Dr. Todd Coté: Focusing on Sustainability from the Outset
Interview with HPM Physician
Todd Coté, MD
by Larry Beresford
The key to building a successful hospice and
palliative medicine (HPM) practice is to focus on financial sustainability from
the outset, says Dr. Todd Coté, chief medical officer of Hospice of the
Bluegrass and the Palliative Care Center
of the Bluegrass in Lexington,
Kentucky. Dr. Coté describes
himself as self-taught in the business of physician practices at the
"grassroots level," from reading manuals, attending workshops and
conferences, talking to other physicians and applying what he learned -- even
at times doing his own billing and accounting.
He has practiced in a variety of settings,
from a community hospice in Bakersfield, California, to a privately held hospice in Southern California, the corporate hospice settings of
VITAS Innovative Hospice Care and VistaCare, and the nation's first hospice,
Connecticut Hospice in Branford, with gradually increasing administrative
responsibilities, academic affiliations and opportunities to build new
Dr. Coté came to Hospice of the Bluegrass, one
of the country's most admired hospice innovators, in 2007 and today leads a
formal department of medicine with 11 employed physicians and seven full-time
advanced practice nurses, a hospice census of over a thousand patients, and a
large palliative care practice with multiple hospital and nursing home
It all started in 1989 when, shortly after
hanging his shingle as a solo family practice physician in his hometown of Bakersfield, he was asked
by the local hospice if he wanted to replace its retiring medical director.
"I had learned community health in my family medicine residency and knew
about hospice. I always felt as a family physician that I was supposed to be
doing service to my community. So I started spending my free Wednesday
afternoons at hospice," he says, referring to the traditional 4-1/2 day
schedule for physicians in private practice.
"I quickly realized that these patients'
doctors, who I knew well, were not going to make home visits, and they probably
didn't know much about pain management. So I started teaching myself pain
management, mostly from looking into the British medical literature. I also
felt comfortable working with patients and families at the end of life. I
learned quickly and said, 'Maybe you guys should consider giving me a nominal
stipend. I feel that I have some leadership skills. Maybe you might benefit
from having me attend more meetings.' So I found my niche in hospice."
When he moved to San Diego four years later, there was an
opportunity to work half-time for the local VITAS office. "I started
looking more into leadership roles and applying the skill sets I'd been reading
in the manuals," he relates. "My point is it's all grassroots. That's
how I started. That's the path I followed all the way to today. I felt my real
forte was a community-based type of practice. Here at Hospice of the Bluegrass, it's still grassroots, yet more sophisticated
-- really a recognized community institution and asset. You want to serve your
community, but how are you going to sustain it? How is it going to become part
of a bigger master plan?"
Dr. Coté's sustainability model for HPM
physicians is "to pay them well, respect their competency and expertise
and expect them to work -- with a focus on career development, finding the
balance between work and personal life, and meeting productivity expectations
as defined by the patient and family. It's about how you pay your most
expensive employees, with an expectation in return for efficiency and
He recommends putting the sustainability plan
on paper, figuring out what level of income is required for the position to be
sustainable, and then taking care of the billing to meet that target. "But
these computations are not rocket science. What are they making now for the
amount of time you want? Work backward from there. Physicians already know how
to see patients efficiently in the clinic setting, and that efficiency can
translate well into hospice," he says. He believes that covering salaries
from billing is attainable with hard work and efficiency -- although the wild
card in this equation is the benefits package.
"Some of my colleagues seem to want to
make good money and just do hospice administration. If that's the case, they
should just be the CEO of hospice. I'm not interested in being a hospice CEO. I
think every hospice chief medical officer should also be seeing patients,"
There should also be a focus on continued
career development, "which I'm still doing, and which I'd encourage other
physicians to think about. When I talk to other HPM physicians, sometimes
there's a lot of enthusiasm on the physician's side, but also a lot of struggle
and conflict. I find myself saying: Maybe it's not the right place for you.
Maybe it's not your problem, but the agency's lack of commitment to the
No Typical Work Week
After his many cross-country moves, Dr. Coté
was drawn to Bluegrass by its national
reputation and history of innovation in palliative care, "piggybacked on
an excellent hospice, which is a nice model to follow." Dr. Coté estimates
that he works 60 hours a week, although that includes some weekend work and
some days when he leaves the office by 5 pm. "I have been balancing
project development with bedside care. I love that dualistic approach.
