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I think Nantucket is very pricey with regard to rents  staff salaries etc prob food etc-- being an island  As an example  my overhead is about 30,000/yr incl rent malpr billing dues emrs supplies aetcrent is 610/mo + lawn /plow/elec/phone

 

 

LOTS of paper towels!

I just grabbed a big number to be conservative. Have not shopped for rooms to even know what is available. Also, I needed that overhead number to represent other hidden costs, e.g., utilities, EMR fees, billing fees, etc.

G

>

> Why u want to pay 60k for rent?

> 1 room ony? How many paper towels you are

> Gonna use?

>

> Adolfo E. Teran, MD

>

>

--      MD          ph    fax

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What's the local zoning like? Can you work out of your house if you wanted to?KenSent from my iPad

I think Nantucket is very pricey with regard to rents staff salaries etc prob food etc-- being an island As an example my overhead is about 30,000/yr incl rent malpr billing dues emrs supplies aetcrent is 610/mo + lawn /plow/elec/phone

LOTS of paper towels!

I just grabbed a big number to be conservative. Have not shopped for rooms to even know what is available. Also, I needed that overhead number to represent other hidden costs, e.g., utilities, EMR fees, billing fees, etc.

G

>

> Why u want to pay 60k for rent?

> 1 room ony? How many paper towels you are

> Gonna use?

>

> Adolfo E. Teran, MD

>

>

-- MD ph fax

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Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

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Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

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Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

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If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are?

 Please be mindfulJean

 

Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

--      MD          ph    fax

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Greg where are you? small place?

I love photography too, I am a wanna be.

take care, adolfo

To: Sent: Thursday, February 9, 2012 7:00 AMSubject: Re: thinking out loud...

Thanks Sharon for all of the thoughtful advice!I had forgotten about the Venus. Love to know it is framed. Photography and graphic design is my hobby and, as physician burnout has started to smolder, it has progressed to even a PT job, as I now show in local galleries.A few thoughts about below. Thoughtful shaping of the payor mix is important to me. I do do obstetrics, and will likely give this up, but because of this, I take care of a lot of young families. This made me think of a family rate. But I have even considered a "kids under 18 are free" policy, seeing that they usually result in more and easier visits.I am concerned about the HMO problem. Like said, I do not want to add undo burden to my local colleagues (ESP. After getting off the ferris wheel and leaving the remaining 3 with even larger patient panels). A symptom of how bad it is right now, last Friday, I was seeing an HMO patient for abdominal pain, wanted

to get an abdominal CT, space avail right away in radiology, and had the insurance on hold for approval and was told that approval would take two hours, or maybe until Monday. So what did we do? We sent the patient to th ER where it could be done without such approval!And yet, the HMO products are growing here. High deductible, state and commercial HMO's are how we have complied with Romneycare.Regarding seasonal memberships, I think I would offer them, but without the discount. Our seasonal visitors would not blink at the amounts involved. In fact, going into a summer is going to be my best option, I believe. I'm considering the option of doubling as an urgent care center. Walkin clinic. Post info about the membership and member rates, as well as rates that are doubled, per visit, for non-members. In the summer, if the word is out, it will likely be pretty easy to fill with walk-in's.Regarding HelloHealth, I have a conf call

with them this morning. At least their website leads me to believe that they are alive and well. New version just released this month, advertising 10,000 physician users, and Meaningful Use certification. I'll report back on what I learned.Greg> > >> > > What if...> > >> > > Micropractice. Single exam room. No other

employee. Direct pay; no> > insurance.> > >> > > HelloHealth model. Membership (either yearly or monthly, family rate)> > and price this to include the typical access (cell, after-hours, email),> > PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient> > care. (We don't have hospitalists and any hospital visit would involve> > impersonal care by one of the other PCPs or the ER PAs.) Then charge a> > reasonable rate for visits, and a lower one for virtual visits.> > >> > > What if the rates were $400 indiv membership, $600 family membership.> > And the virtual visits were $25 and the office visits were $60?> > >> > > If I then signed up 400 people/families and generated $200K in> > membership fees, and saw 30 visits per week for an extra $70K.> > >> > >

Then if I paid $10K in malpractice and $60K in rent and supplies.> > >> > > Final take home of $200K.> > >> > > Help me here. Where am I being naive? What am I missing?> > >> >> > > >>

