The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
Issue No. 7                                                                                 September 2010
Greetings!

There are many ways to organize a hospice/palliative medicine practice. With the low overhead of the mobile, floating consultant, it is possible to see patients across settings, from hospital to hospice to home. One approach is the independent practice -- whether lone wolf or small group and with a variety of possible relationships with hospitals, hospices and other potential sources of referrals. In this issue, we highlight two independent practices. Amy Davis, DO, has a solo practice in which she does her own billing from home after hours. Sandra Gomez, MD, has grown a larger practice to include professional collaborators. But both have had to master essential business skills and satisfy their contract partners while balancing their own bottom lines.


Tim Cousounis

In This Issue
HPM Practitioner Profile - Dr. Amy Davis
WilliamsonDr. Amy Davis: There are Always Trade-offs
Interview with HPM Physician
Amy Davis, DO, MS   
by Larry Beresford
Dr. Amy Davis

However a hospice and palliative medicine (HPM) practice is organized, there will be trade-offs, observes Amy L. Davis, DO, MS, who has a solo private palliative medicine practice that operates in three hospitals and an outpatient clinic in suburban Philadelphia, PA. "When I considered establishing a solo practice, people told me that I would be trading one set of problems for another, but these are the problems I'm most comfortable with."

After an academic fellowship in palliative medicine at Mount Sinai School of Medicine in New York City, she started asking a lot of people -- physicians, medical office managers and others -- about the challenges and opportunities of the solo practice. The American Academy of Hospice and Palliative Medicine annual meeting was a good source of information, while many of her contacts referred her to others.

"During my fellowship, I observed palliative medicine practiced with different business models, and I realized there were many ways to do what I wanted to do," she explains. "I talked to a private national hospice company that was in the process of starting a palliative medicine practice, but I wouldn't have been able to do research or teach house staff, as I do now. I also looked at an academic medical center position, but saw that I would lose some freedoms there, too. Right now I don't have to worry about (job) goals someone else sets for me. I wasn't sure I could make a private practice work, but so far, so good. I'm tailoring what I do to my interests," she says about the sole proprietorship, which she launched 20 months ago.

But she had to teach herself business techniques, drawing on web-based resources such as the Center to Advance Palliative Care and the American College of Physicians -- and by asking a lot of questions. Dr. Davis uses her home office to do her own medical billing. The outpatient clinic space is leased two half-days a week from an internal medicine group, which also provides her with office staff and scheduling.

She works with three of the four hospitals of the Main Line Health System, including Lankenau Hospital, an academic medical center in Wynnewood, PA. The lion's share of her time is spent providing palliative medicine consultations to patients. "I also spend time teaching the residents, although I don't have a teaching service per se. I lecture to them and am consulted on their patients. I'm also starting to get into clinical research, working with two nursing fellows and a family practice resident to study the language that is used when we talk with patients about code status." The time she spends on the research and teaching is not compensated, but she feels that she is reimbursed through improved job satisfaction and increased consultations from colleagues who see how palliative care can improve their patients' care.

Coincidentally, the three hospitals also employ palliative care nurses, although their services are not billed. Those nurses and Dr. Davis's palliative care practice are administratively distinct, with separate intake but a certain amount of overlap, cross-referral and curbside consults. "When I started, I sat down with each nurse and said, 'I'm not here to step on your toes.' The reality is that there's so much need for palliative care to go around." She compares the co-existing palliative care services to a hospital where two separate cardiology practices might find ways to work alongside each other and share certain equipment or services.

Her best analogy for being a solo private practitioner in palliative care is a primary care practice in internal or family medicine -- except that she is the recipient of referrals and the provider of consultations, rather than the reverse. Just like other private practitioners, she needs to line up access to services like laboratory and ultrasound, and she doesn't have the caseload yet to justify a full-time biller or office manager or to make investing in the electronic medical record cost-effective. Pennsylvania has a malpractice catastrophic insurance pool, to which she belongs, paying the premiums of an internist.

Dr. Davis estimates that she works 65 to 70 hours a week and she carries a pager 24/7, although she has found that patients and staff don't call after hours unless it's important. She hopes the hours will go down once the practice is fully established. She's looking to hire a nurse practitioner soon and to engage a billing service, "although I would not have given up the opportunity to learn on my own by actually doing my own billing. I got such an education that I could not have gotten any other way."

