Contrarian Posted April 5, 2011 Share Posted April 5, 2011 This article was submitted to Advance for PA and was published in 2005... Stop looking for a Job… Create A Career House-Calls…offering A Healthcare Access Solution. I was a Airborne Army Medic, a ER nurse, a Critical Care Nurse, and now PA/NP. Like many PAs, I continually educated myself to broaden my scope of practice. While in the military, I accepted the fact that I didn’t have any control of my quality of life or pay, but did enjoy the job security. After 8 years in the Army, it was time to get out and the thought of “looking for a job” in the civilian sector was a stress/nausea provoking event. After several paramedic and nursing jobs, I realized that I still had no control of my quality of life, pay, and had lost the job security. I decided to go back to school. While attending PA school, I noticed that entrepreneurial minded providers (MDs, PAs, NPs) were rare and most expected to “look for a job,” and “go work for somebody” when they completed school. I had heard the horror stories of PAs “looking for a job” for 8-14 months after graduation. My immediate response would be, “why are they looking for a job, they should be creating a career.” At the time I was naive and preached practice buy-in contracts, profit earnings, and true PA/MD financial partnerships to my PA school classmates. I assumed that if my billing was equivalent to the MD’s, then I would be considered an asset to the practice and treated accordingly. During clinical rotations, I noticed that complex internal medicine patients with altered mentation, and mobility challenges required enhanced practice resources to manage. Due to complex medical issues… (physical- pain:mobility, or cognition- cva:coma:dementia) this population of patients must often endure gross physical/mental insults to receive adequate acute/routine healthcare. It is not uncommon when, “Psychotropic and Pain Medication Adjustments” become a necessity simply to provide safe, basic care for some dementia and chronic pain patients attempting to “re-orientate” to their “residences” after a simple office visit. The typical patient was a 80 year old accompanied by the spouse and in-law whom had to take a day off work to get their loved one seen for needed care. Many seniors simply can't get out of their homes, nursing homes or hospice centers to receive medical care. Quite often, the initial indication that something is seriously wrong with this underserved patient population is discovered in the ambulance on the way to the emergency department. I immediately thought, “There’s got to be a better way”! So while in school, I wrote a business plan to start a clinical practice that featured housecalls as the foundation. I shared this plan with anyone (MDs, PA-Cs, NPs, MBAs) who would listen. Most responses were positive but skeptical. After school I accepted a position practicing Cardiology for several years, enjoyed it, but soon learned that the real world financial arrangements and job security are far different than I envisioned. I was treated as an “ancillary staff” employee whom just happens to bill greater than $400,000 a year for the practice. I agitated for production bonuses and even offered a $100,000 cash- percentage buy-in when the practice was cash strapped and expanding. Each attempt at justice resulted in a pat on the head and then being sent home with my $70,000 salary. I also felt that my hard earned “generalist” knowledge was slowly eroding. I decided that I needed to practice Adult Primary Care Medicine, follow my own advice and create a Career. As a transitory step in creating a career in Primary care, and to re-immerse myself in the medical care of the elderly, I took a nursing job as a resident care manager in a large skilled nursing care facility. I directed the standard of patient care, and served as the intermediary between nursing staff, family, and providers. I was eventually promoted to assistant medical director within this facility. After about a year, I formed a Professional Limited Liability Corporation, retained an accountant service and attorney, bought tablet computers, EMR, and searched for an open-minded physician to serve as medical director of the company. The company is owned by PAs/NPs and we contract with MDs for “supervision/collaboration.” It’s a win-win arrangement when you consider the fact that MD’s earnings are limited by the number of patients he/she can see during a normal work day and the only way for them to make more money is to see more patients and anything over 27 patients a day severely affects quality of life. By contracting with us, a physician can increase their practice panel and revenue by just answering their mobile phone… without seeing any additional patients or allocating expensive office resources (overhead). Now…Five days a week, I leave my 10’ x 8’ office (which is in my home), drive approx. 180-200 miles roundtrip...