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Loving the pics. They are beautiful. Will go back to your site to look at more as time allows. Great hobby! From: [mailto: ] On Behalf Of gregandamyhinsonSent: Thursday, February 09, 2012 8:56 AMTo: Subject: Re: thinking out loud... I am in Nantucket, MA.I have a website that used to be my practice website, was no longer needed when I became employed by Mass General, and now is my photography website.www.ackdoc.comThe island is beautiful, is the inspiration for my art, and the reason (along with the people here) why I put up with the crazy medical environment.Greg>> Greg where are you? small place?> I love photography too, I am a wanna be.> take care, adolfo

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Greg,

How is access to primary care in your area? Is there a group such as business owners who would apy a fee to have eas of access created by virtual visits, email consults and same day/next day access. Could this be a niche to create inside your current practice??

Musings....

Dannielle Harwood, MD

www.MyStudioMD.com

To: Sent: Wed, February 8, 2012 11:02:00 PMSubject: Re: Re: thinking out loud...

Hi Greg,

I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine. I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe. (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice. Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true). Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that. (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that). I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't. I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for. (This is a side note, but I eventually learned to market to efficiency and time saving rather

than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e. higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).

How would you handle seasonal membership? Or do you not need to worry about those that are only there part time? You could always add some type of plan for them if you needed to.

Are you ready to give up OB? If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice. But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be. But I don't know that some of the founders truly had primary care at the heart, like you do. Lots of other pioneers out there though: Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now.

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week. Hareschwww.onefamilydoctor.com

>> What if...> > Micropractice. Single exam room. No other employee. Direct pay; no insurance.> > HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.> > What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were

$60?> > If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.> > Then if I paid $10K in malpractice and $60K in rent and supplies.> > Final take home of $200K.> > Help me here. Where am I being naive? What am I missing?>

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We are in network.  We will usually not sign on the dotted line unless the patient comes for a visit.  If the patient wants to use their insurance, then they have to play by the insurance co rules.  They always have the option to pay cash....

Pratt

 

If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are?

 Please be mindfulJean

 

Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

--      MD          ph    fax

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Me too.... Have to ask which synchro team that is on the holiday show photos?!?  My daughter is also a synchro skater :) Pratt

 

Loving the pics.   They are beautiful.  Will go back to your site to look at more as time allows.  Great hobby!

 From: [mailto: ] On Behalf Of gregandamyhinson

Sent: Thursday, February 09, 2012 8:56 AMTo: Subject: Re: thinking out loud...

   I am in Nantucket, MA.I have a website that used to be my practice website, was no longer needed when I became employed by Mass General, and now is my photography website.

www.ackdoc.comThe island is beautiful, is the inspiration for my art, and the reason (along with the people here) why I put up with the crazy medical environment.Greg

>> Greg where are you? small place?> I love photography too, I am a wanna be.

> take care, adolfo

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why don;t you think about starting a practice and taking insurances but not take all of them Take the best payors and do a low volume imp practice You can a dd more payors later but don't be overwhelmed  Do you have a  way to moonlight while the practice builds? ANY source of income?

 

This is how things are with my current practice. I recognize the headache! And this is why this is one of my biggest concerns with the model I am thinking about.

>

>

>

> If I am a network PCP and someone who is charging some hundreds of dollars

> /family/yr, called me and said could you order this XYZ, exactly what

> do you think I should do ?

> do it for free?

> Are docs treating each other exactly like we complain the insurances are?

> Please be mindful

> Jean

>

--      MD          ph    fax

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Greg,I have not been following this entire thread, but if you want to look at my website, my membership sponsored IMP practice has been up and running since August of 2008, when I dropped all insurance and have been employed directly by my patients ever since. 

www.mountainviewmd.comI would be happy to email directly with you if you have questions.  Ewing , M.D.IMP since 2005Patient Employed since 2008

Durango, CO

 

This is our local skating club. Nantucket Ice. It's a relatively new program, but it is growing quickly and my youngest son and daughter are both heavily involved.

In that same gallery, there are several pictures of my son Maddux, then 5 years of age, in his Pairs skate with Dorothy Hamill (an island resident) !!!

Greg

> >

> > Greg where are you? small place?

