As the healthcare environment changes, some spine surgeons and specialists are considering converting their practice into a concierge medicine model that will allow patients to have exclusive access to the physician and medical services.
"There is a need out there for concierge spine services especially for patients who are getting care on an ongoing, long-term basis," says Wayne J. Miller, Esq., a healthcare transaction and regulatory attorney and founding partner of Compliance Law Group in Los Angeles. "Insurers are often cutting off coverage for patients who are claimed to be at a point where they can't improve any more even if the doctor or surgeon believes additional therapy can help. A concierge practice is often better able to allow patients to continue with their care."
Mr. Miller discusses six steps for surgeons to convert their practice into a concierge medicine model.
1. Opt out of Medicare, other payors. The first thing spine practices should do when converting to a concierge medical practice is decide whether they will opt out as a participating or network provider of Medicare and other payors. Oftentimes, the types of volume of procedures they want to include in their program exceed the level of coverage these payors are willing to accept, or the financial terms aren't beneficial for the practice.
"They have to decide if they are going to opt out," says Mr. Miller. "If so, this means they will need to make some major changes to their practices. For example, opting out of Medicare would require the doctor to contract with each beneficiary agreeing not to bill for their services. Likewise, the practice may evolve into a 'self-pay' arrangement with commercial payors where patients, not the practice, are required to seek reimbursement for their out of network service benefits."
2. Structure an appropriate payment program. There are several options for structuring a concierge spine practice: surgeons can choose to provide 24/7 service for patients, charge patients per episode of care or a combination of both. There might be a monthly or yearly fee for patients to participate in the program.
"The practice might provide 24/7-type of access for patients with chronic spine issues requiring multiple visits, which might be a situation where you have a per-episode arrangement with the patients," says Mr. Miller. "For other patients who have periodic spine health needs, a monthly or yearly retainer type of arrangement may make sense."
In this case, patients would be paying a flat fee for membership to the practice and then additional fees for each procedure or service they receive as a member. The terms would be specified in a written agreement. "One of the difficulties of concierge practices is the willingness of patients to continue to use your services for an extended period of time," says Mr. Miller. "It will only work if the patient is willing to commit via contract for a year or many months at a time, and he or she agrees to pay for concierge care in advance. At the same time, the practice will need to live up to its contract obligations to, for example, provide around-the-clock availability and personalized care."
You also have to address in the contract what will happen if the patient decides to leave your care or fails to live up to their obligations during or after the initial contract period. "If a patient is undergoing care for a chronic problem, the surgeon might find it difficult to stop in the middle of treatment unless another qualified surgeon is able to assume the patient's care," says Mr. Miller. "In this situation, the contract might provide for a reasonable period, such as 60 days, to enable the patient's care to be appropriately transitioned.
3. Consider offering additional ancillary services. Patients with spine issues and back pain often have a variety of specialists working on their care. At a concierge spine practice, consider whether it is possible to include pain blocks, physical therapy and other procedures besides just spine surgery as part of a concierge practice. If those services aren't offered at the practice, you may want to seek another provider or facility that also caters to concierge patients to ensure continuity of the level of care.
"To provide a full care menu to concierge patients, offer either a full range of services in-house that would be included, or arrange or contract with other providers — such as hospitals, ASCs or physical therapists — provided they offer similar levels of care for the patients," says Mr. Miller. "For example, they should provide the same type of 24/7 availability that the surgeon is trying to provide so the level of care is seamless for the patient. This may mean coordinating pricing, availability of services and other issues between your office and other healthcare providers."
Mr. Miller cautions that arrangements that involve referrals in-house or to outside providers must meet regulatory constraints. From a legal standpoint, there are federal fraud and abuse/anti-kickback as well as self-referral or "Stark law" issues that could come into play if there is a financial relationship between the referring surgeon and the referral recipient. Even if the surgeon is opting out of Medicare, the federal law may apply because the other providers receiving the referrals may continue to be Medicare providers. State laws will likely have similar requirement to the national laws on this matter and may apply to all patient referrals regardless of source of payment.
"Referral arrangements must not be tainted by unlawful financial inducements between the doctor and other providers, such as a hospital or surgery center," says Mr. Miller. "These arrangements should solely focus on how each party can contribute to the full care of the patient and what particular services are offered by each provider."
4. Devise care coordination agreements. If possible, devise written care coordination programs with other providers. "Laws don't usually prohibit bona fide coordination of care or referral agreements," says Mr. Miller. "These agreements might say when we have patients in the concierge program and we need a hospital or ASC service, the patient will be referred to you provided that the other provider offers a concierge-level of care at a specific price."
However, be careful not to structure a deal where there is payment going back and forth unless this is for valid services provided between the parties that is unrelated to the volume or value of referrals. "What has to be avoided is any kind of payment that might be construed as compensation for referrals," says Mr. Miller. For example, compensation between parties may be appropriate if, for example, the surgeon practice provides staff or other needed resources to other providers to enable them to offer a higher level of service to patients.