(400-600 miles a week...12-22 patients a day) to serve as a primary care provider for “homebound” patients. A patient is classified as home-bound if an office visit requires ambulance transport or an office visit requires excessive physical/psychological effort or pain. Many of these patients have dementia and an office visit would/could/usually significantly disrupts their fragile “orientation.” My entire practice consists of modern day house calls, which means going to see patients where they live, whether it is the family home, nursing home, assisted living center, adult family homes, group homes or hospice centers. When I go into my patients' homes, I see them in their most personal and vulnerable state. I speak to the medical director and the other Sponsoring Physicians daily (mostly cellular), and see them weekly to exchange the on call pager(s). According to my attorney, there is a limitation on the number of PAs a MD can supervise, but not on the number of Sponsoring Physicians a PA can have which equates to job security. I pay the Sponsoring Physicians a percentage of billing for “supervision,” and to take over when the patient’s care needs exceed my level of knowledge. We use Tablet PCs, an EMR, and secure VPN connection for clinical documentation and messaging. I “sync” my encounter documentation to my SP’s desktop nightly for review and billing. TOOLS: 2005 Subaru Baja (decent gas mileage, and all wheel drive for snowy days on the hills of the Pacific Northwest). Satellite radio (commercial free comedy, jazz, Caribbean, news, talk, sports). BlueTooth GPS (to find patient’s place of residence) I had been using an Acer Tablet since Sep 2004... (I found the 4.5 lbs to be a limiting factor in convertible Tablet PCs. While in facilities...I find myself looking for a place to put it down...because the arm starts to cramp after about 3.5 patients... so I purchased a Motion LS800 slate tablet. It actually fits in a lab coat pocket!) I have installed an EMR & Billing, Quickbooks Premier, MS Office 2003 Pro Suite, Infopath 2003, 5MCC 2005, Epocrates desktop, Current Clinical Concepts 2005, Dragon Naturally Speaking 8, Harrison's IM 2005, and Tops ICD9 on the LS800 Tablet PC. A Mobile stand w/ port replicator and power inverter for the Tablet PC is installed in the vehicle. Treo 650 w/Bluetooth dial up networking for unlimited internet access (fax/email) anywhere in my service area and a Bluetooth hands free speaker phone. In my home office, (I see no patients here, only for clinical administrative tasks) I have, three PCs. I use winfax for faxes, and have a wireless cable internet access network set up so when I pull into the driveway...Voila'...the pc in my lab coat pocket talks to the pc in the office via BT or WiFi... I guess I was fortunate in that the Medical School I attended for my PA program required each student to report on the first day with a laptop & PDA in hand. (Go Cardinals!!) Since then, I have always actively sought ways to incorporate technology to "work smarter… not harder." Business is great. We are now looking for more Sponsoring Physicians so we can add more PAs. I now have control of my quality of life, pay, and job security. I had to Stop looking for a Job… and Create A Career Contrarian, PA-C PrimeCare, PLLC. Doctors Home Visits. Mr. Contrarian is a graduate of the Stanford School of Medicine/Foothills College PA/NP program. He is available for meetings and conferences to present/discuss PA/NP entrepreneurial concepts and opportunities. Contrarian@comcast.net This may or may not be relevent today... but hopefully it will inspire others to take the leap...:wink: Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 5, 2011 Moderator Share Posted April 5, 2011 but what are you doing now?? still doing the same thing? How did it go? Link to comment Share on other sites More sharing options...
Contrarian Posted April 5, 2011 Author Share Posted April 5, 2011 I did this from Oct 2003-Feb 2005 and had around 460 patients on my panel. At the time I could only find 1 Physician (BC EM) willing to serve as a contracted SP. There were 5 NPPs working with this guy. Me and 4 ARNPs. The ARNPs did ok and averaged ~$100k/yr by seeing about 10 patients per day 5 days per week and doing their own billing then paying him. Me... not so good because all my billing had to go through him and He would only do it through his corp and his wife did all the billing. So they would submit the billing, get paid then pay me. I made about $47k that yr but suspect there was lots of billing fraud and "skimming" going on. When I questioned the billing, they would suggest that I upcode and see more patients. I looked at the Physician's numbers and he seemed to be seeing a impossible number of patients in a short amount of time. Especially when you factor in travel. I looked deeper into the numbers and found that several of the ARNPs were not only upcoding, and basically "making up" visits, but were also paying the doc substantially less for "collaboration" versus my fee for "supervision." It left a bad taste, so I got away from them ASAP, reported them to the Med Board and the Medicare Fraud Unit and took a Locum job in Iraq for a boatload of cash. I'm seriously considering doing it again... and have a few semi-retired physicians in mind. Contrarian Link to comment Share on other sites More sharing options...
