Patient Attendance

by Tina Gunaldo, PT, DPT, MHS

If you search the literature for patient attendance, there are plenty of articles from different health care practices asking the same question: What factors affect patient attendance? There are many factors related to patient attendance, such as gender, cognitive status, insurance type, patient education, practitioner cultural competence and patient financial status. However, depending on the setting and clientele, these factors vary.

Interesting enough, there were 103 individuals who participated in the Patient Attendance Burning Question, but only approximately 1/3 of those completed the entire survey. Participation clearly dropped with the questions related to patient demographics. Therefore, information presented in this blog will represent information provided by mostly hospital-based practice settings.

Most facilities define a no-show visit as “patient does not show for appointment (given all day)” and a cancellation visit as “patient call to cancel appointment or patient call within 24 hours of the scheduled appointment.” Attendance for initial evaluations ranged from 70-99% and attendance for subsequent treatment visits ranged from 72-99%. There were multiple ways in which facilities encouraged patient attendance; however, patient education and phone calls were used the most. The factor that was indicated to affect patient attendance the most was an increase in patient co-payments or deductibles.

The reason the HPA chose the topic of patient attendance for a burning question was because this topic is of interest by managers on an annual basis. The use of an electronic scheduling system can assist managers in determining patient demographics and associated attendance rates in an efficient manner. Take advantage of the reporting mechanism offered in your system and start to find what factors affect patient attendance the most. One article discussed the concept of patient coordination and treatment flow within the clinic as a potential area of improvement. Are most no-shows or cancellations noted during the busiest times in the clinic? Is this because patients have to wait for a piece of exercise equipment or private treatment room? Many articles focus on patient diagnosis when determining patient compliance for visits. Does patient diagnosis affect the attendance rate in your clinic?

Managers wanting to improve patient compliance should evaluate attendance rates by therapist, patient demographics (gender, insurance type, co-payments, diagnosis, etc), patient coordination and treatment flow, and any other system policies which may impact compliance.

Staff Motivation

by Jennifer Green-Wilson, PT, MBA, EdD

Summary of Results n=134

Let’s Talk about YOU:
69.4% of respondents reported they are fully engaged, while 26.1% reported they are somewhat engaged.

52.2% of respondents reported they rely on intrinsic sources of motivation [they are passionate about their work!], while 45.5% reported they rely mostly on intrinsic and some extrinsic sources of motivation.

Let’s Talk about your TEAM:
60.4% of respondents reported their team as somewhat engaged, while 29.1% reported that their team is fully engaged.

47.8% of respondents reported that their team relies mostly on intrinsic sources of motivation and some extrinsic sources. Only 17.2% of respondents reported that their team overall relies on sources of intrinsic motivation.

When asked about strategies used to motivate their team, 53% of respondents reported that they mostly use methods to tap into sources of intrinsic motivation.

Discussion
Imagine what it would be like if you could increase the level of engagement in your teams and within your organizations! Deci and Ryan (1985), as part of their self-determination theory (SDT), claim that intrinsic motivation is dependent upon: autonomy, competence, and relatedness; while Pink (2009) suggests that ‘Type I behavior’ is fueled by: autonomy, mastery, and purpose. Pink describes Type I behavior as pertaining to the inherent satisfaction of an activity and less with the external rewards to which an activity leads. Furthermore, Pink claims: “If we want to strengthen our organizations, get beyond our decade of underachievement,…, we need to move,.., to Type I.” (pp.75-76)

Resources:
Deci, E. L. (1995). Why We Do What We Do. New York, New York: Penguin Books.
Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum.
Pink, D. H. (2009). Drive: The surprising truth about what motivates us. New York: Riverhead Books.

HPA members may access the summary and full data for this poll on the HPA Burning Question page.

Jennifer Green-Wilson is a member of the Section on Health Policy & Legislation (HPA) and a member of the American Physical Therapy Association Board of Directors.

Medicare Therapy Cap

by Jaclyn Warshauer, PT

On December 23, 2011, President Obama signed into law a 2-month extension of the Therapy Cap exceptions process. This extension allows Medicare Part B patients to continue to receive medically necessary therapy services above the current Therapy Cap amount of $1880 for PT/SLP combined, and $1880 for OT.

Since the inception of the Therapy Caps as we know them, the service settings impacted include therapists in private practice, outpatient rehabilitation facilities/rehab agencies, CORFs, SNFs providing services to outpatients or residents who are not in covered Part A stays, and home for outpatients who are not receiving Medicare-covered home health care. Outpatient therapy services billed by hospitals are not included in the limits.