> > I love photography too, I am a wanna be.

> > take care, adolfo

>

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and Greg,Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient " signed up " with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.

Patient gets care they want and need with insurance covering the parts it will;outside doc has the practice and provides the care they want;

HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.I certainly know a few HMO docs that pride themselves on having patients on their panel they never see.

That's the situation I meant.

Sharon

 

If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are?

 Please be mindfulJean

 

Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

--      MD          ph    fax

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I  don;t know any capitation  except my own pilot project where the deal is I take care of them  to lower costs I would never order a test becasue someone else said to  You gonna sit next to me in court? or more likley ,what if I disagreed? The patietn sees someone else as the trusted PCP but I get to order the test?

Nuts to that .The system is so bad everybody is lookin to survive and we dump on  anyone we can find Just pass it off to patietns to billers to volunteers up to specialists down to  PCPs, becasue things are bad

 BAd Ophthalmologists call me and want to' know someone s A1 c If I didnt refer them  then  go look it up! ERs wants ss#  on and onwe are all shifting work to try to breathe I get the causeIn primary care we are nearly dead

 Now I did this you see I worked at the VA and was  paid a fortune to  type like a  monkey   into the formulary S I M VA S TA T I N, l a s i x  etc . when the community docs did all the real  work was up nights and made less I was acutely aware and true it was sometimes a safety as if lipids had not been followup up I did i t but what a price for society to double- do care,   and to risk mistakes

   I dont; support such an approach I support Greg in his need to practice sanely and make a living and I hope he finds a path Jean

 

and Greg,Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient " signed up " with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.

Patient gets care they want and need with insurance covering the parts it will;outside doc has the practice and provides the care they want;

HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.I certainly know a few HMO docs that pride themselves on having patients on their panel they never see.

That's the situation I meant.

Sharon

 

If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are?

 Please be mindfulJean

 

Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

--      MD          ph    fax

--      MD          ph    fax

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There were circumstances where I did order things for other when I was the HMO doc so the insurance would pay.  I saw this as benefitting the patient.  And liked helping them.  Certainly not if I disagreed; nor would I ever want anyone to order something they disagreed with.  Not what I'm talking about.

Maybe the captiation thing doesn't exist where you are in Maine, so it is irrelevant.  And of course, everyone needs to do what they are comfortable with.  I was just trying to explain a situation that has existed, maybe rarely, where everyone does benefit.  That's all.

Sharon

 

I  don;t know any capitation  except my own pilot project where the deal is I take care of them  to lower costs I would never order a test becasue someone else said to  You gonna sit next to me in court?

 or more likley ,what if I disagreed? The patietn sees someone else as the trusted PCP but I get to order the test?

Nuts to that .The system is so bad everybody is lookin to survive and we dump on  anyone we can find Just pass it off to patietns to billers to volunteers up to specialists down to  PCPs, becasue things are bad

 BAd Ophthalmologists call me and want to' know someone s A1 c If I didnt refer them  then  go look it up! ERs wants ss#  on and onwe are all shifting work to try to breathe I get the causeIn primary care we are nearly dead

 Now I did this you see I worked at the VA and was  paid a fortune to  type like a  monkey   into the formulary S I M VA S TA T I N, l a s i x  etc . when the community docs did all the real  work was up nights and made less I was acutely aware and true it was sometimes a safety as if lipids had not been followup up I did i t but what a price for society to double- do care,   and to risk mistakes

   I dont; support such an approach I support Greg in his need to practice sanely and make a living and I hope he finds a path Jean

 

and Greg,Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient " signed up " with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.

Patient gets care they want and need with insurance covering the parts it will;outside doc has the practice and provides the care they want;

HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.I certainly know a few HMO docs that pride themselves on having patients on their panel they never see.

That's the situation I meant.

Sharon

 

If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are?

 Please be mindfulJean

 

Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

--      MD          ph    fax

--      MD          ph    fax

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I hope Greg find his path ( his Santiago de Compostela).I think the trick is finding ur passion again.Adolfo E. Teran, MD

I don;t know any capitation except my own pilot project where the deal is I take care of them to lower costs I would never order a test becasue someone else said to You gonna sit next to me in court? or more likley ,what if I disagreed? The patietn sees someone else as the trusted PCP but I get to order the test?

