Re: Federated Micropractices

August 30, 2012

Ben, I agree that it seems most of us are " non-profit " without the tax benefits. It is something I have been thinking about. " Profit " is income beyond a reasonable salary. Certainly around here, doctors working for most non-profit clinics have a higher salary than I do. Anyway, not to take anything away from what is doing, but it is an interesting topic. (And I enjoy my part-time flexible schedule and being able to see folks who can't pay without any additional paperwork to verify and all that.....).

SharonSharon McCoy MDRenaissance Family Medicine

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

A non-profit still has to pay the providers. Primary care is often " non-profit " by accident.

I'm glad has found a way to get grants to help the social work aspect. Go !

Working for a small hospital. I still have the ability to control my workflow and templates and so on.

The difference is that I can't just buy what I want (better EMR and the interfaces to go with it) with the hospital's money without approval of the CEO if it's under $5000 or the board of directors if it's over $5000.

Here's another twist on aggregation -

The regional tertiary care center has been telling my referred patients that they should change to a PCP within their system so " all your records will be in one place " .

They do it in the ER, post surgery, and at hospital discharge.

Their clinic runs 70% overhead, they communicate poorly with

those not employed by their system and won't take a Medicaid patient without intervention from God. They run Epic EMR.

But hey, they're one of those aggregated (aggravated?) systems that's supposed to be the future.

I think if their reimbursement was cut 10% on inpatient care, radiology and surgery, they'd go under.

Healthcare consolidation is getting " too big to fail " and the big players are just digging in.

Ben

To: Sent: Wednesday, August 29, 2012 9:30 AM

Subject: Re: Federated Micropractices

The thing is that what does is a non profit .She does wicked cool stuff.DroolShe does it locally IMPs are spread out The docs on the lsit serv responding to this are for prfoit

MAria servs a population many docs will not even see

and runs off or partly off grants. does she? Docs on the l sit serv are working with payors that she isn;tso I look at her stuff but cannot find what I can replicate I guess (move to land ??)

Meeting weekly and going over quality and clinical issues and sharing info is good stuff UNtil it cuts into the money earning time to have the weekly mtg.:)Good support would be sharing info systems with the consultants and labs and imaging.

Once " aggragted " one can be subsumed possibly into " forms committees " and loss of individualized templates or other tools that keep a practice nimble. MAria looks ot have prepared for that- Ben's place not so much!

Support of small practice would mean first and largely reduced paper work- (MORE new forms created by the bureacucacy yesterday! it is staggering out there the pressure to Just sign this just do it and that

doc you HAVE to!)

You can do this in an integrated COMMUNCIATION system This should cross EMRs and towns We talk so much and waste hrs on faxing/ lost faxes/ typing up note to consultants / consultants saying we don't hear form primary care/repeating of tests etc. .

Then ,support would mean different payment because the job has become different - hospital systems cannot do that ,becasue payors give them the money in the same old way .So far.

Support for small practices can come from initiatives at legislative / statewide levels. Is this why docs are being eaten in MASs- the structure of the legislation is such that I guess? that large playors are allowed to cut

out the individual practices with rules that stifle them and then reduce competition( looking for better quality and consistency should not equal the form vs function problem Gordon so wisely points out) CO, and NC(in its is Medicaid thing), have created initiatives that look good and

are innovative so the way to improve our situations and get support goes back to politics and the professiona l societies where we need to have a voice To have a voice IMP needs to fin d a mechanism

support also means means getting the professional societies t o pressure manufacturers to sell prevanr and tubersol and many tools ( emrs) in packaging we can use not large volumes SUpport

means giving me access to data I can use so i can get feedback for changes In THAT snese subsuming a practice into a data basis that is common t o all is useful, so the parameters are a level playing fiedl(I am not that bright here and understand n a little about granulairty, that Medicare has to look at 25000 lives to see results, and how the " one " transplant can ruin your data)

Aggragtio to share a nurse/coordinator is a great ideaNOt sure how much IMP can do but we are the only ones I hear thinking 'bout some stuff. I wish more folks on thelsit serv woud join imp and come to camp to the member meeting and bring ideas and get more projects goin!

Bodie can talk about teams and help guide by academic principle which I am interested in and trying to re work my practice to do better but in changing job descriptions to one that is barely paid we await leglsialting and political support to make it possible to DO the new job description

It is a ways away still and things are tough out here.Sorry I talked so much Helps me thnkJeanOn Wed, Aug 29, 2012 at 9:12 AM, Dr. Izquierdo-Porrera MD PhD wrote:

The whole federation has been many years in the making. I came from the community health center world and my struggle was not how to avoid the influence of big corporations (I have not seen a drug rep or heard from a hospital in years and 96% or our patients were uninsured so…) but how to provide high quality care.

As I worked to improve the care provided to our patients I met Gordon and was intrigued by the model but was unsure whether it would work . One of our main problems is that our patients need a significant level of case management that is a non reimbursable service.

Eventually my business partner and myself decided to dive in and instead of creating individual micropractices create an umbrella organization that will support the individual micropractices. The way we function is that each individual practice manages their site as they see fit. We have some general design requirements: use a common EHR, have an outreach component, establish partnerships with the surrounding community, collect utilization and quality data. Each individual practice can organize and function as the clinician wants. Each clinician manages the budget of his/her site but to date we have an employee relationship with the organization.

