PA Owned Headache Clinic--An Update

[jmj11]

Some of you know that I've had a dream of creating and owning my own headache practice (with two sites to start with, adding two more later). It has been a long process of start and then a impassible barrier. The biggest barrier is finding the right SP and reaching an agreement that the two of us can live with.

 

I started this process one more (and last) time about four months ago. It happened with a physician, who was my # 1 competitor (and a good personal friend) 25 miles away suddenly announced his retirement. He closed his practice and he referred his headache patients to me.

 

I started "courting" him and trying to sell him on my vision. We've had several meetings until we've worked out the details that we could both live with. He's now quite excited about it.

 

I knew the greatest obstacle would be getting the State's Medical Quality Assurance committee to bless our practice plan. The problem was that the SP is only going to see patients twice a month and not at the main clinic where I will be working. The regular Practice Plan requires the PA and MD be in the same clinic 25% of the time. The "Remote Practice Plan" requires the PA and the MD to be in the same clinic 10% of the time. Other conditions have to be approved on a case by case basis. I would put our chances at 50:50. I did write up a pretty impressive argument for our cause.

 

I wish I could go through the details of how much work it takes to even get to this point. I've had many hours of meetings with not just my SP, but lawyers, malpractice insurers, CPAs, insurance contractors, Realtors, health insurance brokers, building contractors, bankers and etc.

 

So, we knew that the make or break point is the practice plan (if it is rejected as is . . . the whole plan will follow the fate of the Titanic). We submitted the plan on Friday . . . now is the waiting. I'll let you know how it turns out.:sweat:

[rev ronin]

Best wishes in this!

[andersenpa]

Mike- continuing good luck from all of us.

 

Also- you're a strong writer and I think that the outcome of this, up or down, would make a good piece for PA Professional (if the AAPA would have you!).

[EMEDPA]

best of luck mike. I hope scott was able to help a bit.

[marilynpac]

You know I've always been in your corner....

[jmj11]

Thanks all! That was very kind words. Scott has been very helpful, saving me a lot of $$ in legal fees + other things.

[PASun]

Good Luck...Sounds like a great you created a opportunity. What state are you in??

[jmj11]

Good Luck...Sounds like a great you created a opportunity. What state are you in??

Washington

[chatcat]

Best of luck with this getting approved!

[primadonna22274]

Hey Mike, I've been out of the loop but this is very exciting!! I am saying big prayers that the WA BME sees the wisdom of this and approves your plan as submitted. Strong work!

[jmj11]

Hey Mike, I've been out of the loop but this is very exciting!! I am saying big prayers that the WA BME sees the wisdom of this and approves your plan as submitted. Strong work!

Thanks, I'll keep you posted. Got an e-mail from my potential SP, he signed off on the packet and mailed it on Monday so now it is a matter of waiting.

[jmj11]

I just got an e-mail from the Health Care Quality Assurance Board regarding my application. I am a coward . . . I have not opened it. The sender is a DC, that's all I know. The reason I haven't opened it is that I have a full schedule and I must focus on my patients today. If I open it and it says we have a "Green Light" then I will crap in my pants. That means I have a huge amount of work in front of me (as well as a huge financial risk). If it is a red light, I will be damned depressed. So . . . I will opening over a beer when things are quiet tonight . . . or over a mocha this after work.

[rev ronin]

I subscribe to the Schrodinger's cat model of envelope (and email, I guess...) contents: until you open it and observe the contents, they aren't really fixed. :-)

 

He's hoping it's good news for you!

[meaux]

Best of luck, however; I say a beer should be opened regardless of time.

[jmj11]

Okay, this is the kind of madness I've faced every step of the way. The Healthcare Quality Assurance Committee says that they will not even consider my application until I have an established clinic. Does that make sense to anybody? How can you establish a clinic if you don't have an approved practice plan? The malpractice insurer says that they will not even consider giving us insurance until they have an approved practice plan in their hand. How do you open a clinic with no practice plan and no malpractice insurance? If I knew that the approval was an assured thing, which I don't, I would go through all the steps, set up the clinic and then wait. But if they rejected the application at that point . . . my *** would be grass.

[marilynpac]

Do they tell the docs the same thing??? Maybe that's what you'll have to do...very risky..

[jmj11]

Do they tell the docs the same thing??? Maybe that's what you'll have to do...very risky..

