FHO billing

[gogogo]

It seems accepted wisdom that FHO GPs are typically making a comfortably high salary; I've seen it mentioned here that billings of 400k-500k is the FHO ballpark before overhead. I've just shadowed 2 FHO GPs, and both told me that with a roster of 1000, you bill ~150k before overhead. I've heard that the average roster is ~1200 patients (corroborated by data on page 14 here). Extrapolating, that means the average FHO GP should be billing 1.2 x 150k = 180k. I know they can also bill a small percentage of FFS for each visit, but that's capped around 60k, so even with that maxed, they should be billing 240k with an average roster of 1200. What explains the 160k-260k difference between the math I'm doing here and the hearsay of 400k-500k billings?

I can't imagine most FHO GPs just compensating by having a larger roster to make the higher billings. One of the ones I shadowed has a roster of 2000 and expects it to build to 3000 before 2022. At this roster size, all he was doing was renewing meds, referring, routine bloodwork, and brushing off a lot. I'm no expert and he may be managing his patients well, but I don't see how most could handle such a large patient load without taking shortcuts. 

[JohnGrisham]

55 minutes ago, gogogo said:

It seems accepted wisdom that FHO GPs are typically making a comfortably high salary; I've seen it mentioned here that billings of 400k-500k is the FHO ballpark before overhead. I've just shadowed 2 FHO GPs, and both told me that with a roster of 1000, you bill ~150k before overhead. I've heard that the average roster is ~1200 patients (corroborated by data on page 14 here). Extrapolating, that means the average FHO GP should be billing 1.2 x 150k = 180k. I know they can also bill a small percentage of FFS for each visit, but that's capped around 60k, so even with that maxed, they should be billing 240k with an average roster of 1200. What explains the 160k-260k difference between the math I'm doing here and the hearsay of 400k-500k billings?

I can't imagine most FHO GPs just compensating by having a larger roster to make the higher billings. One of the ones I shadowed has a roster of 2000 and expects it to build to 3000 before 2022. At this roster size, all he was doing was renewing meds, referring, routine bloodwork, and brushing off a lot. I'm no expert and he may be managing his patients well, but I don't see how most could handle such a large patient load without taking shortcuts. 

In pure FFS without allied health support, this is how most urban* clinic-only FM docs make >300k after overhead, and working +++ hours. 

If your FHO docs have funded NPs and RNs in the clinic where they can pass off more complex psychosocial work too, then that does definitely increase efficiency.

[gogogo]

1 hour ago, JohnGrisham said:

In pure FFS without allied health support, this is how most urban* clinic-only FM docs make >300k after overhead, and working +++ hours. 

If your FHO docs have funded NPs and RNs in the clinic where they can pass off more complex psychosocial work too, then that does definitely increase efficiency.

Thanks for answering. What number would you put on "+++ hours"? 

I don't judge the doctors for doing so because I'm not there yet, but it's unfortunate to see this type of care. Do you know much about the FHO model I'm describing? Is a 1200 roster closer to 240k billing or 400-500k?

[blah1234]

1200 roster billing doesn't get you to 400-500k unless you are doing things out side of the clinic like hospitalist, ER, or whatever.

[JohnGrisham]

28 minutes ago, blah1234 said:

1200 roster billing doesn't get you to 400-500k unless you are doing things out side of the clinic like hospitalist, ER, or whatever.

Agreed, I have seen some creative scenarios like hiring an NP to see your patients 2 days a week, while you do Hospitalists or ER shifts - and come out ahead financially for example. And adding on extra weekend semi-urban coverage etc.

[offmychestplease]

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[JohnGrisham]

12 hours ago, offmychestplease said:

who would be paying the NP? does this mean the MD gets paied for Hospitalist/ER shift on top of the patients that are being seen by the NP?

That specific instance, the MD paid an NP to see their clinic patients. So the patients were still being seen, but the MD would go do hospitalist/ER work, which would pay more than what they were paying the NP to see their clinic patients. 