Her longer range goals include establishing an outpatient center in palliative care -- perhaps with a massage therapist and a social worker or psychologist on staff -- although she has been careful not to grow the practice too quickly.

How to Pitch the Practice

When first pitching her solo services to Main Line Health, she found that they did not have much experience with the physician's role in palliative care. "That meant starting with the basics and emphasizing that this is not just hospice. I also needed to show how I could help them by decreasing lengths of stay, ICU stays and utilization of services while doing things that improve satisfaction, like taking care of pain and helping with staff morale. And, frankly, they were thrilled when they heard it wouldn't cost them anything."

She spoke to the chief of medicine, who spoke to other leaders within the system and they created a section of pain and palliative care, with Dr. Davis as its chief. The system has three other physicians -- an oncologist, a pulmonologist and a cardio-thoracic surgeon -- who sat for and passed the HPM subspecialty boards with Dr. Davis, but they are mainly interested in incorporating HPM techniques into their existing practices.

"A lot of the patients I see are self-referrals. If I had things to do over again, I would have focused more of my marketing on that from the outset. But I'm now working with the system on direct-to-consumer marketing of palliative care as a unique service available to our patients."

Dr. Davis acknowledges that she likely would make more money in a palliative care staff position than she does currently. "How am I doing? I'm doing okay. The money isn't my biggest concern right now, and I also get paid in the satisfaction of seeing other physicians respond to my work. I know the money will come; I'm not worried," she says. "But you need to go in with both eyes open. When you're footing the bill for the practice, you're footing the bill. But there are a lot of benefits if it's right for you." She accepts Medicaid patients and those without insurance, but prefers not to take on pure chronic pain patients.

In addition to the unusual approach of being a solo practitioner, Dr. Davis also brings a professional background as a Doctor of Osteopathy, which while not unprecedented in HPM, is not as common as Doctor of Medicine. A mentor had told her that osteopathy has changed a lot in the past 50 years. "He felt it was the best fit for my practice style. There are also a lot of the same principles in the osteopathic world as in palliative care -- not that I was thinking of that during my initial training. Philosophically, osteopathy has a certain understanding of the connections among the mind, body and spirit." In many states the same licensing boards or rules apply to both types of doctors, although in Pennsylvania the boards are separate and Davis had to complete two medical internships.

"When I was in school, I went to a brief lecture given by volunteers from a local hospice program. They said, 'If anyone is interested in volunteering, give us a call.' I don't know what made me make that call, but I did, and I was with them for a little over a year. I didn't think just sitting with terminally ill patients would be fun, but it was. Then, where I did my residency, there was a small palliative care program. I was surprised by how satisfying that work could be."

Dr. Davis grew up in the Philadelphia area, where her family still lives. She loves gardening and spending time in nature, and tries to pay attention to self care, given the nature of her solo work in palliative care. "I keep my friends and family close," she says.

Dr. Davis would like to hear from other solo practitioners for networking, either formal or informal. Let us know or contact her directly at amydavisdo@aol.com if you are interested in exploring the prospects for networking among private practitioners.


PracticeOpportunityFeatured Practice Opportunities


The Evolving Role of Hospice and Palliative Medicine Leadership

As hospices and palliative care services evolve into advanced palliative care organizations with greater scope and influence over late-life care within their communities, a "new" physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the "chief community palliative care officer".

These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:
  • build and sustain relationships that evolve into community-wide palliative care networks
  • disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance
  • inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics 
  • envision and stimulate a change process that coalesces the community around new models of late-life care
If you're considering advancement along your career path and would like to learn more about currently available physician leadership opportunities, contact Tim Cousounis at tcousounis@digital-action.com or (610) 941.9419

For more opportunities, click here.

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.

This issue marks the one-year anniversary of the inaugural publication of HPM Practitioner. Your feedback is important to us -- let us know your thoughts, suggestions for improvement or topics you'd like to see us cover.  

Click here to send us your comments.

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StratonDr. Sandra Gomez: Just Give Independent Practice a Try
Interview with HPM Physician
Sandra Gomez, MD                       
by Larry Beresford
Dr. Sandra Gomez

For Dr. Sandra Gomez, a hospice and palliative medicine (HPM) physician in Kingwood, a suburb of Houston, TX, and the president of Symptom Management Consultants, P.A., an independent HPM practice offers several distinct advantages. One is the ability to serve multiple hospitals and hospice programs in the community that choose to contract for its medical services. In previous positions as a hospice medical director, she did not enjoy that freedom.