The current 2 month extension of the Therapy Cap exception process, which expires on February 29, 2012, did not change the exceptions process, except for updating the annual limit to $1880. However, some modifications in the process had been introduced in the original House bill. These modifications could still be on the table as the congressional conference committee hammers out the deal between the two chambers to prevent the Therapy Cap extension process from going away March 1, 2012.

The original House bill had created a 2-stage exceptions process. In this 2-stage process, therapists would submit claims using the KX modifier when the $1880 cap is reached and medically necessary therapy will be provided over the cap. At $3,700 a manual review would be required to ensure that the plan of care is medically necessary. Additionally, Therapy Caps would be extended to the hospital outpatient department setting.

There were 89 respondents to HPA’s Therapy Cap poll. Thirty-six practiced in settings that are currently impacted by the Therapy Cap. While this is not a large response and not a scientific poll, consider the following findings and discussion points.

How often was the Therapy Cap met? In those practice settings impacted by the Therapy Cap in 2011, Medicare patients met the Part B cap 20% of the time or less for over half of the respondents, with most (36%) indicating 1-10% meeting the Therapy Cap.

When the cap is met, most respondents indicated that medically necessary services were provided over the cap, allowing for the KX modifier. In half of the practices, 80-100% of the patients received further therapy meeting the criteria for appending the KX modifier.

Discussion Point. Consideration should be given to where your practice lands in terms of frequency of meeting the cap and providing services over the cap with the KX modifier. The findings in this poll are generally consistent with past studies CMS has conducted on the Therapy Cap. For example, a CMS study of therapy users in CY2006 found that 12.0% of PT, 15.3% of OT and 8.8% of SLP were over the cap.

If your practice is consistently having a majority of Medicare patients meet or exceed the therapy cap (over 20% of the poll respondents indicated that 70+% met the therapy cap), you may run the risk of being an outlier on Medicare’s audit screen. While every practice is clinically unique, and having a significant number of patients meeting the therapy cap may be medically reasonable and necessary, documentation must be consistently strong to support medical necessity and skilled services to reduce the audit risk.

If the modifications in the House bill had been put into effect, what might be the impact?

Of the 36 respondents, 55% indicated that 10% or less of their Medicare Part B patients would meet or exceed the $3700 level which would have required a manual review. However, there were some practices that indicated that 91-100% of their Medicare Part B patients would meet or exceed $3700. The manual review would put a significant burden on practices and would likely tie up cash flow.

The other modification in the House bill added the outpatient hospital setting to the Therapy Cap. This survey did have 35 outpatient hospital practices respond. While most answered N/A to the Therapy Cap questions, some did respond. The responses generally mimicked the patterns described above for those practices currently under the Therapy Cap.

Jaclyn Warshauer is a member of the Section on Health Policy & Administration’s (HPA’s) Government Affairs & Practice Committee.

Additional Resources:

American Physical Therapy Association Medicare Therapy Cap advocacy page

Measurement of Productivity

by Ed Dobrzykowski, PT, DPT, ATC, MHS

Productivity: there may be no other topic in the management of physical therapy and rehabilitation services that is more misunderstood and conflicting. How is productivity defined? How does one consider the variability among patients and practice settings? Why is the measurement of productivity needed? How do you benchmark?

As seen in this HPA burning question survey, there are patterns and variability seen. The 171 respondents include practices which may derive productivity data from their billing and financial information management systems, to practices which utilize multiple indicators and deploy methodology unique to their physical therapy practice.

The variability of responses is attributable to differences seen in the five primary areas of PT practice (acute care, skilled nursing, inpatient rehab, home health and outpatient) and patient mix.

BTU (billed treatment unit of 15 minutes) is the metric predominately used (39.2%). This data reflects my own experiences in queries of management class attendees. Visits per day or visits per week may be used in any practice type; I suspect that the majority are home health or outpatient services. The utilization of minutes of service are indicative of skilled nursing or inpatient rehabilitation where the time measurement is crucial to billing in these practice areas and reflective of their payment based patient classification systems. In home health, a combination of metrics is sometimes used, such as a point based system where values are assigned to opening of a case, completing an evaluation and a follow up visit.

The worked hours per unit of service question was unclear and did not permit responses that included decimal points. However, the expected level of productivity for a PT working 8 hours a day as reflected by BTUs averaged 22.76, and for PTAs averaged 21.74. This metric is available in financial software linking billing (units of service) to hours worked (exclusive of paid time off and sick time). Questions 7-8 indicate an outpatient target of 0.4 worked hours per unit of service for practices primarily of patients with musculoskeletal conditions, and slightly higher for practices containing primarily patients with neurologic or pediatric case mix. This is consistent with information that I have seen our own practices and with information sharing by rehab managers.