We meet once a week discuss clinical issues, QI activities, practice management and overall organization issues. We do our contracting as a group. Our malpractice covers all practitioners because we cover each other’s absences. We have a board of directors that oversees the general organization.

IN addition to the advantage of bringing additional funding into the practice (i.e. we were just able to sign a contract with the county that will bring up to $60K for indigent care), common contracting and purchasing, we have people to bounce ideas with, local partnership, coverage for our absences and we are able to afford to care for a poor community that has traditionally been challenging for micropractitioners.

We are still figuring it out but we are quite nimble so we can change when something is not working for us. We have gone through some iterations as we try to figure out how to make it work but we have some very interesting data coming out from our quality. This is the overview of what we are doing. I hope I responded some of your questions

Izquierdo-Porrera MD PhD

Executive Director & Co-founderCare for Your Health, Inc

Phone Fax

http://www.care4yourhealth.org/

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

Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php

From: [mailto: ] On Behalf Of Kathleen

Sent: Tuesday, August 28, 2012 11:08 PMTo: Subject: Re: Federated Micropractices

I would like to learn more about the Federated Micropractices concept as well. Might there be an answer to the conundrum of how to be a small practice responsive to the personal health needs of your patients while benefiting from the resources of a larger entity? Without the top down administrative burdens and financial controls imposed by the mega aggregate systems?

Ben, I'm saddened to hear your practice has been subsumed. Can you share how this happened? Do they just annex you? The way it's been working in Massachusetts, it's been part courtship for some practices, mostly bullying for most, some buying out for a few. I know of only one tiny hold out in the Boston area.

Adolfo, thank you for the smile. Anti-aggregant? too funny were it not so sad.

Kathleen

Ben beat me to it. I'd like to hear more about this Federated Micropractices concept.

Does a " federation " lead to business advantages or are the grants and the nonprofit status the main advantages of your model?

PierceRockport, Maine

,

This sounds interesting. Are you essentially a group practice if you contract and bill together?

If not a group practice, make sure you've taken steps to protect youselves from " vicarious liability " If you look and act like a group, you can inadvertantly be dragged into another doctor's legal problems.

Ben

November 25, 2011Understanding the perils of vicarious liability

By W. II,Rush S. Jr., JDWhy you may be responsible for the professional actions of the physician with whom you share space

W. II

The terms " apparent agency " and " vicarious liability " sound like nebulous legal theories, but they can land you in court, or at least cost you attorney's fees if you're named in a lawsuit.

Rush S. Jr., JD

Most physicians realize that they are responsible for the professional actions of their office staff and those who are directly employed by their practice. Many physicians are unaware, however, that they can be sued for the actions of those they don't employ.

First, let's define a few terms: Vicarious liability—liability for an injury that is imposed on a person who did not act negligently, but who has imputed or actual legal ties to the party that did cause the injury.

Independent contractor—an individual who performs a job such that even if the job is performed negligently, the negligence stays with the individual. The law specifies that if no one other than the contractor controls the time, manner, method, or place of the services, then that person is an independent contractor and there is no vicarious liability.

Apparent agency—a relationship that is imposed by law when a principal leads a third party to reasonably believe that another is the principal's agent, and the third party is injured by relying on, and acting in accordance with, that belief. This court-made doctrine attempts to create liability for the acts of an independent contractor for an otherwise faultless individual or corporation—for example, a hospital being held liable for the negligence of an emergency department physician who is an independent contractor.

WHAT A REASONABLE PERSON VISITING THE OFFICE WOULD THINK

Now, let's look at a litigation scenario that could arise when two physicians share space. Dr. Adam and Dr. Baker share 2,500 square feet of office space. Together, they employ a receptionist, a registered nurse, and a bookkeeper/billing clerk. They each signed the landlord's 5-year lease and personally guaranteed the performance of the lease. One of Dr. Adam's patients had a biopsy performed, and the hospital pathologist sent the report to the physician's office, where the receptionist misplaced it. The patient didn't learn of the biopsy results—which were positive and indicated that he needed prompt treatment—until he mentioned the test during a routine office visit the next year. A lawsuit followed naming Dr. Adam, the Adam & Baker Medical Practice, Dr. Baker, the receptionist, and the registered nurse. The patient alleged in the

lawsuit that the delay in notifying him of the positive biopsy result placed him at substantial risk of a poor treatment outcome.

No actual agency relationship exists between the physicians; they are just sharing common expenses. However, because a reasonable person visiting the office may view this situation as a group practice, a patient filing a medical malpractice lawsuit against one physician in the group may, therefore, name the other physician, alleging vicarious liability and apparent agency. The question of whether the conduct of the parties created the perception for the patient is one for a trial court to determine based on factual and legally sufficient evidence.

