Clinical Full-time Equivalents Research Articles

Impact of business infrastructure on financial metrics in departments of surgery

In the current environment, pressure is ever increasing to maximize financial performance in surgery departments. Factors such as physician extenders, billing and collection, payor mix, contracting, incentives from the Centers for Medicare and Medicaid Services, and administrative incentives may greatly influence financial performance. However, despite a plethora of information from the University HealthSystem Consortium and the Association of American Medical Colleges, best-practice information for business infrastructure is lacking. To obtain a sampling of current practices, we conducted a survey of departments of surgery. An anonymous 30-question survey addressing demographics, productivity, revenue and expense profile, payor mix, physician extender and staff personnel, billing and collections methodology, and financial performance was distributed among members of the Society of Surgical Chairs via SurveyMonkey. This was approved by the Loyola Institutional Research Board. Multivariate linear regression analyses and t tests/rank-sum tests were performed, as appropriate. Data are presented as mean ± SEM. A total of 25 (19%) departments responded; 14 were integrated with the hospital/health system, and 11 were integrated with the medical school. In 60% (n = 15), the main hospital had 500 to 1,000 beds; 48% (n = 12) had >4 hospitals in their system. For FY10, MD clinical full-time equivalents (FTEs) were 49 ± 10; total work relative value units (wRVUs) were 320 ± 8 k; and total billed cases were 43 ± 16 k. A total of 23 of 25 used physician-extenders with an average of 18 ± 5 per department and in 22 of 23, the physician extenders billed. On average, there were 18 ± 6 clinical-support staff, 25 ± 11 front-office staff, and 13 ± 3 back-office support staff FTEs. Among these FTEs, there were 16 ± 5 devoted to business operations (billing, coding, denial/claims management, financial oversight). Collections/wRVUs were $60 ± 3 (range, 39-80). Regression modeling demonstrated that total wRVUs were determined by the number of MD FTEs (P = .01), number of physician extenders (P = .01), number of front-office staff (P = .01), number of back-office staff (P = .02), and number of total business staff (P = .01). Collections/wRVUs were predicted by number of hospitals (P = .04), number of MD FTEs (P = .03), number of physician extenders (P =.01), and number of cases/total business staff (P = .02). Interestingly, wRVUs/MD was predicted by number of MD FTEs (P = .01) but were not greatly impacted by numbers of clinical or business support staff. In 4 of 25, the billing and coding staff were incentivized and had a Collections/wRVU = 64 ± 5 whereas nonincentivized staff had collections/wRVU = 59 ± 3. (P = NS) Also, %Accounts receivable >90 days (15% vs 25%) were not substantially different. Only 48% (12/25) have departments have recouped Centers for Medicare and Medicaid dollars for Physician Quality Reporting Initiative, Meaningful Use, Patient-Centered Medical Homes, or other Accountable Care-like programs. One-half (13) of the departments had both an inpatient and outpatient electronic medical record. Finally, on a scale of 1-10 (10 =highest), the average level of satisfaction with billing and collections processes was6. Our results indicate that the physician extender, clinical support staff, and business staff environment can impact surgeon productivity, and there is opportunity for improvement. Determining best practices for ratios of support staff/MD and optimizing the role of electronic medical record in workflow and billing/collections are critical in the current environment. Our pilot study requires extension across more institutions for validation.

Growth of an Academic Palliative Medicine Program: Patient Encounters and Clinical Burden