Nuts to that .The system is so bad everybody is lookin to survive and we dump on anyone we can find Just pass it off to patietns to billers to volunteers up to specialists down to PCPs, becasue things are bad

BAd Ophthalmologists call me and want to' know someone s A1 c If I didnt refer them then go look it up! ERs wants ss# on and onwe are all shifting work to try to breathe I get the causeIn primary care we are nearly dead

Now I did this you see I worked at the VA and was paid a fortune to type like a monkey into the formulary S I M VA S TA T I N, l a s i x etc . when the community docs did all the real work was up nights and made less I was acutely aware and true it was sometimes a safety as if lipids had not been followup up I did i t but what a price for society to double- do care, and to risk mistakes

I dont; support such an approach I support Greg in his need to practice sanely and make a living and I hope he finds a path Jean

and Greg,Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient "signed up" with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.

Patient gets care they want and need with insurance covering the parts it will;outside doc has the practice and provides the care they want;

HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.I certainly know a few HMO docs that pride themselves on having patients on their panel they never see.

That's the situation I meant.

Sharon

If I am a network PCP and someone who is charging some hundreds of dollars /family/yr, called me and said could you order this XYZ, exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are?

Please be mindfulJean

Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!www.impcenter.org

Sharon

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1. So far, no problem with Medicare (there was a threat, but gone for now)

2. PPO's: generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's: I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617

PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

www.SharonMD.com

Hi Greg,I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine. I still have that framed picture!

Thoughts:

I don't see why you wouldn't do a membership model practice in the demographic you describe. (Especially being the first one as others have noted.)

I would think about including the virtual visits as part of the draw to signup for the practice. Less hassle for you to keep track of.

Family rates are smart because usually only one high needs person per family (although not always true). Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that. (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that). I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't. I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for. (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

Consider tiering your rates to get the profile you'd like.....i.e. higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).

How would you handle seasonal membership? Or do you not need to worry about those that are only there part time? You could always add some type of plan for them if you needed to.

Are you ready to give up OB? If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice. But also change your lifestyle......

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be. But I don't know that some of the founders truly had primary care at the heart, like you do. Lots of other pioneers out there though: Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now.

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

www.SharonMD.com

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week.

Haresch

www.onefamilydoctor.com

>

> What if...

>

> Micropractice. Single exam room. No other employee. Direct pay; no insurance.

>

> HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

>

> What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?

>

> If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

>

> Then if I paid $10K in malpractice and $60K in rent and supplies.

>

> Final take home of $200K.

>

> Help me here. Where am I being naive? What am I missing?

>

-- MD ph fax

-- MD ph fax

=

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Not necessarily true Sharon. The HMOs give us PCPs reports on how we are doing meeting metrics and getting appropriate tests done, vaccinations, meds for certain diseases. If they don’t get that care through participating doctors than it is not done. We lose credit. WE are told we are bad doctors. It’s not a win-win. And the $8 a month doesn’t really help a lot. Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing From: [mailto: ] On Behalf Of Sharon McCoy Sent: Thursday, February 09, 2012 3:45 PMTo: Subject: Re: Re: thinking out loud... and Greg, Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient " signed up " with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.Patient gets care they want and need with insurance covering the parts it will;outside doc has the practice and provides the care they want;HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.I certainly know a few HMO docs that pride themselves on having patients on their panel they never see. That's the situation I meant. Sharon If I am a network PCP and someone who is charging some hundreds of dollars /family/yr, called me and said could you order this XYZ, exactly what do you think I should do ?do it for free? Are docs treating each other exactly like we complain the insurances are? Please be mindful Greg,One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.And if you're not a member, now's the time!www.impcenter.org Sharon On Thu, Feb 9, 2012 at 12:07 AM, Sharon McCoy wrote:Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:1. So far, no problem with Medicare (there was a threat, but gone for now)2. PPO's: generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience3. HMO's: I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generallySpecialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok. It can actually feel pretty good to not be propping up the system that is not much good for much of anybody. Sharon Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.comHi Greg, I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine. I still have that framed picture! Thoughts: I don't see why you wouldn't do a membership model practice in the demographic you describe. (Especially being the first one as others have noted.) I would think about including the virtual visits as part of the draw to signup for the practice. Less hassle for you to keep track of. Family rates are smart because usually only one high needs person per family (although not always true). Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that. (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that). I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't. I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for. (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.) Consider tiering your rates to get the profile you'd like.....i.e. higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join). How would you handle seasonal membership? Or do you not need to worry about those that are only there part time? You could always add some type of plan for them if you needed to. Are you ready to give up OB? If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice. But also change your lifestyle...... Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically. By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be. But I don't know that some of the founders truly had primary care at the heart, like you do. Lots of other pioneers out there though: Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable. SharonSharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week. Hareschwww.onefamilydoctor.com>> What if...> > Micropractice. Single exam room. No other employee. Direct pay; no insurance.> > HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.> > What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?> > If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.> > Then if I paid $10K in malpractice and $60K in rent and supplies.> > Final take home of $200K.> > Help me here. Where am I being naive? What am I missing?> -- MD ph fax

