Boost your Grades with us today!
describe the metric(s) you will use to evaluate the organization’s productivity
Read Case 3: Physician Care Services, Inc., including Tables 3.2 and 3.3. Review the issues that surround provider productivity, to evaluate whether the organization can be successful in the new era of health care reform.
Describe the metric(s) you will use to evaluate the organization’s productivity. Explain how you will use the metric in evaluating productivity, and how the data will help measure the potential of the organization’s success in the new era of health care reform.
Physician Care Services, Inc. (PCS), was founded as a for-profit corporation on January l, 2000. Three physicians each own 20 percent of the stock, and one physician owns 40 percent. PCS currently offers nonemergent care services in two locations-at the Alpha Center just outside the city limits of Middleboro in Mifflenville and at the Beta Center in Jasper, close w\he Jasper industrial park and suburban neighborhoods. At these locations ambulatory medical care is provided on a walk-in basis. PCS centers do not offer emergency services. If a patient arrives needing emergency services, an ambulance is called to transport the patient to the nearest hospital emergen cy department. The Alpha Center opened in January 2000. Originally, it only treated occupational health clients. This policy was changed in 2004 when private patients were accepted. The Beta Center opened in January 2006 and has always treated private as well as occupational health clients. PCS specializes in providing services that are deemed convenient by the general public. Patient satisfaction remains its highest operational goal. At present, staff physicians employed by PCS do not provide continuing medical care. PCS physicians refer patients to area physicians as warranted for continuing and/or specialized medical care. Although patients often return to a PCS center, chronic illness management is not provided. 77 78 The Middleboro Casebook PATIENT SERVICES OCCUPATIONAL HEALTH CLIENTS Occupational health clients are sent to a PCS center by their employer for treatment of a work-related injury (which is usually covered by workers’ compensation insurance), for pre-employment or annual phys icals, and for health testing, which are paid for directly by the employer. Because of special work conditions, usually involving hazardous chemicals or materials, some local corporations contract with PCS to provide comprehensive physicals in accordance with Department of Transportation and ocher federal and state laws and regulations. Local corporations consider PCS a cost-effective and convenienr alternative to a hospital emergency department. These corporations use PCS in lieu of employing a phy sician. Corporate clients expect PCS to assist with all phases of case management involving worker injury. They hold PCS accountable that their workers receive timely, appropriate, I and cost-effective services. Physicals for Occupational Safety and Health Adminisrration compliance are cur rently priced between $300 and $500 each. Physicals for local police and fire include pulmonary function tests (PFn, laboratory tescs, and electrocardiograms (EKGs). 1h ey are currently priced between $250 and $350 per physical, depending on contractual vol ume. Pre-employment physicals are typically priced becween $60 and $95 and include a urine dip test. Services provided for occupational health clients are billed directly to the employer. PRIVATE (RETAIL) CLIENTS Private clients also seek medical care from PCS centers. AU aspects of general medical care are provided except 08/GYN. Private patients are attracted to PCS because they do not need an appointment. PCS accepts cash, checks, and credit cards at time of service. As of 2008, PCS directly bills the larger health insurance plans covering ics market area: + + + + Statewide Blue Shield American Health Plan Cumberland River Health Plan Central Scace Good Health Plan At time of service, retail clients covered by these plans are screened to verify eligibil ity and to determine whether they have satisfied any required deductibles. If deductibles have been met, patients will be required to pay just the copay amount, and a bilJ is sent electronically co the insurance plan for the account’s balance. If deductibles have not been met, then the insur. patient d, ro claim r A recent i approxim Ai vice is ref sive credi Pa stirute 80 ORGAN Each ceff services. in a smal building locations E: 9:00 a.m Day, Jul) furnishec excess sp: F< clerk, om advanced based on days and also assis 11 is locared director, bookkee1 CHARGE Each cen each yeai Case 3: Physician Care Services, Inc. met, then the patient will pay the bill at time of service, and PCS will enter the bill into the insurance company’s system as partial fulfillment of any outstanding deductible. If the patient does not have coverage from one of these insurance companies, she receives a bill to claim reimbursement directly from her insurance plan. PCS also directly bills Medicare. A recent study suggested chat these four private insurance companies and Medicare cover approximately 85 