Athletic Trainers as Physician Extenders: Past, Present, Future

Athletic Trainers as Physician Extenders: Past, Present, Future Forrest Q. Pecha MS, ATC, LAT, OTC, CSCS Program Manager, Director of Athletic Training Services Emory Sports Medicine Center Atlanta GA. 30329 Disclosures Institutional and Research Support Ossur Americas DJO Linvitech Arthrex Consultant DJO Ossur Americas 1

AT s as Physician Extenders The Past Residency programs The Job Economic Impacts NATA Involement The Future? Who is a Physician Extender Look Around You All Athletic Trainers are physician extenders To work under the guidelines and supervision of a physician To evaluate, treat, prevent athletic injuries (orthopaedic) Know your state practice act 2

Evolution and History Early 1970 s Temple University Ted Quedenfeld ATC Joseph Torg MD Sports Med center for H.S. Athletes & adult recreation to be seen by MD and given same care as college University: Early 1970 s Temple University: Early 1970 s Sports Med center for H.S. Athletes & adult recreation to be seen by MD and given same care as college Ted Quedenfeld ATC Sports Med center for H.S. Athletes & adult recreation to be seen by MD and given same care as college Evolution and History University of Wisconsin Hospital: 1981 Brad Sherman ATC Bill Clancy MD An ATC worked within physician clinic seeing patients and performing high school outreach for an academic hospital The physician/athletic trainer relationship was the key component to success then and it remains the same today. 3

Evolution and History Indianapolis Indiana Ortho Indy 1983 Marje Albohm ATC (current NATA president) Merrill Ritter, MD Started with collegiate AT position team doc asked her to join clinic operations. She moved on to become practice administrator (maybe first as ATC as practice administrator) Evolution and History OASIS San Diego CA. 1985 Mark Howard ATC Gary Losse MD AT decided to leave NFL and approached Dr Losse for a job. Dr Losse wanted MSK specialist in clinic and OR Duel credentialed as OTC allowed assist in OR Saw Collections in OR with ATC duel credentialed (maybe first ATC assist in OR) 4

Evolution and History Baltimore MD: 1984 John Lopez ATC Baltimore Colt MD Training Room Model Walk in clinic run by ATC and MD Geared to the recreational athlete and HS that didn t have access to AT s NATA Q s Early 1980 s Should there be 2 certifications for Athletic Trainers? Traditional setting Athletic Training room Sidelines Athletic Trainers working in the clinic New setting NATA decided: Education goals for certification will meet all settings needs Today? 5

Past: How to find a PE Position AT working in U or HS: MD approached AT visa vera Recent: AT s more aggressive in pursuit for position less demanding hrs Transition position as MA Educational training programs History 6

Athletic Trainers as Physician Extenders 1970 s 1980 s We showed the pioneers 1990 s Institutions started creating educational programs 2000 s NATA starts to recognize and promote physician extender role NATA s creates and approves post professional residency standards Athletic Training Fellowships & Residencies New Hampshire Musculoskeletal Institute Started 1993 Steadman Hawkins Clinic Started 1995 Emory Sports Medicine Center Started 2004 University of Wisconsin Madison Started 2008 7

Athletic Training Fellowships & Residencies University of South Florida Started 2009 University of South Carolina Washington University St. Louis Started 2010 Starting in 2011..? University of Michigan University of Miami Ochsner Healthcare What does AT PE offer MD? A highly trained professional who is a recognized health care provider A clinician who can provide optimal patient care and knowledge of musculo skeletal injuries. Increase Physician efficiency in clinic, giving them the ability to see more patients & ^ collections ATC can use PM&R codes and perform services in incident to the physician and can be billed for. Ability to hire an educated individual at approx 60% of a PA salary 8

How AT s support MD practice AT s work as liaison b/w MD and patients MD having a MSK specialist as a clinician AT s increase patient care with education AT s can improve cost effectiveness in clinic Taking patient histories Performing complete physical exams Presenting findings to physicians Pre operative instructions/booking surgeries Post operative care AT Clinical Skills 9