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And those of us not capitated would be doing the work for free....

 

Not necessarily true Sharon.  The HMOs give us PCPs reports on how we are doing meeting metrics and getting appropriate tests done, vaccinations, meds for certain diseases.  If they don’t get that care through participating doctors than it is not done.  We lose credit.  WE are told we are bad doctors.  It’s not a win-win.  And the $8 a month doesn’t really help a lot.

 

 

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

 

 

 

From: [mailto: ] On Behalf Of Sharon McCoy

Sent: Thursday, February 09, 2012 3:45 PMTo: Subject: Re: Re: thinking out loud...

 

 

and Greg,

 

Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient " signed up " with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.

Patient gets care they want and need with insurance covering the parts it will;

outside doc has the practice and provides the care they want;

HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.

I certainly know a few HMO docs that pride themselves on having patients on their panel they never see.

 

That's the situation I meant.

 

Sharon

 

If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free?

 Are docs treating each other exactly like we complain the insurances are? Please be mindfulJean

 

 

Greg,

One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!

www.impcenter.org

 

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:

1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

 

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

 

Sharon

 

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,

 

I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

 

Thoughts:

 

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

 

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

 

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

 

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

 

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

 

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

 

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

 

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

 

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week. Hareschwww.onefamilydoctor.com

>> What if...> > Micropractice. Single exam room. No other employee. Direct pay; no insurance.> > HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

> > What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?> > If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

> > Then if I paid $10K in malpractice and $60K in rent and supplies.> > Final take home of $200K.> > Help me here. Where am I being naive? What am I missing?>

 

 

 

--      MD          ph    fax

 

-- Pratt

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If it's not win-win, don't do it.  Doesn't  apply to your situations.  Let's move on...Sharon

 

And those of us not capitated would be doing the work for free....

 

Not necessarily true Sharon.  The HMOs give us PCPs reports on how we are doing meeting metrics and getting appropriate tests done, vaccinations, meds for certain diseases.  If they don’t get that care through participating doctors than it is not done.  We lose credit.  WE are told we are bad doctors.  It’s not a win-win.  And the $8 a month doesn’t really help a lot.

 

 

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

 

 

 

From: [mailto: ] On Behalf Of Sharon McCoy

Sent: Thursday, February 09, 2012 3:45 PMTo: Subject: Re: Re: thinking out loud...

 

 

and Greg,

 

Sometimes when HMO's capitate PCP's and the PCP gets paid for a patient " signed up " with them whether or not they see them, having an out of network doctor actually providing the primary care, except for a signature on a mammogram or colonoscopy order form done by the PCP getting paid by the HMO for having that patient enrolled, actually benefits the HMO doc and everyone wins.

Patient gets care they want and need with insurance covering the parts it will;

outside doc has the practice and provides the care they want;

HMO doc gets paid for essentially doing hardly any work in the system they've chosen to work in.

I certainly know a few HMO docs that pride themselves on having patients on their panel they never see.

 

That's the situation I meant.

 

Sharon

 

If I am a network PCP and someone who is charging some hundreds of  dollars /family/yr,  called me  and said  could you order this XYZ,  exactly what do you think I should do ?do it for free?

 Are docs treating each other exactly like we complain the insurances are? Please be mindfulJean

 

 

Greg,

One more thing; if you are an IMP member, listen to the podcast from last Thursday's call on Community Supported Healthcare with Pierce.

