The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
Issue No. 5                                                                                                          April 2010
Greetings!

Two physicians with thriving, perhaps too busy, hospice and palliative medicine practices are profiled in this newsletter. Both started in private practice, one in internal medicine and the other in family medicine. One put down roots in his native Rhode Island after completing his residency, started working part-time for the local hospice and gradually increased his role until the hospice position became full-time 21 years later. The other has practiced in diverse hospice settings and moved his family cross-country several times in pursuit of opportunities for career development. But both are doing the work they love in hospice and palliative medicine full-time, seeing patients while building innovative end-of-life care programs.


Tim Cousounis

In This Issue

HPM Practitioner Profile - Dr. Todd Coté
NiscoDr. Todd Coté: Focusing on Sustainability from the Outset
Interview with HPM Physician
Todd Coté, MD   
by Larry Beresford

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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 programs.
 
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 collaborations.
 
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 volume."
 
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," he says.
 
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 physician's role."
 
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 work."
 
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 Medical Center. "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," he says.
 
"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 tcote@hospicebg.org)

 

PracticeOpportunityFeatured Practice Opportunity


Showcase both your clinical expertise and business savvy as you implement clinical and service growth strategies for a hospital-based palliative consult service in Florida.  The service is well established (almost eight years old), and has helped redefine how late-life care is provided in the 458-bed flagship hospital of this regional health system.


While this service is well-established and some strategy is in place and activities have been underway for some time, you'll put your personal stamp on these programs as you expand development efforts and provide palliative services to patients in acute and long-term care settings throughout the health system.  The palliative care service has been instrumental in the hospital's citation by the DAI Hospital Palliative Performance Profiles as an Exemplar Hospital for its late-life care practices and outcomes. 

The opportunity is an employment-based position with the hospital-affiliated physician group, and will be viewed as the palliative medicine expert within the community.


To learn more about this opportunity (confidentially, of course), send an email to Tim Cousounis at tcousounis@digital-action.com

For more opportunities, click here.

CompensationCompensation Conundrum


I'm asked 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 compensation models?"

 

The most 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. 

 

We are 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. 

 

Choosing 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".

 

Incentive 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.

 

The metrics that are used, in the end, are not as important as the process of valuing physician activity.


Contact Us

Tim Cousounis
Managing Director,
DAI Palliative Care Group
Phone: (610) 941-9419

tcousounis@digital-action.com


Larry Beresford
Editor
Phone: (510) 536-3048
larryberesford@hotmail.com
www.larryberesford.com
Larry's Blog

The DAI Palliative Care Group is a national consultancy partnering with hospices and palliative care practices to build their medical staffs. Recruiting, medical staff development planning, physician performance management and opportunity assessments for palliative medicine practices are our competencies. We invite a discussion of how a partnership would benefit you.

What do you think of our publication? How can we best serve the needs of the HPM community? What would you like to know about the business and practice issues facing HPM doctors today? What do you know that your HPM colleagues need to learn?

Click here to send us your comments.

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BullDr. Ed Martin: Growing Alongside the Agency
Interview with HPM Physician
Ed Martin, MD                       
by Larry Beresford
Dr. Ed Martin


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.


Administrative 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 University.


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 this year."


A Great Career Path


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.


Smaller hospices 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 emartin@hhcri.org)


PracticeSubsidyWhat's the Right Amount of Practice Subsidy?

Why does a particular Hospice and Palliative Medicine (HPM) practice require more 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 vary so widely from one practice to another.

First, there isn't a uniform definition of subsidy. Some refer to subsidy as the difference between a practitioner's guaranteed salary (some will include benefits as well in this figure) and the amount of professional fee revenue generated. Others will carve out non-clinical time (such as administrative activities) from the subsidy calculation, and will treat that portion of practitioner compensation as an administrative expense. It's not unusual to see this difference in definition amount to $50,000 annually per practitioner.

Some other common reasons for the wide variance in subsidies:

Documentation, Coding, Billing, and Collecting

This is an area in which many, if not most, practices have room for improvement. One simple way to estimate how your practice is doing in these processes is to think about how you're performing on the following tasks:

  • Do all 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)?
  • Does the practice have a reliable method of charge capture that minimizes problems like lost charges? Is there an established "chain of custody" of this information, from the HPM practitioner to the biller?
  • Is there a periodic review or audit of the biller's performance? Does the practice 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 identifying the status of each bill (e.g., paid, written off, or perhaps the bill has vanished or never made it into the billing system).
Payor Mix

The payor mix for most HPM practices is primarily Medicare, but in those areas with heavier penetration of Medicare Advantage plans, the contracted (negotiated) payment from the Medicare Advantage plan may be significantly different from the standard Medicare reimbursement.

Practitioner Productivity

Some hospices and hospitals have systems of care that interfere with HPM practitioner productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or practitioners being expected to do clerical work. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency.

The "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, will be valuable in determining your "right" amount.

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