Pay For Performance in EM

[docB]

“Pay for performance” is a concept that is becoming more wide spread in Emergency Medicine. Basically it means that you are paid more if you do more work. That sounds simple but it’s actually not been the rule in a field dominated by hourly payment.

These systems run the gamut from plans that give small rewards to docs with the highest productivity to plans where all payment is based on productivity. The plans where your total compensation is based on your productivity are called “fee for service” or “eat what you kill” plans. There are also hybrid plans that pay an hourly base rate and then provide additional payment based on productivity.

So who cares? Well, these systems are becoming much more widespread because they are very popular with hospital administrators. They are perceived to push docs to “move the meat” resulting in faster turnover which equates to more billing for the hospital and improved patient satisfaction due to shorter ED length of stay. So you should care because if is increasingly more likely that you will one day work under a system like this.

What are some pros and cons? Well the good thing about getting a financial reward for higher productivity is that it motivates some good behaviors like not leaving a bunch of charts for the next doc and not signing out a ton of stuff that could be dispositioned. It also helps to know that when you are getting killed you will get something for it. It also tends to cause better documentation as productivity is based on documentation. Bad things about the system are that it can motivate bad behaviors like cherry picking charts to see more of whatever gets rewarded in your particular system eg. If you get paid based on money collected you will want to avoid seeing the uninsured. It can motivate docs to try to dispo patients too quickly and miss things. It can cause resentment among docs is someone is seen as being a “chart hog.”

I work under a hybrid system that pays a base hourly rate then rewards productivity to the tune of about 20% of your gross. It is a really good system because it means that if you have a slow shift you can still pay the mortgage but if you get killed you get something for it. It reduces the number of signouts and charts don’t sit in the rack but people don’t act like their lives depend on the productivity because it’s only 20%. We are paid based on billing, not collections, so there is no disincentive to see the uninsured. The cost of seeing the uninsured (about $150K per doc per year) is spread out across the whole group.

A note about how productivity is measured. The most common way to do it is using RVUs or Realtive Value Units. This is essentially a way to equalize the work done across different numbers and kinds of patients. For example if two docs saw 10 patients each but one saw 10 ankle sprains and the other saw 10 acute MIs the MI doc will get credited with a significantly higher number of RVUs than the ankle doc. It’s a way of trying to compare apples to apples which is important if compensation is to be based on productivity.

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[DropkickMurphy]

“eat what you kill” plans

Sadly, that's the way I get paid at the funeral home I work at. Business slows down, my paycheck dwindles....

 

[EctopicFetus]

docb i had a question, so if it costs your group about 150K per doc to see uninsured would you guys make more if they did something like is Massachusetts or national healthcare. Now to be clear I am not in favor of those plans but rather just curious on how you think it would effect compensation.

(btw thanks for the vegas help)

 

[Dr.Evil1]

Just wait until you move over to a "seen 30 min or less" system like we have here in the system I am training in. No more cherry picking charts, no blocking etc. You just keep getting patients no matter what.

The attendings here where I am training get paid a base salary plus twice yearly bonuses based on experience, RVUs and other factors (primary night-only workers make more). I think that it is a good system and rewards you doing the right things (documentatio etc.).

 

[docB]

docb i had a question, so if it costs your group about 150K per doc to see uninsured would you guys make more if they did something like is Massachusetts or national healthcare. Now to be clear I am not in favor of those plans but rather just curious on how you think it would effect compensation.

(btw thanks for the vegas help)

Good question. We would make $150K more per year if we didn't see the uninsured and saw 100% insured of the same mix we see now (the mix is the percentage of medicaid, medicare, HMO and private insurance). Now that's just theoretical. It's never going to happen. If suddenly everyone were insured like in the MA plan, where all the working poor are put on medicaid we might make more initially. I suspect that things would equalize and various forces would readjust reimbursements so that any benefit would be minimal. I don't like socialization either but the biggest advantage for me in the ER is I wouldn't have to worry about fighting with consultants about the uninsured.

