Operator:
Hello everyone. Thank you for holding and welcome
to the Rural Health Clinic Technical Assistance call sponsored by
the Office of Rural Health Policy. We are recording today's conference.
And at this time, I'd like to turn the call over
to your moderator, Bill Finerfrock. Please go ahead, sir.
Bill Finerfrock:
Thank you. I'd like to welcome everybody to today's
presentation entitled "Benchmarking - Keeping it Simple."
I'm Bill Finerfrock, executive director of the National Association
of Rural Health Clinics. Our speaker today is Linda Goldsmith, president
and principal associate in Goldsmith & Associates, which is
a rural health clinic-consulting firm. She provides a variety of
services designed to optimize administrative performance of rural
physician groups and hospitals.
Today's call will be followed up by a call later
on using your benchmarking data to establish a budget for your RAC.
Today's program is schedule for one hour. The first 45 minutes will
be Linda's presentation and then we will open up the lines for questions
and answers.
This series is sponsored by the Health Resources
and Services Administration's Federal Office of Rural Health Policy
in conjunction with the National Association of Rural Health Clinics.
The purpose of the series is to provide rural health clinic staff
with technical assistance and RHC-specific information. This is
the eleventh call in the series, which began in 2005.
As you all know, there is no charge for participation.
This is fully funded by the Office of Rural Health Policy. Individuals
can sign up and receive announcements regarding call dates, topics
and speaker presentations - www.ruralhealth.hrsa.gov/rhc. A transcript
of today's call, as well as the slides - the slides are already
available and a transcript will be available in a few weeks on the
ORHP site at that location. We will request that callers during
the Q&A provide their name and location before their question.
Linda, we're looking forward to your presentation
and the line is yours.
Linda Goldsmith:
Thank you very much, Bill. And, I'd like to say
good afternoon to everybody. I hope wherever you are located that's
its cool and not too hot today.
Today's presentation is about benchmarking and
it's intended to serve as an introductory-level course to this topic.
I would like to suggest that if you are interested in a more advanced
discussion about the topic to let Bill know and maybe he can schedule
a follow up session in the future.
Please go to my PowerPoint presentation, starting
with Slide #3 where the course objectives are referenced. As stated
it is hoped that at the conclusion of this session (l) you will
be able to understand what is meant by the term "benchmarking,";
(2) understand the benefits of benchmarking, (3) be able to develop
a plan to benchmark, using key indicators for your own clinic and,
finally, (4) understand the limitations of benchmarking.
On slide #5, I have the Webster's Dictionary
definition for benchmark and that is, "benchmark is a standard
by which something can be measured or judged." Therefore, benchmarking
for a rural health clinic owner or manager is the process of comparing
the performance of selected indicators from your clinic to the performance
of other clinics.
As a practice management consultant, I get requests
from clinic managers and owners to assist them with a specific problem.
For example:
" An owner will can and say "my office manager wants to
hire more people and I think we have too many already, especially
compared to the number I used to employ several years ago. How do
I know if we really need additional staff?"
" An office manager will call and say "I am new to the
rural health clinic program and I need some help with knowing whether
or not certification as a rural health clinic continues to be a
good reimbursement program for us."
" Lastly, an owner will call and say "why am I not earning
more money? I seem to be working harder than ever and bringing home
less."
As a practice management consultant, the primary focus of my approach
to answering such questions and solving perceived problems is by
undergoing the process of benchmarking. If the owner thinks he has
too many employees --- then let's compare his staffing ratio to
similar clinics. If the office manager wants to know how profitable
operating as a rural health clinic is --- then lets compare her
financial ratios to the financial ratios of similar clinics. And,
finally, for the owner that is working too hard, the process of
benchmarking will help measure is clinic's profitability and cost
management.
On slide #6, I would like to provide a little
history about benchmarking. In his book, In Search of Excellence,
Tom Peters wrote, "you cannot manage what you do not measure."
As you know, there is a lot of truth to that. The process of benchmarking
helps a manager measure. Therefore, benchmarking is used by most
if not all industries and has been around for a long, long time.
For example, automobile manufacturers benchmark their EPA miles
per gallon to industry standards. Chip makers, such as Intel, want
to know how many defects they have per million chips manufactured.
To measure this critical aspect of their operation they benchmark
the number of defects that they have to their own data base as well
as other chipmakers. Hotels also use benchmarking to compare their
occupancy rate and guest satisfaction to a national database. And
finally, hospitals use benchmarking by comparing their number of
falls out of the bed, medication errors and infection rates to a
national database. Benchmarking is even used to measure sporting
indicators such as earned run averages for baseball and par scores
for golf. In summary, benchmarking is used very broadly in both
corporate and non corporate environments.