5. Detail what will (and won't) be covered in membership fees. The concierge agreements should be in writing and patients should sign a contract detailing what services will and won't be covered within the membership fees. "The agreement needs to be clear about what the patients are getting for their money, and also explain what they are not getting," says Mr. Miller. "For example, if the payment is an annual retainer that is intended to ensure around-the-clock access only, make it clear that patients aren't paying for actual care; they must understand there will be additional costs for the actual care provided."
The contract should also make sure the patient doesn't abuse the "24/7" care policy by contacting the office so often that it becomes disruptive. "There needs to be some kind of understanding in the contract that the patient can't be abusive," says Mr. Miller. "This could be done by a general admonition that the office is only available where there is a medical need or alternatively by setting a certain number of times the patient can visit or contact the doctor per month."
Finally, the financial agreement must be clear and the contract should outline expectations if the patient decides to end concierge care at your practice.
"The financial terms have to be really clear and there has to be the understanding that if the patient wants to opt out of the contract terms they need to give adequate written notice," says Mr. Miller. "At that point, the contract may indicate that they will not have the same level of access or that the patient will need to find a new physician. The surgeon may need to help place the patient with another doctor to avoid any allegation that he is unlawfully abandoning the patient. Sometimes these arrangements lead to financial and other disputes and there should be a clear and formal procedure for resolving issues with respect to the concierge agreement which may include mediation or arbitration procedures."
6. Clarify that you aren't an insurance company. In some states, concierge services may be construed as an attempt to provide unlicensed insurance services on the theory that the provider is acting as an insurer by accepting money in advance for future care for the patient.
"Make sure to review concierge contracts with counsel to ensure that they don't create an insurance arrangement where that is not intended," says Mr. Miller. "In some states, laws have exempted concierge medicine from insurance regulation. In others, there continues to be a lack of clarity as to whether insurance regulations apply; in these states, surgeons may need advice as to whether they can legally pursue a concierge model."
Additionally, if you are dealing with patients who have Medicare and your practice does not opt out, you should also consult with experts to ensure that patients aren't charged for services under the concierge contract that are already covered by Medicare, says Mr. Miller. For example, a concierge fee that includes an annual physical may inappropriate if the paid service would duplicate the "annual wellness visit" covered by Medicare.
More Articles on Spine Surgeons:
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"There is a need out there for concierge spine services especially for patients who are getting care on an ongoing, long-term basis," says Wayne J. Miller, Esq., a healthcare transaction and regulatory attorney and founding partner of Compliance Law Group in Los Angeles. "Insurers are often cutting off coverage for patients who are claimed to be at a point where they can't improve any more even if the doctor or surgeon believes additional therapy can help. A concierge practice is often better able to allow patients to continue with their care."
Mr. Miller discusses six steps for surgeons to convert their practice into a concierge medicine model.
1. Opt out of Medicare, other payors. The first thing spine practices should do when converting to a concierge medical practice is decide whether they will opt out as a participating or network provider of Medicare and other payors. Oftentimes, the types of volume of procedures they want to include in their program exceed the level of coverage these payors are willing to accept, or the financial terms aren't beneficial for the practice.
"They have to decide if they are going to opt out," says Mr. Miller. "If so, this means they will need to make some major changes to their practices. For example, opting out of Medicare would require the doctor to contract with each beneficiary agreeing not to bill for their services. Likewise, the practice may evolve into a 'self-pay' arrangement with commercial payors where patients, not the practice, are required to seek reimbursement for their out of network service benefits."
2. Structure an appropriate payment program. There are several options for structuring a concierge spine practice: surgeons can choose to provide 24/7 service for patients, charge patients per episode of care or a combination of both. There might be a monthly or yearly fee for patients to participate in the program.
"The practice might provide 24/7-type of access for patients with chronic spine issues requiring multiple visits, which might be a situation where you have a per-episode arrangement with the patients," says Mr. Miller. "For other patients who have periodic spine health needs, a monthly or yearly retainer type of arrangement may make sense."
In this case, patients would be paying a flat fee for membership to the practice and then additional fees for each procedure or service they receive as a member. The terms would be specified in a written agreement. "One of the difficulties of concierge practices is the willingness of patients to continue to use your services for an extended period of time," says Mr. Miller. "It will only work if the patient is willing to commit via contract for a year or many months at a time, and he or she agrees to pay for concierge care in advance. At the same time, the practice will need to live up to its contract obligations to, for example, provide around-the-clock availability and personalized care."
You also have to address in the contract what will happen if the patient decides to leave your care or fails to live up to their obligations during or after the initial contract period. "If a patient is undergoing care for a chronic problem, the surgeon might find it difficult to stop in the middle of treatment unless another qualified surgeon is able to assume the patient's care," says Mr. Miller. "In this situation, the contract might provide for a reasonable period, such as 60 days, to enable the patient's care to be appropriately transitioned.
