Re: Charging patients for 24x7 phone access

March 10, 2012

THis sounds fantastic. (Sorry run out of cynicism just yesterday) I have done a lot of palliative care in my life and agree that it is a very needed services. The only thing I can think as a comment is that although you will not offer yourself as the PCP (in my experience) you will become their de facto PCP. I am not sure if you don’t want to advertise as PCP or you don’t want to be their PCP (two very different things in my opinion) but as I am sure you are aware, the second you show up providing this kind of care, is approximately the same time the PCP disappears (at least in my experience) Finally, if you have a group of people coming from the same insurance company, consider selling the program to the insurance people, the pitch of course being the money you will be saving them by doing this Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " From: [mailto: ] On Behalf Of Stew MonesSent: Friday, March 09, 2012 9:43 PMTo: Subject: Charging patients for 24x7 phone access I have become an inadvertent lurker but appreciate the group very much. I want your input and advice.For those who don't know me, I started my FP solo imp in 2009 with much inspiration and assistance from this list. I do 50% office FP work (low overhead/micro) and diversify my income with 50% of my time doing home visits for a medium sized hospice. I love the balance.I have been charging my FP patients $10/ month for 24x7 access and phone advice in lieu of office visits when it is the right thing to do. Patients can opt out and pay per phone visit but most gladly pay $100 in Jan or feb for the whole year with little hassle for me and my one assistant (this lump salary really helps with taxes)and it is a steal really for my patients and it has been good enough for me, I like that patients are really happy with it and insurance companies are happy with it too. Recently I have been struggling with some sick patients who have become over utilizers but as a hospice and palliative care doc, I pride myself in helping people get good care with fewer burdens then the typical office imposes on sick patients. Still I struggle with the fact that our choices are always stark - between either giving our services away or creating two tiered medicine. (I know some will say " or ridding ourselves of third parties " - thank you but that is a different debate)I have a new idea and want to share it with the group and get ideas about the potential pitfalls ( I'm inviting your cynicism and doom-saying). Today I thought of offering a service of palliative care 24x7 phone access to patients who need a palliative care doctor. These are high needs patients who are not hospice appropriate yet, but also are tired of making office visits or can't go to the ER or don't want to be admitted - they may have been kicked off hospice for " failure to die " and don't have an adequate medical support system to help them avoid that next hospitalization. I would NOT offer to be their PCP but only their palliative care specialist (thus differentiating them from my FP patients) and I would charge $100 a month for the phone access, willingness to make home visits, but would charge insurances if/ when I make a home visit. I could not handle very many of these, but might accept 20-40 patients total ($2000-$4000/month is not a bad compensation). I would also offer a sliding scale for those who don't have the finances. There is a huge need for this and nobody is willing to step in to help people in the chasm between home health and hospice for bed bound/ home bound patients. So this is the kernel of an idea. Please tell me your impressions or if any docs are already doing this.Stew Mones MDEugene, Oregon

March 10, 2012

Thanks for your optimism. I'm worried that I haven't thought of the dark

under-belly of this idea yet.

I know I will be refilling meds and filling out the FMLA forms even though I'm

not the " PCP " but the key issue is that I cannot tell all my present patients

that they now have to pay 10 times more and It would be wrong to have a stark

two tiered system within my patient population as well. I won't do boutique

medicine. It is hard enough to explain to someone that they have a chronic

illness that can only be palliated - imagine adding to it that now that i have

named them a " palliative care patient " they have to pay me 10 times more.

Eeeech!

But in reality, the service is worth that much for the ill patient for the 6-18

months until they qualify for hospice. Once they go on hospice I will no longer

bill them because the hospice team takes over.

Stew Mones MD

Eugene, OR

>

> THis sounds fantastic. (Sorry run out of cynicism just yesterday)

>

> I have done a lot of palliative care in my life and agree that it is a very

> needed services.

>

> The only thing I can think as a comment is that although you will not offer

> yourself as the PCP (in my experience) you will become their de facto PCP. I

> am not sure if you don't want to advertise as PCP or you don't want to be

> their PCP (two very different things in my opinion) but as I am sure you are

> aware, the second you show up providing this kind of care, is approximately

> the same time the PCP disappears (at least in my experience)

>

> Finally, if you have a group of people coming from the same insurance

> company, consider selling the program to the insurance people, the pitch of

> course being the money you will be saving them by doing this

>

> Izquierdo-Porrera MD PhD

>

> Executive Director & Co-founder

>

> Care for Your Health, Inc

>

> Phone

>

> Fax

>

> www.care4yourhealth.org

>

> " Don't ever let injustice go by unchallenged. "

>

> From:

> [mailto: ] On Behalf Of Stew Mones

> Sent: Friday, March 09, 2012 9:43 PM

> To:

> Subject: Charging patients for 24x7 phone access

>

> I have become an inadvertent lurker but appreciate the group very much. I

> want your input and advice.

