Posts tagged with pediatric benchmarks

We've been working on it for a long time (toooo long), but we are just about to officially release our Practice Vitals Dashboard service to PCC customers.

"Dashboard?" you ask. "What's a dashboard?"

You'll know them as soon as you see them. In fact, here's a quick sample of a piece of one:

This is a quick snapshot of just the initial graphical display of one of six benchmarks we hope to display to them at first (Revenue-per-Visit, E&M Distribution, RVU-Per-Visit, Pricing, Sick-to-Well ratio, A/R Days). The example above shows that the E&M distribution for this sample customer is 18.7%, putting them at the lower end of the "Good" scale.

Each of the benchmarks, like the one above, is "clickable" for more detail. Thus, you could log into pcc.com using your special login and would be immediately presented with your most important management measurements, complete with detailed explanations of the benchmarks, comparisons to other pediatricians around the country and in your region, and an historical view. It's really cool to click on a PCC customer and watch their Revenue/Visit rise every year. Actually, here's what it looks like!

Pretty cool, eh?

I mention all this for a couple reasons:

• We are going to make some very simplified versions of these benchmarks public as part of our new pediatric resources WWW site (more about that later). You won't be able to find this information anywhere else.
• P CC customers will have access to more than I am describing here - super cool.
• PCC customers who are also part of our "Practice Advancement Plan" will receive the Advanced Practice Vitals Dashboard, which will include many more benchmarks as well as the ability to drill down like crazy. You want to know your RVU-Per-Visit for Doctor X in 1999? Click it!

Obviously, all of these reports are available in our system and our clients can run them at any time on their. This service exists for the majority of physicians who don't have the time or inclination, however, to do that. We think it will go over pretty well!

Any suggestions for benchmarks welcome!

I've had a request to post some information about the 2008 RVU impact, but I've decided to wait a day or two for the dust to settle about the latest news. Hope you don't mind. In the meantime, let's return to a simpler time...like this year...when the only curve-ball is the Budget Neutrality adjustment. Igor was looking at the soon-to-be-ready benchmarks for 2007 and realized that the average price for PCC customers dropped from 150% of Medicare to 147% of Medicare. Alarm bells! We both agreed that the largest culprit would be the increase in RVU values to E&M codes that outpaced our customers' corresponding price increases. Let's check!

CPT Code	2006 AVG RVU	2007 AVG RVU	2006 AVG FACF	2007 AVG FACF	RVU Diff	$$ Diff
99212	1.04	1.05	151%	155%	+1%	+3%
99213	1.43	1.71	151%	133%	+19%	-12%
99214	2.3	2.61	141%	129%	+13%	-9%
99215	3.31	3.51	141%	140%	+6%	-1%

Because I never have enough time to make tables properly, here's a quick explanation. In 2006, the average RVU value for our customers for a 99214 was 2.3 RVUs. In 2007 it was 2.61 (a 13% increase, as noted in column 6). In 2006, the average PCC customer charged 141% of Medicare for a 99214, but that dropped to 129% in 2007 (a 9% drop, as indicated in column 7). In absolute terms, you can see that the customer price for a 99214 went up 4% (the difference between columns 6 and 7), but that wasn't enough to keep pace with the RVU changes. Interesting. At least to us RVU nerds.

Need proof that this is the best pediatric practice management resource on the planet? Check it out.

 

Oh, first: major drama at PCC's office last night. Let's hope this post is the closest I come to being a war correspondent. I don't like the proximity of the event to yesterday's message about flooding.

 

Meanwhile...Igor and I were doing some work on our [secret project, still] and were looking at E&M distribution among pediatricians. Here's a trick question - should 9921X codes that result from an initial well visit be counted as part of your distribution? Most people say yes - but I'm not convinced. Sick codes discovered during well visits should, by their nature, have a different distribution. It's not as if, for example, Mom waits until next week for her scheduled physical to talk about that seizure or red, sore throat (ok, some wacky ones do, but you get the point). 99214s and 99215s come to the office as a rule. I believe that -25 modified codes will have a different distribution. I'll post the results later.

 

What we did look at, though, is how many pediatricians actually use the -25 modifiers in the first place and how often they do. Here it is, data you can't get anywhere else:

 

What this shows is that 2% of our clients put -25 modifiers on 40% (or more) of their E&M codes. 12% put it on 20% or more. Get it?

