Re: Can the IMC model work in a homeless population?

April 13, 2007

Since I am a perpetual optimist I would say YES.

BUT you would need some creative financing strategies so that

you do not have to get back on a treadmill. Sounds like the

federal funds would force you back on the assembly line

with the numbers you quoted for panel size per FTE.

SO here are some ideas after maxing out what your patients

can pay which sounds like it would not much.

Get local money.

1) Do the Robinhood thing. There are 2 docs

on the site who essentially got funded through their church

family. Benefactors were found and they donate a yearly fee

to sort of " adopt " another family who is uninsured. Network with

those who are well funded and would like to contribute to your

worthy mission. Have a practice that serves wealthy and poor

and pays your salary.

2) Network with those who save money due to your ability

to care for this group who will then not be a burden to

the " system " - hospital, county, etc..

3) Ancillaries - run a high priced derm service on the side.

4) Bake sale?

5) When all else fails, hold a town hall meeting and explain

your idea. Get the group brainstorming on creative solutions

with you. It is really wonderful. This is how I created my practice.

I'll send you an FAQ if you like which may help you on this

one. Email me.

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

>

> Dear group; This is my first post.

>

> Please help me answer these questions:

>

> 1. Is the IMC model financially viable if our patient panel consists

> of persons who are uninsured, homeless and/or chronically inebriated?

>

> 2. If the answer to #1 is yes, then how would we need to modify the

> IMC model to work in our population?

>

> Since our population seems to be different from the " typical " panel

> that most doctors would have, here is a description of what we do:

>

> We serve a segment of the Native American population in Minneapolis,

> Minnesota. We specifically target a population that is not served

> well by traditional clinics - most of our patients are ones who " fall

> through the cracks " and end up in Emergency rooms. For the last 6

> years, a single physician has been seeing an average of 5 patients a

> day in a walk in center in the mornings, and then going out into the

> community to find those that do not come in. He has been mostly

> providing urgent care services, then encouraging the patients to go

> to other clinics for continuity of care. It is done on a real

> " shoestring " - the one doctor has been on his own with volunteer help

> only. They have survived on some grant money from the county

> (intended to reduce ER visits to the county funded hospital) as well

> as very limited Medicaid reimbursement. I am just now joining him,

> and he has encouraged me to look into ways the service can expand to

> be medically comprehensive and more financially viable (He was the

> one who saw Gordon's recent article in the Wall Street Journal and

> thought it could work for us).

>

> In some areas, we already are following IMP ideals: The service is

> 100% " open access " . There is no scheduling and patients are helped

> as they come in or are found in the community. The one physician

> freely gives out his cell phone number and can be called anytime.

> Amazingly, he says that this is seldom abused. There is close

> collaboration with an inpatient detox unit and an outpatient chemical

> dependency treatment center. The visits focus almost exclusively on

> what concerns the patient at the moment. We need to upgrade to

> include provision of basic PHC serves.

>

> We also have the potential benefit of a fairly well defined, stable

> patient panel (homeless, and/or chronically inebriated Native

> Americans in Minneapolis). Surveys indicate that between 1,000 and

> 2,000 people are in our target population.

>

> The only way I think we can make this work financially is to apply

> for status as a Federally qualified health center and/or Health Care

> for the Homeless Program. This would give us access to grant funding

> (our umbrella organization has a good track record for grant

> writing), increase per visit reimbursement and may mean we would not

> have to pay for malpractice insurance. The philosophy of the program

> seems to fit an IMP model - open access, decreasing disparities in

> health-care, but are the federal requirements for designation

> compatible with your IMP model? The one that worries me the most is

> that Federally qualified health centers should have 4,200 visits per

> FTE physician per year - this translates into about 20 visits per day

> per physician. We would like to have a cap of 10 to 12 patients a

> day.

>

> Does anyone out there have any experience as a Federally qualified

> health center and/or Health Care for the Homeless Program? Or does

> anyone else have more ideas how to be financially viable if your

> patient population is poor and uninsured?

>

> I realise that a computerized EMR/Billing/Registry system will be

> essential to getting reimbursement, documenting the impact of our

> service, and lowering overhead, but I will save those specifically

> technological questions for a later post to the list.

>

> Thanks in advance for your help.

>

> Steve Andersen, MD

> AAFP

>

April 13, 2007

RE serving the underserved and making a living.

Without outside funding, you can't do it and make a living.

See if you can get the County Health Dept to hire you for this most important work.

What use is billing software if there is noone to bill?

Good luck to you!

If anyone else thinks differently, I'm up for it!!

Dr Matt LevinFamily MedicinePittsburgh PaDr_Levin@... Office Fax.