 

[GeneralVeers]

Good question. We would make $150K more per year if we didn't see the uninsured and saw 100% insured of the same mix we see now (the mix is the percentage of medicaid, medicare, HMO and private insurance). Now that's just theoretical. It's never going to happen. If suddenly everyone were insured like in the MA plan, where all the working poor are put on medicaid we might make more initially. I suspect that things would equalize and various forces would readjust reimbursements so that any benefit would be minimal. I don't like socialization either but the biggest advantage for me in the ER is I wouldn't have to worry about fighting with consultants about the uninsured.

DocB raises the same question that was raised by doctors in Canada in the 1960's. The government realized this, and told them that if national health was implemented that doctors would get paid less per visit, but net more collections and therefore more income as all reimbursement was being paid by the government. Based on this argument doctors there did not fight the socialization and a national health system was implemented. The government has since halted the growth of reimbursement (despite inflation, cost of living increases, etc) and instituted other measures like salary caps to minimize physician salaries. In short socialization of medicine destroyed the ability of most doctors to receive adequate reimbursement, which has had a net negative effect on the quality of care in that country.

 

[BKN]

DocB raises the same question that was raised by doctors in Canada in the 1960's. The government realized this, and told them that if national health was implemented that doctors would get paid less per visit, but net more collections and therefore more income as all reimbursement was being paid by the government. Based on this argument doctors there did not fight the socialization and a national health system was implemented. The government has since halted the growth of reimbursement (despite inflation, cost of living increases, etc) and instituted other measures like salary caps to minimize physician salaries. In short socialization of medicine destroyed the ability of most doctors to receive adequate reimbursement, which has had a net negative effect on the quality of care in that country.

All true, but . . . Organized medicine fought medicare and medicaid as hard as they could in the same era because it was "socialized medicine". Ultimately the Ms made US medicine into a teaching, researching juggernaut while making the docs rich.

The AMA often gets it wrong.

 

[Miami_med]

All true, but . . . Organized medicine fought medicare and medicaid as hard as they could in the same era because it was "socialized medicine". Ultimately the Ms made US medicine into a teaching, researching juggernaut while making the docs rich.

The AMA often gets it wrong.

Just wait. Boomer retirement will upend Medicare reimbursement.

 

[SanDiegoSOD]

At the ER I worked at in San Diego, the physicians were paid entirely for the procedures that they billed for. You better believe that those clipboards moved as fast as possible and that waiting times at this particular ER were well below regional and national averages.

Of course, the unintended consequences of that payment structure means that the homeless and uninsured get less treatment time than the paying customers.

 

[BKN]

Just wait. Boomer retirement will upend Medicare reimbursement.

Not as long as we're old farts that vote.

 

[BKN]

Of course, the unintended consequences of that payment structure means that the homeless and uninsured get less treatment time than the paying customers. But hey, thats life, and thats how medicine should be as long as everyone gets adequate care.

 

[emtp6811]

I agree...

 

[docB]

At the ER I worked at in San Diego, the physicians were paid entirely for the procedures that they billed for. You better believe that those clipboards moved as fast as possible and that waiting times at this particular ER were well below regional and national averages.

Of course, the unintended consequences of that payment structure means that the homeless and uninsured get less treatment time than the paying customers. But hey, thats life, and thats how medicine should be as long as everyone gets adequate care.

It's important to make the distinction between payment systems based on billing and collections. If you're paid on billing then you don't have an incentive to do less on the uninsured (I'm oversimplyfing and will explain later). If you're paid on collections then you do. Some hospital administrators favor the collections method because they want the docs to have an incentive to shortchange the uninsured. One way to tell if your new job pays based on collections if if you have to wait ~90 days for your first paycheck. Thats about how long it takes for reimbursements to roll in.

I was oversimplyfing before when I said that if you are paid on billing then you don't have an incentive to skimp the uninsured. Everyone loses money on the uninsured but if your structure is based on billing (ie. straight RVUs, work done, etc.) then the losses on the uninsured are spread across your whole group. Obviously the bigger the group the more spread out the loss but the bigger the group the more uninsured visits so it all comes down to payor mix like usual.