 

What the chart doesn't show is that 22% of PCC's clients never use a -25 modifier.
That's crazy. Especially when you consider the fact that we have good customers. So, how about you? How many of your E&Ms have -25 modifiers?

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Last week, Igor and I were looking at the usage of -25 Modified E&M codes as the information about them is a bit of an unspoken subject in our business. I can't find any good, definitive sources so, as usual, we have to create our own.

Two days ago, I posited that the distribution of -25 modified E&M codes should be different from non-modified codes for a simple reason: acute medical issues typically generate their own sick visits and the most common type of modified E&M would be an "Oh, by the way..." Those OBTWs don't often rise to the level of a 99214 or 99215, at least as often as a walk-in would.

That was the thought, anyway. Here are the results, complete with my original estimate of what it would be:

What do we learn? That -25 modified E&M codes actually mimic "normal" E&M codes quite closely. Fewer 99213s, certainly...but more 99214s and 99215s! The opposite of what I predicted. Figures.

So, why were we wrong (I'm trying to spread the blame)? First, we learned that our clients have as many modified E&M codes as non-modified! In other words, even with 22% of our clients not using the codes at all, boatloads of -25 modified codes go out the door of our practices. Why? A faithful reader - who will go unnamed until she asks for credit - offered the following insight:

They are not only when there is an associated well visit
Asthma Checks
When we do spirometry at these visits, we don't get paid unless we put a -25 on the E/M.
Imms visits
When there is a recheck of illness, Imms won't pay unless there is a -25.
Infant Bili-Weight Check Visits
When We do a transcutaneous bili, we need the -25 on E/M.
Sick visits with opth complaints, migraines, injuries
Visual testing won't pay without the modifier.
Sick visits with hearing, tinnitus
Hearing testing requires us to add the -25 on the E/M.
If the modifier -25 is not used , we would get "bundled" payments from quite a few inscos.

Well, that explains that. Perhaps Igor and I will explore looking only at E&Ms at well visits after all! Harumph.

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A note over on an MGMA mailing list reminded me that I haven't done any good benchmarks in a while, so why not quickly publish our latest pediatric E&M distribution results. Here's a comparison of PCC's pediatric E&M distribution, 2007 vs. 2003, when we started pushing our clients on this issue...

 

For those scoring at home, the data:

	2003	2007
99212	9.3%	6.4%
99213	81.0%	77.2%
99214	8.9%	15.1%
99215	0.9%	1.2%

That's a good increase in 214s and even 215s. I'm proud of that!

Igor and I have been working tirelessly on the various pediatric benchmarks we track for our customers (and the rest of the world). In fact, we've been focusing on developing a single PCC financial benchmark figure, with a clinical one to follow.

As a result of building this page, we have had to do a lot of thinking about normalization of scores, benchmark "ranges" and more. I thought I'd share a quick review of a tiny part of what we've seen so far. Here are three interesting changes in the values of key measurements from 2006 to 2007:

Year	Median A/R Days	Revenue / Visit	Revenue / Visit (no imms)
2006	32.28	$90.83	$72.52
2007	30.03	$100.87	$74.58

First, I like seeing that 7% drop in the median A/R days! It's particularly notable when we realize that even more PCC customers dropped capitation this year (bye bye, BCBS HMO of NJ).

Also interesting is the "Revenue Per Visit" data. For the first time ever, PCC clients have passed the magic $100/visit line - an increase of over 10% - good news. Great news, actually. Until you pull the immunizations out of it...and realize that nearly 80% of the increase our customers saw in their revenue last year got plowed straight back into the pharms. No wonder they have such bad reputations.

Still, no need to sneeze at a 3% increase in per-visit revenue when report after report shows things moving in the opposite direction.

Meanwhile, some of you may want to check out this blog/podcast, the Pediatric Pearls Show. In an ideal situation, I envision a practice getting a call from a mom about, say, wanting care for her kid with a cold, but not having the time to bring him on - perhaps the nurse could direct the mom to the episode about The Common Cold? Of course, you have to vet these for yourself, but it's an overdue idea.

