webinar examines benchmarking medical practice performance

July 30, 2013

Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7

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© 2013 Business Valuation Resources, LLC

Benchmarking for Medical Practices

Lori A. Foley, CMA, PHR, CMM

Tynan Olechny, MBA/MPH, AVA


July 30, 2013


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What is Benchmarking?

• Process of measuring and comparing an organization’s performance to national, and regional, or industry averages

– Provides quantitative data to support informed decision-making

• Internal vs. External

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Why Benchmark?

• Insight into:

– How business is operating compared to peers

• net income/overhead

– How individuals/entities are producing compared to peers

• production, compensation

– How efficiently staff or processes are working

• A/R days, collection rates, A/R aging

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Benchmarking Applications

• Routine daily management

• Situational analysis

• Self evaluation in contemplation of a sale

• External evaluation in contemplation of a purchase

• By appraiser to understand and normalize the business

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What Can Be Benchmarked?

• Production

– Procedures - Patients - RVUs

– Cases - Medical records - wRVUs

– Visits - Hours worked

• Compensation/Benefits

– Compensation per wRVU

– Compensation to collections ratio

• Overhead

– Numerous expense categories

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What Can Be Benchmarked?

• Staffing Complement

• Efficiency Ratios

– Days in A/R

– Gross/Adjusted Collection %

• Collections

– Collections per wRVU

• Payor Mix

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Benchmarking Resources

• Financial Surveys

– Medical Group Management Association, American Medical Group Association, Sullivan Cotter & Associates, Towers Watson, etc.

• E/M Bell Curve Data Book

• Specialty Medical Associations

– NERVES Socio-Economic Survey

• Entity itself (trending)

• Proprietary Internal Databases

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Financial Surveys

• Medical Group Management Association• Physician Compensation & Production Survey

• Management Compensation Survey

• Cost Survey

• Individual Specialty Surveys (i.e. Anesthesia, etc)

– Most comprehensive; largest sample of physicians

– Generally represents small, single specialty medical groups

– Shifting split between private practice and Hospital/IDS-owned

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Financial Surveys

• American Medical Group Association• Compensation & Financial Survey

– Generally mid-to-large multi-specialty medical groups

– Not as many expense category benchmarks available

• Sullivan, Cotter & Associates• Physician Compensation & Productivity Survey

• Physician On-Call Pay Survey

– Generally represents larger organizations, including hospital-based systems and academic groups

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Undertaking the Task

Critical to understand:

- The data you have

- What the benchmarks measure

- How they are defined and calculated

- What they [might] mean

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Obtaining the Data

• Clearly understand what information you are seeking

• Cooperate with entity to get what you need

– Discuss systems, capabilities and data inputs

– Any gaps/overlaps due to system conversions

– Provide detailed requests for information

– Communication, communication, communication!

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Working with the Data

• Understand what you received – is normalization required?

– Any providers/services/locations added or deleted?

– Significant changes to charge master/fee schedule, reimbursement contracts, expenses?

– Double check report parameters and time periods

• Matching

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Working with the Data

• Understand what you received – is annualization required?

– The more months included, the better.

– Does the period reflect the norm?

– Are there alternatives to annualization?

• 12 months “moving”/TTM

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Remember:

• Data comes from a variety of sources– Not always comparable

• Collection of data is often contingent on how systems are set up– Varying levels of sophistication

– Close, but not quite “there”

• Definitions may differ according to situation

• Varying degrees of “electronic” data

• Always subject to interpretation

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Using the Benchmark Resource

• Read the narrative – make sure you know what is being measured and how

– Often includes disclaimers as to how it should or should not be used

– May narrate differences from previous years’ benchmarks

– Identifies and discusses trends in the data

• Be as specific as possible to each situation

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• Review the formula to perform the calculation

• Differentiate between Median and Mean

• High percentiles – it’s not always good to be at the top of the chart!

– Example – 90th percentile in collections vs. 90th percentile in expenses

• Understand the metric definition – total compensation in one survey may not equal total compensation in another survey

• Consider the number of survey respondents

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• Data results from one benchmark metric do not always correlate to data results from another benchmark metric

– Example – Collections vs. Charges:

2013 MGMA Physician Compensation & Production Survey

Description Data Points25th

Percentile Median Mean75th

Percentile90th

Percentile

Family Medicine - Total Collections 2,136 $ 325,241 $ 418,763 $ 433,343 $ 524,404 $ 637,880

Family Medicine - Gross Charges 2,378 $ 515,475 $ 656,422 $ 708,798 $ 841,652 $ 1,072,879

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Understanding the Benchmark

• Result of the calculation seldom tells the entire story – dig deeper!

– Surrounding circumstances and other factors should be considered.

• Creates a starting point for additional questions, analysis and understanding

– Double check: Does the result of the calculation make sense in light of the other information?