Benchmarking for medical practices did not really
begin to develop until the 1980s, at which time clinics began to
computerize their accounts payable systems and accounts receivable
systems. This made it easier to gather specific data, and as a result,
for organizations such as Medication Group Management Association
(MGMA), to develop sell a dataset as benchmark information. Benchmarking
for RHCs is still very much in its infancy and unless an effort
is made on a national basis, RHCs will have to continue to benchmarks
to non RHCs.
On slide #7, you may be wondering "Why start
benchmarking now? My response is "When is there a better time?"
Specifically, many rural health clinics are struggling with increased
overhead, capped rural health clinic all-inclusive rates, discounted
fees, increased indigent population, shortage of qualified and motivated
staff, and to complicate these problems our patients are becoming
more demanding. In addition to a changing financial environment,
years of routine can institutionalize effectiveness and prove costly
to a rural health clinic. How many times have you gone to work somewhere
and asked, "why do you do something this way," and the
answer is, "I don't know, it's just the way it's always been
done."
Benchmarking can open the eyes of the practice
by showing you how well you are functioning and why it is important
to question why and how you are performing selected tasks.
On slide #8, "What can benchmarking do for
your clinic?" The reason I like to benchmark is because the
process will identify missed opportunities and create an environment
to work smarter. Another way to say the same thing is that benchmarking
will give you, the office manager or owner, a much better sense
of the clinic's weak and strong areas of performance.
Slide #9: Before we review the steps to begin
the process of benchmarking, I want to review the following benefits:
" The process of comparing your clinic to similar clinics gives
the owner or manager constructive feedback regarding areas of operation
that need improvement.
" Benchmarks provide a baseline or foundation to begin to measure
improvement.
" Benchmarking provides an objective basis for discussing operations
improvement. I really like this particular benefit, because it focuses
on a more objective versus subjective approach to problem solving.
" Benchmarking encourages new ideas, innovation and creative
thinking. And that occurs once you have confirmed that you have
a problem and the impact of the problem.
" Benchmarking identifies specific improvement opportunities.
Specifically, it can be used to develop a comprehensive budget and/or
used to motivate staff by initiating an incentive program.
Keeping all the benefits in mind, let's get started.
Slide #11: "Identify Clinic Indicators You
Want to Benchmark".
Step number one is the need to determine the indicators that you
want to benchmark. You have heard me mention the term "key
performance indicators," so let me take this opportunity to
discuss some of the indicators that are valuable to a rural health
clinic. First, you have the indicators that relate to the clinic's
finances --- after all, if there's no profit margin then there is
no viable practice. I am going to highlight the basic financial
indicators and give you a definition. Because these indicators are
fairly basic, I did not provide a written definition of formula
in the PowerPoint presentation, but they will be provided in the
written transcript.
So, with our first area, let's talk about CHARGES:
Annual gross charges. The total receipts (collections) for patient
services per FTE provider. This does not include other practice
income received. These are charges that are billed by the clinic
for professional services, including ancillary services. If a clinic's
annual gross charges fall short of a benchmark this could indicate
several problems such as (l) your fees are too low; (2) your productivity
is too low, or (3) your providers are undercoding.
Percentage of various payers. Another indicator
that I like to benchmark is a percentage of various payers. This
could be very important to a rural health clinic because, obviously,
our revenue is enhanced the most by having a larger percentage of
Medicaid and Medicare. But, more important, we need to know what
percentage of our clinic is commercial and PPO, because it is in
this area that we have to pay special attention to charges due to
heavy discounting. Also, by benchmarking the percentage of various
payers, you will be able to answer the question pertaining to financial
advantages of continued participation in the RHC program. My experience
is the primary financial benefit of operating as an RHC is in regards
to the volume of Medicaid encounters. If many of your Medicaid patients
have defected to a CHC which just opened a block from your RHC,
you will want to monitor the impact of this new competition in order
to evaluate the cost benefits of continued participation in the
RHC program.
Adjustments Percentage. The amount not collected
on fees for services due to contractual write-offs, charitable adjustments,
free services and other discounts divided by gross charges. This
measures the percentage amount of what a practice bills which is
not actually collected. A lower figure is better. It also will identify
the amount of charitable care you provide and how much the charitable
care costs you in addition to zero collections.
Now, let's talk about COLLECTIONS.
Annual Collections. The total receipts (collections)
for patient services per FTE provider. Does not include other practice
come received. I like to benchmark Annual Collections because it
directly relates to Annual Charges and my budget process.
Gross Collection Percentage. Annual collections
(receipts minus refunds) on fees for services divided by annual
gross charges.