percent of PCS’s private clients. Any client who has a history of bad debt at PCS or is unable to pay at time of ser vice is referred ro a hospital emergency department for service. PCS maintains an aggres sive credit and bad debt collection policy and does not serve Medicaid patients. Patients living within a 30-minute crave! distance from a PCS center typically con stitute 80 percent of PCS’s private pay patients. ORGANIZATION AND MANAGEMENT Each center is located in approximately 6,000 square feet of rental space devoted to patient services. The Alpha Center is located on main roads between Middleboro and Miffienville in a small shopping center. The Beta Center is located on the first floor of a new office building adjacent to a large shopping mall in Jasper. Ample parking is provided in both locations. Each center maintains attractive signs. Each center is open 60 hours per week, 8:00 a.m. to 7:00 p.m. on weekdays and a.m. to 2:00 p.m. on Saturdays. Both centers are closed on Sundays and Memorial � Day, July 4, Thanksgiving, Christmas, and New Year’s Day. Each center has four fully furnished patient examination rooms and one extra room. Currently each center has some excess space. For patient care the minimum staffing at each center is one receptionist/billing clerk, ohe medical assistant, and one physician or nurse practitioner. Additional staff (e.g., advanced registered nurse practitioner, physician assistant, medical assistant) is scheduled based on anticipated high-volwne days. Typically the nurse practitioner works on Satur days and assists with physicals and other services on high-volume days. Physician assistants also assist on high-volume days. The central administrative and billing office is an additional 2,500 square feet and is located adjacent to Alpha Cenrer. The central office staff includes the president, medical director, director of nursing and patient care, business office manager, and the billing and bookkeeping staff. CHARGES Each center uses the same price schedule. The basic visit charge (CPT 99202) has changed each year. 79 So The Middleboro Casebook January-December Private Pay ($) Occupational ($) 2010 94 161 2011 99 170 2012 104 180 2013 110 189 2014 120 201 Current detailed prices include: CPT Procedure Code Description Price($) 96 99201 Office visit, brief, new 99202 Office visit, limited, new 120 99203 Office visit, inter, new 201 99204 Office visit, comp, new 226 99211 Office visit, min, est 65 99212 Office visit, brief, est 96 99213 Office visit, limited, est 201 99214 Office visit, inter, est 201 99215 Office visit, comp, est 294 Additional charges are levied for ancillary testing and specialized physician services, such as suturing. A patient rerurning for a medically ordered follow-up is charged $96 for the return visit. Based on Current Procedural Terminology (CPT) comparison, PCS fee levels are competitive within the area. No similar medical service is offered within a 45-minute radius from each center. In the past-as part of an advertising campaign to attract private pay patients–each May and June PCS has offered discounted physicals, such as camp physicals for children at $48 and for all children in a family for $69. Steve J. Tobias, MD, board chair and president of PCS, says national studies sug gest that urgenc care visits are at least $10 less than a visit to primary care physician in Case 3: Physician Care Services, Inc. private practice. Other studies indicate that urgent care visits cost $250 to $600 less than emergency department visits for the same CPT code. Some occupational health clients are charged based on a negotiated volume-based price, especially for physicals. PCS’s medical director negotiates specific fees for physi cals and specific medical tests ordered by an employer. Typically, an employer approaches PCS in need of a specific type of physical, such as the annual physical required by the Department ofTransportacion for all operators of school buses, or specific medical test for employees. PCS submits a bid to perform a specific number of physicals based on a flat rate per physical. As of 2007, PCS does its own payroll. Employees must have direct deposit with a local bank. Each employee receives an electronic pay stub biweekly (with accrued balance of vacation and sick time) and a W-2 at the end of the year. BOARD OF DIRECTORS The board of directors is composed of the four physician owners and meets quarterly co review operations. The annual board meeting occurs in December, at which time officers are elected for the coming year. As majority stockholder, Dr. Tobias is chairman of the board and president of PCS. JayT. Smooth, MD, is the board secretary. Other board mem bers are Rita Hottle, MD, and Laura Cytesmath, MD. Current owners have che option ,�uying any available stock at its current book value. An outsider can purchase stock in This company only if all the current owners refuse to exercise this option and he receives the approval of the existing owners. It should be noted chat PCS has paid a stock dividend in three of the last five years. PRESIDENT AND MEDICAL DIRECTOR Dr. Tobias is also the medical director of PCS. He is a