And if you're not a member, now's the time!

www.impcenter.org

 

Sharon 

Oh, and re: ordering stuff and having it be covered by a patient's insurance when you are out of network/opted out:

1.  So far, no problem with Medicare (there was a threat, but gone for now)

2.  PPO's:  generally easy as long as lab/radiology/specialist is in network; may have to do prior auth but not harder than in network in my experience

3. HMO's:  I've had no problems with prescriptions; radiology: plain x-rays ok at the right facility; CT's, MRI's, even mammograms sometimes have to be ordered by in network PCP generally

Specialty referrals generally have to come from in network PCP; when I first started, I could send a note and they would just do the referral, no longer possible (but could be an anomaly because the PCP's are at the University and the docs get paid per visit now even though the group is capitated.

I've been doing it out of network over 5 years in Southern California, and last year was the first time I had any problem with one HMO not paying for labs I ordered even though done at an in network lab; mostly though, labs have been ok.

 

It can actually feel pretty good to not be propping up the system that is not much good for much of anybody.

 

Sharon

 

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

Hi Greg,

 

I remember you as the designer who took Botticelli's Venus and added a stethoscope around her neck when I asked opinions on the name Renaissance Family Medicine.  I still have that framed picture!

 

Thoughts:

 

I don't see why you wouldn't do a membership model practice in the demographic you describe.  (Especially being the first one as others have noted.)

 

I would think about including the virtual visits as part of the draw to signup for the practice.  Less hassle for you to keep track of.

 

Family rates are smart because usually only one high needs person per family (although not always true).  Seems like a big discount though if you consider a family of 6 or so....unless you particularly want to draw that.  (Course part of that is coming from my practice because I currently include all the visits in my fees; charging per visit will make up for some of that).  I think the charge per visit along with membership fee keeps things more balanced; I disagree with H that $400 per year without visit fees would be fine, unless you have a random mix; which you likely won't.  I think to some degree, they higher your fees, the more complex the patients that are willing to pay, so you just want some safeguards that you are getting a mix you want to care for.  (This is a side note, but I eventually learned to market to efficiency and time saving rather than as long of visits as you want; I do the same thing but different types of people are attracted.)

 

Consider tiering your rates to get the profile you'd like.....i.e.   higher rates for elderly if you don't want to be elderly heavy (since they tend to be higher needs and may preferentially choose to join).  

 

How would you handle seasonal membership?  Or do you not need to worry about those that are only there part time?  You could always add some type of plan for them if you needed to.

 

Are you ready to give up OB?  If you do, of course, that will make malpractice cheaper, and eventually decrease volume (when I was doing OB I saw almost all well babies, pre-natal visits, and well women exams) and increase the age of your practice.  But also change your lifestyle......

 

Definitely do a recurring transaction for membership (easy with Quickbooks Merchant Service) so you don't have to bill; and have contract renew automatically.

 

By the way, my understanding is that Hello Health went under pretty fast.....partly because software promised never came to be.  But I don't know that some of the founders truly had primary care at the heart, like you do.  Lots of other pioneers out there though:  Marty Schulman in Encinitas was one of the earliest on the list doing a membership fee with fee for service; but plenty out there now. 

 

We (as a collective) really want good docs like you to survive and thrive, so definitely choose make changes so your practice is sustainable.

 

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

 

I could easily survive on $400 per patient per year, without charging for visits (would just have to figure out the regulation-as-insurance issue). The only real question is whether there are 400 people willing to sign up. It's tough to figure out. Even a survey wouldn't tell you the real answer. But if you have 2500 loyal patients, it's at least possible.

For me, 30 visits a week without any help is a lot (but I take insurance). But 500 patients will probably bring closer to 20 established-patient visits per week. Hareschwww.onefamilydoctor.com

>> What if...> > Micropractice. Single exam room. No other employee. Direct pay; no insurance.> > HelloHealth model. Membership (either yearly or monthly, family rate) and price this to include the typical access (cell, after-hours, email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND Inpatient care. (We don't have hospitalists and any hospital visit would involve impersonal care by one of the other PCPs or the ER PAs.) Then charge a reasonable rate for visits, and a lower one for virtual visits.