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Benchmarking Charges

– Better internal measure (e.g. year over year for the same entity) than external

– Establishment of charges is subjective for the entity

– Important to understand if calculating gross collection rate (GCR) [payments/charges]

– Often benchmarked as a percent of the Medicare fee schedule

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Benchmarking Charges

• Example

– Practice A sets charges at 200% of the Medicare allowable and has GCR of 62.5%

– Practice B sets fees at 400% of the Medicare allowable and has GCR of 31.25%

– Benchmark is 66%

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Benchmarking Payments

• More objective measure than charges

• Remember - not all payment types may be included in the benchmarks

– Read the benchmark to understand what to include for comparison

– Understand the data to ensure that only applicable amounts are included

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Benchmarking Payments

• Payment considerations:

– Is A/R high?

– Are billing and collection processes routine and operating as they should be?

– Are new providers credentialed so that claims can be processed?

• An adjustment may be warranted to paint a more complete picture for decision making.

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Benchmarking Compensation

• Not all types of compensation are included in the benchmarks

– Read the benchmark to understand what to include for comparison

– Understand the data to ensure that only applicable amounts are included

• Influenced by a variety of factors – ownership, net income, contract, compensation formula, sources of compensation

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Benchmarking Compensation

• Compensation considerations:

– Does the provider have a contracted salary or ownership interest?

– Is compensation allocation tied to production?

– Is provider in a start-up or wind-down situation? Buying in?

– Does the physician receive compensation for call coverage, medical directorship, etc.?

– Is compensation being taken in the form of rent, personal expenses, etc.?

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Benchmarking Operating Overhead

• Can benchmark actual dollars or expense as a percent of net patient revenue – both may be relevant

– Again, beware of benchmark definitions!

• Personal and discretionary expenses are typically excluded

– Often requires a significant amount of normalization

• Non-recurring/extraordinary items are often excluded or normalized

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• Operating overhead considerations:

– Keep in mind a function of both collections and expenditures – “reasonable” expenses in terms of $$ but low collections yield high percentages

– If you are analyzing part of a larger whole, are all expenses fully captured?

• If not, how should they be accounted for?

– If forecasting, consider fixed versus variable

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A C D E G

Entity Financial Statements 12/31/10

Allocable Expenses ($) (3)

Allocation Basis (4)Allocation Rate (9)

Common Size

Revenues1 Professional Fees 2,000,000 (500,000) 1,500,000 Professional 0 12 Professional Fees - Direct 500,000 500,000 Percent Technical Revenue (1) 86.3% 431,657 (11) 100.00% 23 Total Income 2,000,000 431,657 3

4 Non-Physician Expenses 45 Accounting Fees 15,000 15,000 Percent Revenue 21.58% 3,237 0.75% 56 Automobile Expense 7,000 (1,000) 6,000 Percent Revenue 21.58% 1,295 0.30% 67 Automobile Expense - Direct 1,000 1,000 Direct 100.00% 1,000

V 8 Bank Service Charges 5,000 5,000 Percent Revenue 21.58% 1,079 0.25% 8V 9 Collection Costs 1,500 1,500 Percent Revenue 21.58% 324 0.08% 9

Ancillary ServiceRevenue & Expense Allocations

B F

Direct Adjustments ($) (2)

Allocated Ancillary Income Statement ($)

(10)

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Benchmarking Production

• Important because it is a key driver of revenue (along with reimbursement rates)

• In many of today’s affiliations, production is a direct driver of provider compensation

• Measured in a myriad of ways

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Measure Issues to Consider

Office Visits Number of patients seen in an ambulatory (office) setting

Encounters Can mean ambulatory visits or procedures

Procedures Can mean every CPT submitted or the number of times a certain case is performed

Cases Often comprised of multiple CPT codes or procedures; assistant surgeon cases may be reflected

RVUs/wRVUs Impact of modifiers, multiple procedure discounts

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• Production considerations:

– If the entity has non-physician practitioners (NPPs), understand how they are tracked in the reports

• Billing provider vs. rendering provider

– Are the results reasonable - can one provider see ___ patients per day?

– Are there any planned changes with regards to production?

• Retirement/slow down, loss of patient base or key referral source, etc.

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Benchmarking Staffing

• Often one of the Practice’s highest line item expenses

• Certain levels of staffing needed to achieve certain economic results

• Both under and overstaffing may yield less net income; consider during normalization process

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Benchmarking Staffing

• Staffing considerations:

– Must understand classifications and who is included

• Some benchmarks exclude NPPs, others include

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Benchmarking Financial Indicators

• Reflect the results/efficiency of certain processes, usually A/R related

– Days/months in accounts receivable

– % of A/R in each aging bucket

– Gross Collection Rate

– Adjusted Collection Rate

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A/R Benchmarking Considerations

• Accounts Receivable Indicators

– Understand the entity’s process for writing off bad debt/uncollectible accounts

– Identify aging parameter – time of service, time of filing, re-aging impact

– If entity changed billing systems during analyzed period, make sure to account for related activity in both

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GCR Benchmarking Considerations

• Gross Collection Rate =

Payments

Charges

• If fee schedule is set very low, GCR can be very high and vice versa – does not necessarily reflect efficiency of collections

• Material changes in fee schedule affect comparison from one period to the next

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ACR Benchmarking Considerations

• Adjusted Collection Rate =

Payments

[Charges – Mandated Adjustments]

• Effective calculation relies on how sophisticated entity is in tracking adjustments by category

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ACR Benchmarking Considerations

• Different benchmarks treat certain categories differently

– Professional courtesy

• Can exceed 100% due to timing issues but not for sustainable period of time

• Can be a measure of effectiveness of collections

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Applying Benchmarks

• Once appropriate benchmarks are identified, valuation experts should use this information to guide their analysis, looking for areas in the practice that may deviate from the applicable benchmark data

– Identify areas requiring adjustments

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Applying Benchmarks

• What questions should you ask to better understand what’s going on in the practice, using benchmark data as an indicator of the norm?