Igor and I have continued to follow up on the recession and its impact on our pediatric clients and have discovered some interesting results.  We published a formal interview with the two of us here, the teaser follows:

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In December, we researched the growing concerns about the impact of the economy on your practices. Specifically, we looked at monthly charge and revenue trends for pediatric practices using the PCC Partner Practice Management System. According to the data at the time, PCC clients, on average, had not seen a decrease in visit revenue and were still experiencing strong growth trends. Even though some practices were definitely seeing fewer patients as the result of the economy and slow flu season, others were generating even more revenue than last year. This past week, we reexamined these numbers using the most recent data and wanted to share the results of our findings.

As you looked for the impact of the recession on PCC clients, what did you find?

Chip Hart: The results were an interesting mix of both good and bad news. The bad news, at first, appears to be no surprise; average visit rates are down among PCC practices, with sick visits down about seven percent this December compared to last year. However, despite the decline in visit volume, charges and deposits are up for the same period. PCC clients made more money per workday this year than they did last year. This was interesting news and worth investigating.

Tim Proctor: Additionally, median A/R days dropped significantly in the fourth quarter. If visits are down and insurance companies are taking longer to pay, as we have been hearing, A/R would be going up. In fact, we've had the biggest fourth quarter drop in median A/R since we've been recording this data–almost 12%. In addition to more practices using electronic or direct deposits for insurance checks, PCC clients have gotten better at collecting money.

 

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To read the rest of the piece, go here.

 

Over the next few days, I will share some of the actual data - with some purdy pictures and surprising results - on the blog.

 

The other day, I posted our new Sick:Well visit benchmarks that take into account the -25 modifier usage.  I remarked that there appeared to be an interesting dip in the benchmark in 2004 and asked if anyone had an explanation. 

Turns out that Chipsblog Super Fan (my label) Dr. Suzanne Berman did a little research in her practice and may have come up with some of the answer.  At first, she wrote to me:

I betcha one reason is because the 2003/2004 flu season was so screwy and awful. We recall it in our practice annals as the Awful Influenza Year -- influenza vaccine was delayed, no one paid for FluMist yet, the vaccine was a mismatch, and worst of all, the season hit way early (November), before we were prepared for it. This would push a lot of kids that you'd normally see in early 2004 to late 2003, making the 2003 ratio higher and the 2004 ratio lower.

She then confirmed that her S:W ratio dropped quickly in 2004 and jumped up slightly in 2005.  She ran off to test her hypothesis and came back with this beauty...

 

 

The X-axis is the month of flu diagnosis.  The Y-axis is the overall percentage of flu diagnoses for that season (if 70% of the flu diagnoses for the season (Nov-April) were made in February, February's Y axis is a 70).

Sure enough, 2003 came a few months early, pushing a stack of kids who would have otherwise shown up sick in 2004 back into 2003. She then pointed me to this cool CDC flu site showing that a similar trend was felt across the country, saving me from having to run the data for our clients...

Here's the kicker - Dr. Berman realized that this trend above would only really affect the ratio if flu diagnoses make up a significant portion of sick visits on an annual basis.  Turns out, at least in her office, the flu shift that year was part of the cause - but not all of it.  Was the super-late arrival of the 2004 flu mean that you didn't actually see all the sick kids you'd normally see, as you were already into your well schedule/season?

Anyone else?  This is great stuff.  Thanks, Dr. Berman.

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Hey, check out frequent Chip's Blog poster Brandon Bettancourt making a splash on the AMA WWW site in a piece about chosing a PM system during this age of EHR purchasing.  I have to say that I can't argue with the list of questions everyone should ask any potential PM vendor.

Meanwhile, back with some data.  One assumption made by many is that larger practices make more money per provider - not necessarily true, as I have pointed out before.  In fact, I think that practices who merge (vs. grow organically) make less money. 

Although the graph below doesn't address the cost side of the balance sheet, it provides interesting detail about the earning potential of pediatric practices. To summarize: there is a slight negative correlation between the size of a practice and the expected income per physician.  In other words, our smaller clients earn more $$.  More about that in a second.

I deliberately left off the values on the axes so that an extra-curious reader can't figure out information about some of our clients.  And, I removed from the image a few outliers who would have been easy to identify (namely, the larger practices).  But as you climb the Y axis, you are looking at larger practices.  As you extend on the X axis, you are looking at physicians generating more revenue. 