Net Collection Percentage. Total collections (receipts
minus refunds) on fees for services divided by adjusted charges
(total gross charges minus contractual, professional, charity &
other discounts for which payment is not expected). This benchmark
tells you if your cash flow is good or bad. The net collection benchmark
for a family practice clinic, in the southern region of the United
States, is roughly 98 percent. Most of my rural health clinics in
the same region have a net collection percentage in the range of
105 to 115 percent. This ratio runs higher for RHCs because of the
AIR (all inclusive rate) we receive for Medicare and Medicaid encounters.
Therefore, if your RHC is below 105%, and for sure, below the 98
percent benchmark for non RHCs, you know you have a problem with
your billing and collection systems.
Accounts Receivable Ratio. Total accounts receivable
divided by average monthly gross fee or service charges; also referred
to as number of months of receivables outstanding. This particular
benchmark is going to let you know how well your people are working
unpaid accounts.
A/R Percentage 0-30 days. Percent of total accounts
receivable that are 30 days or less. This is determined from a practice's
accounts receivable aging report. Because of the high number of
citizens living below the poverty rate, low median family income,
and high uninsured population in most rural areas of American, for
RHCs, this percentage should be a minimum of 50% of your A/R. However,
even with the poor economic conditions of rural areas, if (l) you
transmit claims daily, (2) assertively work old accounts, and (3)
are fairly disciplined about writing off uncollectible balances
on a routine basis, your percentage should be between 60% - 65%.
Days Gross Charges inA/R. This is the number of
days of charges that are in A/R. The formula to determine this benchmark
is: Total Account Receivable
Annual Gross Charges divided by 365
In a perfect world, RHCs can have 50 to 55 days
of charges in your A/R.
In summary, benchmarks pertaining to charges and
collections will tell you how well you are managing the revenue
components of your clinic's finances.
There are also key performance indicators related
to expenses. For example:
Total Practice Expenses. Operating costs of a
practice excluding physician and paraprofessional compensation.
Total practice expenses are all expenses excluding physician compensation,
physician benefits, paraprofessional compensation and benefits divided
by total collections. These benchmarks tell you how well you are
doing, with regards to profitability and cost management.
Expenses to Charges Ratio. Total operating expenses
divided by total charges. This measures productivity in terms of
what it costs to produce the fees charged by the clinic. If percentage
goes up (over 65%) or down (30%) you will need to determine the
cause.
There are other very important indicators, in
addition to expenses and in addition to collections.
Staffing Ratio - Total Employees. This is the
number of full time equivalent employees per physician, excluding
APN, PA-C., etc. To determine your ratio, total the number of hours
all employees worked during a 12 month period of time and divide
by 2,080 hours. If you have more than 1 FTE provider, divide the
FTE staffing ratio by the number of FTE providers. For example,
the employees of a FTE family physician and FTE PA-c, worked a grand
total of 17,350 hours (includes office manager, medical assistants,
LPNs & RNs, X-Ray & Lab techs, receptionist, insurance clerks,
and billing clerks). 17,350 divided by 2,080 = 8.34 FTE. Divide
8.34 by 2 FTE providers = 4.17 staffing ratio per provider. The
benchmark for a family physician is 4.9. One could conclude that
you are understaffed since your ratio is 4.17, but by much.
Visits Per Week. This indicator is important because
it speaks directly to the productivity of a provider and overall
demand for patient services, which is necessary in determining what
the staffing ratio should be.
I have clients that like to benchmark their hospital
inpatient visits per week, nursing home visits per week, and new
patients per week. I like new patients per week because it helps
me evaluate the demand for services which determines if it is necessary
to recruit additional providers.
I have just identified some basic performance
indicators that from my perspective will be useful for a rural health
clinic to benchmark. There are many more indicators, but due to
time I had to omit from the presentation, but you can identify additional
indicators when you purchase your dataset.
Slide #14. Step 2: Identify Appropriate Dataset.
This probably is the hardest step in the process, but getting easier
as more and more commercial resources are getting into the business
of collecting data to create a larger dataset. By dataset I mean
a set of national, regional, or local norms for you to use to engage
in the process of benchmarking, because benchmarking is comparing.
Remember, you are going to compare your clinic's performance to
a similar clinic's performance, so the dataset you purchase contains
the norms most similar to your clinic.
In order to select a dataset, you will need to
find a source that best matches your clinic's profile. Therefore,
you have to go shopping for a dataset. You are going to first start
with a data source that is the same specialty (or most similar)
as your clinic. For example, if the scope of services for your clinic
is general in nature or resembles the services provided by a family
physician's office, then find a dataset that is representative of
family physicians. Do not use a database that reflects a surgery
clinic or cardiology clinic. To select a non family practice dataset
is the same as comparing apples to oranges.
To digress for a moment. I don't know if this
happens to you, but I often talk to owners who will read in a journal,
perhaps "Medical Economics", where the staffing ratio
of a medical office is 3.5. He/She wants to know why their ratio
is 4.17. When an article does not identify the specialty of the
medical office, I explain to the owner that the ratio is useless.
