Business/Practice News and Views for Physicians
Hospice and Palliative Medicine
Issue No. 7 September 2010
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.
Dr. Amy Davis: There are Always Trade-offs
Interview with HPM Physician
Amy Davis, DO, MS
by Larry Beresford
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
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
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
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
How to Pitch the
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 email@example.com
if you are interested in exploring the prospects for networking among private
Featured Practice Opportunities
The Evolving Role of Hospice and Palliative Medicine Leadership
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
director or chief medical officer positions, and is progressing
toward what we refer to as the "chief community palliative
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 firstname.lastname@example.org
or (610) 941.9419
opportunities, click here.
DAI Palliative Care Group
Phone: (610) 941-9419
Phone: (510) 536-3048
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
Click here to send us your comments.
Dr. Sandra Gomez: Just Give Independent Practice a Try
Interview with HPM Physician
Sandra Gomez, MD
by Larry Beresford
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
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
basic building block of this independent practice 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
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,"
"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
"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."
Hospice Physician 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
Contact Tim Cousounis at email@example.com or (610) 941.9419 to learn more about how DAI Palliative Care Group can help with an assessment of your billing practices.