Peripatetic Services a lasting relationship?

RE: Peripatetic Services a lasting relationship?

James Dunne — Thu, 09 Mar 2017 21:30:06 GMT

Like anything, these ventures need careful planning and consideration. We have visiting consultants in ophthalmology, dermatology, physiotherapy and surgery. Both myself and a colleague, while perhaps short on in-depth knowledge, have reasonable technical abilities and are advanced practitioners in surgery and medicine respectively. I must say, I have found that the system we have works well for us and while we don't make millions from it, there is a benefit to clients mainly in terms of not travelling vast distances. We learn a lot from the consultants and they make a living and maintain their clinical skills without a massive financial investment. With regard to complications, we have ground rules for surgery so that things that are very likely to need major postoperative intervention like thoracotomies or PSS are not taken on in-house and are referred distant anyway. Likewise for ophthalmology; we don't have the cataracts done in house - they do go to the consultant's distant centre, but correction of more complex eyelid deformities are undertaken than perhaps would have been in the past. There are many ways that the visiting clinician can be paid; either a percentage of the total, a fixed salary, a split of the fees etc etc. It boils down to what is acceptable to both parties. If you look at it as a better service for your clients/patients, it works. if you look at it purely as a profit-driven enterprise, it is probably cost-neutral.

RE: Peripatetic Services a lasting relationship?

Rob Loxley — Thu, 09 Mar 2017 19:46:48 GMT

I'd be really keen to know what the backup is - if we can't do the surgery can we sort the complications when the specialist is unavailable or out-of-hours; and is the expectation from the client that the specialist will do the followup/backup? This has happened to us when a peripatetic ophthalmologist was on holiday postop when it went pear-shaped.
We worked with a peripatetic dermatologist and that worked well (rare to need rapid backup) but like Braden, they wanted to be seeing more cases than we could regularly get together, so cases now get referred off (to the same person at a local referral centre).

RE: Peripatetic Services a lasting relationship?

CatherineThomas — Thu, 09 Mar 2017 19:13:07 GMT

[quote user="Gillian Mostyn"]

[quote user="CatherineThomas"]The operations are a bit more tricky because I need to use their facilities and nurses so it needs to be fitted in around their normal operating list, but it's worked well so far.[/quote]

Who does the post op care? (Most of our exotics patients tend to be hospitalised for a few days.) I am genuinely interested because we have this problem - not all the vets are happy handling large parrots, snakes etc so if continued care is needed, it can sometimes be difficult even with a 'normal' practice rota.

[/quote]

I take them home with me where I have a large cupboard/small room set aside for this purpose. Unless it's something simple that the practice staff are happy to deal with. If it's something that I don't think I or the practice could cope with i'll them to the nearest exotics practice but that's about an hour and a half away. The closest practice is only 15 minutes from home so sometimes i've hospitalised at the practice with instructions for the staff there to do basic care and i'll stop in once a day or something to check on things. The practices also have my mobile number so they can call me if there's ever any problems with one of my cases out of hours or if they have an exotics emergency they can't deal with. These days I can't always go in to deal with it myself because of my baby but I can give the vet advice over the phone of how to deal with it.

RE: Peripatetic Services a lasting relationship?

Mike Dale — Thu, 09 Mar 2017 15:12:31 GMT

Short answer, No. I have used peripatetic services in the past driven primarily by need and client unwillingness/inability to travel to/pay for referral centres. Surgical specialists seem to secure lion share of fee out of proportion to cost to the practice of time, space and staff consumption. Probably in a situation where regular work can be guaranteed there is better chance of hitting a happy medium of fee splitting related to impact on practice resources.

RE: Peripatetic Services a lasting relationship?

Anthony Dennison — Thu, 09 Mar 2017 14:56:20 GMT

At our practice we currently have an orthopaedic surgeon, a cardiologist and an ultrasonographer visit us on a fairly regular basis. The cardiologist has one day a month, the other two come in on a case by case basis.

For all of them we charge the client a fee which is the specialist's fee plus a small mark up. We do the post-op care and monitor treatment plans by the cardiologist.

RE: Peripatetic Services a lasting relationship?

Gillian Mostyn — Thu, 09 Mar 2017 13:11:48 GMT

RE: Peripatetic Services a lasting relationship?

CatherineThomas — Thu, 09 Mar 2017 05:16:11 GMT

I do this, although i'm not a "Specialist", just an advanced practitioner in exotics. So I don't charge anywhere near the prices quoted above. I visit the practices on a weekly basis, I advertise and book my own clients in as well as the base practices booking their clients. I fit my consulting times around the availability of a consult room, so I start after their vet has finished consulting/admitting to start operating. I have a list of fees that I will charge the practice - i.e. a consult fee, microscopy, blood sample, non-surgical procedure time, surgical procedure time and the practice puts a fee on their system which covers my fee plus their mark-up. All drugs are supplied by the practice so I don't take anything from them but I also don't have the hassle of keeping/transporting drugs. They do keep some drugs on the shelf which they didn't use before, but only things that I use regularly. I have some of my own equipment which I take in with me. I have my own vds cover just like a locum would.

It works really well for me as I get to do the work I love and can invest in equipment I want, run it how I like. When I was employed I found my employers didn't want to invest in any equipment I needed for exotics or on advertising because they didn't think it was worthwhile. So this way i'm doing all of that myself and actually gaining from it rather than putting in the extra work etc and feeling unappreciated. The practices seem to be happy with how it works, it means they can hand over any complicated exotics cases they don't want to do themselves and they get extra income from my consults. The operations are a bit more tricky because I need to use their facilities and nurses so it needs to be fitted in around their normal operating list, but it's worked well so far.