> For those who don't know me, I started my FP solo imp in 2009 with much

> inspiration and assistance from this list. I do 50% office FP work (low

> overhead/micro) and diversify my income with 50% of my time doing home

> visits for a medium sized hospice. I love the balance.

>

> I have been charging my FP patients $10/ month for 24x7 access and phone

> advice in lieu of office visits when it is the right thing to do. Patients

> can opt out and pay per phone visit but most gladly pay $100 in Jan or feb

> for the whole year with little hassle for me and my one assistant (this lump

> salary really helps with taxes)and it is a steal really for my patients and

> it has been good enough for me, I like that patients are really happy with

> it and insurance companies are happy with it too.

>

> Recently I have been struggling with some sick patients who have become over

> utilizers but as a hospice and palliative care doc, I pride myself in

> helping people get good care with fewer burdens then the typical office

> imposes on sick patients. Still I struggle with the fact that our choices

> are always stark - between either giving our services away or creating two

> tiered medicine. (I know some will say " or ridding ourselves of third

> parties " - thank you but that is a different debate)

>

> I have a new idea and want to share it with the group and get ideas about

> the potential pitfalls ( I'm inviting your cynicism and doom-saying).

>

> Today I thought of offering a service of palliative care 24x7 phone access

> to patients who need a palliative care doctor. These are high needs patients

> who are not hospice appropriate yet, but also are tired of making office

> visits or can't go to the ER or don't want to be admitted - they may have

> been kicked off hospice for " failure to die " and don't have an adequate

> medical support system to help them avoid that next hospitalization. I would

> NOT offer to be their PCP but only their palliative care specialist (thus

> differentiating them from my FP patients) and I would charge $100 a month

> for the phone access, willingness to make home visits, but would charge

> insurances if/ when I make a home visit. I could not handle very many of

> these, but might accept 20-40 patients total ($2000-$4000/month is not a bad

> compensation). I would also offer a sliding scale for those who don't have

> the finances. There is a huge need for this and nobody is willing to step in

> to help people in the chasm between home health and hospice for bed bound/

> home bound patients.

> So this is the kernel of an idea. Please tell me your impressions or if any

> docs are already doing this.