[Egg_McMuffin]

I don't have an answer to your question but according to this article, the average FHO doc in Ontario billed 400k for a roster size of 1300 and worked 3.5 days a week a few years ago. I assume the 400k is from their FHO practice only...Assuming overhead of 25% they'd take home ~300K before tax. This was before the government wanted to impose claw backs so maybe things aren't as rosy now, but 150k for 1000 patients seem low.

Also pretty surprised that the government is allowing docs to hire NPs unsupervised to do their work and pocket the billings... since they're so concerned with bringing costs down.

[gogogo]

On 10/24/2020 at 10:24 PM, Egg_McMuffin said:

I don't have an answer to your question but according to this article, the average FHO doc in Ontario billed 400k for a roster size of 1300 and worked 3.5 days a week a few years ago. I assume the 400k is from their FHO practice only...Assuming overhead of 25% they'd take home ~300K before tax. This was before the government wanted to impose claw backs so maybe things aren't as rosy now, but 150k for 1000 patients seem low.

Also pretty surprised that the government is allowing docs to hire NPs unsupervised to do their work and pocket the billings... since they're so concerned with bringing costs down.

I read that article too, hence my confusion with how it doesn't line up with what the FHO doctors told me. I don't think either of them had any motivation to obfuscate their true earnings. Having said that, I think the 3.5 days noted is wrong. The FHO GP I shadowed with the 2000 roster building to 3000 would wake up every weekday at 4, study until 7, run errands, then be at his clinic seeing patients from 9-5. No work when he got home or on weekends; he did this 5 days a week. And he was never not working from 9-5...jumping from room to room, filling charts, making referrals, etc.

[medigeek]

On 10/26/2020 at 12:48 AM, gogogo said:

I read that article too, hence my confusion with how it doesn't line up with what the FHO doctors told me. I don't think either of them had any motivation to obfuscate their true earnings. Having said that, I think the 3.5 days noted is wrong. The FHO GP I shadowed with the 2000 roster building to 3000 would wake up every weekday at 4, study until 7, run errands, then be at his clinic seeing patients from 9-5. No work when he got home or on weekends; he did this 5 days a week. And he was never not working from 9-5...jumping from room to room, filling charts, making referrals, etc.

n = 1

[gogogo]

9 hours ago, medigeek said:

n = 1

For sure, but looking at the same 2018 document on FHOs I posted (found here), it says the average FHO capitation per patient is $139.12 (page 16 of the pdf in the "Key Features of FHO Models" section). $139 x 1000 patients lines up pretty well with the $150,000 quoted by the 2 FHO doctors I spoke to. Of course, you could have a panel that gets more per patient, but by these calculations, it seems that the vast majority of patients would have to be elderly and complex.

My calculations must be wrong/missing something given that people always say FHO is lucrative (e.g., the quoted 400k for 1300 patients) and I doubt--though may be wrong--that the only lucrative FHOs are the ones with a very old and complex panel. So, I'm trying to understand where I'm going wrong.

[medigeek]

5 hours ago, gogogo said:

For sure, but looking at the same 2018 document on FHOs I posted (found here), it says the average FHO capitation per patient is $139.12 (page 16 of the pdf in the "Key Features of FHO Models" section). $139 x 1000 patients lines up pretty well with the $150,000 quoted by the 2 FHO doctors I spoke to. Of course, you could have a panel that gets more per patient, but by these calculations, it seems that the vast majority of patients would have to be elderly and complex.

My calculations must be wrong/missing something given that people always say FHO is lucrative (e.g., the quoted 400k for 1300 patients) and I doubt--though may be wrong--that the only lucrative FHOs are the ones with a very old and complex panel. So, I'm trying to understand where I'm going wrong.

There's a lot of shadow billing and other fees you can accumulate. It would be way over 150k. Consider that not everyone will be honest on their earnings as well. Or that they may tell you their post corp tax income, or their net or whatever else. There are so many ways to frame physician income in Canada that the numbers are not clear ever. 