Frequently, physicians not involved directly in a plaintiff/patient's care are dismissed from an action such as this one. In the case of Dr. Adam and Dr. Baker, however, several facets of the space-sharing relationship might prevent—or, at the very least, complicate—early dismissal for Dr. Baker. These include but are not limited to:

Advertising. The " apparent agency " perception begins the minute the patient becomes aware of your practice through advertising. Avoid co-branded advertising unless it clearly specifies that two different practices are being advertised.

Phone. Answering a common phone line with " Drs. Adam's and Baker's office " gives patients the impression that the two are connected. Whenever possible use separate phone and fax lines for each physician. If doing so is impractical, then instruct office personnel to answer the phone by saying, " Dr. Adam's office and Dr. Baker's office, " thus distinguishing between the two practices.

Signage. How the practice is listed in the lobby, signage on the door, and signage within the space is very important. In this example, the signage should not read " Drs. Adam & Baker " or " Adam & Baker Clinic. " Separate and distinct signs should be posted in each area distinguishing the two practices. Further, the nametags and attire worn by your staff shouldn't have a cobranded message. Some states have very specific legal criteria as to what constitutes proper notice to patients. For example, Georgia's statute for hospitals trying to avoid agency liability goes so far as to define the size of the letters on the sign. Check with your local medical society to see whether your state has specific requirements.

Registration forms. The relationship between the physicians should be specified during the office registration process. Such a disclosure on the initial patient intake and history form, or a separate sheet for the patient to sign—acknowledging that the patient understands that the physicians are not in practice with one another, do not participate in the practice management of the other, and are independent contractors—is important. Here's an example of language your practice might use in such a form:

Patient forms/stationery. All charting forms, if labeled, ought to be labeled with the individual physician's name and not be cobranded. Any letterhead paper, prescription pads, or other documents used by both physicians should be separate and distinct from one another.

Billing statements. Many space-sharing physicians use a common billing system, because the addition of a provider to an existing system is far less costly than establishing a new system. The questions that need to be asked relative to this situation: Will the billing system print separate invoices for each provider with separate physician identification? If a patient is seen by multiple providers within the space-sharing arrangement, is the invoicing aggregated? To prevent " apparent agency " and/or " vicarious liability " issues, send bills that specify which physician is billing for what service. Avoid generic titling such as " Offices of Dr. Adam and Dr. Baker. "

Shared employees. Often, the employees in a space-sharing arrangement portray a cohesiveness to patients that does not exist between the physicians. In an effort to blur the lines, plaintiffs' attorneys typically ask employees who they work for while performing different functions. Complicating matters, one space-sharing physician might pay all the employees from his or her payroll account and then seek reimbursement from the other physicians sharing space. More often than not the " master employer " in these situations becomes responsible for the actions of the employees, even those he or she does not supervise.

ACQUIRE INSURANCE FOR EMPLOYEE ACTIONS In the case of Dr. Adam and Dr. Baker, liability resulting from the receptionist's mishandling of the biopsy results is difficult to avoid. To the extent that both physicians employ the receptionist, both can be liable for her negligence. Typically, this potential liability is covered by acquiring insurance for employee actions. In a subleased employee scenario, coverage can be obtained through a " leased employee " endorsement to the doctors' professional liability policies. Separate corporations employing the nonphysician staff can also be created. Even better, office procedures regarding lab results, radiography, and other studies should be in place to prevent these practice errors.

LEASING AND SUBLEASING OFFICE SPACE Space-sharing arrangements also give rise to questions about whose name is on the lease and who is subleasing the space. If both doctors signed the lease and guarantees, should one of them leave without honoring the lease terms, not only will that physician be liable, but so will the other. That's because almost all leases provide joint and several liability, holding each physician responsible for the entire amount due under the lease—not just for half. Is the sublease with or without the consent of the landlord?

Without proper counsel and arrangements, a plaintiff could allege that a space-sharing arrangement is really a general partnership. Such partnerships can exist in the absence of any documentation, and all partners are jointly and severally liable for all partnership debts, including lawsuits. If the physicians refer to one another, regulatory considerations exist as well. Do the doctors comply with fraud and abuse guidelines when sharing imaging or other equipment?

TAKE THE TIME TO KNOW THE OTHER PHYSICIANS As with most business dealings, before sharing office space with other physicians, take the time to know them and their backgrounds. Be sure these physicians have references, credit ratings, and credentials that you believe are acceptable. Then have your insurance adviser review insurance policies to identify what coverage is available or may be needed to protect you from vicarious liability allegations, and consult with a knowledgeable corporate attorney to assist you in forming business structures that protect your interests.

W. II is a principal in Sterling Risk Advisors, based in Atlanta, Georgia. Rush S. Jr., JD, is a founding partner of Hall, Booth, & Slover, a law firm headquartered in Atlanta. Send your feedback to medec@... [medec@...]

The physicians in this office are not partners or otherwise affiliated in the same medical practice, nor do they manage each other. Each physician is an independent practitioner and simply shares office space, equipment, and some staff in his/her separate practice. The doctors are not responsible for each other's practices nor for the care rendered to each other's patients.

W. IIRush S. Jr., JD

You may forward this article or get additional permissions by typing http://license.icopyright.net/3.7503?icx_id=749298 into any web browser. Advanstar Communications Inc. and Modern Medicine logos are registered trademarks of Advanstar Communications Inc. The iCopyright logo is a registered trademark of iCopyright, Inc.

