Re: Productivity

September 14, 1998

Regarding PPS and the Medicare 5 day assessment, please refer

to the HCA Provider Reimbursement Manual, Part 1, where it

addresses reporting minutes of therapy in Section T:

" ....in the case of a Medicare 5 day assessment, the clinician captures

minutes of therapy that are anticipated for the patient during the first 15

days of his nursing home stay. This makes it possible for the patient to

classify into the appropriate RUG rehabilitation group based on his

anticipated receipt of rehabilitation therapy when the assessment is done

during the first few days of the SNF stay and there has not been enough time

to provide more than the beginning of a course of rehabilitative therapy. The

RUG grouper takes into consideration both the days and minutes expected to be

received in the first 15 days of the stay. " (Except, I have heard, in the

cases of Ultra High and Very High RUGs. Anticipated is not used.)

This is how the SNF will be reimbursed -- hence PROSPECTIVE payment system.

It is also my understanding the 3 grace days during the 5 day assessment are

just that, grace days. I understand FIs will consider review/audits when an

MDS is continually late (i.e., after day 8). Also, Ive heard that FIs will

review/audit when a SNF has a high volume of Ultra High and Very High RUGs

patients.

I also attended quite a few seminars regarding PPS and constantly heard that

therapy will be required 7 days a week. For the two months that we have been

providing therapy in 12 PPS SNFs, that has happened, maybe, once or twice.

Mostly because the SNF thinks the eval must be done on the first day of

admission. If you read the Federal Register, page 26265, referring to Section

T of the MDS, they state, " As rehabilitation services often are not initiated

until after the first MDS assessment's observation period ends, we believe

that allowing the patient time for transition is appropriate. "

I would think if HCFA was expecting 7 day a week therapy, they would have

required it at least in some of their minimum requirements of the RUGS groups.

Anybody else have any other interpretations? Would love to hear what you have

heard.

Kathy Shields

Professional Therapy Providers

St. Louis, Missouri

______________________________________________________________________

September 14, 1998

In a message dated 98-09-14 11:18:44 EDT, you write:

<<

I would think if HCFA was expecting 7 day a week therapy, they would have

required it at least in some of their minimum requirements of the RUGS

groups.

Anybody else have any other interpretations? Would love to hear what you

have

heard.

Kathy Shields >>

Kathy

Excellent post with specific references - Very useful. Thanks

Kovacek

______________________________________________________________________

September 17, 1998

Carol,

>Do you include ALL staff in that .441 factor, or just PT's, PTA's, and

techs who

> are generating billable units?

EVERYONE is included ==> therapists, PTA's, techs, clerical, administrative.

Mark Dwyer, MHA, PT

Kansas City, Kansas

mdwyer1@...

______________________________________________________________________

September 17, 1998

Moira,

>Re: the speech therapy, we've found a way to equate " relative value

>units " to the " procedures in speech therapy which are close to the

" average "

>time units which would be spent on the procedure. This has allowed us to

>continue tracking " productivity " ......It is also built into the " billing "

>system.

That makes sense and is something that I would like to do, but cannot as

long as we remain a Columbia hospital. That is probably going to change in

the next few weeks, so we will see if our productivity changes and allows

for more flexibility in light of the CPT changes.

Mark Dwyer, MHA, PT

Kansas City, Kansas

mdwyer1@...

______________________________________________________________________

October 19, 1998

Todd:

In response to your query re: productivity, you may want to consider the

following:

a. USE OF A MULTIPLIER

When using a multiplier (examples given were .44 to about .52/procedure;

I'll use .50 for the example) you are actually calculating time allotted

for all paid personnel to provide one unit of therapy which is generally a

15 minute procedure. In this example, you would be allocated .50 hrs of

paid time to provide one 15 minute procedure. This paid time generally

includes ALL support staff, managers, secretarial staff, etc. in the

department and since it is paid time any benefit hours paid out during the

time period being examined.

