Kim Baird, RN, MSN, FNP Director and FNP Care Provider Woodbine Family Care Center, Woodbine, GA

How is your practice organized?

Mission and Objectives: To provide cost effective primary care throughout the lifespan and to provide excellent quality care to an underserved rural population.

Ownership and legal structure: I am a contracted employee of the Southeast Georgia Regional Medical Center. As soon as they learned of my interest in setting up practice, the Medical Center was interested in supporting my clinic as part of their obligation to provide care to the underserved.

Although the clinic is owned by the hospital, I am also incorporated as a professional corporation. I feel that this legal setup provides more protection as well as tax advantages. I incorporated because I knew I would have more than my contract with the hospital. Indeed, in addition to my clinic work, I pay visits to patients in the hospital, and I also have a separate contract with the county to visit the local detention center. Having a professional corporation facilitates my ability to bill insurance companies which require a Tax ID number (although I understand that they will also accept social security numbers).

At the outset, I was a skeptical about contracting with a hospital and losing control of my clinical practice; but I was also worried about financing the practice. The hospital needed to use some of their indigent care trust fund money (federal money applied for through the state health dept and distributed based on application) and was interested in backing me. This support removed many of my financial worries, but I also don't have control over setting the fee schedules.

At the time I set up practice in 1994, I was acutely aware of the cost cutting trends in medicine, the difficulties with payment issues, and the nebulous nature of 3rd party reimbursements to NPs. So, on balance, I feel that I have made a wise decision.

The Medical Center now buys supplies for the clinic and rents the space. They also upgraded my software to Medical Manager and in the near future will upgrade to Cerner Medical software which provides system-wide capacity that links the Medical Center with outlying clinics. If you got down to brass tacks, the hospital owns the clinic. But there are very few strings attached. The hospital has an administrator who is responsible for keeping tabs on the clinic but visits only infrequently. I am considered the Director of the Family Care Center. The hospital also provides an FNP to do certified diabetic work, including teaching and handling pumps. The hospital also pays my preceptor (the collaborating physician mandated by the State of Georgia).

Clinical relationships (collaborating physician, referrals, on call) In Georgia, the NP and preceptor must write a protocol letter that designates that the preceptor will be available by telephone, fax, and by beeper after hours. My preceptor comes 3 1/2 hours per week for collaboration, to be of general assistance and help (i.e. seeing some patients), and to review about 10% of the week's charts, including all physicals. He visits every Thursday from 1:30 - 5:00pm.

Although the hospital hired my physician and pays him $1500 per month, I retained the right to pick him. I had trouble with my first preceptor who often didn't show up for his designated hours and had become very demeaning towards me. So I took the bull by the horns, spoke with the hospital to set up a meeting to mediate the situation. The result was the termination of that preceptor relationship. However, in preparation for that contingency, I had located another physician who was happy to work with me and I was ready with a new preceptor agreement in hand for my new partner to sign as soon as the meeting ended. This advance preparation prevented me from experiencing any lapse in coverage.

There are many creative ways to reimburse the precepting physicians. Although in my case, the hospital pays my preceptor, some NPs may arrange to give 10% of proceeds from insurance reimbursements that are co-signed by the preceptor. I have a friend who uses the same preceptor as me but she doesn't pay him a monthly fee because he doesn't review charts. This NP only uses a physician because Lockheed wants pre-employment physicals performed by specifically by a physician. Instead, she pays him 45% of the collections received from Lockheed. There has been so much ground broken now; it's possible to find all kinds of creative ways to set up collaborations.