To: Sent: Tuesday, August 28, 2012 7:24 PMSubject: RE: request input for Tom Bodenheimer call topic

I am not sure many of you know but we created care for your health as a 501c3 that supports a federated model of micropractices. We have my practice, a second one opening in 15 days and a third one coming n board 2013. We not only contract and bill together, we have common data collection strategies, common policies and procedures, common fundraising, common advocating and apply for grants together.

This was important for us because we intentionally locate in areas where most our patients are uninsured, Medicaid and medicare (medicare being the better paying payor J) so it was important for us to be able to apply for other sources of funding.

Izquierdo-Porrera MD PhD

Executive Director & Co-founderCare for Your Health, Inc

Phone

Fax http://www.care4yourhealth.org/

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

Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php

<image003.jpg>

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Checked by AVG - http://www.avg.com/Version: 2012.0.2197 / Virus Database: 2437/5231 - Release Date: 08/28/12

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Checked by AVG - http://www.avg.com/Version: 2012.0.2197 / Virus Database: 2437/5231 - Release Date: 08/28/12

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August 30, 2012

,Thank you for the explanation of your Federated Micropractices. I think it's ingenious. You've come up with a way to get personal health care to those who have fallen through the cracks, those who must rely on skimpy resources and sketchy 'coverage' . Wonderful that you're building your own network to share contracting, purchasing, med mal, EHR, grant writing and support. God speed to you, ! Sans grant support and non-profit status advantages, it there a way to harness the principles for an umbrella of IMP practices? Scalable for a series of umbrellas? Gordon, care to weigh in?KathleenOn Aug 29, 2012, at 9:12 AM, Dr. Izquierdo-Porrera MD PhD wrote:

The whole federation has been many years in the making. I came from the community health center world and my struggle was not how to avoid the influence of big corporations (I have not seen a drug rep or heard from a hospital in years and 96% or our patients were uninsured so…) but how to provide high quality care. As I worked to improve the care provided to our patients I met Gordon and was intrigued by the model but was unsure whether it would work . One of our main problems is that our patients need a significant level of case management that is a non reimbursable service. Eventually my business partner and myself decided to dive in and instead of creating individual micropractices create an umbrella organization that will support the individual micropractices. The way we function is that each individual practice manages their site as they see fit. We have some general design requirements: use a common EHR, have an outreach component, establish partnerships with the surrounding community, collect utilization and quality data. Each individual practice can organize and function as the clinician wants. Each clinician manages the budget of his/her site but to date we have an employee relationship with the organization. We meet once a week discuss clinical issues, QI activities, practice management and overall organization issues. We do our contracting as a group. Our malpractice covers all practitioners because we cover each other’s absences. We have a board of directors that oversees the general organization. IN addition to the advantage of bringing additional funding into the practice (i.e. we were just able to sign a contract with the county that will bring up to $60K for indigent care), common contracting and purchasing, we have people to bounce ideas with, local partnership, coverage for our absences and we are able to afford to care for a poor community that has traditionally been challenging for micropractitioners. We are still figuring it out but we are quite nimble so we can change when something is not working for us. We have gone through some iterations as we try to figure out how to make it work but we have some very interesting data coming out from our quality. This is the overview of what we are doing. I hope I responded some of your questions Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org "Don't ever let injustice go by unchallenged." Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php <image002.jpg> From: [mailto: ] On Behalf Of KathleenSent: Tuesday, August 28, 2012 11:08 PMTo: Subject: Re: Federated Micropractices I would like to learn more about the Federated Micropractices concept as well. Might there be an answer to the conundrum of how to be a small practice responsive to the personal health needs of your patients while benefiting from the resources of a larger entity? Without the top down administrative burdens and financial controls imposed by the mega aggregate systems? Ben, I'm saddened to hear your practice has been subsumed. Can you share how this happened? Do they just annex you? The way it's been working in Massachusetts, it's been part courtship for some practices, mostly bullying for most, some buying out for a few. I know of only one tiny hold out in the Boston area. Adolfo, thank you for the smile. Anti-aggregant? too funny were it not so sad. Kathleen Ben beat me to it. I'd like to hear more about this Federated Micropractices concept. Does a "federation" lead to business advantages or are the grants and the nonprofit status the main advantages of your model? PierceRockport, Maine, This sounds interesting. Are you essentially a group practice if you contract and bill together?If not a group practice, make sure you've taken steps to protect youselves from "vicarious liability " If you look and act like a group, you can inadvertantly be dragged into another doctor's legal problems. BenNovember 25, 2011Understanding the perils of vicarious liabilityBy W. II,Rush S. Jr., JDWhy you may be responsible for the professional actions of the physician with whom you share space W. IIThe terms "apparent agency" and "vicarious liability" sound like nebulous legal theories, but they can land you in court, or at least cost you attorney's fees if you're named in a lawsuit. Rush S. Jr., JDMost physicians realize that they are responsible for the professional actions of their office staff and those who are directly employed by their practice. Many physicians are unaware, however, that they can be sued for the actions of those they don't employ. First, let's define a few terms: Vicarious liability—liability for an injury that is imposed on a person who did not act negligently, but who has imputed or actual legal ties to the party that did cause the injury. Independent contractor—an individual who performs a job such that even if the job is performed negligently, the negligence stays with the individual. The law specifies that if no one other than the contractor controls the time, manner, method, or place of the services, then that person is an independent contractor and there is no vicarious liability. Apparent agency—a relationship that is imposed by law when a principal leads a third party to reasonably believe that another is the principal's agent, and the third party is injured by relying on, and acting in accordance with, that belief. This court-made doctrine attempts to create liability for the acts of an independent contractor for an otherwise faultless individual or corporation—for example, a hospital being held liable for the negligence of an emergency department physician who is an independent contractor. WHAT A REASONABLE PERSON VISITING THE OFFICE WOULD THINK Now, let's look at a litigation scenario that could arise when two physicians share space. Dr. Adam and Dr. Baker share 2,500 square feet of office space. Together, they employ a receptionist, a registered nurse, and a bookkeeper/billing clerk. They each signed the landlord's 5-year lease and personally guaranteed the performance of the lease. One of Dr. Adam's patients had a biopsy performed, and the hospital pathologist sent the report to the physician's office, where the receptionist misplaced it. The patient didn't learn of the biopsy results—which were positive and indicated that he needed prompt treatment—until he mentioned the test during a routine office visit the next year. A lawsuit followed naming Dr. Adam, the Adam & Baker Medical Practice, Dr. Baker, the receptionist, and the registered nurse. The patient alleged in the lawsuit that the delay in notifying him of the positive biopsy result placed him at substantial risk of a poor treatment outcome. No actual agency relationship exists between the physicians; they are just sharing common expenses. However, because a reasonable person visiting the office may view this situation as a group practice, a patient filing a medical malpractice lawsuit against one physician in the group may, therefore, name the other physician, alleging vicarious liability and apparent agency. The question of whether the conduct of the parties created the perception for the patient is one for a trial court to determine based on factual and legally sufficient evidence. Frequently, physicians not involved directly in a plaintiff/patient's care are dismissed from an action such as this one. In the case of Dr. Adam and Dr. Baker, however, several facets of the space-sharing relationship might prevent—or, at the very least, complicate—early dismissal for Dr. Baker. These include but are not limited to: Advertising. The "apparent agency" perception begins the minute the patient becomes aware of your practice through advertising. Avoid co-branded advertising unless it clearly specifies that two different practices are being advertised. Phone. Answering a common phone line with "Drs. Adam's and Baker's office" gives patients the impression that the two are connected. Whenever possible use separate phone and fax lines for each physician. If doing so is impractical, then instruct office personnel to answer the phone by saying, "Dr. Adam's office and Dr. Baker's office," thus distinguishing between the two practices. Signage. How the practice is listed in the lobby, signage on the door, and signage within the space is very important. In this example, the signage should not read "Drs. Adam & Baker" or "Adam & Baker Clinic." Separate and distinct signs should be posted in each area distinguishing the two practices. Further, the nametags and attire worn by your staff shouldn't have a cobranded message. Some states have very specific legal criteria as to what constitutes proper notice to patients. For example, Georgia's statute for hospitals trying to avoid agency liability goes so far as to define the size of the letters on the sign. Check with your local medical society to see whether your state has specific requirements. Registration forms. The relationship between the physicians should be specified during the office registration process. Such a disclosure on the initial patient intake and history form, or a separate sheet for the patient to sign—acknowledging that the patient understands that the physicians are not in practice with one another, do not participate in the practice management of the other, and are independent contractors—is important. Here's an example of language your practice might use in such a form: Patient forms/stationery. All charting forms, if labeled, ought to be labeled with the individual physician's name and not be cobranded. Any letterhead paper, prescription pads, or other documents used by both physicians should be separate and distinct from one another. Billing statements. Many space-sharing physicians use a common billing system, because the addition of a provider to an existing system is far less costly than establishing a new system. The questions that need to be asked relative to this situation: Will the billing system print separate invoices for each provider with separate physician identification? If a patient is seen by multiple providers within the space-sharing arrangement, is the invoicing aggregated? To prevent "apparent agency" and/or "vicarious liability" issues, send bills that specify which physician is billing for what service. Avoid generic titling such as "Offices of Dr. Adam and Dr. Baker." Shared employees. Often, the employees in a space-sharing arrangement portray a cohesiveness to patients that does not exist between the physicians. In an effort to blur the lines, plaintiffs' attorneys typically ask employees who they work for while performing different functions. Complicating matters, one space-sharing physician might pay all the employees from his or her payroll account and then seek reimbursement from the other physicians sharing space. More often than not the "master employer" in these situations becomes responsible for the actions of the employees, even those he or she does not supervise. ACQUIRE INSURANCE FOR EMPLOYEE ACTIONS In the case of Dr. Adam and Dr. Baker, liability resulting from the receptionist's mishandling of the biopsy results is difficult to avoid. To the extent that both physicians employ the receptionist, both can be liable for her negligence. Typically, this potential liability is covered by acquiring insurance for employee actions. In a subleased employee scenario, coverage can be obtained through a "leased employee" endorsement to the doctors' professional liability policies. Separate corporations employing the nonphysician staff can also be created. Even better, office procedures regarding lab results, radiography, and other studies should be in place to prevent these practice errors. LEASING AND SUBLEASING OFFICE SPACE Space-sharing arrangements also give rise to questions about whose name is on the lease and who is subleasing the space. If both doctors signed the lease and guarantees, should one of them leave without honoring the lease terms, not only will that physician be liable, but so will the other. That's because almost all leases provide joint and several liability, holding each physician responsible for the entire amount due under the lease—not just for half. Is the sublease with or without the consent of the landlord? Without proper counsel and arrangements, a plaintiff could allege that a space-sharing arrangement is really a general partnership. Such partnerships can exist in the absence of any documentation, and all partners are jointly and severally liable for all partnership debts, including lawsuits. If the physicians refer to one another, regulatory considerations exist as well. Do the doctors comply with fraud and abuse guidelines when sharing imaging or other equipment? TAKE THE TIME TO KNOW THE OTHER PHYSICIANS As with most business dealings, before sharing office space with other physicians, take the time to know them and their backgrounds. Be sure these physicians have references, credit ratings, and credentials that you believe are acceptable. Then have your insurance adviser review insurance policies to identify what coverage is available or may be needed to protect you from vicarious liability allegations, and consult with a knowledgeable corporate attorney to assist you in forming business structures that protect your interests. W. II is a principal in Sterling Risk Advisors, based in Atlanta, Georgia. Rush S. Jr., JD, is a founding partner of Hall, Booth, & Slover, a law firm headquartered in Atlanta. Send your feedback to medec@... [medec@...]The physicians in this office are not partners or otherwise affiliated in the same medical practice, nor do they manage each other. Each physician is an independent practitioner and simply shares office space, equipment, and some staff in his/her separate practice. The doctors are not responsible for each other's practices nor for the care rendered to each other's patients. W. IIRush S. Jr., JD 2011 Advanstar Communications Inc.. Permission granted for up to 5 copies. All rights reserved. You may forward this article or get additional permissions by typing http://license.icopyright.net/3.7503?icx_id=749298 into any web browser. Advanstar Communications Inc. and Modern Medicine logos are registered trademarks of Advanstar Communications Inc. The iCopyright logo is a registered trademark of iCopyright, Inc. To: Sent: Tuesday, August 28, 2012 7:24 PMSubject: RE: request input for Tom Bodenheimer call topic I am not sure many of you know but we created care for your health as a 501c3 that supports a federated model of micropractices. We have my practice, a second one opening in 15 days and a third one coming n board 2013. We not only contract and bill together, we have common data collection strategies, common policies and procedures, common fundraising, common advocating and apply for grants together. This was important for us because we intentionally locate in areas where most our patients are uninsured, Medicaid and medicare (medicare being the better paying payor J) so it was important for us to be able to apply for other sources of funding. Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax http://www.care4yourhealth.org/ "Don't ever let injustice go by unchallenged." 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August 30, 2012

