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starting a new practice faq:

management care


There are any number of workplace safety regulations that apply to medical practices in California that are administered by the California Division of Occupational Safety and Health (Cal-OSHA). These include regulations pertaining to bloodborne pathogens, hazardous materials, medical waste, and worker injury and illness prevention. Every practice must have established policies and procedures that address these regulations. The regulations themselves are likely written in legalese, and not a practical, "can do" source of information. The best resource on this subject is the California Medical Association's "CMA On-Call" document series, which are available free of charge to CMA members and for sale to non-members. To view a list of available articles, go the CMA's website, proceed to "CMA On Call," and click on the "office safety" subject heading. Cal-OSHA also provides information on safety and health training requirements.

Another useful resource is the Cal-OSHA consultation service, which provides education and information about how to comply with workplace laws. This service is not in any way connected to the inspection unit, and it is a highly recommended source of one-on-one assistance. Contact the Cal-OSHA consultation service at 800-963-9424 for more information.
A health plan recently sent a contract to most of the PCPs in the area to contract with them directly on a fee-for-service basis. The contract also covers the IPA model, but comes into force when the plan deems that there is a problem with their IPA contract. Should the PCPs sign it?

This kind of action is becoming more commonplace. Theoretically, IPAs are the closest thing to collective bargaining that is available to independent physicians. However, this strategy may not work for several possible reasons:

1. The IPA bargains effective rates, but does not share the surplus with the physicians. In the scenario, the plan offers a favorable rate to the IPA; however the intended amount for the individual physicians never reaches their hands.

2. The IPA negotiates a favorable rate, but mismanages, or mis-allocates the dollars in the split between primary and specialty budgets. The net effect is the same: not enough of the money gets into the intended hands.

3. The health plan acts in bad faith, and purposely puts a "divide and conquer" plan in motion with the intention of contracting directly with the physicians. In this scenario, the health plan purposely disadvantages the IPA in the negotiations/ rate proposals, in order to "bust" the union. When the IPAs refuse to deal with such health plans, the plan's recourse is to go directly to individual physicians to try and cut individual deals. The initial contracts are often "teasers" with premium short-term rates. Later, when the physicians have lost all collective bargaining power, the plans convert to the rates they intended to pay in the first place.

When considering whether to sign an individual contract, you need to evaluate it based on the potential of the contract to contribute to the short- and long-term profitability for your practice, including potential volume offered in the contract, the current number of your patients that are serviced under the plan in question, and, if favorable, the potential for the proposed rates to be sustained. At the same time you need to take into account the overall picture of your practice's finances and your strength in future negotiations, as an individual, with a large, powerful health plan. You need to weigh this against the integrity, strength and skill of your local IPA to do the right thing for its members.
New provisions recently went into effect strengthening continuity of care for patients. A health plan, at the patient's request, must provide continued coverage with the terminated provider beyond the termination date for certain acute and chronic conditions (up to 12 months), for the duration of a pregnancy, for the duration of a terminal illness, for the care of children ages 0 to 3 years (up to 12 months), and for surgeries previously authorized and scheduled to take place within 180 days of contract termination. Plans may require the physician to agree to the same terms and conditions as a contracted provider, and patients must pay the same deductibles and co-pays. Health plans were expected to file newly updated continuity of care policies, including a template of the notice they are using to inform patients of their right to completion of covered services, with the Department of Managed Health Care by March 31, 2004. For more information, go to http://www.cmanet.org/ and check out CMA On-Call document number 1055.
Hiring a midlevel provider can be an important way of expanding the care you are able to provide in your practice. Nurse practitioners are trained in nursing schools, while physician assistant training programs are commonly aligned with medical schools and may be more interdisciplinary in nature. PAs are dependent practitioners working in close collaboration with MDs under delegatory services agreements. NPs practice more independently, but must follow standardized procedures that are developed in collaboration with physicians. PAs tend to have more varied health care backgrounds and, as a group, are more bilingual/bicultural. Both groups have their own professional organizations.

These differences aside, studies that have compared NPs and PAs working in the same settings have not shown significant differences between the two. Therefore, your best course of action might be to advertise for either an NP or a PA, and hire the candidate best suited to fit in with the practice and meet your patients' needs. For samples of PA delegatory services agreements and/or NP protocols, send your fax number to Sonia Kantak. For more information about NP scope of practice laws, visit The California Board of Registered Nursing; for more information about PA scope of practice laws, visit California Department of Consumer Affairs, Physician Assistant Board. You should also contact your malpractice carrier before adding a midlevel to your practice.
Since NPs and PAs are licensed differently, there are different supervision requirements for both. NPs practice under standardized procedures with protocols; PAs can practice with one of two mechanisms for supervision: the MD countersigns the chart notes (or some percentage thereof) or the standardized procedures/protocols required of NPs. Both professionals can practice with remote supervision by telephone, but of course, that will depend on the experience of the PA or NP. Many sites use the same method of supervision for both NPs and PAs who practice there. You may wish to reference certain texts as the basis for your clinical protocols. Two examples include:

1. Nurse Practitioner/Physician Collaborative Practice: Clinical Guidelines for Ambulatory Care, UCSF Nursing Press, GM Collins-McBride and JM Saxe, Editors, ISBN 0943671161.

2. The Roles of Physician Assistants and Nurse Practitioners in Primary Careby Kay Clawson, ISBN 1-879694-07-7.

Your malpractice carrier might also be able to suggest sources of sample protocols.

It is essential that the supervising physician be comfortable with the amount of oversight he or she has with midlevel providers, as the physician employee typically covers the midlevel under his or her malpractice policy. (Occasionally, midlevel providers have their own malpractice insurance.) For more information about NP scope of practice laws, visit The California Board of Registered Nursing; for more information about PA scope of practice laws, visit California Department of Consumer Affairs, Physician Assistant Board. Be sure to contact your malpractice carrier before adding a midlevel to your practice.