3. Consider offering additional ancillary services. Patients with spine issues and back pain often have a variety of specialists working on their care. At a concierge spine practice, consider whether it is possible to include pain blocks, physical therapy and other procedures besides just spine surgery as part of a concierge practice. If those services aren't offered at the practice, you may want to seek another provider or facility that also caters to concierge patients to ensure continuity of the level of care.
"To provide a full care menu to concierge patients, offer either a full range of services in-house that would be included, or arrange or contract with other providers — such as hospitals, ASCs or physical therapists — provided they offer similar levels of care for the patients," says Mr. Miller. "For example, they should provide the same type of 24/7 availability that the surgeon is trying to provide so the level of care is seamless for the patient. This may mean coordinating pricing, availability of services and other issues between your office and other healthcare providers."
Mr. Miller cautions that arrangements that involve referrals in-house or to outside providers must meet regulatory constraints. From a legal standpoint, there are federal fraud and abuse/anti-kickback as well as self-referral or "Stark law" issues that could come into play if there is a financial relationship between the referring surgeon and the referral recipient. Even if the surgeon is opting out of Medicare, the federal law may apply because the other providers receiving the referrals may continue to be Medicare providers. State laws will likely have similar requirement to the national laws on this matter and may apply to all patient referrals regardless of source of payment.
"Referral arrangements must not be tainted by unlawful financial inducements between the doctor and other providers, such as a hospital or surgery center," says Mr. Miller. "These arrangements should solely focus on how each party can contribute to the full care of the patient and what particular services are offered by each provider."
4. Devise care coordination agreements. If possible, devise written care coordination programs with other providers. "Laws don't usually prohibit bona fide coordination of care or referral agreements," says Mr. Miller. "These agreements might say when we have patients in the concierge program and we need a hospital or ASC service, the patient will be referred to you provided that the other provider offers a concierge-level of care at a specific price."
However, be careful not to structure a deal where there is payment going back and forth unless this is for valid services provided between the parties that is unrelated to the volume or value of referrals. "What has to be avoided is any kind of payment that might be construed as compensation for referrals," says Mr. Miller. For example, compensation between parties may be appropriate if, for example, the surgeon practice provides staff or other needed resources to other providers to enable them to offer a higher level of service to patients.
5. Detail what will (and won't) be covered in membership fees. The concierge agreements should be in writing and patients should sign a contract detailing what services will and won't be covered within the membership fees. "The agreement needs to be clear about what the patients are getting for their money, and also explain what they are not getting," says Mr. Miller. "For example, if the payment is an annual retainer that is intended to ensure around-the-clock access only, make it clear that patients aren't paying for actual care; they must understand there will be additional costs for the actual care provided."
The contract should also make sure the patient doesn't abuse the "24/7" care policy by contacting the office so often that it becomes disruptive. "There needs to be some kind of understanding in the contract that the patient can't be abusive," says Mr. Miller. "This could be done by a general admonition that the office is only available where there is a medical need or alternatively by setting a certain number of times the patient can visit or contact the doctor per month."
Finally, the financial agreement must be clear and the contract should outline expectations if the patient decides to end concierge care at your practice.
"The financial terms have to be really clear and there has to be the understanding that if the patient wants to opt out of the contract terms they need to give adequate written notice," says Mr. Miller. "At that point, the contract may indicate that they will not have the same level of access or that the patient will need to find a new physician. The surgeon may need to help place the patient with another doctor to avoid any allegation that he is unlawfully abandoning the patient. Sometimes these arrangements lead to financial and other disputes and there should be a clear and formal procedure for resolving issues with respect to the concierge agreement which may include mediation or arbitration procedures."
6. Clarify that you aren't an insurance company. In some states, concierge services may be construed as an attempt to provide unlicensed insurance services on the theory that the provider is acting as an insurer by accepting money in advance for future care for the patient.
"Make sure to review concierge contracts with counsel to ensure that they don't create an insurance arrangement where that is not intended," says Mr. Miller. "In some states, laws have exempted concierge medicine from insurance regulation. In others, there continues to be a lack of clarity as to whether insurance regulations apply; in these states, surgeons may need advice as to whether they can legally pursue a concierge model."
Additionally, if you are dealing with patients who have Medicare and your practice does not opt out, you should also consult with experts to ensure that patients aren't charged for services under the concierge contract that are already covered by Medicare, says Mr. Miller. For example, a concierge fee that includes an annual physical may inappropriate if the paid service would duplicate the "annual wellness visit" covered by Medicare.
More Articles on Spine Surgeons:
5 Spine Surgeons on Practicing Defensive Medicine
7 Biggest Factors Impacting Spine Research & Innovation
5 Tips to Market Minimally Invasive Spine Surgery Practices