And 1k is a somewhat smaller roster. And the large X variable is how frequently your patients need follow up. If you have people coming in for refills of routine meds - you lose time (as an example). The people making a lot from FHOs have 2.5k ish patients and know how to bill really well. They also supplement income by doing other things (nursing home, inpatient, ER .... medmal reviews (lol) or any one of a million things you can do as a family doc). 

So yes, if your goal is money - you will be busy. And that's the case in most industries too. Of course, you can be a sellout and hire some midlevels to see your patients. If you want to work money before ethics. 

[JohnGrisham]

32 minutes ago, medigeek said:

There's a lot of shadow billing and other fees you can accumulate. It would be way over 150k. Consider that not everyone will be honest on their earnings as well. Or that they may tell you their post corp tax income, or their net or whatever else. There are so many ways to frame physician income in Canada that the numbers are not clear ever. 

And 1k is a somewhat smaller roster. And the large X variable is how frequently your patients need follow up. If you have people coming in for refills of routine meds - you lose time (as an example). The people making a lot from FHOs have 2.5k ish patients and know how to bill really well. They also supplement income by doing other things (nursing home, inpatient, ER .... medmal reviews (lol) or any one of a million things you can do as a family doc). 

So yes, if your goal is money - you will be busy. And that's the case in most industries too. Of course, you can be a sellout and hire some midlevels to see your patients. If you want to work money before ethics. 

I think most people in full scope family medicine would agree, that a roster of 2500 patients - is likely to be very busy, even for the most efficient physicians, if its a moderatly diverse panel with a fair mix of complex/chronic/older patients.  More patients leads to more busy work, more chronic care /specialist followups and care-coordinating that is unevitable and unavoidable. Most would not have much time to do other things outside of clinic to further supplement income. 

Unless of course you are cherry picking  your patients - which i'm not sure if is possible/common with FHO in Ontario. But it is not uncommon in FFS in non-Ontario provinces.

The FHO docs i know are doing well, in the quoted ranges of 300-500k, and are working hard 5 days a week, but usually have weekends off - unless they top up a weekend a month with community ER work or hospitalist coverage. These are physicians i would consider very efficient, and thorough, and not necessarily cherry picked easy patients - or cutting corners with sloppy workups and referrals. 

[windsormd1]

From personal experience as well as talking to LOTS of docs in the community; FHO income is about 30% more than FFS income.  For example, for a roster of 1000 patients, average payment is around 225-300 per patient, all inclusive of extra billings, walk-ins, shadow etc.  The age mix makes a huge difference too; a younger panel will gross on the lower end; older-complex patients on the higher end.  The stories of working 3.5 days a week and grossing 400k+ are more in rural areas; not in the center of Toronto or Vancouver.  The docs also have to worry about outside use, walk-in clinic use in heavily urbanized areas.  Average docs in desirable areas can bill 400k, but you'll be working 4-5 days a week plus the occasional weekend/evening to make it work.  There's also a lot of paperwork.  Overhead also tends to be in the 25-35% range in big cities.  There are lots of factors in play; FM is a great choice.  Ultimately, the income and workload depends on you.  However, the location, patient mix, and clinic management/setup have a HUGE play in how easily or difficult that might end up being.

[MD_scientist]

17 hours ago, windsormd1 said:

The stories of working 3.5 days a week and grossing 400k+ are more in rural areas; not in the center of Toronto or Vancouver.

I wonder where this difference between rural areas and urban areas income come from ? aren't the billing codes the same ? sorry this might sound like a naive question 

[windsormd1]

19 hours ago, MD_scientist said:

I wonder where this difference between rural areas and urban areas income come from ? aren't the billing codes the same ? sorry this might sound like a naive question 

It's a complicated situation due to chargebacks from walk-in clinic use, ability to roster patients, etc.  For example, they'll use walk-in clinics and are not as loyal.  The other thing is that they are 'needier'; if you have a FHO is a rural area, the patients will accept more issues to be handled over the phone, not come in for unnecessary issues, etc.  Very very complicated in practice...............