ContextInformation regarding the challenges of clinical growth and staffing of palliative care programs is limited. ObjectivesOur aim was to describe the growth and staffing structure of a palliative care program at a comprehensive cancer center. MethodsDuring fiscal years ending in 2000 through 2010, we recorded all billed palliative care consultations and follow-ups. To determine the yearly clinical burden per physician, advanced practice nurse (APN), and physician assistant (PA), we calculated the mean number of patient encounters per clinical full-time equivalents. Increase in absolute number of patient encounters and relative (%) growth from year to year were calculated. ResultsOver the 10-year history of the program, the number of outpatient consultations tripled, whereas the inpatient consultations increased from 73 to 1880. In all cases, with the exception of the first year of operation, the vast majority of clinical activity was in the inpatient hospital setting. Growth in the ratio of inpatient consultations per operational hospital beds was noted during the first five years of the program followed by a more modest increase in the succeeding five years. In fiscal year 2010, palliative care physicians had 6.2 patient encounters per working day, and APNs/PAs independently evaluated and treated 4.0 additional patients. ConclusionOver the 10-year history, there has been an increase in the number of patient consultations seen by our palliative care program. The clinical burden was manageable during the first three years but quickly became too burdensome. Active recruitment of new faculty was required to sustain the increased clinical activity.

Implementation of an acute care surgery service at an academic trauma center

Background The establishment of acute care surgery is rapidly becoming a solution to meet emergency surgical needs. Challenges include competition for emergency surgery opportunities and the ability to economically sustain a practice. Methods Clinical activity was measured by reviewing the institutional and practice plan databases. Work relative value units and practice plan collection rates defined clinical activity and revenue. Results Operative procedures and intensive care unit activity accounted for 52% and 36% of activity, respectively. Although procedures on the digestive tract accounted for half of the operative activity, significant activity was observed in nearly all other systems. Overall clinical productivity remained constant but did demonstrate a 25% increase in operative work relative value units. Current billing activity supports 4.0 clinical full-time equivalents, but estimated collections would cover <73% of physician direct costs. Conclusions The authors describe the implementation of an acute care surgery service that combines trauma, emergency general surgery, and surgical critical care in an established academic surgery department. Developing a sustainable economic model must include income sources other than patient service revenue.

Resource-Based Relative Value Scale Analysis Between Teaching and Nonteaching Hospitalist Services

Resource-based relative value scale is an objective estimate of physician work that allows comparisons of physician productivity, yet few studies have explored its use to compare the productivity between teaching faculty and nonteaching hospitalists. Demographic and billing data of patients assigned either to a resident-staffed teaching service or a hospitalist service, the number of encounters per provider, relative value units (RVUs) generated, and total charges were obtained from billing records (November 2006-April 2007). Age, race, sex, insurance status, case mix index, and length of stay were also analyzed. The mean RVUs generated per unit of encounter and the mean charges generated per unit of encounter were not significantly different between the 2 services. However, mean RVUs generated per full-time equivalent provider and mean charges generated per clinical full-time equivalent were significantly higher in the teaching service. Based on a resource-based relative value scale analysis, the clinical productivity of teaching faculty was superior to that of nonteaching hospitalists. The difference may be attributable to lower time requirements of the teaching attendings compared with full-time hospitalists.

Benchmarks in Clinical Productivity: A National Comprehensive Cancer Network Survey

Oncologists in academic cancer centers usually generate professional fees that are insufficient to cover salaries and other expenses, despite significant clinical activity; therefore, supplemental funding is frequently required in order to support competitive levels of physician compensation. Relative value units (RVUs) allow comparisons of productivity across institutions and practice locations and provide a reasonable point of reference on which funding decisions can be based. We reviewed the clinical productivity and other characteristics of oncology physicians practicing in 13 major academic cancer institutions with membership or shared membership in the National Comprehensive Cancer Network (NCCN). The objectives of this study were to develop tools that would lead to better-informed decision making regarding practice management and physician deployment in comprehensive cancer centers and to determine benchmarks of productivity using RVUs accrued by physicians at each institution. Three hundred fifty-three individual physician practices across the 13 NCCN institutions in the survey provided data describing adult hematology/medical oncology and bone marrow/stem-cell transplantation programs. Data from the member institutions participating in the survey included all American Medical Association Current Procedural Terminology (CPT®) codes generated (billed) by each physician during each organization's fiscal year 2003 as a measure of actual clinical productivity. Physician characteristic data included specialty, clinical full-time equivalent (CFTE) status, faculty rank, faculty track, number of years of experience, and total salary by funding source. The average adult hematologist/medical oncologist in our sample would produce 3,745 RVUs if he/she worked full-time as a clinician (100% CFTE), compared with 4,506 RVUs for a 100% CFTE transplant oncologist. Our results suggest specific clinical productivity targets for academic oncologists and provide a methodology for analyzing potential factors associated with clinical productivity and developing clinical productivity targets specific for physicians with a mix of research, administrative, teaching, and clinical salary support.