The expected level of productivity for 48% of respondents was nearly 23 BTUs, which equates to 72% productivity. The minutes of billable service was 67% using a denominator of 450 potential minutes (7.5 hour day); if assuming skilled nursing this level appears low based upon managers’ class surveys noting 80-90% billable time. The visit per day metric is used in home health and inpatient acute services; the visit per week metric is used in home health. The worked hours per unit of service responses are highly variable with a mean that is not interpretable.

The expected level of productivity for PTAs tends to be lower than for PTs, with the exception of CPTs billed and worked hours per unit of service responses which were similar to PTs.

The types of practices, variability in metrics, and results are in line with managers’ reporting in educational classes. In order to manage and improve productivity the following steps are recommended: 1) measure your staff efficiency to create a baseline; 2) set targets for improvements annually for both individual staff and practice; 3) utilize productivity measures in context of and balance with other practice metrics related to quality, patient satisfaction, outcomes, revenue, and expense. Our challenge in management is making improvements that continue to add value to the patient experience while reducing cost over time.

The HPA hopes that the Burning Question, the results from the survey and this blog have provided you with some valuable information on the topic of productivity. For members and non-members, please use this blog as a mechanism to continue the conversation on productivity.

For detailed information on the poll results, please visit the HPA website, where you can view or download the responses in spreadsheet format (members only).

A presentation is planned on this topic by Ed Dobrzykowski, PT, DPT, ATC, MHS at the APTA Combined Sections conference in Chicago on Feb. 9 (sponsored by the Acute Care Section).

Suggested References

Arslanian L, Gonzales Dean M, Soper S. Productivity Metrics and Outcomes in Acute Care. CSM 2006
Bohannon R. Productivity among Physical Therapists: An Evaluation of One Department. Phys Ther 1984; 64:1242-1244
Kovacek, P. Improving Productivity Without Sacrificing Quality Rehab Services. 1994, 1995, Rev. 2011. www.ptmanager.com
Wiersma, R et al: Rethinking Productivity and Efficiency CSM 2005. PT Magazine, May 2005, p. 54

1 Comment

by hpaapta on January 9, 2012 • Permalink

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Tagged physical therapy, productivity

Posted by hpaapta on January 9, 2012

http://hpaapta.wordpress.com/2012/01/09/measurement-of-productivity/

Physical Therapy Staffing

by Tina Gunaldo, PT, DPT, MHS

First, let me thank all of those who participated in the HPA’s first Burning Question. This area is an open blog for anyone to view and offer input on the topic of Physical Therapy Staffing. The question we asked was “How many patients does a PT or PTA see in an 8 hour day?” For detailed information on the results, please visit the HPA website, where you can view or download the responses in spreadsheet format (members only).

The providers of information were mostly in an administrative or supervisory role as compared to a clinical role. Most of the information collected was from staff in Acute Care and Outpatient Hospital-based settings. The average number of patients seen by a clinician in an 8 hour day varied by setting, 6 (IRF) – 17.6 (OP Private Practice) patients.

When you review the literature, you may find information on how health care provider staffing affects patient safety and patient outcomes (Decker, F.H., 2008). There are many factors which influence clinician staffing, such as the setting, patient diagnosis, state or federal regulations and number of support staff. Many managers also seek information on staffing for productivity reasons.

There are many trends in health care, including transparency and value-based purchasing. HealthCare.gov and Leapfroggroup.org are examples of national organization websites pushing transparency in health care. Some health care facilities in Massachusetts and New Jersey are required to post staffing ratios. New England Baptist in Massachusetts has a site that indicates the direct number of hours of direct care a patient can expect to receive from an RN, and in New Jersey, hospitals are required to report and post staffing and patient-to-staff ratios. There are many reasons mangers review staffing plans, and relating clinician:patient ratios to patient outcomes should be considered.

The HPA hopes that the Burning Question, the results from the survey and this blog have provided you with some valuable information and food for thought on the topic of Physical Therapy Staffing.

Tina Gunaldo is Chair of the HPA Member Services Committee and a member of the HPA Board of Directors.

5 Comments

by hpaapta on November 16, 2011 • Permalink

Posted in Uncategorized

Tagged health care staffing, physical therapy

Posted by hpaapta on November 16, 2011

http://hpaapta.wordpress.com/2011/11/16/physical-therapy-staffing/

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