The advantages of this system are:

1. you can easily do the calculation from billed procedures - the

assumption is that a certain amount of educational and paperwork time are

built into the calculation - and do not have to keep additional manual

tracking systems if you are billing on 15 minute units or simple

procedures; hours paid is also usually available from payroll without

manual support

2. many hospitals and chains use this system and so there is some

comparative data out there

3. you can pick and choose what types/levels of staff you are using as the

multiplier does not take into account skill mix.

The disadvantages are:

1. #3 above; there is certainly a tendency if you are counting FTE's (and

this is essentially what this system does) that you will use the highest

skilled people so that you are not caught unable to provide the appropriate

level of service

2. it is difficult to compare apples to apples: certainly skill mix and

time for each patient is different in various settings (acute, skilled,

outpatient) and there do not seem to be good standards that look at acuity

3. by having a standard that counts hours there is less liklihood of

appropriate skill mix which may be a better way to achieve cost effective

treatment - example: if you look at " cost " to provide treatment rather

than hours worked, you can provide 8 units of treatment in a given time

frame with 2 therapists or with one therapist and one assistant - the

second scenario will give you a lower cost for the same units; the

multiplier does not account for this.

b. USING A %AGE OF TIME BILLED PER PROVIDER

While this sounds reasonable it works best only when you have very minimal

support staff since it does not account for the time spent by support

staff. Example: Therapists and Assistants might track their billed time

but this could be highly variable if technicians transport patients versus

treatments given bedside; also inpatient versus outpatient, rehab versus

acute. Again it is very difficult to compare apples to apples.

=================================

A THIRD OPTION HAS NOT HAD MUCH DISCUSSION ON THE LIST BUT MAKES A LOT OF

SENSE

An alternative way to look at this problem would be to look at the COST TO

PROVIDE THE CARE. This has some advantages in that it allows skill mix when

it is appropriate, accounts for ancillary personnel and their use, and

gives us a mechanism that takes care of some of the variables. (There would

still be and expected higher cost with higher acuity patients.)

I have been able to achieve higher allocated multipliers in some situations

by doing the math and proving that FTE's alone (which is what the

mulitiplier really is) are not necessarily the only way to control costs.

I actually did a skill mix example using teams of therapists, assistants,

and techs as compared to a staff of primarily therapists and was able to

increase our allocation/standard/multiplier by about 30% (if you count

hours paid only) but decrease costs by 10-12%.....

Be careful how you present this. You may end up changing skill mix with

your current standard and thus reducing quailty along with cost and FTE's

if your management does not recognize quality as a factor. That is

certainly not the goal of this argument.

Good Luck.... Hope this helps

Angie

Images@...

RR8, Box 22-13

407 South Shore Drive

Amarillo, TX 79118

At 03:26 PM 10/19/98 -0500, you wrote:

>A recent question was posed regarding tracking productivity. Some

respoded by describing a system in which a " target multiplier " was used.

Others used a percentage figure based on billed units vs. total worked

hours. Does one system have advantages over the other? Why use a

multiplier? Is there any practice specific standards in place? Our

accounting department recently did a survey of 250 Primier hospitals to

compare productivity. They looked at visits and procedures per worked

FTE's. I need some information to discuss this issue with them. They

grouped IP, OP, Trainers, ancillary and receptionist staff into this

report. I would appreciate any information you may have.

>Thanks

>T

>

>^^^^^^^^^^^^^^^^

>Todd Cepica, P.T.

>Assistant Director

>Physical Medicine and Rehabilitation

>University Medical Center

>Lubbock, Tx 79417

>Ph: Fax:

>ntc@...

>

------------------------------------------------------------------------

October 20, 1998

Angie

Thanks so much for your valuable input!

T

^^^^^^^^^^^^^^^^

Todd Cepica, P.T.

Assistant Director

Physical Medicine and Rehabilitation

University Medical Center

Lubbock, Tx 79417

Ph: Fax:

ntc@...