 

 

The implication here is that larger practices don't generate more income per pediatrician.  And, as a rule, they don't.  To test my theory, I ran a similar analysis comparing practice size and patient volume - it looks nearly identical.  Smaller practices are also busier.  What a surprise.

So unless there is some magic on the accounts payable side of the equation for larger practices (which there is...sometimes good, sometimes bad), smaller practices generate just as much revenue as larger practices on a per-provider basis.

What do you say about that?

[Quick segue - come see the likes of me, Susanne Madden, Richard Lander, Rick Oken, and more speak at the VA AAP and Pediatric Alliance 4th Annual Meeting in March.]

Igor has been really, really busy lately and it's great!

He's off researching a concept for Dr. Schwartz (I can't remember what clever nickname I gave him here on the blog once) where the latter posits that part of the decline in visits for 2011 can be attributed to the higher HDHP plans and, as a result, they are seeing fewer "multi-patients-per-visit" episodes.  In other words, it used to work that a mom would bring in Sick Kid #1 and toss in one or two "oh, by the ways" because the copay was just $10 per or something.  Now, with the HDHPs hitting the deductible for each of those kids, the docs will stare a sick kid right in the eye and the mom'll say, "Oh, he's fine."

We're looking into it.  Igor and I have a plan.

Meanwhile, SOAPM folks discussed the concept of "Dollars Per RVU" recently as a benchmark.  When you discuss "Dollars CHARGED per RVU" in your office, it creates what's known as your "Frequency Adjusted Conversion Factor" and essentially tells you how much, on average and relative to Medicare, you charge.  

When you look at it on a "Dollars PAID per RVU" you get a sense of how much you are being paid.  Sadly, as you'll see in a moment, our clients aren't getting paid much more than the 95-99% of Medicare they were getting a few years ago.  That's not to say they don't make more money, per se - simply coding properly can generate a lot more income, even at a steady or declining payment rate.

So, Igor and I took at a look at all the PCC clients from 11/09 through 10/10, cleaned up the appropriate outliers, removed all non-RVU-valid procedure data, and here's what we learned.

PCC's pediatric customers generate, on average, 97% of 2010 Medicare rates in payments.  It worked out to about $35.14-per-RVU.  If you want to figure out $$/Work RVU, just remember that Work RVUs are part of the 50/48 split, so you really just need to double it to figure it out.

This is essentially identical to the figure I calculated almost 10 years ago when I first looked at the data.

Playing with the numbers, what do I see?

The range for the figure is from $13.74 (38%) to $57.67 (160%).  That's right - we've got practices who average less than 40% in Medicare and practices who average over 160% of Medicare.  For the very same work.  95% of PCC's practices are between 76% and 118%.  About 10% are under 70% and 10% are over 120%.

Any correlations I could find?

• Practices with a Sick:Well visit ratio less than 2.0 hopped up to 103% and those over 2.5 drop to 91%.  However, many of our clients with the largest S:W ratios (>4) jump way up to 115% and beyond.  I suspect they could be coding differently.
• Our clients who perform a lot of 99214s and 99215s - as a group, they average over 75%, some over 90% - perform very poorly, with a 76% Medicare payment rate.  Most of these practices are extremely high Medicaid, but not all.
• Our clients who charge the most - over 200% of Medicare - do alright, as they collect 103% of Medicare.  Those who charge too little (< 140%), fare poorly at 86% of Medicare.  Those who charge much too little (< 120%) are at 76% of Medicare.
• There is clearly massive regional bias.  NJites bring in 86%.  NY brings 97% (to my surprise). And the state that Jon Caine loves to hate, MA, averages - you ready? - 122% of Medicare.  Our sample size may be suspect (about $25m in charges), but our MA clients clearly get paid well.  So does NH. Oklahoma - 112%.
• Gut instinct tells me that Medicaid volume affects this number, but I can't prove it much.  I don't trust the Medicaid percentages from our clients (not all of them configure it in such a way we know it's a Medicaid plan without manual intervention), but there looks like slight correlation.  The top 10% Medicaid practices come in at 92% while everyone who sees NO Medicaid, has 99%.  But take that one with a BIG grain of salt

How's that for a night's work?