Once you have decided on a specialty, select
a dataset that is most representative to the size of your clinic.
For example, is your clinic owned by one provider or owned by a
group? A small group versus a large group is going to have different
outcomes.
For smaller clinics, I almost always use benchmarks
for a solo or small family practice group, even if the primary provider
is a physician assistant or a nurse practitioner, assuming, of course,
that they are providing the same scope of services a family physician
provides. I have a couple of pediatric clinics and we use the pediatric
benchmarks for them.
So, now that you have identified your specialty
and the size of your clinic, try to find a dataset that provides
a similar geographical background. Again, matching your clinic to
a similar clinic will give you a truer database to use as benchmarks.
By geographical, I mean a dataset that provides benchmarks specific
to your region or better yet, state. You can imagine that the cost
to operate a rural health clinic in Hawaii, where everything is
very, very expensive, is going to be much higher than operating
a clinic in McGehee, Arkansas where we think overhead tends to run
lower than many other regions in the country. So, in order for your
benchmarking process to be of value, you need to find a dataset
that representative of as many clinics as possible in your specific
geographical area.
Some resources that I'm going to talk about later
on also will provide benchmarks broken down to rural versus urban
settings.
Let's say your RHC is located in Iowa and has
one FTE board certified FP, one FTE GP, and one FTE APN specializing
in adolescent medicine. You have decided you are in the market for
a dataset representative of a small group practice of family physicians
operating in the Midwest. Given that information, let's go to slide
number 17, because you have several resources where you can obtain
your dataset.
Slides 17- 21. I have listed six different resources
that provide datasets matching the profile above. The first is Practice
Support Resources. You will see that I have provided the telephone
number. I think PSR is a very good source and one that I frequently
use because it provides benchmarks by geographical regions, it has
surveyed a large number of clinics (the recent dataset for family
physicians is representative of 1,600 family physicians working
in small groups. Also, it is fairly inexpensive.
The second resource is MGMA. You will see that
I have provided the telephone number for MGMA. MGMA's dataset is
especially good if you have a large group (six or more full-time
providers). It's even better for specialty groups, or multi-specialty
groups. It's also does a very good job of explaining the definition
for each indicator.
And, with that in mind, I need to make sure that
I emphasize the importance in selecting a dataset that is the most
current (most datasets available for purchase represent data collected
two years prior to the printing of the results) and provides excellent
definitions pertaining to each indicator. Without a clear definition
of the indicators you will not be able to benchmark your performance
with accuracy.
Another benefit of using MGMA is that they have
benchmarks for the general population of clinics surveyed as well
as selected "best practice" benchmarks. This is important
because one must always remember that benchmarks are equal to status
quo. By that I mean, they are the average - some clinics are doing
better and others are doing worse. I like to set the "bar"
regarding performance for my clinics higher than the benchmark (unless
it is labeled "best practice") which should be representative
of the better practices.
The third resource is the National Association
of Healthcare Consultants and that's on slide 19. I have provided
their telephone number. I have never used them before, but I've
seen them referenced in credible reports and journals. In reviewing
their dataset products, they do have benchmarks for regional areas.
They are a little expensive, but not as expensive as MGMA.
The fourth resource is The American Academy of
Family Physicians - if you are working for a family physician or
a mid-level provider specializing in family practice - the AAFP's
web site is excellent with regards to the productivity of a family
physician. The dataset is titled "Facts About Family Physicians."
I use their facts as a benchmark and I really like it because the
number of family physicians surveyed (their membership which is
over 100,000 FPs) is significantly higher than the other resources.
They also present the dataset by geographical areas as well as urban
and rural. It's very, very good with regards to productivity, number
of average patients per week, number of weeks per year, number of
hospital admits, etc. Perhaps the best feature is that it is free
if your owner is a member of the AAFP. The website is www.aafp.orgquery.html.
Search: Facts About Family Physicians.
The fifth resource is the National Association
of Rural Health Clinics. At the Summer Institute in Reno, Ron Nelson
presented cost report benchmarking data for rural health clinics.
His presentation is going to be available on the National Association
of Rural Health Clinics web site soon. I missed his presentation
in Reno, but if I understand the handout that I got, he benchmarked
rural health clinics using Medicaid data in Michigan. And, it is
a fairly large database that compares RHCs to FQHC and Independent
RHCs to Provider-based RHCs. Because it contains cost report information
from Michigan clinics it is for sure representative of Michigan
RHCs as well as neighboring states. This is a very, very useful
benchmark source for the clinics in that area. And, with the exception
of a dataset published a couple of years ago by the Washington State
Association of Rural Health Clinics (representative of RHCs located
in Washington), it is the only other dataset to my knowledge that
is exclusive to RHCs.