>

> Stew Mones MD

> Eugene, Oregon

>

March 12, 2012

I have been thinking about this all morning. I do some amount of palliative care myself and it had never occurred to me to think about it from this perspective (thanks Stew) Even most my patients are uninsured or Medicaid/medicare, I think most would be willing to pay a monthly fee to be taken care of at home. End of life care is somewhat of a specialized service so I understand the ‘specialist’ sales pitch, and I believe our patients would too. In my experience, most patients have been my patients and then when the catastrophic diagnosis happens, the relationship changes and I start taking care of them mostly at home and whenever they need it. There is also a lot more time spent with the relatives and coordinating with hospice services if they are available. They are aware of the difference in approach and I think they would understand having a different fee schedule. I have never tried it though. I think I will go back to the children and family members of some of my palliative patients and ask them how they would feel about paying for this service. I will let you know what the feedback is. Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " From: [mailto: ] On Behalf Of Dr. BradySent: Monday, March 12, 2012 9:50 AMTo: Subject: RE: Charging patients for 24x7 phone access ,I agree with you. I was not suggesting that the fee be sliding scale based on the individual patient’s need. What I was trying to address was the concern Stew had with charging up to 10X as much for the palliative care patients as he does for his regular patients. To me, if the average time needed to take care the palliative care patients is going to take 10X as much time to manage than a typical FP patient, then the fee is reasonable. If not, then adjust the fee up or down to approximate the average. This fee should be capitated and the same for everyone enrolled in that program. No question. From: [mailto: ] On Behalf Of Izquierdo MD PhDSent: Monday, March 12, 2012 9:27 AMTo: Subject: RE: Charging patients for 24x7 phone access I always find the charging discussions fascinating. It seems we go from a fee for service mentality to a capitation one in the same thought. I struggle with this myself. But more and more, (as I get older J) I try to think of it in terms of capitation i.e. how much money do I need to make the money I think I should be making. It is true that palliative patients have ups and downs in terms of their needs. The intake or new patient period you have long visits because they are struggling with the idea the end is near. Then you come in and control their symptoms and the needs are controlled for a while. When their sx get out of whack or there is an emotional problem with pt or family the need increases. That is why in my opinion it is really challenging to set tear payments for these patients. You never know when the crisis is going to ensue. I think Stew’s concept of a capitation system that serves his needs is going to be far more easy to manage. The ones that have less crisis will go for those with more and at the end of the day Stew will have a stable income (more or less) that can be counted on. Just my two cents. Good luck, and as Brady please keep us posted Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " From: [mailto: ] On Behalf Of Dr. BradySent: Monday, March 12, 2012 7:21 AMTo: Subject: RE: Charging patients for 24x7 phone access Stew,I agree with that this is a very important portion of the population which is currently underserved. Also, with the baby boomers getting older, the number of people needing this service will only increase. However, unless their PCP does home visits, you will become the de facto PCP. After all, if a patient is unable to make it to their doc's office, how long can they remain under that doc's care? Further, what would the PCP be doing that you cannot? I would think parcelizing (did I just make that word up? ) out palliative care stuff from everything else is artificial and would become frustrating for both you and the patient.Seems to me the real question is simply one of compensation. These are far more complex patients, but they will also be needing more visits, so you can definitely make money by seeing them more regularly (initially once a month and then ?more frequently as the illness progresses). In your experience, how many phone calls are you expecting/patient/month? More specifically, how many more phone calls are you expecting from this group of patients vs. your regular patients? If it is 10X as much or if you feel the conversations will last 10X as long, then the difference in charges is worth it. If not, then maybe you should scale the fee to whichever factor is most accurate. That way, you have a solid case to present to your patients when/if they fall into this new level of care. I would also be up front about the cost of these services so patients are aware that your prices go up if their needs increase (that prevents sticker shock later). Either way, this is a cool idea. Please let us know how it continues to develop. From: [mailto: ] On Behalf Of Stew MonesSent: Friday, March 09, 2012 9:43 PMTo: Subject: Charging patients for 24x7 phone access I have become an inadvertent lurker but appreciate the group very much. I want your input and advice.For those who don't know me, I started my FP solo imp in 2009 with much inspiration and assistance from this list. I do 50% office FP work (low overhead/micro) and diversify my income with 50% of my time doing home visits for a medium sized hospice. I love the balance.I have been charging my FP patients $10/ month for 24x7 access and phone advice in lieu of office visits when it is the right thing to do. Patients can opt out and pay per phone visit but most gladly pay $100 in Jan or feb for the whole year with little hassle for me and my one assistant (this lump salary really helps with taxes)and it is a steal really for my patients and it has been good enough for me, I like that patients are really happy with it and insurance companies are happy with it too. Recently I have been struggling with some sick patients who have become over utilizers but as a hospice and palliative care doc, I pride myself in helping people get good care with fewer burdens then the typical office imposes on sick patients. Still I struggle with the fact that our choices are always stark - between either giving our services away or creating two tiered medicine. (I know some will say " or ridding ourselves of third parties " - thank you but that is a different debate)I have a new idea and want to share it with the group and get ideas about the potential pitfalls ( I'm inviting your cynicism and doom-saying). Today I thought of offering a service of palliative care 24x7 phone access to patients who need a palliative care doctor. These are high needs patients who are not hospice appropriate yet, but also are tired of making office visits or can't go to the ER or don't want to be admitted - they may have been kicked off hospice for " failure to die " and don't have an adequate medical support system to help them avoid that next hospitalization. I would NOT offer to be their PCP but only their palliative care specialist (thus differentiating them from my FP patients) and I would charge $100 a month for the phone access, willingness to make home visits, but would charge insurances if/ when I make a home visit. I could not handle very many of these, but might accept 20-40 patients total ($2000-$4000/month is not a bad compensation). I would also offer a sliding scale for those who don't have the finances. There is a huge need for this and nobody is willing to step in to help people in the chasm between home health and hospice for bed bound/ home bound patients. So this is the kernel of an idea. Please tell me your impressions or if any docs are already doing this.Stew Mones MDEugene, Oregon

March 12, 2012

I'm listening. I have not charged my NCBF to my Hospice patients. How could I if I am signing that they won't live a year? I would feel guilty, But they are more work and lots of it. I'm starting to see it differently. So I'll keep listening rather than assuming this work is "part of the package" of being a doctor to seniors. To: Sent: Monday, March 12, 2012 9:26 AM Subject: RE: Charging patients for 24x7 phone access

