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November/December 2014
Building From Within: 5 Strategies for Growing a Geriatrics Practice Developing a thriving geriatrics practice that is both professionally and financially rewarding depends on calculated planning and specialized strategies. Most older adults receive primary care from family practices, internal medicine practices, and specialists. Very few see a fellowship-trained geriatrician as a primary care provider. There's no reason to believe this trend will change. Further, we can expect more older adults to rely on nonphysician providers for their primary care. This is likely to be the case in most types of practices, including private practice, hospital-based clinics, and federally qualified health centers (FQHCs) as well as in nonhospital settings such as homes, assisted-living facilities, nursing homes, and in clinics. This article will help practices develop a competent geriatric focus with the diverse primary care providers on your staff. A practice seeking to build geriatric services does not need a geriatrician. But it does need providers who like caring for older adults and their families. Developing a compensation plan that rewards, or at least does not penalize, providers who take the extra time to deliver good care to older adults and their families is the single most important element. Starting Point 1. Allow Adequate Time Practices that provide other services during a visit, such as pharmacy and social work consultation, allow patients and families to experience a team approach to important geriatric services. However, if providers rarely can spend extended time with complex patients, they are unlikely to embrace a growing panel of elders. As much as providers might want to focus on care of complex patients, they will likely feel like the proverbial mouse expected to run faster on the wheel. Without one or more providers who are enthusiastic about their work, a system cannot build geriatrics from within. Spending adequate time with patients, at least for some, is essential. 2. Devise Fair Compensation Strategies A fairly compensated geriatric champion who treats fewer yet more complex patients will likely thrive and succeed in building geriatric services. Before long, the practice grows beyond the walls of the clinic. Three mechanisms allow for fair and attractive compensation for providers providing good geriatric care. The first is salary. A competitive salary allows a provider to focus on quality of care rather than simply on quantity of visits. The risk of offering an attractive salary is that a provider may not be as productive as he or she should be to build the practice. Incentives, with most based on volume, do matter. Successful practices find the right balance between salary and volume expectations. Further, successful practices prorate salaries so that providers can work part-time. Caring for the expanding population of older adults will require commitments from the growing pool of part-time providers. The second mechanism is a relative value unit (RVU) plan. Practices can design RVUs that reflect the time needed for various visits. For example, a geriatric provider gets three RVUs for spending one hour with a complex patient and family. Her colleague who is seeing three follow-up visits in the same time period would get the same three RVUs. The geriatric provider is not being penalized for the time required to provide good geriatric care. Further, the geriatric provider can rotate from the lower volume (geriatric) segment of the practice to the higher volume (more traditional family practice and internal medicine) as desired and needed by the practice. An RVU plan makes compensation fair regardless of how much time a provider devotes to geriatric services. The real challenge of designing a fair RVU system lies in the accounting and human resource departments. It creates extra work for them. Clinicians can readily agree on a fair RVU plan. Practices that solve the accounting and payroll puzzles are the ones most likely to build geriatrics from within. The third mechanism, though germane only for traditional fee-for-service, is compensating providers based on their thorough knowledge and implementation of evaluation and management (E/M) guidelines and time-based billing. Providers who know how to capture their work through good use of E/M and time-based billing will be compensated fairly for focusing on geriatric care (see website for MESA [Medicare Experts/Senior Access] at coloradomesa.org). Although their compensation will not be as high as providers who are seeing 20 to 25 patients per day, the difference is not as great as many might believe. In short, the geriatric champion will not feel penalized for seeing only 14 patients per day. When she knows how to capture all of the work involved with caring for those 14 patients, she and her practice will feel fairly compensated for this geriatric service, and she will be incentivized to build the geriatric practice. An administrative bonus to recruit other providers to join the practice helps to extend the geriatric team from one to three or more providers. When a practice has three or more providers committed to geriatric care, it can extend beyond the walls of the clinic. 3. Expanding to Home Visits Successful practices address the two key challenges of providing home visits. One involves logistics and overhead. Scheduling appointments, windshield time for providers, unexpected no-shows, and the like all cost time and money for the practice. The key to cost-effective delivery of home visits is geographic grouping. A practice providing home visits to patients in three assisted-living facilities near the clinic and some independent homes in the neighborhood can provide good service with relatively little overhead. In contrast, a practice providing home visits for four patients who live in different parts of a metropolitan area cannot do so cost effectively. A large practice or health care system may choose to subsidize the inefficiencies of starting a geriatric home visit program. This burden would be too great for a small practice. The second challenge is fair compensation for the providers who perform the home visits. Again, this