The sixth resource which could be RHC specific
may be the individual that prepares your cost report. For the first
time this year, I have developed a dataset representative of all
my clients that is available only to my clients. So, perhaps your
consultant has a dataset as well.
Slide #22. Step 3: Gather Data to Analyze. Once
you have purchased your dataset, you need to carefully read the
definitions provided for each indicator that you wish to benchmark.
And that is especially important because you want to make certain
the data you collect from your clinic is derived in the same manner
as reflected in the benchmarks.
The second thing you need to do is develop a
strategy to collect your data. That means you want to make certain
you're A/R and A/P systems are able to give you the results you
need in the format that works with your benchmarks. If the A/R system
does not provide the exact data, develop a spreadsheet that will
do the necessary calculations to reach your objective. Making the
extra effort to perform this task will really provide you a more
reliable comparison.
At this point, you know the indicators that you
want to benchmark. You have identified the resource to purchase
a dataset and subsequently have purchased the dataset. And, now,
for step four, you're ready to begin to analyze it.
You now need to set up a spreadsheet to perform the analysis. On
Slide #23, you will see the spreadsheet I use. The first column
describes the indicator that I want to benchmark, the second column
contains the benchmark I am going to use (always reference your
benchmark by name of company and the year the data was collected),
the third contains my results, and the last column contains the
variance. Depending on the project, I either (1) have a fifth column
that contains comments regarding why "my" results lag
or are better than the benchmarks or (2) I will footnote the variance
and have an explanation at the bottom of the page.
Now that you have your spreadsheet developed
and have compared your performance to the benchmarks, you can identify
the indicators where you are out performing the benchmark and those
where you are lagging. Take each area that indicates a lag or underperformance
and proceed to undergo a good old-fashioned problem solving exercise
to identify a set of strategies to implement in order to improve
your clinic's performance in the specific area. The best way to
brainstorm is to gather various employees to suggest things that
can be done to improve the problem without thinking about barriers.
Once you have all the strategies listed, one by one evaluate them
to determine which ones will work and which ones won't. At the end
of this exercise, you should have one or more strategies that you
can implement to improve the performance of the lagging indicator.
Write-up the policy and procedures for implementation then meet
with the key people associated with implementing the strategy to
review the process.
I strongly recommend that you re-evaluate the
effectiveness of the new strategies at least every three months
to determine if there is an improvement. If you initial strategy(s)
did not work then find out why and try something else. We cannot
continue to lag behind the benchmarks representing similar clinics.
Slide #25 references the limitations in the benchmarking
process. The first limitation is to remember that one benchmark
will not tell the whole story. Just because you find an indicator
that appears to be lagging, you may have a reasonable explanation
and therefore, you won't need to start a quality improvement project
to correct it. For example, as a result of benchmarking, you have
realized that your net collection ratio seriously lags behind the
benchmark. However, you also know that your front office was understaffed
by one FTE employee for two months and to make things worse, your
insurance clerk was out seriously ill for three weeks. As a result,
the many essential detailed tasks associated with a higher collection
ratio were not being implemented as routinely as they should. However,
now that you are fully staffed (you have hired a replacement for
the empty position and your insurance clerk is back 100%) the percentage
should improve. However, before you dismiss the potential problem,
you want to continue to monitor the indicator over the next several
months to make certain your problem was a one time situation. If
you continue to lag in that area, you may have a problem that needs
addressing.
Another limitation to benchmarks, as I mentioned
previously, is that benchmarks represent status quo. And operating
at status quo will not get you where you want to be if you truly
aspire to be a better performing RHC. Therefore, if the benchmark
for Gross Collection Percentage is 77% and your percentage is 77,
don't get too happy. Your 77 percent means you are average and there
is room to improve your performance.
In conclusion, it is easy to say there is no
perfect benchmark and as a clinic manager, one should not rely on
just one way of looking at things. However, benchmarking will provide
you the opportunity to open the eyes of the practice and help you
gain success in those areas that are lagging by helping you identify
issues, set targets, take action and measure your success. Finally,
it provides you with a very effective process to be successful.
And, with that I'd like to thank you very much.
This is a difficult topic to address via telephone conference, but
I've tried to lay out the basics for you to get started and try
to have fun with. Hopefully, you will get more good news than bad
news if you choose to undergo the process of benchmarking.
Bill Finerfrock:
Thank you, Linda. We appreciate it. Before we
open it up, I had a couple of things I wanted to ask you about.
In terms of the database that you select, you gave several options
and talked about, you know, national database, regional, state.
Do you have to be concerned about the size of the database?
In other words that you're refining your request
for information to such a small number. When you say, well, I want
information on a family practice, in a rural community, in the southeastern
United States, you know, that the number - the amount of information
or the number of participants in that database gets so small as
to question the reliability of it?