Yup. you totally nailed it: "Is this why docs are being eaten in MASs- the structure of the legislation is such that I guess? that large playors are allowed to cut out the individual practices with rules that stifle them and then reduce competition( looking for better quality and consistency should not equal the form vs function problem Gordon so wisely points out)" The big aggregate receive 'facility' fees just for regular office visits within their buildings/facilities/circle of power. Not completely clear to me, but it seems that this extra money received goes toward funding/subsidizing the primary care practices within their clutches. That is this is what is used to pay the salaries of the practices, apparently. As Ben so aptly put it: "Healthcare consolidation is getting "too big to fail" and the big players are just digging in." Fait accompli here in Massachusetts.

The thing is that what does is a non profit .She does wicked cool stuff.DroolShe does it locally IMPs are spread out The docs on the lsit serv responding to this are for prfoit MAria servs a population many docs will not even see

and runs off or partly off grants. does she? Docs on the l sit serv are working with payors that she isn;tso I look at her stuff but cannot find what I can replicate I guess (move to land ??)

Meeting weekly and going over quality and clinical issues and sharing info is good stuff UNtil it cuts into the money earning time to have the weekly mtg.:)Good support would be sharing info systems with the consultants and labs and imaging.

Once "aggragted" one can be subsumed possibly into "forms committees" and loss of individualized templates or other tools that keep a practice nimble. MAria looks ot have prepared for that- Ben's place not so much!

Support of small practice would mean first and largely reduced paper work- (MORE new forms created by the bureacucacy yesterday! it is staggering out there the pressure to Just sign this just do it and that

doc you HAVE to!)

You can do this in an integrated COMMUNCIATION system This should cross EMRs and towns We talk so much and waste hrs on faxing/ lost faxes/ typing up note to consultants / consultants saying we don't hear form primary care/repeating of tests etc. .

Then ,support would mean different payment because the job has become different - hospital systems cannot do that ,becasue payors give them the money in the same old way .So far.