RE: Peripatetic Services a lasting relationship?

Braden Collins — Thu, 09 Mar 2017 04:21:32 GMT

Hi Lucy.

Rob (the ophthalmology guy) supplies his owner equipment and has his own insurance. We effectively treat everything as his patient, so he is responsible for the follow up, any complications, etc.

For consults, we charge the client $210. Rob takes $150 of that, we take the rest. This covers the consult room space and work by reception. Any drugs dispensed at the time of the consultation come from our supply, and we take any profit from them.

For surgical procedures, we supply the room, nurses to help, and any drugs dispensed. Lab tests are charged separately and paid for by the client - we take any money/profit from those.

We split any surgery fees 50/50, so it's a good deal for us. Although it uses a room and our theatre, it's still profitable after drugs are dispensed.

Rob charges a set amount per procedure. for example, a bilateral cataract surgery with lens implant costs the client $3900. This includes all drugs, procedure fees, etc. This makes it easy to quote on a job and makes it easy to work out how much we get. As you can imagine, $1950 is pretty good for supplying a nurse, space and maybe $150 of drugs.

We take payment at the time of the procedure (we don't do credit or direct insurance claims) then pass half on to Rob.

We tried a similar thing with a dermatologist, but it didn't work as they wouldn't come down without at least 4 cases. This meant that we had to cancel several times when we only had 2-3 cases lined up, and numbers couldn't build as we weren't getting to the point of animals needing revisits. To make it really work, you need the referral service to commit to attending, regardless of the numbers which are booked.

We started offering this service when we were really quiet, and although it is getting hard to fit things around a referral service, we find it well and truly worth the effort from a financial and PR point of view.

RE: Peripatetic Services a lasting relationship?

Lucy Crosby — Wed, 08 Mar 2017 21:24:28 GMT

A bit late to respond to this thread, but it is relevant to our situation at the moment. I'm interested in knowing how to split fees between the practice and the visiting surgeon. It sounds like you are responsible for any debt that might arise? How do you split drugs that are dispensed? What about lab tests? Does your ophthalmologist have their own insurance (professional and for their equipment)?? These are all things I'm thinking about before going down this route. I agree it will be a great service to offer our clients, but am worried about the complexities of the admin and fee management.

RE: Peripatetic Services a lasting relationship?

Braden Collins — Sat, 29 Oct 2016 22:54:48 GMT

We have an ophthalmology referral service visit us once per month. We're 200km away from the nearest referral centre, so other clinics in the south west region refer cases to this guy when he visits.

We add a consult fee for each consult he does (so the client pays his fee plus our consult fee). This covers the cost of him renting the space, and it's still better than people driving to Perth for treatment.

For the surgeries he does, we split the fee down the middle. He supplies the equipment, we supply the drugs and a nurse.

Definately worth our while doing this with him. On a good day, we can end up with an extra $3000-4000 in our pockets.

We process all payments then send his share on to him when he invoices us at the end of the month.

RE: Peripatetic Services a lasting relationship?

Richard Williams — Sat, 29 Oct 2016 22:34:49 GMT

Indeed I was referring to specialist peripatetic clinicians. The questions asks about what is the business terms of these relationships. I'm unconvinced that there is a lucrative proposal from many in this field. I find they quote very close to distant referral centres prices which leaves your practice tied up for hours,with resulting costs and a very small margin. Turnover figures will please but you will only have to suffer a small increase in inefficiency for your margin to be zero or worse.

I may be alone but I find it hard to pay the specialists bill the next day for x Rays they have taken of your case,in your practice with your nurses , using your equipment!

RE: Peripatetic Services a lasting relationship?

Jill Butterworth — Wed, 26 Oct 2016 10:01:07 GMT

Ha ha, sorry, thank you for clarification, Martin! Both models work, and I've used both too. The argument can be related to the 'Vetfresh' post, to get out there and find new ways of working because the world is changing.

RE: Peripatetic Services a lasting relationship?

Martin Atkinson — Wed, 26 Oct 2016 08:51:26 GMT

[quote user="Jill Butterworth"]Not 100% sure about the meaning of your question,[/quote]I think you got the wrong end of the stick Jill. Richard is not talking about cherry picking home visiting or even mobile practices but vets who will visit your practice with their equipment to give your patients a specialist service.

This is very convenient for your clients and often quite lucrative for you as well as the referring practice often shares the spoils with the the referral vet. Specialists who have spent a lot of money setting up a fixed base referral practice may not be so happy and argue that it is not fair on them as the peripatetic provider has much lower overheads and this is as much cherry picking as the ambulatory GP practices. It could be equally argued that the fixes base specialist is able to offer a much more comprehensive service because he/she has access to a much greater amount of equipment and therefore there is not a direct conflict.

A very good friend of mine runs a successful visiting orthopaedic practice which has allowed him to continue working beyond retirement age which he may not have otherwise been able to do.

RE: Peripatetic Services a lasting relationship?

Jill Butterworth — Wed, 26 Oct 2016 00:19:39 GMT

Not 100% sure about the meaning of your question, hence your lack of replies, can you clarify? It is certainly possible to make a living from ambulatory practice, because the overheads are very low.