Linda Goldsmith:
Yes, and thank you for bringing that up. You
do have to question the size of the dataset and also the age of
it. That is why I frequently use the dataset provided by Practice
Support Resources. Their most recent data set for family practice
is the results of the findings of a survey of over 1,600 family
physicians in the southern region alone and it's also representative
of urban as well as rural clinics. And that for me, when I'm working
with clients in the southern region, that's about the best I can
do.
And, also, I think I mentioned on the MGMA slide,
I believe the MGMA dataset is best suited for large practices and
subspecialty groups versus small primary care groups. The last cost
production report I reviewed (several years ago) had an N of 12
for family practice clinics in the whole United States. So, from
my perspective, MGMA is not my choice for as dataset to use in a
RHC in McGehee, Arkansas. So, your point is well taken. When you
are in the process of purchasing your dataset, questions regarding
size, geographical reakdown, and age are good ones to ask.
Bill Finerfrock:
((inaudible)) what is your (end)?
Linda Goldsmith:
Pardon?
Bill Finerfrock:
What is the (end), the number of ((inaudible))
...
Linda Goldsmith:
Well, you know, you want it to be as big as possible
but because there has been no major effort on a national basis to
develop a dataset for RHCs we have to use what we can find that
is most appropriate. The N for Practice Support Resources re FP
in the southern region is 1,600. The N for MGMA the year I considered
their dataset was 12 for family practice. Obviously, Practice Support
Resources has a large dataset than MGMA. The N for the dataset I
have developed for my clients based on cost reports is 18. I feel
comfortable with 1,600 FPs and I feel comfortable with 18 RHCs of
similar size and in the same geographical area. So, its variable,
Bill.
Bill Finerfrock:
OK. There was a question that came in via an
e-mail prior to the call. I'd like to answer it, or see if you could
at least provide some direction. It says, "in RHCs are RVUs
traditionally lower than national averages? If so, why? Is it due
to covering hospital inpatients, since rural areas may not have
hospitals, or is it due to increased numbers of patients with co-morbidity
and increased (psyche) issues among lower-income patients, which
are frequently addressed in primary care offices?"
Linda Goldsmith:
In answer, I don't know if it's true that RVUs
are traditionally lower than national averages. I have not seen
any studies to tell me one way or the other. But, let's look at
the indicator regarding FP salaries earned by rural family physicians
versus urban family physicians. My experience has shown that rural
family physician salaries are equal to, and in many cases greater
than, most urban family practice salaries, so given that comparison,
it's hard to see where rural is lower than national.. But, I do
not use RVUs in a rural health clinic setting because they represent
work units, and because the majority of a rural health clinic reimbursement
is not based on work units, but instead on our all-inclusive rate,
I kind of see no relevance. So, I'd have to say to the person that
submitted the question, I'm just unfamiliar with what he's talking
about. I have not seen any specific studies addressing the issue
and I think that the RVU methodology is more appropriate for large
multi-specialty clinics.
Bill Finerfrock:
OK. All right, Operator, do you want to open
it up to the audience?
Operator:
Absolutely. If anybody has any questions at this
time, simply press star one on your telephone keypad please. Again
that's star one. Please release your mute function before your signal
and you will hear an automated voice prompt on your line to indicate
when the line is open. So once again, it's star one for questions.
We have our first question. Go ahead, please.
Again, your line is open. Go ahead, please.
(Christy):
My question is ...
Bill Finerfrock:
Identify yourself and where you're from please.
(Christy):
Oh, sorry about that. My name is (Christy) and
I'm with (Horn) in Nashville, Tennessee. And, my question is regarding
the resources. What would you say is the best resource for rural
health clinic benchmarks?
Linda Goldsmith:
Well, I have no vested interest in which resource
you use, but the one I use most frequently is Practice Support Resources,
and I use it for many reasons. Number one, it's reasonably affordable.
Number two, they have a large N. For example, for the southern portion
of the United States they surveyed 1,600 family practice physicians
in 12 states. Number three, the profile of practices includes suburban,
urban, rural, solo, group and a variety of years in practice. They
also caution that the majority are established practices at least
2 years or more.
The only problem I have with them is that they
use a range rather than an absolute. But, I can live with the range
because it's the closest in terms of me being able to really know
that I'm comparing similar clinics to similar clinics.
(Christy):
OK, thank you very much.
Linda Goldsmith:
You're welcome.
Bill Finerfrock:
Linda, in terms of the - you'd made some reference
to PAs and nurse practitioners. A lot of the databases only look
at physicians. Is that correct?
Linda Goldsmith:
It does, but ...
Bill Finerfrock:
Is there anything special because of the use
of PAs and NPs?