Multi-tasking for me is an art form, and the secret is having a non-medical
life -- family, exercise and the like," he says.
"You also have to be a good team member
in hospice and palliative care. You have to learn how to flex, playing a
hierarchical role when you meet with hospital administrators and then, going
into Mrs. Smith's hospital room with your palliative colleagues, to ask them:
'What do you think we should do?'"
When he started, the position at Hospice of
the Bluegrass was about 80 percent clinical,
with a strong focus on learning the community and its care settings. But with
the growth of new programs and running a palliative care fellowship based at
the University of
Kentucky, it's now more
like 50/50. The position also includes hospice and palliative care for a
pediatric population, which was a critical component of his career as a family
physician. "I'm the chief medical officer. I have officer status within
the company and I also do clinical work. I think that's a big advantage in my
Bluegrass has a varied continuum of
collaborative palliative care services with four local health systems, a
palliative care outpatient clinic and presence in 12 local nursing homes, two
hospice inpatient units with a third under development, and rural satellite
programs in southeastern Kentucky.
Most of its 11 physicians rotate across sites every two to three months, and
often do hospice and palliative care on the same day. Dr. Coté thinks that
helps keep the job fresh, and lets them see how care is provided in different
settings. "We find that hospitals are so different. I have to believe
rotating through them will give physicians broader perspectives and enhance
their leadership skills," he says.
All but two of the 11 Bluegrass
physicians are salaried. "We don't time-clock people." We expect them
to complete their work and, if they're done by three pm, and call around to
make sure there isn't anything left undone, then I expect them to go
home." He also encourages leadership development. "I try to promote
junior leaders around me, with wider perspectives on things. If they have an
idea for a project, I say: Let's see if we can do it."
There is no typical week for Dr. Coté,
although his day begins by dropping his two sons, aged 11 and 9, at school.
"Sometimes I'll leave the office at lunch and go on a hospice home visit a
couple miles away, and then come back to a senior leadership meeting.
Personally, I'd be scared to be stuck in any one venue all the time."
Along with other regular meetings there are
now two more per month to formalize an expanded palliative care collaboration
at UK, which includes a new
hospice consulting service at the University
"We have admitting privileges as hospice physicians at the medical center,
and they even gave us four parking passes for the hospice team. That's unheard
of for an academic medical center. It has to do with bed management, money and
quality, which are the keys to successful palliative care collaborations,"
"We're also talking with another local
hospital about a care management/transitional care model for their patients
going home from the hospital. We'd like to get in on that game, which seems to
hold great promise in health care reform."
(For more information, contact Dr. Coté at firstname.lastname@example.org)
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from time to time what are the prevailing compensation rates for HPM
physicians. The follow-up to that question is often, "what are the most common
common compensation model for HPM Practitioners is a guaranteed (straight)
salary. Guaranteed base salary is straightforward, thus simple to implement.
Its greatest value is in its simplicity. But one of the results of straight
salary is that often role confusion emerges, because expectations are not
clearly articulated, and often misaligned.
beginning to see variable (incentive) pay used more frequently than in the
past. Base salary with incentive (or what we refer to as a hybrid model) is
becoming more common -- where base salary is set, we've found, is critically
important to how meaningful are the incentives.
Conventional wisdom suggests that at least 20% of compensation should be
at risk for the incentives to alter behavior.
metrics to be used for incentive pay, however, is a daunting process, and it is
why straight salary remains the most common plan today. Yet, choosing metrics
is a highly valuable process, and the mere exercise of that process yields
substantial benefits. In a compensation
plan with incentives, the key stakeholders will sit down and eventually come to
an agreement on which metrics are most important, and then quantify those
metrics. It is a process we refer to as "valuing physician activity".
pay is typically based upon a work effort metric (such as RVUs, collected
revenue, patient visits/encounters). There are metrics in addition to work
effort, although at present their use in HPM compensation plan design is
uncommon. I'm familiar with a couple of hospices that require a quality gate be
passed through before incentives kick in. I'm familiar with plans in which
exceeding certain scores in family satisfaction surveys will trigger a bonus
payment. And there are a small but growing number of compensation plans that
reward what we refer to as group citizenship -- or activities such as committee
participation, or mentorship.
metrics that are used, in the end, are not as important as the process of
valuing physician activity.