Another is the opportunity to shape hours, schedules and even days off to the particular needs of the practice's members. In this case, the three HPM-certified physicians and two nurse practitioners are women of roughly the same age. All but one have young children, so the practice's days off are reconciled with the school calendar. They took turns over the past summer enjoying three-day weekends and spending the time with their families.

Dr. Gomez launched the palliative care practice in March of 2006. She added staff as it grew, but she owns the company and is responsible for its management. "The first year was the toughest. It really took us three years to get everyone to what I think are decent salaries for the field we're in," she says. "I also think we've whittled it down to where most of the providers, except me, only have to deal with medical care. The tradeoffs have always been a good working environment, a focus on family time and the flexibility of the work." The other medical staff are either salaried or paid based on productivity with a base.

Dr. Gomez had to do a lot of "home schooling" to launch the practice. "I have a husband who worked in management for 12 years and he taught me a lot of things. I took business classes, and listened to books on tape. The big motivation for me was to have a job I loved. I wasn't going to be able to stay in palliative medicine otherwise."

Currently the firm's practitioners divide into two alternating groups, one dedicated to staffing hospital-based palliative care consultation services in the Memorial Hermann hospital system and the other staffing six hospices for contract medical direction or home visits, with a service area that covers the Houston metro area. Swapping the teams' responsibilities every week helps prevent burnout, Dr. Gomez says.

"We also provide medical house calls for a home health agency's outpatient palliative care program, as well as making independent family practice/internal medicine home visits for patients who graduate from home health or hospice," she says. The staff mentors palliative medicine fellows from M.D. Anderson Cancer Center, where Dr. Gomez is on faculty. The practice also provides CME lectures for honorariums and other medical consulting, such as for chart reviews.

A distinctive feature of the practice is a licensed vocational nurse who makes visits with the home-based medical team. The LVN is responsible for scheduling appointments, obtaining directions and driving to the patient's home, freeing up the physician to do charting and phone calls en-route. In the home, the LVN does family education while the physician tends to the patient. Productivity targets include 5 to 8 house calls per day, "with a goal of manageable 'windshield time' and drive times of a half-hour or less between calls," Gomez says. An assistant in the office answers the phone, assembles face sheets for billing and makes sure the practice runs smoothly.

The Lost Art of Medical House Calls

The basic building block of this independent practic
e is the home visit or house call, which Dr. Gomez learned during her medical training in Washington State. A geriatric faculty member "believed that house calls were making a comeback, and tried to incorporate that into our training. I learned in a nice setting. Then, when I was in my first practice in Texas, I talked the hospital into devoting a little money for me to make house calls a half-day per week. Word quickly got around," she relates.

"The next thing you know, the local hospice heard about it and said, 'Here's a doctor who has a good practice, is not afraid to make house calls, and is willing to write prescriptions for morphine.' So they asked me to be an associate medical director and paired me with the LVN who works for me now. That's how I started in hospice care. I was starting a family around the same time. It was hard to find work/home balance, but here was a chance to make house calls, with flexibility, while doing what I love."

Eventually, however, she realized there was an unmet need for community-based, inpatient palliative medicine consulting, and her hospice wasn't in a position to offer that service. "I started my independent practice, got my malpractice insurance, and just decided to do it for myself. After about a year, I had enough volume to hire a nurse practitioner. From there it just ballooned. There are very few palliative care physicians around these parts willing or able to do home visits. We do very little marketing and we get a lot of requests."

Dr. Gomez describes her business model as basic diversification. "You have to be affiliated with multiple agencies to pay everyone's salaries. One hospice or one hospital cannot support a practice like this. We approach hospices by saying: These are our services. This is what we can do for you but, by the way, we cannot be exclusive. The people who are comfortable with that hire us. We offer a menu of services and a fee schedule for each. For hospitals, that ranges from 24/7 coverage plus staff training and CME offerings to just consulting visits based on an hourly rate," she explains.

How Big Can the Practice Grow?

"We made a commitment early in the practice that we'd see patients regardless of financial considerations or insurance coverage. Every patient we see has symptomatic needs -- we try not to do purely administrative visits for hospices," Dr. Gomez says. Physician home visits take up a lot of the practice's time but represent only about 30 percent of its income. "It helps to offset our costs but it wouldn't sustain the practice." Hospital work represents 30 to 40 percent of its income, depending on census, and the rest comes from hospice medical director stipends, honorariums and medical consulting.

