The most common and reasonable electronic communication with a collaborating physician is via telephone. Telephone communication can come from either a beeper call to the physician or to the physician's secretary/office manager. The physician response time can range from 15 to 30 minutes, which should be described in the collaborative agreement. A schedule should be in place at the office identifying the "general" whereabouts of the physician. However, there should be office practice procedures describing what happens if the physician does not respond in this timely fashion. Those types of procedures do not have to be listed in the collaborative agreement. Follow-up issues can be recorded via fax for documentation purposes. This concept of electronic communication with the physician covers all aspects of practice including consultation and patient-related issues, as well as drug interactions and so on.

Compensation for the collaborative physician implies that the APN is not an employee of the physician, and is truly an independent provider. If the APN is an employee, then it is a moot point and no compensation should be paid to the physician. Compensation to the collaborative physician is centered on three basic tasks:

• Availability to the APN to comply with licensing and payer requirements as well as other regulatory agencies.
• Establishing and maintaining protocols.
• Some UR time reviewing some charts between APN and physician.

There is no standard of compensation, and it is all related to what the market will bear. That is, you have to fight with the right physician who is willing to do this, and what his/her time is worth. Time is money, and the physicians think that they will be expending a lot of time to your practice. Try to quantify (as best as possible) the physician's time for this collaborative agreement. Establishing and maintaining protocols should take about 4 hours to establish, and maybe 15-20 hours over the course of a year. UR time, if done on a quarterly basis and say at 1 or 2 hours per session, comes to 8 hours for the year.

The biggest issue is physician availability and their time. For some reason, physicians often think that they are on call 24 hours per day/7 days per week for you. Education and innovation needs to intervene here. In talking with APNs throughout the country, my experience (and this is purely subjective) tells me that consultation with a physician via telephone ranges from 10-15 calls per month. A lot of that depends of APN practice experience, patient characteristics, etc and etc. If each call per patient problem takes 20 minutes (including the phone tags that go with it), then the physician may be contributing between 3-5 hours per month. Therefore, the physician would contribute about 50 hours per year for availability + 20 hours for protocols + 8 hours for UR for a total of 78 hours for the year. These types of tasks do not warrant "the premium dollar" for the doctor's time.

However, they will tell you otherwise: "my practice I make $125 - $200 per hour." In my opinion, this time is worth about $30 per hour, which would make the collaboration worth about $2,500 for the year. Whether it is through their education or through their ego and god-like personal attributes, the docs feels that a collaboration agreement is worth $10,000 and more per year. They generally start off at $15,000.

Their perception that anything under $10,000 is not worth their time. I guess they like the sound of these numbers. I generally offer a package of $5,000 per year, and explain and quantify the time involved. Unfortunately, at that point, the doc says, "it is not worth my time for such little money and constant calls from you, and besides, I am held liable for your patients if you screw up." With regards to liability, that is not accurate. Malpractice insurance companies do not consider this a liability issue. It is treated as consultation in the same manner that a cardiologist is brought in by a primary care physician to review the patient, or patient is referred to the cardiologist at his/her office.

My recommendation is to be calm and explanatory to the facts of what is involved. I would not pay a physician more than $7,500 per year for a collaborative agreement. If need be, you can be more creative and put in some "work-load" parameters (i.e. calls per month that exceed so many per month will be paid at $xxx/month). Last, if you hear, " what do I get out of this but just $5,000 per year", it is time to move on and find another physician because it is not worth the time and effort to retrain an "old dog with bad habits."