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Phone: (510) 536-3048
The DAI Palliative Care Group is a national
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performance management and opportunity assessments for palliative medicine
practices are our competencies. We invite a discussion of how a partnership
would benefit you.
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Dr. Ed Martin: Growing Alongside the Agency
Interview with HPM Physician
Ed Martin, MD
by Larry Beresford
Dr. Ed Martin's interest in hospice care
started routinely enough as a general internist in a new small group practice
in his home state of Rhode Island
in 1984. "A couple of my patients were cared for by the local hospice. The
feedback from their families was so positive -- unlike any other encounters
with the health care system. When you went to the wakes, families would be
effusive in their praise of hospice."
In 1986 he approached the hospice, Home
and Hospice Care of Rhode Island, to ask about the possibility of working for
them. In 1987 he began eight hours a week for the hospice, joining a retired
physician doing very part-time work. This job gave him an opportunity to work
alongside hospice nurses and other members of the interdisciplinary team,
"highly competent, caring people who were really helping patients and families
at a very difficult time, maximizing quality of life and supporting patients to
remain at home -- something that just made sense to me."
Dr. Martin's involvement in the hospice
grew slowly, along with its census. His internal medicine residency training
had given him a primary care focus, including a fair amount of psychiatry and
social aspects of medicine. He also learned palliative care on the job, going
on visits with experienced hospice nurses as well as reading extensively in the
management of pain and other symptoms. "I wanted to be more of a clinical
expert and resource for the team," he explains. Dr. Martin was board-certified
and recertified in HPM by the original American Board of Hospice and Palliative
Medicine and then, when the American Board of Internal Medicine began certifying
the subspecialty in 2008, he was recertified by ABIM.
Along the way he
had to gradually relinquish other job commitments, both for the group practice
and as medical director of the Rhode
Island State Hospital. In October 2008, Dr. Martin
finally went full-time as chief medical officer for the hospice, which today
has a census of 440 hospice patients, a 24-bed freestanding inpatient unit and
a busy palliative care consulting service in two hospitals and in nursing homes
around the state. Its medical component includes five other part-time
physicians who range from four to 20 hours a week plus weekend call shifts, and
four full-time nurse practitioners.
"When I started in
hospice in 1987, I'm not sure a full-time medical position would have been a
possibility," Dr. Martin relates. "And I'm not sure I would have wanted to make
the move to full time any sooner than I did. But in 1993, when we opened our
inpatient unit, I needed to show up and make rounds every day, so my hours
increased from 8 to 20, and I had to start cutting back my other activities."
He felt some
reluctance to give up the security of the salaried state hospital job, and
leaving the private practice felt a little like leaving the real world of
medicine behind. "It was tough for me to give up my office and my relationships
with my patients. I really enjoyed general internal medicine and, in my mind,
my identity as a doctor was tied to seeing patients in an office. But I knew I
was really interested in hospice. It got to the point where it was just too
much, and I wasn't going to give up hospice."
But there's a
catch. "Right now, this job has exploded into almost more than I can handle,"
says Dr. Martin, who puts in well over 60 hours a week doing daily hospital
palliative care visits and rounds at the inpatient unit while trying to keep up
with administrative responsibilities as hospice medical director. The work
spills into the evenings and he doesn't always get to the day's emails until
then. His weekends include on-call shifts and a medical position with the
National Guard. But help is on the way, he says, with another full-time
physician joining the team in July. Until then, he will try to keep a bandage
on the burgeoning job demands.
responsibilities as hospice medical director include reviewing hospice
admissions as they come in, participating in performance improvement projects,
reporting on quality and clinical issues to the agency's Board of Trustees,
"and on a daily basis dealing with things as they come up." One current
performance improvement project focuses on enhancing communication with
referring physicians. Dr. Martin is a member of Home and Hospice Care's senior
management team and is developing an HPM fellowship program, which he will
direct, in collaboration with Brown
But other than the
current work overload, which reflects tremendous growth in demand for
palliative care and the challenges of bringing on new HPM physicians in an
orderly fashion, he loves his job. "It's been great. I spend every day doing
the thing I love. I often have rotating medical students, residents and fellows
with me on rounds, and I love the opportunities for teaching. Three of the
internal medicine residents I worked with last year went into HPM fellowships
Dr. Martin sees
enormous potential for HPM as a growing field and as a career path for
physicians. He is sometimes consulted by young physicians about its prospects.