– Does this benchmark make sense in light of other information? What other factors could be causing this result? How can or should practice performance be adjusted to get to the norm?

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Case Study 1: Physician Productivity

When comparing 2012 financials to those of previous years, a valuation expert notices a decrease in revenue. Valuation expert investigates by looking at individual physician production.

-Physician A made $251,000 in 2012, and generated 4,800 wRVUs.

-Physician B made $300,000 in 2012, and generated 2,000 wRVUs.

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Case Study 1: Physician ProductivityNational Compensation Survey Data, Neurology



Percentile90th

Percentile2013 MGMA Physician Compensation and Production Survey 693 $ 221,076 $ 265,443 $ 298,599 $ 343,410 $ 470,966 2012 SullivanCotter Physician Compensation Productivity Survey 781 $ 201,991 $ 247,948 $ 253,185 $ 271,276 $ 347,365 2012 AMGA Medical Group Compensation and Financial Survey 1,062 $ 211,009 $ 249,250 $ 273,255 $ 301,540 $ 396,081

Average of Surveys, Rounded $ 211,359 $ 254,214 $ 275,013 $ 305,409 $ 404,804

wRVU Survey Data, Neurology



Percentile90th

Percentile2013 MGMA Physician Compensation and Production Survey 587 3,818 5,158 5,589 6,810 9,155 2012 SullivanCotter Physician Compensation Productivity Survey 432 3,655 4,454 4,977 5,844 7,627 2012 AMGA Medical Group Compensation and Financial Survey 846 3,643 4,717 5,185 6,158 8,058 Average of Surveys, Rounded 3,705 4,776 5,250 6,271 8,280

Physician A Physician B

Physician B Physician A

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• Physician A is compensated at the median level, and seems to be producing accordingly.

• Physician B is compensated near the 75th percentile, and is producing far below the 25th percentile.

– Physician B’s compensation and production levels do not align.

– Physician B historically produced at the 90th percentile.

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• Does this account for the decrease in revenue?

– It could. However, all possible factors that affect revenue should be explored.

• What next?

– The valuation expert should investigate Physician B’s compensation levels in previous years.

– Understand how compensation is calculated in the practice. Is a portion of revenue shared, e.g. Is there a direct correlation in the formula between production and compensation?

– The valuation expert should investigate other potential causes.

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• What other questions should the valuation expert ask in this situation?

– Is the decrease in revenue a new trend, or has it been ongoing? Is it expected to continue?

– Could the decrease in revenue be caused by factors other than Physician B’s production?

• Are practice reimbursement rates normal? Are there problems with collections? Has there been an increase in expenses? Have there been any operational changes within the practice?

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• What would any willing Buyer adjust to get revenue back on track?

– Which of these findings require normalization in the valuation?

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Case Study 2: Operating Overhead

Valuation expert analyzes operating overhead of a family medicine practice in comparison to other similar practices. Currently, the practice spends about 30% of its revenue on general operating costs (excluding physician compensation and benefits).

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• The practice’s operating overhead approximates the MGMA 25th percentile. What does this mean?

General Operating Cost as a Percentage of Revenue, Family Medicine

Description Data Points 25th Percentile Median Mean 75th Percentile 90th Percentile2012 MGMA Cost Survey 372 29.19% 41.04% 50.77% 62.12% 90.19%

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• What questions should the valuation expert ask in this situation?

– Expenses may be low, but are they appropriate? Is the practice understaffed or undersupplied?

– Are collections much higher than the norm, resulting in lower expenses as a percentage of revenue?

– Are all expenses accounted for?

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Keys to Remember

• Benchmarks do not tell the whole story, but instead offer insight.

• Not all benchmarks are relevant, and not everything is worthy of comparison.

• Keep it in perspective!

– A benchmark with an n = 356 is probably more reliable than one with an n = 28.

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Keys to Remember

• Finally, always step back and look at the relationships of the analysis to see if they make sense. If wRVUs and collections are greater than the median and expenses are at or below the median, why isn’t compensation greater than the median? What is missing?

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Thank You

Lori A Foley, CMA, PHR, CMM

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404.266.9876

www.pyagatesmoore.com

Tynan Olechny, MBA, MPH, AVA

[email protected]

404.266.9876

www.pyagatesmoore.com

July 30, 2013


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webinar examines benchmarking medical practice performance

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