I always find the charging discussions fascinating. It seems we go from a fee for service mentality to a capitation one in the same thought. I struggle with this myself. But more and more, (as I get older J) I try to think of it in terms of capitation i.e. how much money do I need to make the money I think I should be making. It is true that palliative patients have ups and downs in terms of their needs. The intake or new patient period you have long visits

because they are struggling with the idea the end is near. Then you come in and control their symptoms and the needs are controlled for a while. When their sx get out of whack or there is an emotional problem with pt or family the need increases. That is why in my opinion it is really challenging to set tear payments for these patients. You never know when the crisis is going to ensue. I think Stewâ€™s concept of a capitation system that serves his needs is going to be far more easy to manage. The ones that have less crisis will go for those with more and at the end of the day Stew will have a stable income (more or less) that can be counted on. Just my two cents. Good luck, and as Brady please keep us posted Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax 240 254

0842www.care4yourhealth.org "Don't ever let injustice go by unchallenged." From:

[mailto: ] On Behalf Of Dr. BradySent: Monday, March 12, 2012 7:21 AMTo: Subject: RE: Charging patients for 24x7 phone access Stew,I agree with that this is a very important portion of the population which is currently underserved. Also, with the baby boomers getting older, the number of people needing this service will only increase. However, unless their PCP does home visits, you will become the de facto PCP. After all, if a patient is unable to make it to their

doc's office, how long can they remain under that doc's care? Further, what would the PCP be doing that you cannot? I would think parcelizing (did I just make that word up? ) out palliative care stuff from everything else is artificial and would become frustrating for both you and the patient.Seems to me the real question is simply one of compensation. These are far more complex patients, but they will also be needing more visits, so you can definitely make money by seeing them more regularly (initially once a month and then ?more frequently as the illness progresses). In your experience, how many phone calls are you expecting/patient/month? More specifically, how many more phone calls are you expecting from this group of patients vs. your regular patients? If it is 10X as much or if you feel the conversations will last 10X as long, then the difference in charges is worth it. If not, then maybe you

should scale the fee to whichever factor is most accurate. That way, you have a solid case to present to your patients when/if they fall into this new level of care. I would also be up front about the cost of these services so patients are aware that your prices go up if their needs increase (that prevents sticker shock later). Either way, this is a cool idea. Please let us know how it continues to develop. From: [mailto: ] On Behalf Of Stew MonesSent: Friday, March 09, 2012 9:43 PMTo: Subject: Charging patients for 24x7 phone access I have become an

inadvertent lurker but appreciate the group very much. I want your input and advice.For those who don't know me, I started my FP solo imp in 2009 with much inspiration and assistance from this list. I do 50% office FP work (low overhead/micro) and diversify my income with 50% of my time doing home visits for a medium sized hospice. I love the balance.I have been charging my FP patients $10/ month for 24x7 access and phone advice in lieu of office visits when it is the right thing to do. Patients can opt out and pay per phone visit but most gladly pay $100 in Jan or feb for the whole year with little hassle for me and my one assistant (this lump salary really helps with taxes)and it is a steal really for my patients and it has been good enough for me, I like that patients are really happy with it and insurance companies are happy with it too. Recently I have been struggling with some sick patients who have become over utilizers but as

a hospice and palliative care doc, I pride myself in helping people get good care with fewer burdens then the typical office imposes on sick patients. Still I struggle with the fact that our choices are always stark - between either giving our services away or creating two tiered medicine. (I know some will say "or ridding ourselves of third parties" - thank you but that is a different debate)I have a new idea and want to share it with the group and get ideas about the potential pitfalls ( I'm inviting your cynicism and doom-saying). Today I thought of offering a service of palliative care 24x7 phone access to patients who need a palliative care doctor. These are high needs patients who are not hospice appropriate yet, but also are tired of making office visits or can't go to the ER or don't want to be admitted - they may have been kicked off hospice for "failure to die" and don't have an adequate medical support system to help them

avoid that next hospitalization. I would NOT offer to be their PCP but only their palliative care specialist (thus differentiating them from my FP patients) and I would charge $100 a month for the phone access, willingness to make home visits, but would charge insurances if/ when I make a home visit. I could not handle very many of these, but might accept 20-40 patients total ($2000-$4000/month is not a bad compensation). I would also offer a sliding scale for those who don't have the finances. There is a huge need for this and nobody is willing to step in to help people in the chasm between home health and hospice for bed bound/ home bound patients. So this is the kernel of an idea. Please tell me your impressions or if any docs are already doing this.Stew Mones MDEugene, Oregon

March 12, 2012

I believe a fee should be all of the above. Fair to all, based on workload but also the commitment we make to 24x7 access has a value in itself and can be determined by the individual parties and "by what the market will bear". In this example patients will only agree to the service if they see that it has value commensurate to the price.I particularly like a system that is a pre-paid package of availability and communication because it does the opposite of what the copay, deductible and coinsurance does- it incentivizes patients to reach out before the emergency occurs. Stew