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1. REPORT DATE (OO-MM-YYYY) 12. REPORT TYPE 25/07/2018 presentation

4. TITLE AND SUBTITLE Understanding Your Value Using Real Math: Applying a Fee for Service and Fee for Value Construct

6. AUTHOR($)

Fisher, Reid Dr.

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES)

59th Clinical Research Division 1 JOO Willford Hall Loop, Bldg 4430 JBSA-Lackland. TX 78236-9908 210-292-7141 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES)

59th Clinical Research Division 1100 Willford I I all Loop, Bldg 4430 JBSA-Lackland, TX 78236-9908 210-292-7141

12. DISTRIBUTION/AVAILABILITY STATEMENT

Approved for public release. Distribution is unlimited.

13. SUPPLEMENTARY NOTES

National Athletic Trainer's Association Annual Meeting, Louisiana, 25-30 July 2018

14. ABSTRACT

15. SUBJECT TERMS

16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER

a. REPORT b. ABSTRACT c. THIS PAGE ABSTRACT OF PAGES

3. DATES COVERED (From - To)

07/25-30/2018 Sa. CONTRACT NUMBER

Sb. GRANT NUMBER

Sc. PROGRAM ELEMENT NUMBER

5d. PROJECT NUMBER

Se. TASK NUMBER

Sf. WORK UNIT NUMBER

8. PERFORMING ORGANIZATION REPORT NUMBER

17921

10. SPONSOR/MONITOR'S ACRONYM($)

11. SPONSOR/MONITOR'S REPORT NUMBER($)

19a. NAME OF RESPONSIBLE PERSON

Clarice Longoria 19b. TELEPHONE NUMBER (Include area code)

210-292-7141 Standard Form 298 (Rev. 8/98)

Prescribed by ANSI Std Z39 18 Adobe Profe:3sional 7 .0

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Athletic Trainers Provide High Value Medical Cet~s Drivers of Value

Individual / Athlete

Wellness

Institutional Performance

Low-Cost Provision of

Care

Avoidance of Future Care &

Cost

Support for individual and athlete wellness

• Maximized performance, in life and in sport • Accelerated return to play

Support for organizational success

• Improved productivity and team performance • Support for institutional success factors

Highly efficient care delivered to patients at rates often below market

• Reduced and/or more efficient use of fee-for-service medical services • Lower cost structure of care, often resulting in lower costs for individuals and TPPs1

Through preventative care best practices, avoidance of current and future costs

• Reduced future health care expenditures • Reduced drivers of cost: Workplace injuries, presenteeism, production delays

1) TPP: Third Party Payers; Insurances

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Valuation of Services

Work RVU ReiMbur5eW\eV\.t • Medicare pays the provider a set rate per wRVU; per

the CMS physician fee schedule, set to $35.99 in 2018

• Private insurances contract with providers directly, usually at or above Medicare rates

Work RVO AW\OUV\.t per CP"l wRvu Work Medicare

CPT Description RVU Rate1

97110 Therapeutic Exercise 0.45 $16.20

97140 Manual Therapy 0.43 $15.48

97162 Physical Therapy Eval. (Moderate) 1.20 $43.19 -

97171 Athletic Trainer Eval (Moderate) 0.00 $0.00

99203 Office Outpatient Visit, New (Physician) 1.42 $51.11

99213 Office Ou1j?iatient Visit, Established .97 $34.91 1) Without~~rothera 'f;:itment 21 Nonfacilily, 1 ~ Health Fee Calculator, April 2018

ost healthcare organizations aim to be "profitable" at Medicare rates, allowing

profit to be earned for private payer contracts set above Medicare rates.

RBRVS Full Medicare Rate Average Charge Data, (NOLA)2 Private Insurance (NOLA)

$3285 $64.49

$28.74 $63.12

$82.84 N/A

$0.00 N/A

$109.92 $173.18 -

$73.85 $103.87

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Market Position

Is it bad to be "Low Cost'? Many companies today specifically compete on a "low cost" basis. For these companies and their consumers, it does not mean that they are offering goods or services of lesser (low) quality.