is the key strategy for building and sustaining successful geriatric practices. The providers have to be compensated for their travel time, whether via salary, stipend, RVU, or a combination. Revenues from the Centers for Medicare and Medicaid Services are fair and attractive for home visits in a fee-for-service world. As long as providers know how to capture their work while providing home visits, the revenues cover the costs and can provide a thin margin. In a FQHC practice, the flat fee for any visit is not really sufficient to cover the costs of home visits. However, an FQHC may choose to subsidize home visits. Mission, satisfaction of patients and providers, reducing risk of inappropriate hospitalizations, and anticipation that payment changes will eventually cover costs for an FQHC are all compelling reasons to subsidize home visits. Another compelling reason is competition. If a clinic-based practice or a large health care system operates in a market where other providers are providing home visits, the clinic-based providers can count on losing some of their patients to the providers offering home visits. When providers from a geriatrics practice show up and provide good services at an assisted-living facility, some of the other residents will likely shift to that geriatric practice, no matter how connected they may feel to their clinic-based primary care provider. It is much more convenient for patients, the families, and the facility's staff to establish care with a practice that provides home visits. 4. Expanding to Nursing Homes When the geographic grouping of visits is convenient, a provider can reach the volume goals—the sweet spot of 13 to 15 patients per day—with a good variety of visits. For example, a nonphysician provider might see 20 patients in the family practice clinic on Monday and see 13 on Tuesday, the day designated for geriatric services. He might see six elders in the clinic on Tuesday morning, six in the nearby nursing home (both skilled and long-term patients), and one at an assisted-living facility on his way home. As in any other setting, the geriatric provider must know how to capture his work in the nursing home. He must know how to deliver and bill for a 10-minute visit, and he must know how to deliver and bill for a 70-minute visit. Although providing services in nursing homes can be more financially rewarding for a practice, with the ease of seeing a higher patient volume within a smaller space and time than in providing home visits, it creates additional stresses for the practice. Three are worth noting, with the first being the volume of calls from nursing homes. The number of phone calls for 100 nursing home patients is significantly higher than the number of calls for 100 clinic and home-based patients. Someone has to take those calls in the middle of the night. The second stress is the acuity of care provided in most subacute units, ie, the skilled beds in nursing homes. Many of the patients in subacute units in 2014 would have had longer hospital stays in 1994. Providers must feel comfortable with the acuity of care provided in most nursing homes. The third stress involves the time pressure to see patients in nursing homes. This includes both the visits (H/P and follow-up) in subacute care and those (regulatory visits) in long term care. In most situations, the physician (not the nonphysician provider) is expected to complete the H/P within 72 hours of a patient's admission to a skilled unit. In some settings, the time window is shorter, for example, within 24 to 48 hours of admission. An example would be a nursing home in a large metropolitan area that accepts many Medicare managed care patients. In other settings, the time window is longer, for example, a nursing home in a small rural community. These time pressures are not as prevalent in a practice focusing only on clinic and/or home visits. 5. Building Geriatrics as a Recruiting and Retention Strategy Practices should consider the financial and emotional costs of replacing unfulfilled providers, particularly those who can become disillusioned with the typical hectic office practice. Recruitment, provider training, waiting for provider efficiency to grow after starting, staff morale, and patient relationships are all expensive building blocks for any practice. Offering a reprieve from the typical time constraints in a primary care practice, if even for only one or two sessions per week, can improve provider satisfaction. This is often the best recruiting strategy. Colorado Practice Example Continuous Learning Providers cannot keep up on everything, but disciplined review of selected resources will give providers the knowledge and confidence to build a successful practice. Collective Experience As in any other field of medicine, confidence is important. Confidence comes with experience, and experience takes time. A young provider may have the passion and tools (specifically, administrative support) to build a successful geriatric practice from within, but she will not have had the experience and confidence to impart to the patients, staff, and colleagues to build a thriving practice. She need not wait 10 years to gather that individual experience. She can gather the collective experience of her medical colleagues, office and triage staff, and specialists. Team meetings, case studies, sidewalk chats (HIPAA compliant), and phone calls all contribute to building the collective experience and confidence. Summary — Donald J. Murphy, MD, FACP, a practicing geriatrician, is the medical director of Medicare services for Colorado Access in Denver. — L. Elane Shirar, MD, is the founder and owner of Rocky Mountain Senior Care in Golden, Colorado. — Shannon M. Tapia, MD, is a practicing geriatrician in Denver. — Genie H. Pritchett, MD, a practicing internist-geriatrician, is vice president of medical service for Colorado Access. — Debra Parsons, MD, FACP, an internist-geriatrician, is a senior medical director at Colorado Access and a clinical professor in the department of medicine at the University of Colorado School of Medicine. — Christine McLemore, DO, a practicing family physician, is medical director for Metro Community Provider Network in Englewood, Colorado. |