More about me--Using SOAPware since 1997Solo Practice started Dec 1st 2004 in Greensburg PA, east of PittsburghPart-time practice technology consultant

Can the IMC model work in a homeless population?

Dear group; This is my first post.Please help me answer these questions:1. Is the IMC model financially viable if our patient panel consists of persons who are uninsured, homeless and/or chronically inebriated?2. If the answer to #1 is yes, then how would we need to modify the IMC model to work in our population?Since our population seems to be different from the "typical" panel that most doctors would have, here is a description of what we do:We serve a segment of the Native American population in Minneapolis, Minnesota. We specifically target a population that is not served well by traditional clinics - most of our patients are ones who "fall through the cracks" and end up in Emergency rooms. For the last 6 years, a single physician has been seeing an average of 5 patients a day in a walk in center in the mornings, and then going out into the community to find those that do not come in. He has been mostly providing urgent care services, then encouraging the patients to go to other clinics for continuity of care. It is done on a real "shoestring" - the one doctor has been on his own with volunteer help only. They have survived on some grant money from the county (intended to reduce ER visits to the county funded hospital) as well as very limited Medicaid reimbursement. I am just now joining him, and he has encouraged me to look into ways the service can expand to be medically comprehensive and more financially viable (He was the one who saw Gordon's recent article in the Wall Street Journal and thought it could work for us).In some areas, we already are following IMP ideals: The service is 100% "open access". There is no scheduling and patients are helped as they come in or are found in the community. The one physician freely gives out his cell phone number and can be called anytime. Amazingly, he says that this is seldom abused. There is close collaboration with an inpatient detox unit and an outpatient chemical dependency treatment center. The visits focus almost exclusively on what concerns the patient at the moment. We need to upgrade to include provision of basic PHC serves.We also have the potential benefit of a fairly well defined, stable patient panel (homeless, and/or chronically inebriated Native Americans in Minneapolis). Surveys indicate that between 1,000 and 2,000 people are in our target population.The only way I think we can make this work financially is to apply for status as a Federally qualified health center and/or Health Care for the Homeless Program. This would give us access to grant funding (our umbrella organization has a good track record for grant writing), increase per visit reimbursement and may mean we would not have to pay for malpractice insurance. The philosophy of the program seems to fit an IMP model - open access, decreasing disparities in health-care, but are the federal requirements for designation compatible with your IMP model? The one that worries me the most is that Federally qualified health centers should have 4,200 visits per FTE physician per year - this translates into about 20 visits per day per physician. We would like to have a cap of 10 to 12 patients a day.Does anyone out there have any experience as a Federally qualified health center and/or Health Care for the Homeless Program? Or does anyone else have more ideas how to be financially viable if your patient population is poor and uninsured?I realise that a computerized EMR/Billing/Registry system will be essential to getting reimbursement, documenting the impact of our service, and lowering overhead, but I will save those specifically technological questions for a later post to the list. Thanks in advance for your help.Steve Andersen, MDAAFP

April 13, 2007

Steve,

Since your signature includes AAFP, may I

suggest you subsribe to Private Sector or Practice Management listservs of the

AAFP. There are several outspoken members of the listserv who run Federally

Qualified Health Centers and I recall seeing something on the Native American

clinics in particular and how well they pay. When you have a FQHC designation,

you are paid much better. It’s still Medicaid, but the rates are higher,

plus a facility fee for every visit. I don’t know much more about it

though.

The IMP model would be perfect for this

population other than you do need to get paid something by someone to survive.

So first step would be to find out if you can get someone to pay you for your

work.

Kathy Saradarian, MD

Branchville, NJ

Solo low-staff practice since

4/03

In practice since 9/90

Practice Partner User since 5/03

April 13, 2007

Steve,

I was previously medical director for a CHC with a Healthcare for the

Homeless program and cost-based reimbursement (although not fully

FQHC). I'm now starting a solo IMP.

I would agree with you and others that many of the IMP ideals can be

reached for within the FQHC model but that fully implementing them

would be very difficult. The increased Medicaid/Medicare reimbursement

in FQHCs is cost-based, i.e. your expenses this year affect your

reimbursement level (per visit) for next year. So the feds definitely

have an interest in seeing that efficiency is high.

Our CHC also had a lot of private funding, and many grantors are also

interested in seeing high productivity. Many of them will want to see

increasing goals for numbers of patients seen per provider.

I love the patients and the ethic of CHC/homeless work, but the days

when doing that work meant the ability to spend extra time with

patients are quickly passing. The hamster wheel got there later, but

it's definitely getting there.

I think that the real (but also stopgap) innovation is in setups like

those here who find/create a board that is in tune with IMP ideals and

work to find funding models that are compatible. Because a lot of

funding options come with non-IMPish strings attached.

Haresch