"Low cost" is actually a direct reference to their business model. They compete by offering lower prices, driven from lower operational costs. Athletic Trainers already

Examples: Avoidance of "Hubs"

Standardized fleet configuration

Examples: Consolidated brand offerings

Fewer in-store novelties

Examples: Fewer outparcel locations

Dependent on other cell towers

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Athletic Trainers as Low Cost Providers

Tbte FouV\dation of Atbt{etic Tro.i"'-i"'-9 is o~en Low Cost Athletic Trainers have already adopted a "low cost" business model, as compared to other health professions. This is due to a number of factors, including:

✓ Accelerated care results in fewer "visits" ✓ Lower overhead, often working from smaller or embedded facilities ✓ Less dependence on modalities ✓ Lower employee costs (although we would like to seek salary parity with our

professional peers)

By positioning Athletic Trainers as high quality., low cost providers., we gain a unique leverage point in the healthcare marketplace.

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Replicating a Fee-for-Service Methodology

Pv-ovider EV\.rOIIW\eV\.t Athletic Trainers have a growing understanding of healthcare finance and the requirements to bill for their work. Currently, few third party payers (insurances) contract with athletic trainers directly. To maximize reimbursement, providers should enroll or contract with insurances to become a "participating provider".

i--- Participating Provider

Healthcare providers who enter into an agreement with an insurance carrier. The provider accepts a contracted reimbursement rate for certain services.

Non-Participating Pro~ider

Healthcare providers who chose not to enter into an agreement, or those who are ineligible for an agreement, with an insurance carrier. An insurance may or may not partially pay a "Non-Par" provider.

Athletic Trainers are ineligible to be participating providers with Medicare.

Athletic Trainers may be eligible to contract with some insurances, in some states. They remain eligible to bill as "Non-Par" providers with all insurances, but may not receive reimbursement from the insurance.

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Replicating a Fee-for-Service Methodology

Docu '11\.eV\.ta.tioV\. O.V\.d C odiFi co.ti OV\.

In order to submit charges to an insurance carrier for payment, certain criteria must be met. That criteria includes:

✓ Documentation that meets insurance, HIPAA, and OIG requirements

✓ Documentation that meets CMS requirements (note: most insurances default to CMS guidance on the appropriate documentation and codification requirements)

✓ Electronic submission of a claim, or a "clean claim" completed manually on the CMS 1500 form.

Athletic Tv-a.iV\.ers Must ca.refully set ect which CPT codes they will use., a.V\.d eV\.sure docu'11\.eV\.ta.tioV\. is a.ppropria.te For the code selected.

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--.

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Replicating a Fee-for-Service Methodology

SelectiVt9 El i9ible Codes 1.

When caring for a patient, added attention should be given to select the appropriate CPT codes and document those codes to the full requirements. Many codes will be scrutinized, and you should ensure your documentation matches the requirements. Athletic Trainers are ineligible for many other codes, and if used, may attract undue

scrutiny. 1. 'b{ 1 dd d • ( · ·bt E 191 e r A e Scv-ut1Vt!:J2 IVle 191 e3

97169 AT Eval., Low Complex. 97032 Modality/Elec. Stirn 15m

97170 AT Eval. , Mod. Complex. 97035 Modality/Ultrasound 15m

97171 AT Eval., High Complex.

97172 Re-Eval. AT

97110 Therapeutic Exercise

97116 Gait Training Therapy

97140 Manual Therapy

97124 Massage Therapy

97150 Group Therapeutic Proc.

29799 Casting/Strapping

96000 Motion Analysis Video

97750 Physical Performance

1)Appropriate codes will vary greatly by region and insuranJ~ §.tier; Codes shown here are illustrative only 2) Codes with additional scrutiny implies it may be approved, but has significant additional documentation requirements

992## Physician E/M, NP.w/Established 9Z0"4"Eye exam, NP..w/E=stablishedt. M . I t· 9lJ9~1"Cniroprac Ic arnpu a 10n

295## Strapping of (Body Part)

9701 0 Hot or Cold Therapy

9~62 Dynamic Surface EMG

3) Codes shown as ineligible illustrate those that are most likely to be denied or that are specific to another health profession 4)While hoVcold packs may be eligible. they require continued attention by the provider, which is rarely the case: Reimbursement is low for this code. and it is recommended to not be used

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Replicating a Fee-for-Service Methodology

Rep{icatiVt9 Bi({ab(e Charges iVt the USAF Using data provided by ATs serving the USAF trainees, we are able to take a closer look at how their clinical services could be reimbursed over the course of one year.

