F 3.1 18% 8,770$

Total 16.7 48,720$

Since a score of 1 is the minimum, measure points above the minimum to

create a greater differential

Overall Scoring/Payment Greater Differential

Total Weighted

Points

Points Above

Minimum

% of Points/ Incentive

Comp Pool

Incentive

Comp Earned

Provider A 2.1 1.1 10% 4,872$

Provider B 3.4 2.4 22% 10,718$

Provider C 3.6 2.6 24% 11,693$

Provider D 1.6 0.6 6% 2,923$ Failed quality

Provider E 2.9 1.9 18% 8,770$

Provider F 3.1 2.1 20% 9,744$

Total 10.7 48,720$

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Provider Distribution Option 2:

Direct Pool Distribution

Total Incentive Compensation Funding - $20,000

Provider Productivity Funding Distribution 50%

Provider Productivity Pool Distribution - $10,000

Quality Required - No

Provider Work

RVUs/FTE

Dist % Pool Distribution

Handler 2,500 31% $3,100

Jeffreys 2,600 33% $3,300

Smith 2,900 36% $3,600

Total 8,000 100% $10,000

Funding Distribution Among Providers

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Total Incentive Compensation Funding - $20,000 Patient Satisfaction Funding Distribution 25% Patient Satisfaction Pool Distribution - $5,000 Quality Required - Yes

Provider Patient

Satisfaction*


Quality

Handler 94% 52% $2,600 Pass

Jeffreys 89% N/A $0 Fail

Smith 86% 48% $2,400 Pass

Total 180%** 100% $5,000

* percentage of total available survey points

** total of applicable providers only



Contribution to the Organization Funding Distribution 25%

Contribution to the Organization Pool Distribution - $5,000

Quality Required - Yes

Provider Contribution

Calculation


Quality

Handler 50% 41% $2,050 Pass

Jeffreys 100% N/A $0 Fail

Smith 80% 59% $2,950 Pass

Total 135%** 100% $5,000

** total of applicable providers only


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Totals By Provider

Provider Productivity Patient

Satisfaction

Contribution to

the Organization

Total Pool

Distribution

Handler $3,100 $2,600 $2,050 $7,750

Jeffreys $3,300 $0 $0 $3,300

Smith $3,600 $2,400 $2,950 $8,950

Total $20,000


All staff of the health center will be encouraged to

support:

a highly productive organization

a high quality organization

an organization where patient satisfaction is required

superior customer service

efficiency, attendance, and pitching in

Staff Goal Setting

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All line staff are in alignment when they can clearly

articulate how their job responsibilities can assist the center in

meeting its stretch goals

Because it is usually impractical to consider individual goals

for all staff members, one method is to compare organizational

performance in terms of billable visits per provider FTE for

the whole year

An increase is a good proxy measure for increased revenues

Remember: self-pay visits are considered billable, so there

is no conflict with the health centers mission

Staff Goal Setting

Assumption: Prior year average billable visits per provider

FTE was 3,500

Model: Organization must pass minimum quality standard

and minimum patient satisfaction standard, and the center

meets its target of $400,000 net income (after accruing for

incentive payments).

If these are passed, and billable visits increase by at least 5%

or 3,675 billable visits per provider FTE, staff would be

incentivized as follows:

Staff Incentive Compensation

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Current Year Billable Visits

Per Provider FTE Bonus on Salary

3,675 3,850 1.5%

3,850 4,025 2.5%

4,025 4,200 3.5%

> 4,200 5%

Note that this method would already take into account a pro-rating of an employees FTE

SAMPLE STAFF INCENTIVE COMPENSATION

Data Driven Decision Making

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156

Process of making choices based on appropriate analysis of

relevant information.

Important because with the right data at the right time,

decisions have better outcomes

Must establish a system of reporting that answers

managements questions.

Must identify benchmarks and performance targets in order to

measure progress.

157

There is a danger to solely relying on experience and intuition (this is what

worked last time, or this is how weve always done it) and ignoring performance

measurement data. Gut feeling and seat of the pants decisions can lead to less

than desirable results! This system works less well as an organization grows

There are also dangers to an over-reliance of data for decisions. An enlightened

decision maker will balance data analysis results with their experience.

Of key importance is to establish measures to quickly identify trends

Through annual operating budget and longer-term strategic planning processes,

health center should establish goals and objectives for data and

outcomes.measures that indicate progress or lack of progress.

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158

Assign limited resources to different business segments of the health

center:

Sites

Departments

Services

Capital (including IT)

Determine how much business volume will be generated and what types

of services will be provided

Establish where to focus efforts on Process Improvement and/or

reengineering

Determine how employees will be compensated and rewarded

DECISIONS:

159

Developing the Data

Reporting System

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160

Helps to find problem areas, success areas, and stagnant areas.

Evaluates where previous decisions are working, or not working.

Summary data will allow leadership to focus on the most critical

elements, however there must be decisions about what critical elements

are important.

Proper construction of data reports and performance measures can

indicate proper support of the mission and vision of the health center.

Data and reporting need to be designed such that those below senior

leadership can make decisions at the safest level. Policies and

procedures also support this design.

161

Short and concise

May include graphs and charts

Allows for drill down to the details

Can be designed to show relationship between various factors

Can be approximate, rather than 100% accurate, so as to ensure expediency of review.

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162

Identify the performance area and audience

Financial Position and Performance - CFO

Clinical Services/Patient Care - CMO

Operations - COO

Other MIS, Compliance, HR, etc.

Everything!!! CEO, Board

Aggregate all measures in each performance area

Identify measures critical to the centers success

Narrow measures down to those that are the most useful at any given point

in time

163

Design one-page dashboards that:

Present measures based on a fre

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