AT Clinical Skills Answering patient phone calls Completing patient paperwork (FLMA/disability) Understanding of radiological findings Teaching therapeutic exercises to patients Casting, splinting and brace fitting Coding and billing for AT services In Incident to service billing AT Clinical Skills Electronic Medical Records training and utilization Patient medication reconciliation Electronic dictation of patient Scribing for physician dictations 10

AT Operating Room Skills AT obtains scrub privileges May need duel credentialing OTC OPA C Possible to bill with other credential Will increase MD efficiency AT Operating Room Skills AT can Assist Physician in: Prepping and Draping of patients Identifying and marking anatomical landmarks Positioning patients Perform PE under anesthesia Understanding of instruments Retracting Tissue Preparation of ACL grafts 11

AT Operating Room Skills AT can Assist Physician in: Close and dress wounds Apply post op bracing Provide post op instructions and exercises Coding and billing for OTC services Athletic trainers as Physician Extenders Can provide skills of multiple healthcare providers Have an extensive musculoskeletal education Can assist the orthopaedic physician in the clinic and OR Improve the Business model for orthopaedic practices 12

What can an AT expect as PE Rewarding and challenging job Refined and excellent physical exam skills Understanding of the Orthopaedic/Sports Medicine practice How to make your physician efficient in clinic = $$ Good paying position with good benefits and hours Liaison between your physician and patients Economic Impact of AT s as PE s INDIRECT Clinical Efficiency Patient satisfaction DIRECT Clinical Billing In incident to Billing in OR AS modifier w/ surgeons DME Business Ancillary to clinic collections 13

Efficiency Study: Emory 2006 Over 80 clinic days we evaluated Number of patient encounters (visits) Billed charges Collections Efficiency Results 14

Summary of Emory Study All variables showed statistical significance for both Physicians over the three variables (p <.05) Physician A saw increase of 20% for patient encounters Physician B saw increase of 18% patients encounters Physician B daily average patient visits increase from 22.9/day to 27.1/day with ATC University of Wisconsin Study 1997 Evaluated time to task for athletic trainers to do clinical skills Compared to patient time spent in MD office Looked at patient volume if one AT was removed from clinic Table 1: PER TASK Task AVERAGE TIME SPENT Time on Task (min) Evaluation 8.2 Presentation to physician 2.3 Assisting physician with patient 7.2 Follow-up & patient education 1.9 Dictation 4.3 Other 1.1 Total 25.1 15

University of Wisconsin Study 1997 By removing AT s MD s saw a decrease in patient throughput by 15 30% Orthopaedic and Fracture Group Portland OR 2008 09 Established Surgeon Average daily billings pre AT (3yrs)= $6,605/day Average daily billings with AT = $8,076/day Increase billed charges of $1,471/day or 18% 16

Direct Impacts Financial AT s Financially Support Their Costs Use of 97000 PM&R CPT Codes, are not provider specific AT s can bill in incident to physician services ATC/OTC can bill as first assist in OR using surgical assist modifier. AS Build a DME Business in the clinic for Increased ancillary revenue 17

PM&R Usable Clinic Billing codes 97110/97530: Therapeutic Exercise (15 min of education for one parameter of strength, balance, endurance, ROM, and functional activity) 97116: Crutch training or gait training (training in the manner or style of walking or assistance of walking) 97760: Orthotic fitting and training upper or lower extremities (fitting and training of a patient to use an orthotic device or splint (brace) to facilitate stability or function) 97750: Physical Prof tests/ measurements, 15 min. (KT 1000, Biodex, Strength testing) 99211: non physician patient visit AT In Incident to Collections Clinic AT billing and Collections PM&R Codes 97000 Charges Adjustments Approved Amt INS Payments Pt paid Total Collect 2009 $53,022.00 $19,188.00 $16,291.00 2008 $29,466.00 $16,508.17 $9,158.20 $5,504.42 $14,662.62 2008 $29,755.00 $16,906.48 $9,423.88 $2,488.00 $11,911.88 2007 $21,776.00 $7,161.85 $11,356.65 $6,633.68 $5,735.87 $12,369.55 2007 $37,209.00 $11,546.00 $18,624.65 $11,294.89 $5,951.14 $17,246.03 2006 $25,029.00 $5,404.55 $7,697.57 $5,815.63 $6,730.27 $12,545.90 2006 $10,666.00 $2,809.35 $3,768.77 $2,562.29 $3,354.16 $5,916.45 2005 $4,723.00 $1,689.77 18