AT 1 AT2 AT3 AT4 ATS AT6 Description

Total Billable Units: 4144 3392 1708 1504 4362 2932 The total count of C-PT rnriP< rlnrumPntPrl nnrl <uhmittPrl

-Total Reported wRVUs: 2874.8 3348.6 1412.5 1339.7 2976.2 2424.5 The total work RVU value of thP rPT mrlP< rnhmittPrl

-Total "eligible" wRVUs: 2534.8 1644.3 1142.6 830.1 2307.0 1471.1 The total work RVU value deemed to be from "eligihf P" rPT rnrlP<

--Percent "eligible"

88% 49% 81% 62% 78% 61% The relative percent of work RVUs deemed to be from "eligible" CPT codes wRVUs:

Reimbursement value of $91 227

wRVUs, at CMS rate: ' $59,178 $41,112 $29,875 $83,028 $52,945 Total eligible wRVUs x 2018 CMS wRVU conversion factor

Not accounted for in this analysis is the allocation of the Athletic Trainers' time to clinical services and "METLs" (Mission Essential Task List), however, ATs may have included codes from time spent on METLs. Note that AT1 and ATS had received additional training on appropriate documentation and codification of services.

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Replicating a Fee-for-Service Methodology

A Closer Look: AT::L vs AT.2 xzcThat argument will focus on realistic measurement and calculation of financial value, both through a Fee-for-Service (FFS) model and a Fee-for-Value (FFV) model.

AT1 AT2 Paid Units PaidwRVUs AT1 listed "Neuromuscular Reeducation" as

CPT Actual Ac!_ual (All 6 ATsJ (All 6ATsj the top billed code. This was processed and

<= NEUROMUSCULAR RE~ 771 0 0 denied, because this code has added --- requirements to be medically necessary (at least

SLF-CARE TRAIN.DIR CONT.EA 15M 5 766 0 0 one of the following: 1) The patient has the loss

MAN THER TECH, 1/+ REG.EA ~······-- of deep tendon reflexes ... ; 2) The patient has a

15MIN 551 454 1802 1513 nerve palsy ... ; or 3) The patient has muscular - ~ -THER PX,1+,EA 15 MN;THER weakness as a result of a cerebral dysfunction.

EXERC 763 332 3111.9 1435 -ATHLETIC TRAIN EVAL 214 - 315 1278 2198 ( AT2 listed "Hot or Cold Packs Therapy" as the

< ~AW 1X:t: EVl ,I O,NO top billed code. This was processed and denied,

::-::> 226 217 748 1107 because this code requires ongoing supervision - -ND,STER,SZ,EA 113 - 0 0 by the provider, which was not documented (and

---PHYSICAUMANIP THERAPY likely did not occur)

<: PERFORM ==::::> 112 Q. 0 - -HOT OR COLD PACKS THERAPY 1260 82 - 0 0 f Both providers billed for AT evaluation and re--ATHLETIC TRAIN REEVAL 144 68 889 764 reevaluation services. These were approved and - -APP MODAL,1+;ELEC STIM,EA paid at the equivalent physical therapy code 15MN 178 60 422 223

~ - - wRVU value, although these wRVU values are ATHL TRAIN EVL,MOD, 1-2COR,30MN 304 55 824 1219 not specifically assigned by CMS guidelines.

-- -GAIT TRAININGl'.145RAPY 92 53 453 351 RE-EVAL,ATHL TRAIN PLAN,20 MIN l50nfidentia14&Jot to beld@Jl'ied, distribae:t, or reproduced without prior

approval.

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Defining AT Productivity in a FFS Model

DefiVth"·9 Pv-oductivit!j Qoa.ls to Measure Success • A full time position is defined as 2080 hours per year; Assuming 26 days of vacation and

sick time, there are 1872 eligible work hours per year • Due to no shows and cancellations (assuming 80% productive time), there are 1498

targeted work hours per year • Using 97110 (Therapeutic Exercise) as a benchmark, an AT can provide up to 4 units an

hour at .45 work RVUs, an AT can reasonably produce 1.8 work RVU per hour, or 2696 work RVU per year; The potential amount is higher, when using other CPT codes

AT 1 AT 2 AT 3 AT 4 AT 5 AT 6 Total "eligible"wRVUs: 2534.8 1644.3 1142.6 830.1 2307.0 1471.1

% FTE Productivity 94% 61% 42% 31% 86% 55% ~oaf is 3-00% productivity

• However, productive hours should be prorated based on clinical time (traditional, patient­facing), versus sideline/ field-based / METLs duties; The example above does not account for METLs duties