marilynpac Posted April 5, 2011 Share Posted April 5, 2011 Did you ever go back to see what happened with that doc? My best guess is nothing b/c they covered their tracks so well, but it would be nice to know they got bit in the gluts.... Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 5, 2011 Moderator Share Posted April 5, 2011 I am interested in what you do I am tired of making 350k for the practice and only getting paid 84k - going to talk with them this week about long term and how I need to be in the 110-120 range if they want to keep me - strange twist of fate is that a local practice has a doc retiring and he is talking to me about ownership - start to bump into the 'glass ceiling' of 'you are just an employee' and no awareness of the fact I make them $150k per year over my expenses and overhead... recently I have been also thinking about doing a NH business - partner with a couple doc's and round on their patients in the NH and bill through them - but get paid something like 80% of collections (they would have to allow me to have full access to their billings that I generated to avoid the situation you got into) easy schedule in that the patients are at the NH 24/7 and if it is powder day or a beautiful summer day i could easily take the day off.... Link to comment Share on other sites More sharing options...
Contrarian Posted April 6, 2011 Author Share Posted April 6, 2011 Did you ever go back to see what happened with that doc? My best guess is nothing b/c they covered their tracks so well, but it would be nice to know they got bit in the gluts.... Story gets better... Before I reported them... I started seriously agitating for my money and quietly looking for another source of income. The doc kept insisting that I was paid what I was owed and that I needed to do as he does and see EVERY patient on my panel EVERY 6 weeks then document and bill Level III-IV for all of them... !!! I explained that I wasn't going to simply "make $hit up"... and his response was, "They are old... I'm sure you can find something wrong with them if you look hard enough... you can simply adjust a med and bill for that." I refused to get involved with any of that and just bide my time. I soon found a job with a group of Physicians seeing all of their Nursing Home, Adult Family Home, Assisted Living patients. I then quit working with the shady doc but still agitated for an examination of my billing records by a independent billing consultant that I would pay for. Out of spite, when the doc notified his insurance company that he would no longer be "sponsoring" me... the doc then made the off-hand remark to the insurance company that "he had some concerns about the timeliness and accuracy of MY clinical documentation"... They of course wrote this down. The silly part about his off-hand remark was that we used a EMR and Motion tablet PCs. So ALL of my charting was primarilly "point and click" and was therfore completed before I got back in the car to go on to the next patient... but the insurance company didn't know that. So now, I've gotten away from the fraudulent doc, and I am setting up my new office space at the new practice, going to new hire dinners with the physician partners at this new practice, getting through orientation and getting credentialed. We get to malpractice coverage and the Insurance company refuses to cover me for malpractice insurance for a period of 1 yr. They refuse to cover me because when the doc notified his insurance company that he would no longer be "sponsoring" me... he then purposely, in spite, made the off-hand remark to the insurance company that "he had some concerns about the timeliness and accuracy of MY clinical documentation"... The New docs made numerous phone calls and tried to change their minds, but to no avail. They asked the insurance company for specifics, but the insurance company had none. We decided fine... this insurance company didn't have to cover me... we would work together anyway since I had my own mature CM&F policy that actually exceeded the limits of the policy they wanted to put me on and they would reimburse me for my policy premiums... but their insurance company would not simply cover them if they served as my SP. To make matters worse... here in this state, this one particular insurance company covers about 80% of the physicians and practices. So in effect, I was excluded from 80% of the market for a yr... WE Keep Living... hopefully, WE Keep learning...!! :heheh: It was at this time that I finally got really pissed and reported the fraudulent doc to the MFCU (Medicare Fraud Control Unit). To be honest, part of the reason I took the three jobs overseas (Iraq, Afghan, Darfur) was to make lots of cash, but more importantly to put some distance between me and this doc because I was seriously (no, really SERIOUSLY!!!) homicidal for quite a bit of time. Deploying, armed to multiple "2-way live-fire ranges" served as excellent outlets. The article in the OP was actually published at the beginning of my deployment, and the editor and I communicated by email to get it done... Contrarian Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 6, 2011 Moderator Share Posted April 6, 2011 yikes, that is just really scarry I guess we still do live in a physician centered world with a double standard..... Link to comment Share on other sites More sharing options...
Contrarian Posted September 15, 2011 Author Share Posted September 15, 2011 ................ Hmm ................ Link to comment Share on other sites More sharing options...
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