Support for small practices can come from initiatives at legislative / statewide levels. Is this why docs are being eaten in MASs- the structure of the legislation is such that I guess? that large playors are allowed to cut

out the individual practices with rules that stifle them and then reduce competition( looking for better quality and consistency should not equal the form vs function problem Gordon so wisely points out) CO, and NC(in its is Medicaid thing), have created initiatives that look good and

are innovative so the way to improve our situations and get support goes back to politics and the professiona l societies where we need to have a voice To have a voice IMP needs to fin d a mechanism

support also means means getting the professional societies t o pressure manufacturers to sell prevanr and tubersol and many tools ( emrs) in packaging we can use not large volumes SUpport

means giving me access to data I can use so i can get feedback for changes In THAT snese subsuming a practice into a data basis that is common t o all is useful, so the parameters are a level playing fiedl(I am not that bright here and understand n a little about granulairty, that Medicare has to look at 25000 lives to see results, and how the"one" transplant can ruin your data)

Aggragtio to share a nurse/coordinator is a great ideaNOt sure how much IMP can do but we are the only ones I hear thinking 'bout some stuff. I wish more folks on thelsit serv woud join imp and come to camp to the member meeting and bring ideas and get more projects goin!

Bodie can talk about teams and help guide by academic principle which I am interested in and trying to re work my practice to do better but in changing job descriptions to one that is barely paid we await leglsialting and political support to make it possible to DO the new job description

It is a ways away still and things are tough out here.Sorry I talked so much Helps me thnkJeanOn Wed, Aug 29, 2012 at 9:12 AM, Dr. Izquierdo-Porrera MD PhD wrote:

The whole federation has been many years in the making. I came from the community health center world and my struggle was not how to avoid the influence of big corporations (I have not seen a drug rep or heard from a hospital in years and 96% or our patients were uninsured so…) but how to provide high quality care. As I worked to improve the care provided to our patients I met Gordon and was intrigued by the model but was unsure whether it would work . One of our main problems is that our patients need a significant level of case management that is a non reimbursable service. Eventually my business partner and myself decided to dive in and instead of creating individual micropractices create an umbrella organization that will support the individual micropractices. The way we function is that each individual practice manages their site as they see fit. We have some general design requirements: use a common EHR, have an outreach component, establish partnerships with the surrounding community, collect utilization and quality data. Each individual practice can organize and function as the clinician wants. Each clinician manages the budget of his/her site but to date we have an employee relationship with the organization. We meet once a week discuss clinical issues, QI activities, practice management and overall organization issues. We do our contracting as a group. Our malpractice covers all practitioners because we cover each other’s absences. We have a board of directors that oversees the general organization. IN addition to the advantage of bringing additional funding into the practice (i.e. we were just able to sign a contract with the county that will bring up to $60K for indigent care), common contracting and purchasing, we have people to bounce ideas with, local partnership, coverage for our absences and we are able to afford to care for a poor community that has traditionally been challenging for micropractitioners. We are still figuring it out but we are quite nimble so we can change when something is not working for us. We have gone through some iterations as we try to figure out how to make it work but we have some very interesting data coming out from our quality. This is the overview of what we are doing. I hope I responded some of your questions Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org "Don't ever let injustice go by unchallenged."

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From: [mailto: ] On Behalf Of Kathleen

Sent: Tuesday, August 28, 2012 11:08 PMTo: Subject: Re: Federated Micropractices

I would like to learn more about the Federated Micropractices concept as well. Might there be an answer to the conundrum of how to be a small practice responsive to the personal health needs of your patients while benefiting from the resources of a larger entity? Without the top down administrative burdens and financial controls imposed by the mega aggregate systems?

Ben, I'm saddened to hear your practice has been subsumed. Can you share how this happened? Do they just annex you? The way it's been working in Massachusetts, it's been part courtship for some practices, mostly bullying for most, some buying out for a few. I know of only one tiny hold out in the Boston area.

Adolfo, thank you for the smile. Anti-aggregant? too funny were it not so sad.

Kathleen

Ben beat me to it. I'd like to hear more about this Federated Micropractices concept. Does a "federation" lead to business advantages or are the grants and the nonprofit status the main advantages of your model?

PierceRockport, Maine

,

This sounds interesting. Are you essentially a group practice if you contract and bill together?

If not a group practice, make sure you've taken steps to protect youselves from "vicarious liability " If you look and act like a group, you can inadvertantly be dragged into another doctor's legal problems.

Ben

November 25, 2011Understanding the perils of vicarious liability

By W. II,Rush S. Jr., JDWhy you may be responsible for the professional actions of the physician with whom you share space

W. II

The terms "apparent agency" and "vicarious liability" sound like nebulous legal theories, but they can land you in court, or at least cost you attorney's fees if you're named in a lawsuit.

Rush S. Jr., JD

Most physicians realize that they are responsible for the professional actions of their office staff and those who are directly employed by their practice. Many physicians are unaware, however, that they can be sued for the actions of those they don't employ.

First, let's define a few terms: Vicarious liability—liability for an injury that is imposed on a person who did not act negligently, but who has imputed or actual legal ties to the party that did cause the injury.

Independent contractor—an individual who performs a job such that even if the job is performed negligently, the negligence stays with the individual. The law specifies that if no one other than the contractor controls the time, manner, method, or place of the services, then that person is an independent contractor and there is no vicarious liability.