DeW\oVtstv-atiVtg a Positive ROI OVt the AT iVtvestW\eVtt ( iVt a FFS W\ode() • ROI is calculated using the employment costs of the AT versus their productive value • For example, AT1 produced 2534.8 wRVU valued at $91,228 at CMS provider rates; If the

employment cost was $65,000, then the ROI would be 1.41-to-1 Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Important Considerations and Key Takeaways Advice w"'eV\ DeW\0Vtstr-atiVt9 Val«e Via a FFS Model

• Whenever possible, seek to contract with insurance carriers and become a "participating provider11 in their network; A positive outcome from this usually results in the insurance carrier issuing a provider number / credential

• Do not over represent your work when documenting your work via CPT codes; Many ATs fail to recognize the "medically necessary" or "supervision" requirements of codes, thus falsely overrepresenting the value of their work

• When using a new CPT code, research the documentation requirements for the code or consult with a billing expert in your organization

• Keep in mind that AT evaluation/ re-evaluation codes do not have CMS assigned work RVU values; Any insurance carrier who approves you must assign a custom valuation to these CPT codes, else the codes may be approved but pay $0

Confidential. Not to be copied, distributed, or reproduced without prior approval.

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Who are your clients?

AT Integration with USAF Basic Military Training Phase I - Proof of Concept

HUB CLINIC Sports Med Physician

Support Staff

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What matters to your leadership?

Cost of lost trainin time

Cost of delayed graduation

B•lM"tEiLid

Presenteeism

Cost of • In BMT • After first enlistment- lost experience

What matters to your leadership?

• Data

• Evidence

• Demonstration of Effect

So where do you get your data?

6/1/2018

EMR as Mineable resource

• Coding data helps demonstrate productivity rates between practitioners

• Helps develop consistency between providers

AT 1 AT2 AT3 AT4 ATS AT6 Description -Total Billable Units: 4144 3392 1708 1504 4362 2932 The total count of CPT codes documented ond submitted

Tota~orted wRVUs: 2874.8 3348.6 1412.5 1339.7 2976.2 2424.5 The total work RVU value of the CPT codes submitted r, "ellglble" wRVUs: 2534.8 1644.3 1142.6 830.l 2307.0 1471.1 The total work RVU value deemed to be from "eliqible" CPT codes

' Percent "eligible"

88% 49% 81% 62% 78% 61% The relative percent of work RVUs deemed to be from "eligible" CPT codes wRVUs:

Reimbursement value of $91 227 wRVUs, at CMS rate: ' $59,178 $41,112 $29,875 $83,028 $52,945 Total eligible wRVUs x 2018 CMS wRVU conversion factor

• Once you have that consistency you can start tracking injury rates

6/1/201 8

Tracking Outcomes to Make Comparisons , .. lliiiiiiiit

Musculoskeleta/ (MSK) Attrition

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Trainees 164 107 80 27 U25%)

Training Days Lost 9,283 6,048 5,111 937

Absenteeism for MSK Visits

Orthopedics 124 80 45 35

Physical/Occupational Therapy 2,189 1,413 535 878

Trainee Health (MSK only) 2,174 1,402 1,255 147

All MSK Visits 4,487 2,895 1,835 1,060 (!37%)

Missed Hours for MSK Visits§ 31,548 20,352 12,170 8,182 (!40%)

Fiscal Costs

Training (Attrition} Costt $7,319,944 $4,768,760 $3,794,464 $974,296

Healthcare Costt $731,460 $471,841 $324,225 $147,616

Total $1, 121,913¥

*Expected is based on 321 /322 TRS multiplied by ratio in trainees entered (attrition) or in training-days (for rates) §Time is 8 hours for orthopedics and PT/OT (4 for patient and wingman) and 6 hours for trainee health ;cost is $22,898 to recruit, process, and ship one new trainee plus $384 per training day •cost is $837 per orthopedic visit, $104 per physical/occupational therapy visit, and $184 per trainee health visit ¥Additional savings anticipated with decreased time away from training ($16 per hour), but not independent of MSK attrition savings

I

Intervention Control Intervention vs Control (323 TRS) (321 /322 TRS) RR (95% confidence interval)

Overall Attritiont 5.7% 6.8% 0.84 (0.77, 0.92)

Musculoskeletol A ttritiont 0.9% 1.3% 0.70 (0.56, 0.89)

Med Hold Referrals+ 2.5% 3.9% 0.64 (0.56, 0.73)