> > What if the rates were $400 indiv membership, $600 family membership. And the virtual visits were $25 and the office visits were $60?> > If I then signed up 400 people/families and generated $200K in membership fees, and saw 30 visits per week for an extra $70K.

> > Then if I paid $10K in malpractice and $60K in rent and supplies.> > Final take home of $200K.> > Help me here. Where am I being naive? What am I missing?>

 

 

 

--      MD          ph    fax

 

-- Pratt

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Adolfo,Amen.I haven't heard that term for it, but I like it.

Sharon

 

I hope Greg find his path ( his Santiago de Compostela).I think the trick is finding ur passion again.Adolfo E. Teran, MD

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Sharon and Steve,

  How were you able to find those HMO docs to assist you?

Deb

 

SharonI have exactly that relationship with two docs who serve as HMO referral docs for my patients. They only need a meet n greet once a year to keep up with HMO chart reviews.Steve Horvitzstown , NJ

Founder of the Institute for Medical Wellness > >>>>> >> >>>>> > What if...> >>>>> >> >>>>> > Micropractice. Single exam room. No other employee. Direct pay; no

> >>>>> insurance.> >>>>> >> >>>>> > HelloHealth model. Membership (either yearly or monthly, family> >>>>> rate) and price this to include the typical access (cell, after-hours,

> >>>>> email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults AND> >>>>> Inpatient care. (We don't have hospitalists and any hospital visit would> >>>>> involve impersonal care by one of the other PCPs or the ER PAs.) Then

> >>>>> charge a reasonable rate for visits, and a lower one for virtual visits.> >>>>> >> >>>>> > What if the rates were $400 indiv membership, $600 family

> >>>>> membership. And the virtual visits were $25 and the office visits were $60?> >>>>> >> >>>>> > If I then signed up 400 people/families and generated $200K in

> >>>>> membership fees, and saw 30 visits per week for an extra $70K.> >>>>> >> >>>>> > Then if I paid $10K in malpractice and $60K in rent and supplies.

> >>>>> >> >>>>> > Final take home of $200K.> >>>>> >> >>>>> > Help me here. Where am I being naive? What am I missing?> >>>>> >

> >>>>>> >>>>>> >>>>> >>>> >>> >> >> > --> >> >> >> > MD

> > > > > > ph fax

> > > >> > > >>

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Thanks

 

DebOne doc I helped when he started his practice about ten years ago. We have covered for each other for vacas since. It was an easy request.The other is a member of my synagogue, a solo doc, and one of the officers of our county medical society.

All I had to do was ask,Stevestown, NJ > > > >>>>> >> > > >>>>> > What if...> > > >>>>> >> > > >>>>> > Micropractice. Single exam room. No other employee. Direct pay;

> > no> > > >>>>> insurance.> > > >>>>> >> > > >>>>> > HelloHealth model. Membership (either yearly or monthly, family> > > >>>>> rate) and price this to include the typical access (cell,

> > after-hours,> > > >>>>> email), PLUS, a yearly MDVIP-like wellness visit, AND ER consults> > AND> > > >>>>> Inpatient care. (We don't have hospitalists and any hospital visit

> > would> > > >>>>> involve impersonal care by one of the other PCPs or the ER PAs.)> > Then> > > >>>>> charge a reasonable rate for visits, and a lower one for virtual

> > visits.> > > >>>>> >> > > >>>>> > What if the rates were $400 indiv membership, $600 family> > > >>>>> membership. And the virtual visits were $25 and the office visits

> > were $60?> > > >>>>> >> > > >>>>> > If I then signed up 400 people/families and generated $200K in> > > >>>>> membership fees, and saw 30 visits per week for an extra $70K.

> > > >>>>> >> > > >>>>> > Then if I paid $10K in malpractice and $60K in rent and supplies.> > > >>>>> >> > > >>>>> > Final take home of $200K.

> > > >>>>> >> > > >>>>> > Help me here. Where am I being naive? What am I missing?> > > >>>>> >> > > >>>>>

> > > >>>>>> > > >>>>> > > >>>> > > >>> > > >> > > >> > > > --> > > >

> > > >> > > >> > > > MD> > > > > > > > > > > > ph fax

> > > > > > > >> > > >> > > >> > >> >> > > >

>

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