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Branching Out: ATCs expand reach as physician extenders

Talk to certified athletic trainers (ATCs) about their role as physician extenders and you'll hear about their extensive training, smooth working relationships with physicians, rapport with patients and, of course, prompt insurance payments for the care they provide.

All of that's undoubtedly true. Indeed, it's becoming more relevant every day as more physicians—particularly those in orthopedic practices—add ATCs to their office staff.

But it's also about increasing revenue. Physicians hire ATCs as members of the office staff and pay them a base salary; ATCs generate revenue for the office by handling certain treatment duties and receiving reimbursement for skilled services.

"It's a very appropriate model," in which both entities benefit, says Marjorie Albohm, MS, ATC/L, director of orthopedic research and sports medicine at Orthopaedics Indianapolis, a 60 physician-member musculoskeletal practice.

Most ATCs who work as physician extenders typically handle tasks such as taking patient histories, making assessments and reporting findings to physicians. After diagnosis, physicians may ask an ATC to organize further testing, fit a patient for crutches or a brace, develop a rehab program, prepare an injection or retrieve test results. In turn, it frees up the physician, who can see more patients.

ATCs are probably best known by physicians who specialize in sports medicine, orthopedic and musculoskeletal care. But some ATCs have tapped into family practices and primary care facilities, as well as osteopathic and emergency medicine practices.

Physician extenders also have public relations value for a physician's practice. For example, they can help staff events such as health fairs, charity events and the Special Olympics without tying up physicians, says Joe Greene, MS, LAT, supervisor of athletic training services for the University of Wisconsin Health Sports Medicine Center in Madison.

"On one level, it's an old idea; ATCs have been working side by side with physicians for years," says Sue Finkam, MS, ATC/L, CEA, a partner in Ergonomics Plus, an injury prevention consulting firm in Indianapolis. However, the billing portion is new, says Finkam, chair of the National Athletic Trainers Association's (NATA) clinical/industrial/corporate athletic trainers committee.

Finkam, who advises ATCs in selling physician extender services to physician practices, says state licensure laws can determine whether this option makes sense in specific settings. In most situations, the door is open for ATCs. They are now regulated in 41 states, and five other states are actively seeking regulations this year, says Finkam.

The profession's standing among providers also has grown, which makes it easier to convince physicians to add ATCs. "We've been able to show the value of certified athletic trainers in physicians' settings for things such as triage, rehabilitation, outreach and patient education," says Finkam.

"Usually, the facts make ATCs a more logical choice for some of these roles than other nonbillable employees.

Practice managers and physicians are increasingly interested in a modest to significant return on investment." At Albohm's facilities, clinicians put the concept of physician extenders under the microscope for more than a year.

After the 18-month experiment with ATCs, Orthopaedics Indianapolis executives were "very pleased" with the clinics' enhanced efficiency, positive response from physicians and patients, and effective third-party reimbursement for CPT codes billed during patient encounters, Albohm says.

At Orthopaedics Indianapolis, ATCs work primarily with patients for therapeutic exercises, orthotic fitting and crutch training, says Albohm.

Less than 1 percent of ATC-generated claims were denied, she says, and the reimbursement rate for CPT code 97110 (therapeutic exercise) was higher than the overall practice reimbursement rate.

In addition, when ATCs acted as physician extenders, orthopedic physicians could see 20 percent to 30 percent more patients per day, according to a 1998 outcome and efficiency study at the University of Wisconsin Health Sports Medicine Center.

One reason for the easy working relationship between ATCs and physicians is familiarity and a long collaborative history in athletics, says Greene. With this symbiosis in mind, ATCs can also help increase practice revenue through outreach programs with area high schools, industries, fitness centers and sports facilities.

The University of Wisconsin Sports Medicine Center contracts with south central Wisconsin high schools to provide ATCs daily. "The majority of our activity is in high schools," says Greene. Of the 30 ATCs who work at the Sports Medicine Center, approximately 3.5 full-time equivalents work directly with staff physicians in a physician extender role.

When ATCs work in the clinic and high school settings, they can address a school's safety issues and keep open lines of communication among physicians, athletes, coaches and parents. Generally, that means spending about three hours each day, which doesn't include game coverage.

When high schools choose to have an ATC at practices and games, it reduces their liability insurance, Greene says. But schools don't often have the budget to hire their own ATC, so they may contract with a local hospital or clinic to provide services at a reduced cost.

"One of the biggest reasons we're in high school is (because) we're trained to recognize and provide initial care for potentially catastrophic injuries that can occur, including severe head and neck injuries," says Greene.

"Schools are very concerned about depending on a coach with often limited medical training to provide care they weren't trained for." This medical model is already employed in college and professional sports, he says, and has been trickling down to the high school level over the last two decades.

When ATCs serve as physician extenders in high school settings, they should have more extensive knowledge, say experts. For instance, they should have emergency and first aide training for allergic reactions and head injuries, and be able to identify potentially dangerous skin conditions, which can be common among wrestlers or outdoor athletes who spend time in the sun.

As part of their responsibilities, ATCs should understand reimbursement basics, know which services are usually billed and be able to apply appropriate CPT codes for athletic training services.

In Wisconsin, clinicians benefit from a strong state licensure bill that allows ATCs to see a broad scope of patients. ATCs have strong training working with musculoskeletal injuries, says Greene, and the definition of "athletic" is broad and flexible in the state. That allows the Health Sports Medicine Center to use its ATCs in roles similar to those of physician's assistants or nurses.

ATCs in Wisconsin also can see patients alone and bill for initial evaluations, which isn't allowed in every state, says Greene. Moreover, ATCs can treat patients whose injuries are "identical" to athletic injuries, says Greene. For instance, if a patient comes in with a sprained ankle from tripping over a vacuum cleaner, the ATC can handle the case.

Besides treatment services, ATCs can take care of patient education and spend time answering their questions, which is crucial to positive outcomes. In fact, an NATA study showed that patient education helped ATCs achieve a 98 percent or greater patient satisfaction rating.

The benefits are clear. ATCs, in the role of physician extenders, can provide an added dimension of expertise and value to a physician's practice.

Mark E. Dixon