Apparent agency—a relationship that is imposed by law when a principal leads a third party to reasonably believe that another is the principal's agent, and the third party is injured by relying on, and acting in accordance with, that belief. This court-made doctrine attempts to create liability for the acts of an independent contractor for an otherwise faultless individual or corporation—for example, a hospital being held liable for the negligence of an emergency department physician who is an independent contractor.

WHAT A REASONABLE PERSON VISITING THE OFFICE WOULD THINK

Now, let's look at a litigation scenario that could arise when two physicians share space. Dr. Adam and Dr. Baker share 2,500 square feet of office space. Together, they employ a receptionist, a registered nurse, and a bookkeeper/billing clerk. They each signed the landlord's 5-year lease and personally guaranteed the performance of the lease. One of Dr. Adam's patients had a biopsy performed, and the hospital pathologist sent the report to the physician's office, where the receptionist misplaced it. The patient didn't learn of the biopsy results—which were positive and indicated that he needed prompt treatment—until he mentioned the test during a routine office visit the next year. A lawsuit followed naming Dr. Adam, the Adam & Baker Medical Practice, Dr. Baker, the receptionist, and the registered nurse. The patient alleged in the lawsuit that the delay in notifying him of the positive biopsy result placed him at substantial risk of a poor treatment outcome.

No actual agency relationship exists between the physicians; they are just sharing common expenses. However, because a reasonable person visiting the office may view this situation as a group practice, a patient filing a medical malpractice lawsuit against one physician in the group may, therefore, name the other physician, alleging vicarious liability and apparent agency. The question of whether the conduct of the parties created the perception for the patient is one for a trial court to determine based on factual and legally sufficient evidence.

Frequently, physicians not involved directly in a plaintiff/patient's care are dismissed from an action such as this one. In the case of Dr. Adam and Dr. Baker, however, several facets of the space-sharing relationship might prevent—or, at the very least, complicate—early dismissal for Dr. Baker. These include but are not limited to:

Advertising. The "apparent agency" perception begins the minute the patient becomes aware of your practice through advertising. Avoid co-branded advertising unless it clearly specifies that two different practices are being advertised.

Phone. Answering a common phone line with "Drs. Adam's and Baker's office" gives patients the impression that the two are connected. Whenever possible use separate phone and fax lines for each physician. If doing so is impractical, then instruct office personnel to answer the phone by saying, "Dr. Adam's office and Dr. Baker's office," thus distinguishing between the two practices.

Signage. How the practice is listed in the lobby, signage on the door, and signage within the space is very important. In this example, the signage should not read "Drs. Adam & Baker" or "Adam & Baker Clinic." Separate and distinct signs should be posted in each area distinguishing the two practices. Further, the nametags and attire worn by your staff shouldn't have a cobranded message. Some states have very specific legal criteria as to what constitutes proper notice to patients. For example, Georgia's statute for hospitals trying to avoid agency liability goes so far as to define the size of the letters on the sign. Check with your local medical society to see whether your state has specific requirements.

Registration forms. The relationship between the physicians should be specified during the office registration process. Such a disclosure on the initial patient intake and history form, or a separate sheet for the patient to sign—acknowledging that the patient understands that the physicians are not in practice with one another, do not participate in the practice management of the other, and are independent contractors—is important. Here's an example of language your practice might use in such a form:

Patient forms/stationery. All charting forms, if labeled, ought to be labeled with the individual physician's name and not be cobranded. Any letterhead paper, prescription pads, or other documents used by both physicians should be separate and distinct from one another.

Billing statements. Many space-sharing physicians use a common billing system, because the addition of a provider to an existing system is far less costly than establishing a new system. The questions that need to be asked relative to this situation: Will the billing system print separate invoices for each provider with separate physician identification? If a patient is seen by multiple providers within the space-sharing arrangement, is the invoicing aggregated? To prevent "apparent agency" and/or "vicarious liability" issues, send bills that specify which physician is billing for what service. Avoid generic titling such as "Offices of Dr. Adam and Dr. Baker."

Shared employees. Often, the employees in a space-sharing arrangement portray a cohesiveness to patients that does not exist between the physicians. In an effort to blur the lines, plaintiffs' attorneys typically ask employees who they work for while performing different functions. Complicating matters, one space-sharing physician might pay all the employees from his or her payroll account and then seek reimbursement from the other physicians sharing space. More often than not the "master employer" in these situations becomes responsible for the actions of the employees, even those he or she does not supervise.

ACQUIRE INSURANCE FOR EMPLOYEE ACTIONS In the case of Dr. Adam and Dr. Baker, liability resulting from the receptionist's mishandling of the biopsy results is difficult to avoid. To the extent that both physicians employ the receptionist, both can be liable for her negligence. Typically, this potential liability is covered by acquiring insurance for employee actions. In a subleased employee scenario, coverage can be obtained through a "leased employee" endorsement to the doctors' professional liability policies. Separate corporations employing the nonphysician staff can also be created. Even better, office procedures regarding lab results, radiography, and other studies should be in place to prevent these practice errors.