PHYSICIAN SERVICES STRATEGIES IN A NURSING FACILITY (Based on a 160 bed facility) Robert S. Stall, M.D. March 19, 1993 I. Medical Staff Organization A. "Closed staff" 1. Definition and Benefits/Disadvantages a. Limited number of physicians practicing in a coordinated manner. b. Allows administration to arrange uniform physician coverage throughout the week. c. Greatly facilitates communication between physicians and nursing staff (and other disciplines). d. Residents have better access to on-site physician services. e. May help prevent unnecessary transfers to the ER or avoid inappropriate "over-the-phone" evaluation and treatment of patient problems. f. Sometimes prevents practitioners from following their own patients in the nursing home. g. Residents have a limited choice of physicians (has not been a major problem in my experience). 2. Possible strategies a. One physician/40 residents. (1) In a 160 bed home, four physicians would constitute the "Medical Staff". (2) Optimally, they would be on-site on different days of the week and would cross-cover each other for any problems that arise on their day (ex. Schofield Residence). (3) They would also share in cosigning telephone orders and performing employee physicals. (4) Can cross-cover each other on weekends and vacations. (5) A dedicated Medical Director could act as the fifth physician to cover problems on an off day. b. One physician covering the entire home and acting as Medical Director. (1) This is the extreme version of the closed staff. (2) May be difficult to arrange coverage in his absence. (3) Residents have no choice of physician. (4) Can work well with the right physician (ex. Dr. Ferdinand Paolini, Brothers of Mercy). B. "Open staff" 1. Definition and Benefits/Disadvantages a. Unlimited, unorganized Medical Staff. b. Physician visits often unpredictable. c. More difficult to ensure regulatory compliance with timely visits, cosigning telephone orders, adequate documentation. d. Nursing staff and other disciplines spend much more time on the phone (e.g., playing "telephone tag") and more often encounter uncooperative, rushed physicians. e. Physicians and residents can maintain their previous doctor-patient relationship. C. "Combined staff" 1. Definition and Benefits/Disadvantages a. Combines benefits and disadvantages of "Closed" and "Open" staff models. b. Allows flexibility in staffing (may be the only option if there are not enough "closed staff" doctors to care for all the residents). c. May produce two different standards of care. d. Easier to transition to a "Closed Staff" than from a completely "Open Staff". II. Special Physician Considerations A. Medical Director 1. The Medical Director can play a crucial role acting as liaison between Administration and the Medical Staff. 2. He should have an active role in ensuring regulatory compliance (especially with regard to physician services). 3. He should be an active participant in the development and implementation of a good Quality Assessment and Improvement program 4. Adequate dedicated "Medical Director time" will help to ensure that his administrative responsibilities do not get short-changed (a 160 bed facility requires approximately 4-6 hours of dedicated Medical Director time, depending on the extent of his responsibilities (e.g. signing incident reports and telephone orders, attending team meetings and other meetings, conducting resident rounds, developing policies and procedures, participating and responding to surveys) 5. Reimbursement will likely be somewhat higher per hour than attending reimbursement, depending on job duties and qualifications. B. Consultant physicians 1. A qualified, accessible consulting staff is an invaluable asset to a facility. 2. Special efforts should be made to have available the on-site services of the following specialists: a. Neurologist b. Psychiatrist/psychologist c. Ophthalmologist d. Dentist e. General Surgeon f. Dermatologist 3. Other specialists commonly requested include: a. Urologist b. Gastroenterologist c. Cardiologist d. Endocrinologist e. Nephrologist f. Pulmonologist 4. Reimbursement is often an significant issue that deters specialists from coming to the home for consultation. III. Physician Payment Strategies A. Private billing 1. Allow physician to bill for his own services and retain the proceeds. 2. Physician often feels reimbursement is not worth the effort made in making visits, answering phone calls, completing necessary paperwork, etc. (maximum reimbursement likely to be $275- $375/resident/year for all services provided, including office overhead) B. Facility reimburses the physician 1. "Time clock" arrangement a. Physician keeps track of his time (or may sign in and out) and submits a voucher periodically. b. Hourly rates may range between $50-$125/hour depending on job requirements and physician training. 2. "Capitation" arrangement a. Physician receives a fee that varies depending on patient load. b. Typically ranges between $400-$550/ resident/year. 3. "Fixed contractual" arrangement a. Physician agrees on a fixed weekly time commitment with the facility. b. Every ten residents requires approximately one hour of physician time/week. c. Rate as above ($50-$125/hr). d. 160 bed facility would therefore require about 16 hours of attending physician time (approx. 1/2 FTE). IV. Perquisites Recruiting efforts can be enhanced by added benefits. These may include: A. Health insurance B. Vacation time C. CME/Journals/Professional dues allowance D. Bonuses for specific duties (e.g., DNR determinations, comprehensive examinations, employee physicals) E. Billing services V. Facility Reimbursement Strategies The facility may recoup much of its expenses for physician services by: A. Billing for staff physician services. (It is important to understand the requirements under RBRVS in order to maximize reimbursement.) B. Including "Physician Services" in the cost report to obtain a Medicaid rate "pass-through" add-on. (Theoretically, all physician services costs can be recovered this way.) VI. Summary/Recommendations A. A "closed staff" arrangement is increasingly popular and tends to offer a "win-win" situation for both the physicians and facility staff/administration. B. Adequate "capitated" or "contractual" reimbursement overcomes many of the disincentives that exist for physicians to practice in nursing homes. C. A modest investment in physician services is likely to produce great rewards in terms of nursing efficiency, quality of care, and regulatory compliance.