Get Fit Referrals+ 1.3% 1.3% l .04 (0.82, l .30)

During the first 18 months of the study (1 Jan 16 - 30 Jun 17), overall attrition was 16% lower and musculoskeletal attrition was 30% lower in the 323 YRS, as compared to the control squadrons-both of which are statistically significant. The risk of referral to Medical Hold was 36% lower and statistically significant, whereas the risk of referral to Get Fit (i.e., failure to pass the final fitness assessment) was nearly identical between the two arms.

tcalculated as the number who entered the respective squadrons and were discharged for any cause or for a musculoskeletal injury, respectively, divided by all who entered during the squadrons during the surveillance period (data sources: THS medical attrition registry; THS BTMS-based denominator registry} *Calculated as the number in the respective squadrons who were referred to Medical Hold or to Get Fit (due to failure of their final BMT fitness assessment), respectively, divided by all who were eligible for those dispositions during the surveillance period (data sources: 737 TRSS Get Fit database; THS TDR database; THS denominator registry)

6/1/2018

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As we transition to new settings you MUST develop the tools to capture data so you can Identify Needs and Track Intervention Efficacy

6/112018

Legitimate Savings Worth the Fuss?

• Is your clinic worth it? Is expansion worth it?

HUB CLINIC Sports Med Physician

Support Staff

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,' 319 TRS \ \ go to ,',' 326 TRS \ , 1 , hub , , , , l AT ' ' - _ _ - ' , go to , \ @ dispensary ,' ~ \ hub ,' ,

Sports Med Physician

Support Staff

AT Residency Diredor

,

Return on Investment

Costs

Clinic & Equipmentt

Personnel

Supplies

Savings

Return on Investment

First year

Subsequent years

tone-time startup costs

Phase I (323 TRS) I $147,413

$241 ,040

$12,793

$1,121,913

Realized $720,667

Phase II (BMT Wide)

$2,097,000t

$2,136,540

$60,000

$4,482,673

Projected $189,133

Projected $2,286,133

+Includes construction of six 1,200 sq ft clinics estimated at $200/sq ft and $657,000 of equipment

Digging for Gold ... and finding Pyrite

Trainees 164 107 80

Training Days Lost 9,283 6,048 5, 111 ( Absenteeism for MSK Visits

Orthopedics 124 80 45

Physical/Occupational Therapy 2,189 1,413 535

Trainee Health (MSK only) 2,174 1,402 1,255

All MSK Visits 4,487 2,895 1,835

Missed Hours for MSK Visits§ 31,548 120,352 112,170

Fiscal Costs

Training (Attrition) Cost~ $7,319,944 $4,768,760 $3,794,464

Healthcare Costt $731,460 $471,841 $324,225

*Expected is based on 321 /322 TRS multiplied by ratio in trainees entered (attrition) or in training-days (for rates) §Time is 8 hours for orthopedics and PT/OT (4 for patient and wingman) and 6 hours for trainee health tCost is $22,898 to recruit, process, and ship one new trainee plus $384 per training day

2:1...

937 J

135

878

147

•Cost is $837 per orthopedic visit,$ I 04 per physical/occupational therapy visit, and $184 per trainee health visit

U25%)

¥Additional savings anticipated with decreased time away from training ($16 per hour), but not independent of MSK attrition savings

Training Time Lost

• Training Days Lost

• Not really a benefit as that time had to be made up.

• Increases cost because it pulls training instructors away from other duties

• Missed Hours for MSK visits

• As with training days lost no significant$$

• But helps streamline the process

• Cannot discount the effect on people doing their jobs

• Healthcare Cost

Digging Deeper - Delve into Research

• Overweight and Obese individuals have 11 % and 33% increased risk of LE MSK Injury

• Hruby et al (2015). BMI and Lower Extremity Injury in US Army Soldiers, 2001-2011. American Journal of Preventive Medicine

Can your clinic fit into and track a long-term health impact?

Can this impact directly impact the company's cost in insurance premiums?

Other Avenues? Long Term Impact?

• What is the impact of a stress fracture sustained in basic training on career progression?

• What is the impact of early stress fracture intervention and biomechanical correction to prevent recurrence?

• What is the impact of prevention techniques that focus on mitigating known risk factors to developing stress fractures?

• Can we quantify it?

6/1/2018

•

Agenda

' • \

• I • I

• Professional Call to Action - Discussion

/ Specific steps each Athletic Trainer can take to impact the healthcare economy locally and nationally

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