Linda Goldsmith:
I benchmark PAs and NPs the same way I benchmark
physicians. Basically, I do not cut them any slacks "just because"
they are not a physician because in many cases, I have PAs and NPs
that see more patients in the clinic than the physician does while
working the same number of hours. With regards to salary benchmarks,
I believe that all the sources I have referenced in this presentation
have benchmarks regarding PA and NP salaries but they do not have
benchmarks for productivity.
Bill Finerfrock:
OK. All right. Operator, the next call.
Operator:
No questions holding at the moment. Again, it's
star one if you'd like to ask any questions, please.
Linda Goldsmith:
I'd also like to add, Bill, that on the PA issue,
a couple of years ago I was trying to benchmark a physician assistant's
productivity and I was told the Physician Assistant Association
had some benchmarks, but I was never able to get a response to my
request. I think you have to be a member to get their data, but
they had average number of patients that a PA sees a year, the average
going salary, and I think it was even regional.
Bill Finerfrock:
Yes
Linda Goldsmith:
I don't think it could be purchased. I think
you just have to be a member and hopefully they'll provide that
information to you, should you want it.
Bill Finerfrock:
OK. Operator, any questions?
Operator:
We do have some questions holding. We'll move
to the next question. Go ahead, please.
(Maria Parabello):
Hello, my name is (Maria Parabello) and I'm in
mid Michigan. I wonder if you would be kind enough to give us the
web site that you were mentioning earlier in your presentation.
Linda Goldsmith:
I mentioned two web sites. One was the AAFP and
the other one is the National Association of Rural Health Clinics.
Which one did you want?
(Maria Parabello):
Well, I went to the - see, I got notified about
the presentation, but I was not able to get the PowerPoint presentation,
so therefore I really couldn't follow you that well.
Linda Goldsmith:
I'm sorry. Bill, maybe you can address that.
Bill Finerfrock:
Yes, there you need the - it's www.ruralhealth
- one word - r-u-r-a-l-h-e-a-l-t-h - dot hrsa dot gov forward slash
rhc, and it'll be there by date and topic.
(Maria Parabello):
Oh, OK. OK, great.
Linda Goldsmith:
And, we will have a written transcript, so if
you can get the PowerPoint presentation and compare it to the written
transcript then hopefully it will make more sense to you. Benchmarking
can get very confusing and we are doing our best to try to keep
it simple.
(Maria Parabello):
Right. I wanted to be able to access those free
databases or that free benchmarking information that you were talking
about.
Linda Goldsmith:
Well, now, the free is - what type of a doctor
are you working with or for, or are you a ((inaudible))?
(Maria Parabello):
((inaudible)) practice.
Linda Goldsmith:
Pardon?
(Maria Parabello):
A family practice.
Linda Goldsmith:
All right. Is the family physician - is he a
member or she a member of the AAFP ...
(Maria Parabello):
No, I don't think so. We're ...
Linda Goldsmith:
... the American Academy of Family Physicians?
(Maria Parabello):
American - I don't think so.
Linda Goldsmith:
OK. I don't know if you have to be a member or
not, because I've just been on their web site so much. But ...
(Maria Parabello):
Right.
Linda Goldsmith:
... if you go to my PowerPoint presentation,
I have the web site there for you. And, actually, let me get it
right now.
Bill Finerfrock:
I have it here. I'll give it, Linda.
Linda Goldsmith:
OK.
Bill Finerfrock:
It's "www dot aafp dot org forward slash
- the work query - q-u-e-r-y - dot html ...
(Maria Parabello):
OK, got it.
Bill Finerfrock:
... and then you look for facts about family
physicians.
(Maria Parabello):
Very good. Thank you.
Linda Goldsmith:
You're welcome.
Bill Finerfrock:
Operator, next question.
(Laura Black):
Yes, this is (Laura Black). I'm the manager at
the Las Molinas Family Health Center in Las Molinas, California.
And, our practice situation is we have two nurse practitioners who
see the patients primarily, and we have a physician who comes every
other week for a few hours, and so we are primarily a nurse practitioner
based clinic. So, I just wanted to perhaps add a little information
there. The American College of Nurse Practitioners has a lot of
really good data about nurse practitioner practice and numbers of
patients they're seeing and productivity and that sort of thing,
so ...
Linda Goldsmith:
Exactly, just like the PAs. But, also as I said
previously, I benchmark them right to family physician benchmarks.
I mean they are - they're capable of being as productive.
(Laura Black):
They're doing the job.
Linda Goldsmith:
They're doing the job, absolutely, and I have
seen where they are holding their own with a family physician. You
know, obviously, they're going to lag in the hospital area, but
regarding issues pertaining to productivity, such as charging, the
are right there with the physicians if not doing better, so I do
not cut them any slack and they seem to hold up to it.
Bill Finerfrock:
The ACNP - is that publicly available data?
(Laura Black):
yes.