Canadian pediatric gastroenterology workforce: current status, concerns and future projections.

There is concern that the Canadian pediatric gastroenterology workforce is inadequate to meet health care demands of the pediatric population. The Canadian Association of Gastroenterology Pediatric Committee performed a survey to determine characteristics and future plans of the Canadian pediatric gastroenterology workforce and trainees. Estimates of total and pediatric populations were obtained from the 2001 Census of Population, Statistics Canada (with estimates to July 1, 2005). Data on Canadian pediatric gastroenterologists, including clinical full-time equivalents, sex, work interests, opinions on workforce adequacy, retirement plans, fellowship training programs and future employment plans of fellows, were gathered through e-mail surveys and telephone correspondence in 2005 and 2006. Canada had an estimated population of 32,270,507 in 2005 (6,967,853 people aged zero to 17 years). The pediatric gastroenterology workforce was estimated at 9.2 specialists per million children. Women accounted for 50% of the workforce. Physician to pediatric population ratios varied, with Alberta demonstrating the highest and Saskatchewan the lowest ratios (1:69,404 versus 1:240,950, respectively). Between 1998 and 2005, Canadian pediatric gastroenterology fellowship programs trained 65 fellows (65% international trainees). Twenty-two fellows (34%) entered the Canadian workforce. The survey highlights the variable and overall low numbers of pediatric gastroenterologists across Canada, an increasingly female workforce, a greater percentage of part-time physicians and a small cohort of Canadian trainees. In conjunction with high projected retirement rates, greater demands on the workforce and desires to partake in nonclinical activities, there is concern for an increasing shortage of pediatric gastroenterologists in Canada in future years.

Measurement of individual clinical productivity in an academic anesthesiology department.

The ability to measure productivity, work performed, or contributions toward the clinical mission has become an important issue facing anesthesiology departments in private practice and academic settings. Unfortunately, the practice and billing of anesthesia services makes it difficult to quantify individual productivity. This study examines the following methods of measuring individual productivity: normalized clinical days per year (nCD/yr); time units per operating-room day worked (TU/OR day); normalized time units per year (nTU/yr); total American Society of Anesthesiologists (ASA) units per OR day (tASA/OR day); and normalized total ASA units per year (ntASA/yr). Billing and scheduling data for clinical activities of faculty members of an anesthesiology department at a university medical center were collected and analyzed for the 1998 fiscal year. All clinical sites and all clinical faculty anesthesiologists were included unless they spent less than 20% of their time during the fiscal year providing clinical care, i.e., less than 0.2 clinical full-time equivalent. Outliers, defined as faculty who had productivity greater or less than 1 SD from the mean, were examined in detail. Mean and median values were reported for each measurement, and different groups of outliers were identified. nCD/yr identified faculty who worked more than their clinical full-time equivalent would have predicted. TU/OR day and tASA/OR day identified apparently low-productivity faculty as those who worked a large portion of their time in obstetric anesthesia or an ambulatory surgicenter. tASA/OR day identified specialty anesthesiologists as apparently high-productivity faculty. nTU/yr and ntASA/yr were products of the per-OR day measurement and nCD/yr. Each of the measurements studied values certain types of productivity more than others. By defining what type of service is most important to reward, the most appropriate measure or combination of measures of productivity can be chosen. In the authors' department, nCD/yr is the most useful measure of individual productivity because it measures an individual anesthesiologist's contribution to daily staffing, includes all clinical sites, is independent of nonanesthesia factors, and is easy to collect and determine.