 

No. This is the "Practice Plan" which is the same as "Supervisory Agreement" in other states. It describes the relationship between the PA and the SP.

[jmj11]

This is how I've decided to proceed (and I'm not giving up yet).

 

In review (skip this part if you read my previous posting); In the model of my new PA-owned clinic, will have two sites. My SP would only work 3 days/month, two in site 2, and 1 in the primary site. This challenges the standard SP-agreement (Practice Plan) for the state of Washington which requires the SP to be on site >25% of the time). So, to get approval for this type of supervision, you must have a special dispensation.

 

I applied for the Practice Plan and the special dispensation (called the Remote Practice Plan). My application was rejected as soon as it was received because the committee says it MUST have a real physical address of the actual clinic.

 

Now the problem is, I can not get malpractice insurance without the actual APPROVED remote practice plan in their hand. I can't create an PLLC (not a legal restriction but a practical one) or get a loan unless the clinic is a sure thing. The clinic can not be a sure thing unless our unique remote practice plan is approved. So it becomes a Catch 22 situation. It makes no sense that the state basically says that you must have an established clinic before they will consider giving you permission to have an established clinic.

 

What I've decided to do: I contacted the owner of the clinic space which I'm most interested in leasing (primary site 1) and asked them if they would go along with me in pretending that it is already leased to me . . . so I can use their address as my real clinic address. They agreed (although they may think I'm a nut case). In the worse case situation, if my remote practice plan is approved, but then this actual site is not available (two other parties are looking at it), then I will have to do a "change of address" with the state.

 

It is not so easy with my second clinic site (in another city). I don't have any real estate that I've looked at yet. But I had seen patients at one site about five years ago. So I listed that site (a pain clinic) as my second site. So, if the state sends mail for me there, at least the present owners know who I am. I've actually asked them several times to sublet me space once again and they have never given me an answer thus far.

 

I resubmitted the application with those two addresses yesterday, so now it is wait and see.

 

Now all of this has to be done incognito because if my present employer gets drift that I want to create a new (and they could perceive as a competitive entity) they could be (and can be at times) vindictive. If I leave my present employer, I want to do it on my terms and in a positive way. I do not burn bridges.

[MCHAD]

Okay, this is the kind of madness I've faced every step of the way. The Healthcare Quality Assurance Committee says that they will not even consider my application until I have an established clinic. Does that make sense to anybody? How can you establish a clinic if you don't have an approved practice plan? The malpractice insurer says that they will not even consider giving us insurance until they have an approved practice plan in their hand. How do you open a clinic with no practice plan and no malpractice insurance? If I knew that the approval was an assured thing, which I don't, I would go through all the steps, set up the clinic and then wait. But if they rejected the application at that point . . . my *** would be grass.

 

well, just tell them you would be glad to establish a clinic if they are willing to front the money! But seriously...let us know what you figure out this is very interesting

[jmj11]

I wish I could detail all that has happened this week regarding this venture. I was going to blog it, and maybe I should have.

 

Because I am seeking; 1) a PA-owned clinic, 2) a main clinic, plus a remote site, 3) the physician will be working primarily in the remote site, I've created the perfect storm of a whirlwind of confusion for the state. The practice plan application and the remote site application will not accommodate our arrangement in their boxes.

 

In the last three days I've had 27 interactions with the guy at the state ( e-mails, faxes, phone calls). I've filled out the applications in six different ways (following their advice) and all six have been rejected, not because of the supervisory arrangement, but because of "errors" in filling out the forms.

 

The so-called "errors" are where I list my main clinic's address as the business address, which it is (it is our only address). Because it does not match the physician's patient seeing address, the screeners reject it as an "error." But the place where the physician will be seeing patients one day a week does not have a mailing address, just an exam room sublet from another medical group. They do not get this. They say that I MUST make that other medical practice's address the PLLC's address because that is where the physician is seeing patients. But it is not the PLLC's address and I will be lying if I say the business address is this sublet room when we do have a real business address in another town.

 

Speaking of headaches . . . I've gone home with excruciating headaches the past two days, especially considering that I've been overwhelmed with patients while I'm working on this.

 

Today, after my last application was rejected once more due to "errors" I said I've had it. I was going to throw in the towel. But then at lunch I started to think about this again. Everything I'm doing is legal. I'm following all the state laws. However, because the state form does not allow exceptions (in the way it is designed) it is a barrier. So, I'm going to try one more time and I'm going to do it the way they say I must, although it does not reflect reality at all.