"I got a call yesterday from a doctor who had previously chosen to specialize
in sleep medicine. He said, 'I can't do this the rest of my life. I'd really
rather go into hospice.' So he's interviewing hospice agencies to make that
change, and looking into the practice pathway to HPM board certification,"
which requires working with a hospice or palliative care interdisciplinary team
for two years before applying to sit for the boards.
More and more
hospitals, if they don't have it already, are exploring palliative care, Dr.
Martin says, while opportunities for full-time jobs in hospice are also
growing. "This field is in such a tremendous period of growth -- opportunities
appear to be unlimited." Some physicians in the field only do palliative care
or only do hospice but, depending on the setting, there are increasing
opportunities to participate in both.
may not yet see the benefits of having a full-time physician, relative to the
expense. "But sometimes they realize the only way to really grow and meet more
of their community's needs is to hire a full-time medical director ahead of the
need. They will certainly reap the benefits of having a full-time medical
director who can go beyond attending team meetings and establish relationships
with local medical practices, hospitals and nursing homes," he says.
"You can also
cover a lot of your salary with clinical work -- although not all of it, because
some of the work of the hospice medical director is administrative. But for
patients on the hospice benefit, especially seeing them in an inpatient unit,
and for palliative care consultation visits covered under Medicare Part B,
these are not insignificant billing streams," he says. "Here, we have staff
resources to help with billing, and we've had to get more sophisticated about
billing as our palliative care service has grown. There's really no reason to
leave any of that money on the table."
Dr. Martin has
always been active in regulatory issues, including as consultant to the
regional Medicare Part B carrier and on the fiscal intermediary hospice
advisory committee, as well as serving as a regulatory resource within his
agency. "Several years ago, we had major focused medical review, with dozens of
hospice patients denied coverage. It was a cumbersome process to appeal, but
100 percent of the denials were overturned by the Administrative Law Judge. I
had actually seen many of these patients myself, and I was able to explain to
the judge why I thought they were terminally ill. Now we make sure with any
long-stay patients that a hospice physician will see them and thus be in a position
to advocate for them, if necessary."
(For more information, contact Dr. Martin at firstname.lastname@example.org)
What's the Right Amount of Practice Subsidy?
does a particular Hospice and Palliative Medicine (HPM) practice require
support than another? This is one of the most common questions I am
asked. While there is no data to indicate what a
"typical" subsidy may be, it is helpful to understand why the amounts
widely from one practice to another.
there isn't a uniform definition of subsidy. Some refer to subsidy as
difference between a practitioner's guaranteed salary (some will include
benefits as well in this figure) and the amount of professional fee
generated. Others will carve out non-clinical time (such as
activities) from the subsidy calculation, and will treat that portion of
practitioner compensation as an administrative expense. It's not unusual
this difference in definition amount to $50,000 annually per
common reasons for the wide variance in subsidies:
Coding, Billing, and Collecting
is an area in which many, if not most, practices have room for
simple way to estimate how your practice is doing in these processes is
think about how you're performing on the following tasks:
HPM practitioners understand the documentation requirements for each
CPT code, and is their performance in selecting CPT codes audited
regularly (we suggest at least yearly)?
the practice have a reliable method of charge capture that minimizes
like lost charges? Is there an established "chain of custody" of this
information, from the HPM practitioner to the biller?
a periodic review or audit of the biller's performance? Does the
monitor metrics, such as days in accounts receivable, collection rate.
An audit could be as simple as reviewing ten billed
encounters within the past three months for each practitioner, and
status of each bill (e.g., paid, written off, or perhaps the bill has
or never made it into the billing system).
payor mix for most HPM practices is primarily Medicare, but in those
heavier penetration of Medicare Advantage plans, the contracted
payment from the Medicare Advantage plan may be significantly different
the standard Medicare reimbursement.
Some hospices and hospitals have systems of
that interfere with HPM practitioner productivity. These could be such
as a poorly organized medical record, an IT system that requires logging
multiple programs to retrieve data on a single patient, or practitioners
to do clerical work. Every practice should think carefully about the
and activities that might be getting in the way of efficiency.
"right" amount of subsidy is a judgment call,
and so will vary from practice to practice. A solid understanding of the
factors behind the wide variances in
subsidies, and an evaluation of those factors specific to your practice,
be valuable in determining your "right" amount.