She says it is difficult to quantify how many hours she actually works each week, because of the responsibility for being on call and her role as administrator. After hours there is always a hospital team and a house-call team on-call. "If people are going to do this, they should view it like a family practice. There are very few solo family practitioners, because of the call demands."

How big can the practice grow? "There are about a hundred hospices in the Houston area," she responds. Starting in 2011 they will need to provide face-to-face physician visits to patients prior to 180-day recertifications. "I can imagine that every hospice that can't afford to hire a full-time physician might take a look at us. We're different from other physician house-call groups. When we are asked to do a home visit for palliative care -- this is our specialty. Future growth basically depends on the mindset of the owner and staff. We already have plans to add another physician so we can cover an inpatient unit for a local hospice," she says.

"I think my staff can sell this approach better than I can. I am more obsessed with the details of managing the practice. It's actually well oiled, and I think it's replicable. Should other people be trying this? Absolutely!" she insists.

"I haven't met other HPM people who do what I do. Hospitalists would probably be the closest model to our practice." Dr. Gomez's entrepreneurial spirit extends to the training she provides to medical fellows at M.D. Anderson. "I teach them how to bill for a visit and how to hire a staff member -- in other words, how to have a real job in palliative care," she relates.

"The biggest question I get from other HPM physicians is this: How do you manage to deal with so many contracting entities? Basically, you have to be willing to walk away from a relationship that isn't working. My husband has helped me realize that if I want to do what I love, I have to be willing to walk away if it's not a win/win situation for both parties. I also say it's important to hire people with good administrative skills and passion, and then treat them well. You can always train them in palliative care if they have those underlying skills," she says.

"Sometimes I say to other doctors: Just give it a try -- give it a realistic amount of time to see if it works. It may sound intimidating to many, but once you start it, you realize the intimidating part is that not enough people have done it." It's also important for physicians in HPM to start looking at themselves as subspecialists. "Other doctors don't take the abuse we do. We need to see the value we bring to medicine," she says.

The team and teamwork help to prevent burnout, while another secret to the practice's success "is having my family's complete support. In my case, my husband now stays home with our kids, aged 7, 5 and 1. In our first year with Memorial Hermann, the palliative care service was awarded the hospital's top prize for quality and the hospital CEO gave us an awards dinner. We invited our families to the dinner because we wanted them to hear from someone else about the importance of our work," she says.

"When we interview people for the practice, we usually try to meet their spouses, as well. We also have our team meetings in a restaurant and then bring take-home meals home to the family."


CompensationPractice Insights

Hospice Physician Billing

"Billing for physician services for hospice care is a potential program vulnerability given that Medicare may be billed under Part A and Part B", is one of the conclusions drawn in a recent memorandum (OEI-02-06-00224) from the Office of the Inspector General (OIG) to Donald Berwick, MD, Administrator for the Centers for Medicare and Medicaid Services (CMS). While the memorandum did not find the problem to be "widespread", it did urge CMS to "monitor this issue". The OIG study identified "questionable billing" as those claims where Medicare paid physicians directly through Part B for services related to a beneficiary's terminal illness, while Medicare also paid for services from the same physician for the terminal illness under Part A.

The OIG identified nearly 10,000 questionable Part B claims for physician services provided to hospice beneficiaries in 2009. These questionable claims covered more than 4,000 beneficiaries and were submitted by more than 3,000 physicians. More than 600 hospices were involved in these questionable billings. It was not clear in these cases whether the physician used the modifier incorrectly or the hospice billed inappropriately.

As a general rule, Medicare pays for physician services through Part A or Part B, depending on the physician's relationship with the hospice (if the physician is employed or paid under agreement by the patient's hospice provider, then claims are paid to the hospice under part A). We've noted the complexities of HPM physician (and nurse practitioner) billing in previous issues of HPM Practitioner. In those issues we've offered advice on how to best navigate these complexities. Suffice it to say that you should periodically (we recommend semiannually) review your employment agreements, professional service contracts, and billing practices to ensure compliance with their terms and regulatory requirements. 

Contact Tim Cousounis at tcousounis@digital-action.com or (610) 941.9419 to learn more about how DAI Palliative Care Group can help with an assessment of your billing practices.


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