By: Rochelle Glassman
Adding specialty services to you primary-care practice is a great way to grow, better meet patient needs, and be successful with value-based care.
Whether we like it or not, changes in how physicians are being reimbursed are coming. Over the next three-to-five years, we will continue to see the fee-for-service model shrink and more physicians will be paid based on performance. This means that physicians will be reimbursed on their ability to manage patients’ chronic diseases and surgical outcomes as well as keep patients out of the emergency room and the hospital.
We are already seeing this shift. Medicare and Medicare Advantage plans are currently paying family practice and internal medicine physicians between $200.00 and $300.00 when they complete a risk assessment for a patient. And, the proper use of G codes currently allows for an increase in reimbursement on preventative medicine services.
Family practice physicians are the experts at giving away their business and revenue streams by referring out to the specialists. When they make that referral to the specialist for a non-acute illness, patients often do not make the appointment. This will be an issue in the future for family practice physicians who will be reimbursed based on the health of each individual patient. For example, under Healthcare Effectiveness Data and Information Set (HEDIS), many health plans were paying an additional 20 percent on an evaluation and management code (E/M) for diabetic patients referred to and seen by an optometrist for diabetic retinopathy screening. It was reported by one of the major health plans that 80 percent of those patients referred for diabetic retinopathy screening did not make their appointments with the optometrist. Moving forward with the paid on performance model, if the diabetic patient was not screened and got diabetic retinopathy, the primary-care physician managing this patient loses her incentive for that patient.
So how can you better manage your patients? One way is to look at your patient volume by diagnosis code. If the volume is there to support a full or part-time specialist then look at bringing them in-house either full or part-time as an employee or independent contractor.
For example, if your diabetic population is large enough it may support bringing on an endocrinologist, registered dietician, podiatrist, primary care-sports medicine physician, and/or an optometrist. Your practice can create an integrated program that will better manage your diabetic patients and therefore increase the likelihood of you receiving those pay-for-performance reimbursements. You can bring on the entire team or one specialist member at a time starting at a half day a week and potentially growing to full-time based on the patient volume. Patients trust their primary-care physicians, and compliance is much greater when you send the patient down the hallway to see the endocrinologist or dietitian. The specialists and ancillary services can often cross over to treat other types of patients.
A dietitian can also treat patients with hypertension, obesity, and hyperlipidemia. Sixty percent of the US population is obese and there are special incentives for obese patients with a body mass index over 30 who can be treated and lose around seven pounds. Most of these patients have other comorbidities like type II diabetes and hypertension. The primary care-sports medicine physician can manage diabetic foot care if the health plans will not reimburse the podiatrist. They can also see primary-care patients, perform many procedures like trigger point injections, and deal with non-surgical sports injuries.
You have many options in the way you structure bringing a specialist into your practice. First you need to contact your insurance companies and make sure that your payer contract allows you to add the specialist or ancillary service to your existing contract. Confirm that the specialist and ancillary service has actually been added to your contract before you start seeing patients or you will not be paid.
Here are some of the ways you can set up your arrangement.
1. You can hire the specialist as a part-time or full-time employee based on your patient volume. Compensation can be an hourly flat rate, day rate, or salary and benefits. It can also be a base rate and bonus based on specific criteria being met, such as patient volume, patient satisfaction, and compliance (complete and accurate documentation in the patient’s medical record).
2. The specialist can be an independent contractor. The specialist comes in and signs an independent contractor’s agreement with a mutually agreed on rate.
3. Payment can be based on collections. This would be an independent contractor arrangement as well. The payment could be 60 percent of the collections would remain in the practice and 40 percent would be paid to the treating specialist. These percentages can be changed based on negotiations and community standard.
4. Finally, you can set up a rental relationship where the specialist rents space at community standard rates. The rental relationship can be expanded to include the use of staffing, supplies, and equipment if you are referring a designated service within your office. You should contact your healthcare attorney or an experienced healthcare consultant to make sure that the practice is in compliance with the anti-kickback and STARK laws on a state and federal level.