graduate of the medical school at Private University and has completed postgraduate medical education at Walter Reed Army Hospital in general internal medicine. He is board certified in general internal medicine, emergency medicine, and occupational health. He also holds a master’s in public health from State University. As medical director, Dr. Tobias is responsible for medical quality assurance programs and the recruitment and retention of qualified physician employees. He is also responsible for securing the services of consulting radiologists to read all X-rays. He receives a separate salary as medical director and as president. Compeosation for the medical director position began in 2008. Before Dr. Tobias founded PCS, he �as a full-time emergency physician at Middleboro Community Hospital.’He originally worked to estab lish joint venture urgent care centers with Middleboro Community Hospital. When this approach failed, he recruited th� other stockholders and moved ahead with PCS. As presi dent, Dr. Tobias is responsible for the management of all resources and strategic planning. 81 :: The Middleboro Casebook Dr. Tobias schedules the other physicians and the nurse practitioners. He also works in the centers and provides on�call services as needed. He has consulting medical staff privileges in th� Department of Medicine at Middleboro Community Hospital. a a CLINICAL STAFF In total, the clinical staff is composed of eight physicians, three nurse practitioners, and two physician assistants. All physicians hold medical staff privileges at an area hospital. Name f ( Medical Specialty Certification Bennet Casey, MD Family practice Board certified Mark Welby, MD Family practice Board certified’ Steve Tobias, MD, MPH** Emergency medicine Board certified Jay Smooth, MD* Emergency medicine Board certified Rita Hottle, MD* Emergency medicine Board certified Laura Cytesmath, MD* Emergency medicine Board certified Micah Foxx, DO, MPH Occupational health Board certified Melisa Majors, MD Occupational health Board certified Carl Withers, ARNP Family and adult health Jane Jones, ARNP Family and adult health Gerri Mattox, ARNP Family and adult health Rutherford Hayes, PA Mary Fishborne, PA * Owner ** Owner and president Until 2007, staff physicians were retained as independent contractors and received no benefits above their hourly wage. Beginning in 2007 when nurse practitioners were added, physicians (and all ocher employees) who worked more than 1,000 hours were provided comprehensive benefits, including family medical coverage. Also as of 2007, PCS reimburses all physicians and nurse practitioners for their medical malpractice insurance. Full coverage is provided when a member of the medical staff works 1,400 hours at PCS. Others receive a partial reimbursement. Case 3: Physician Care Services, Inc. Physicians are paid $100 per hour. Nurse practitioners receive $50 per hour. These payment levels have been fixed for two years and are considered within the appropriate market range. Ors. Smooth, Hottle, and Cycesmath also work as emergency physicians at Middleboro Community Hospital. Dr. Casey serves as medical director one day per week at an area corporation, where he specializes in occupational health. Dr. Welby also works at Convenient Med Care, Inc., in Capital City. Dr. Foxx, who recently relocated to Jasper with her family, is available to work no more than six shifts per month, a condition she has established until her children reach school age. Dr. Majors also works as an emergency physician in Capital City. Physician assistants are paid $40 per hour and assist physicians on anticipated high-volume days. Dr. Tobias schedules all members of che medical staff for work on a monthly basis with the understanding that if a physician is unable to work, it is her responsibility to secure a replacement from the qualified medical staff of PCS. Physicians and nurse prac titioners work an entire shift (e.g., 11 hours on a weekday). Fridays and Saturdays are typically assigned co the nurse practitioners. Physician assistants are on call for busy days to assist physicians. The clinical staff of PCS meets quarterly to review areas of concern. Dr. Tobias does random reviews of medical records to ensure compliance with standards of clinical practice. He is also responsible for all issues involving credentialing. �ICAL ASSISTANTS Medical assistants at each center are trained to cake limited X-rays, draw specimens for laboratory testing, do EKGs, and conduct simple vision and audiometric examinations. Each center is equipped to do: \ 1. On-site X-ray 2. PFT 3. EKG· 4. Audiometric and visual testing 5. Some laboratory testing (e.g., strep screen, dip urine) 6. Drug and breath alcohol testing A regional laboratory processes more advanced labo�tory work. Two medical assistants are assigned to each weekday shift. One is assigned for 7 hours per day (i.e., 35 hou;rs per week) and the other is assigned for 4 hours per week day and Saturdays (i.e., 25 hours per week). Responsibilities include examination room 83 84 The Middleboro Casebook preparation, assisting the physician or nurse practitioner, patient testing, case manage