[marilynpac]

Remember what I've always said.....whenever a barrier is put up in front of a PA, a PA will go under, over, around or through it...that's the PA way!

[PASun]

Okay, this is the kind of madness I've faced every step of the way. The Healthcare Quality Assurance Committee says that they will not even consider my application until I have an established clinic. Does that make sense to anybody? How can you establish a clinic if you don't have an approved practice plan? The malpractice insurer says that they will not even consider giving us insurance until they have an approved practice plan in their hand.

 

How do you open a clinic with no practice plan and no malpractice insurance?

 

QUOTE]

 

Exactly my expereince with Boards...Masters at creating the Ultimate Catch 22.

 

They offer no guidelines, regulations, legally established requirements or means to acheive your goal.

Bascially they don't feel they are responsible to justify how to achieve their request!

[jmj11]

So things are still in a holding pattern, waiting on the state to approve (or disapprove) the practice plan and the remote site plan. I would put the odds at 50:50. While we are clearly within the law, after beating my head against the wall for over a week with the state, trying to make our clinic's situation fit into their old forms (like trying the proverbial square peg in the round hole) I finally had to list a single exam room, in a different practice, in another city, as the main address of our PLLC. We don't even have permission from that practice yet, to use that exam room twice a month.

 

I don't mean to sound negative on this thing, but the second blow came this week regarding onabotlinumtoxinA (Botox) use in headache. I've been injecting Botox for headache prophylaxis for ten years. I was trained at Mayo Clinic to do it. I presently work with two neurologists (SPs) and they have never done Botox treatments for anything.

 

As many may know, Botox got approval for by the FDA for use in the prevention of Chronic Migraine just three weeks ago. Botox is not a panacea. However, when you have a headache clinic, 90 % of your patients have intractible chronic migraine. Therefore, Botox becomes an important tool in that population.

 

With that said, I spent some time with the Allergan administrative staff this week (the ones who try to get insurance companies to pay for it). They told me that the agreement reached by the insurance companies is to only cover Botox, in the future, when it is done by trained neurologists. Maybe I could squeak by if worked for neurologists.

 

In my own clinic, my SP will be a family practice doc who has been trained in headache and had a headache clinic (my major competition) for ten years before semi-retiring. While this may sound odd to some, the largest headache clinic in the world (Diamond Headache Clinic) was started by an internist and is now directed by a ER doc.

 

The people with Allergan were saying that even if I were the greatest Botox practitioner in the world, that it would not matter with insurance companies because the PA is invisible. They only see the PA as an extension of the doc. We are still trying to clarify that issue and see if they would be willing to make an exception. My greatest argument is that if Botox prior auth is refused because it will be done at my clinic, then my only choice is to refer the patient to one of the headache clinics in Seattle. I do Botox for headache for $700. In Seattle, the other clinics do it (with a facility charge) for $1400.

 

By this time next week, I will know if I have a green light or not. The state could come back and say that the SP has to work with me another few days a month. My potential SP said he did not want to commit to more days than twice a month. So, I will see if he wants to reconsider.

[rcdavis]

Mike.

 

Is time to see your state representative. The state laws are, after all is said and done, what authorizes the med board to exist, and to implement, not to interpret. Get the state involved, and stop approaching the med board from the bottom up. Go from the top down.

Nuke em. You have shown extraordinary patience and perseverance.

davis

[jmj11]

Had a conversation with the physician who directs the state's Medical Quality Assurance Board this morning. He readily admits that my request is the most unusual they've ever reviewed. 1) A PA owned sub-specialty clinic, 2) The SP, while trained is headache, is not board certified in neurology, 3) The SP not working the primary clinic at all, 4) The Sp only seeing patients twice a month in a satellite clinic.

 

I have to say that this physician was much more reasonable than the paper pushers (which work full time for the state) which I had been dealing with. To them, it was only about getting the right addresses on the right blanks. However, the form did not fit our practice. It was like trying to force a square peg into a . . . convoluted star-shaped hole.

 

So what are my odds? Better. They could have simply rejected it but they didn't. The doc this morning seemed to understand and appreciate what we are trying to do He wants to have a conversation with my future SP before giving their final verdict. I will keep you posted here in my pseudo-blog.