Bill Finerfrock:
And do you know their web site offhand?
(Laura Black):
I do not know it. I know they're the American
College of Nurse Practitioners. They're out of Washington, D.C.
Linda Goldsmith:
Do you have to be a member?
(Laura Black):
No.
Linda Goldsmith:
OK, because I remember I tried to get some of
that data years ago and ...
(Laura Black):
I don't think so. I think you can go on their
web site and they have a lot of that data right there ((inaudible)).
Bill Finerfrock:
We'll look into providing a link to that data,
as part of the transcript of the presentation.
(Laura Black):
OK.
Linda Goldsmith:
Thank you very much.
(Laura Black):
Not a problem. Thank you.
(Les Propaul):
Hi, this is (Les Propaul). I'm at Mammoth Hospital
in Mammoth Lakes, California. My question is in regard to the transcript
and when that becomes available and how you go about getting that.
Bill Finerfrock:
Well, what we'll do is in about three or four
days we'll get the transcript from the service. We send that out
to the speaker. The speaker then goes through it. Because it's a
transcript of an audio they - you know, sometimes words get jumbled
up and there needs to be some clarifications, so it takes a little
bit of time for the speaker to go through. Once that's cleaned up
and the speaker releases it, it's then posted on the Web site, and
it'll be the same place where you get the slides, where you got
the PowerPoint slides. Then added to that will be the transcript.
(Les Propaul):
OK. And, Linda made mention that some formulas
and things will be in there for the ratios?
Linda Goldsmith:
Yes. Yes, I'm going to give you the basic formulas
for indicators.
(Les Propaul):
Great. Thank you.
Linda Goldsmith:
You're welcome. Thank you.
(Phyllis Burke):
Yes, this is (Phyllis Burke) from Sioux Valley
in South Dakota, and just a couple of general questions in regard
to these databases. And, I might have missed part of your presentation
here, but it looks like a lot of them refer to the region. As far
as the size of the practice, between a rural and an urban, is there
ones that are more specific ((inaudible))?
Linda Goldsmith:
No - unfortunately, as much as I wish we could
find something specific to rural, at this time, other than Ron Nelson's
cost report benchmarks, the benchmarks developed by the Washington
State Association of Rural Health Clinics, and any benchmarks the
consultant that prepares your cost report may have, the only other
resource is the American Academy of Family Physicians which does
break down some of data by rural versus urban, but even that breakdown
is not regional. It's just rural versus urban.
Again, I tend to - and trust me, I have nothing
gained by promoting Practice Support Resources. I think that theirs
is more rural compared to other datasets.
(Phyllis Burke):
OK. Once of the comments I've gotten from some
of the facilities is "well, benchmarking is good, but we're
((inaudible))."
Linda Goldsmith:
I know. Our patients are sicker.
(Phyllis Burke):
Yes, it's always ...
Linda Goldsmith:
I know. And I promise, you are going to hear
that until the day you die. But, that's why I always explain that
the benchmarking process provides an objective basis for discussion
operations improvement and through the benchmarking process; they
may find areas where they perform better than the benchmarks. Also,
I remind them that one benchmark will not tell the whole story,
but we still need to benchmark. I try my best to put the positive
spin on it. You know, we're looking for the things we do well, but,
you know, we may come across some things that we're not doing so
well. Remember, through benchmarking you can do some exciting motivational
things including developing an incentive program (bonus payments)
based on benchmarks.
(Phyllis Burke):
OK.
Linda Goldsmith:
Good luck.
(Phyllis Burke):
OK.
Bill Finerfrock:
If there's one more question, we'll take it,
otherwise we're going to have to start closing it down. But, if
we have one more question ...
Operator:
There are no other questions holding.
Bill Finerfrock:
Well then it works out well. I want to thank
all of the participants and particularly our speaker, Linda Goldsmith,
and I also want to thank the Office of Rural Health Policy for sponsoring
this teleconference series.
As has been mentioned, the transcript of today's
presentation will be available in the very near future. I want to
remind participants that the call will be followed up with a call
later on using your benchmarking data to establish a budget for
your RHC, and I want to encourage others, who may be interested,
to register for the technical assistance call series, and if you
go to the Web site we've mentioned already, there's a link there
on how to register. That will allow you to get into the database,
so make sure that you get all of the information on these calls
as they occur in the future and any notice we want to put up about
it.
The next call we will send out an announcement
when that has been formally scheduled. And, just in the future,
we suggest that you begin dialing in a few minutes before the call,
so that we can begin promptly at three o'clock.
Again, thank you to Linda Goldsmith, our speaker
today, and the Office of Rural Health Policy for their support for
this project.
Linda Goldsmith:
Thank you.
Operator:
Thanks again, ladies and gentlemen. That concludes
today's call. Have a good day.
END
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