ment, scheduling visit follow-up care, and addressing patient questions. Each center main tains a pool of qualified medical assistants who are trained, evaluated, and scheduled by the director ofnursing and clinical care. soft\\ assist PCS CENTRAL OFFICE STAFF Dr. Tobias devotes his time co being both the president and medical director at PCS and filling in at a center when needed. As president he is responsible for the ove1:aU manage ment of PCS. Joan Carlton, LPN, is director of nursing and clinical care. She trains, supervises, and schedules the medical assistants. She is also responsible for ordering medi cal supplies, meeting with occupational health employers as needed, and general admin istrative duties as assigned by Dr. Tobias. Ifneeded, she substitutes for a medical assistant I at a center. Martha Coin directs the business office and has three full-time staff. She schedules the receptionist staff at each center. She and her staff assist the receptionists and billing clerks at each center, manage all insurance billing, and manage the general led ger, including accounts payable and accounts receivable. If needed, she or a member o her staff substitutes for the receptionist at a center. The central office billing staff also maintains a list of available (and trained) fill-in receptionists to cover absences and other needs. RECEPTIONIST STAFF One full-time (35 hours per week) front desk receptionist is hired for each center. Aside from greeting and registering all patients, the receptionist is also responsible for appoint ments, billing, records for occupational clients, and managing cash receipts. One or more additional receptionists are hired for the remaining 25 hours per week. ADDITIONAL INFORMATION In 2008 PCS began using URGENT CARE MIS, an electronic medical information, gen eral ledger, and billing system. Computer terminals were installed in the reception area in each center, at the central office, and in each examination room. PCS uses this system for all phases offinancial and medical record keeping and billing, appointment services, case management, staff scheduling, and data management. This system captures, stores, and reports all CPT codes and links medical procedures with revenue and expense informa tion. The health insurance billing system has a direct Internet link with the participating insurance companies and Medicare. PCS purchased the hardware and lea�ed the required year dire, still the At t A.fte PC� ity l him “M• Tol: oft hea chis cor off the the PC onl thi1 cer. Case 3: Physician Care Services, Inc. :1- ,y 1d e.s, Ii- nnc d1d d of so 1er nc )re !ll- 1m for case md na ing red software for ten years. It receives hardware maintenance, software updates, and technical assistance from the vendor. A 2013 study of medical records indicated chat the mosr common CPT codes ac PCS are + + + 85029 Auromated Hemogram, and + 71010/2 CbesrX-Ray. 99212/3 and 99202 Office/Outpatient Visit, GOOO I Drawing Blood, Injuries and rechecks generally account for 20 percent of all visits. Paper medical records char existed prior to 2008 arc retained in active file for seven years, and chen transferred to closed files. When interviewed, Dr. Tobias indicated that discharging Nancy Scone, RN, as director of nursing and clinical services in 2012 was a hard decision. Some employees still regret this situation. Scone was well liked bur just could not get along wich some of the phys icians and had a great deal of difficulty coping with multiple job responsibilities. Ac the end of her tenure she refused co provide patient care as needed at the Beta Center. �er she was discharged, Stone complained chat she had “too many duties co do well, and · PCS was more interested in getting patients in and out than in providing patients qual ity medical care.” She has retained an anorney and informed Dr. Tobias that she is suing him and PCS for “wrongful discharge.” As she scared ac the initial hearing for the lawsuit, “Meeting job expectations was hard when the job lacked any formal job description.” Dr. Tobias shared in the interview that he felt compelled co act even though Scone is che sister of the vice president for human resources at Carlstcad Rayon, a growing occupational health client of che Alpha Center, and thar additional details are not available given chat chis case is currently being handled by legal counsel. Dr. Tobias seated chat the owners should look forward to achieving even greater corporate profitability. Dr. Tobias indicated that no one foresaw che terrible first three years of financial losses. He also said chat within the past few years, PCS has earned its place in the regional medical care system and ics future appears solid. le should be noted that, at che end of 2007, one of the original physician parmers, who is no longer affiliated with PCS, exercised his option co be bought out by anocher stockholder. Dr. Tobias was the only partner willing at that time to increase bis ownership in PCS. Dr. Tobias also indicated chat che owners might now be in che position to open a third and even fourtb location. He also discussed purchasing buildings co house che existing centers and adding s