AT Incident to Collections Values Row Labels Chrgs Contr. Adj. Pt Pmts Net Pmts 97110 $ 5,016.00 $ 69.00 $ 2,443.00 97116 $ 156.00 $ 4.00 $ 122.29 97530 $ 1,012.00 $ 15.00 $ 448.18 97750 $ 27,216.00 $ 194.00 $ 6,604.03 97760 $ 15,617.00 $ 158.00 $ 5,406.79 97762 $ 249.00 $ 3.00 $ 76.91 99211 $ 2,508.00 $ 50.00 $ 805.69 Grand Total $ 51,774.00 $ 493.00 $ 15,906.89 AT Incident to Collections Volume Charges Revenue % FY 2003 57 $3287.00 $1989.00 60.50% FY 2004 80 $15,332.95 $8702.47 56.76% FY 2005 98 $16048.40 $8437.14 52.57% 19

Use of OTC/ATC in the OR AT must become Certified Orthopaedic Technologists (OTC) OTC must be AT and working under MD supervision for 6 months As an OTC, can bill as first assist in OR similar to a PA or NP AS modifier Collection rates vary per insurance carrier Current data from 5 states OTC/AT collection rate between 17% 25% as first assist PA Collection rate = 20% 25% OR Billing number for OTC/ATC's ATC Yr St Billed amount Billing period Collections % collections Units Billed Adjustable $$ KM 2008-09 GA $437,813.00 12 mo $42,766.00 9% KM 2007-08 GA $353,229.00 12 mo $59,090.00 17% 168 $333,544.33 KM 2006-07 GA $247,315.50 12 mo $44,689.68 18% 158 $161,610.00 KM 2004-04 GA $293,958.50 12 mo $51,704.07 18% 218 $301,482.57 CK 2007-08 GA $204,416.25 12 mo $51,814.81 25% 452* $144,363.31 *Includes clinical billings JS 2007-08 TX $102,303.00 12 mo $25,467.00 25% 198 $75,864.00 HG 2007-08 CT $236,768.00 12 mo $52,134.00 22% 212 $128,594.00 PH 2008-09 OR $12,649.40 6 mo $3,064.93 24% 126 $3,124.27 SM 2008-09 GA $216,872.10 10 Mo $30,125.78 14%* 402 $140,968.51 *Starting in new practice PM 2008-09 CO $9,480.00 4 Mo $2,084.00 22% 14 20

Ancillary Revenue for Ortho Practice DME Durable Medical Equipment (Bracing) Need to set up business correctly Pre cert patients INS Stock and bill in house ESMC fiscal year 2007 4.5 FTE ~ $130,000 ESMC fiscal year 2008 5.5 FTE ~ $165,000 ESMC fiscal year 2009 6.5 FTE ~ $235,000 So Where are we Today? 21

NATA Involvement Fall 2007 NATA PPEC did site visits of existing programs June 2010 The NATA PPEC Committee recently approved the standards and guidelines for accreditation of Post Professional Athletic Training Residency programs Sept 2010 NATA PPEC finalized the Pursuing and Maintaining Post Professional Athletic Training Document Current Athletic Training Residency sites can start the application process for accreditation NATA will award accreditation to sites in 2011 NATA Involvement Emory University and the University of Wisconsin Hospital plan to apply in the first year. Others may take this step. Goal : offer consistent education for all ATC s graduating from physician extender residencies working in physician clinical practice NATA to follow in other healthcare professions for advanced and specific training within our profession 22

What does our Future Hold? Orthopedic Service Lines Sports Medicine Subspecialty NATA accreditation National Healthcare Utilization of Allied Health Providers Physician supported Opportunity More jobs good hours & good pay Thank You for your Attention Forrest Q. Pecha MS, ATC, LAT, OTC, CSCS Program Manager, Director of Athletic Training Services Emory Sports Medicine Center Atlanta GA. 30329 23