It's important to understand this stuff because it can really affect how you look at a job. Lets say for example you take a job where you are paid based on collections. Frequently the new guys have to work lots of nights and weekends. Some EDs, like mine, see the majority of their uninsured at night (we get a lot of drunks). So you can see how if you are the doc working the night shift you can work really hard but if you see all uninsured you get no money while the day guy has an easy shift of all insured patients and makes a ton.

Another way to tell if you're looking at a group that pays based on collections is if they tell you that they will loan you money or pay you a set amount for the first 3 months and then deduct that out of your eventual paychecks. Some groups talk up these loans as a selling point for taking thier job.

 

[macdaddy23]

This is a really good topic.

The other "pay for performance" that we may need to worry about is pay based on meeting "standards of care". Such as abx within 4 hours for pneumonia. MI(Chest pain r/o) on ASA,Nitrates,B-blockers. CHF on ACE-inhibitors. etc. etc.

What's scary about some of these are who is making up the rules and what literature are they basing these on. Some are great such as the MI, but the pneumonia one and others have there problems.

 

[8744]

This is a really good topic.

The other "pay for performance" that we may need to worry about is pay based on meeting "standards of care". Such as abx within 4 hours for pneumonia. MI(Chest pain r/o) on ASA,Nitrates,B-blockers. CHF on ACE-inhibitors. etc. etc.

What's scary about some of these are who is making up the rules and what literature are they basing these on. Some are great such as the MI, but the pneumonia one and others have there problems.

Aeeieiie! That's one of the reasons I fled Family Medicine.

 

[docB]

This is a really good topic.

The other "pay for performance" that we may need to worry about is pay based on meeting "standards of care". Such as abx within 4 hours for pneumonia. MI(Chest pain r/o) on ASA,Nitrates,B-blockers. CHF on ACE-inhibitors. etc. etc.

What's scary about some of these are who is making up the rules and what literature are they basing these on. Some are great such as the MI, but the pneumonia one and others have there problems.

You're talking about the "core measures" stuff that CMS is pushing now. I don't kow of anyone who is linking pay to meeting the core measures yet but it might happen. What is happening is that the hospitals are making contracts contingent upon meeting core measures just like they have in the past with utilization review, DRGs, satisfaction surveys and so on.

Not to derail here (but since I'm the OP ) the core measures is just a terrific example of how the government sets out with some great idea and winds up with some horrid atrocity due to unintended consequences. For example, to reach the antibiotic within 4 hours mandate it is often necessary to medicate patients before they can get a chest xray. The half joking stories about a bowl of azithro on the triage desk is not that fanciful. To meet this goal we are way over medicating people and we're going to increase resistence.

 

[southerndoc]

The core measures DO affect payments hospitals receive. There is a bonus for those in the top 10%. I think there is less payment for those in the bottom 10% as well.

 

[NinerNiner999]

One of the groups I interviewed with witholds 7.5% of the group's annual pay if core measure compliance is not above 90% (they have not yet held anything back). I'm not sure how tthey go about ensuring compliance during daily operations though. This thread couldn't come at a better time. I'm considering joining a very lucrative fee-for-service practice (gross pay around 33k per month) and am wondering how much of this income will fluctuate on a month-to-month basis. Additionally, I would be employed as an independent contractor, meaning quarterly taxes, etc. Any pitfalls you would watch out for (DocB and anyone else)?

 

[SanDiegoSOD]

I used to work for the Committee in the House of Representatives that handles much of the legislation concerning Medicare (among other things). I tell you, its scary to see who, in the end, is establishing the framework for our healthcare system. Many of these people have never set foot into a hospital, other than to visit a family member or for a quick trip to the ER...

 

[docB]

One of the groups I interviewed with witholds 7.5% of the group's annual pay if core measure compliance is not above 90% (they have not yet held anything back). I'm not sure how tthey go about ensuring compliance during daily operations though. This thread couldn't come at a better time. I'm considering joining a very lucrative fee-for-service practice (gross pay around 33k per month) and am wondering how much of this income will fluctuate on a month-to-month basis. Additionally, I would be employed as an independent contractor, meaning quarterly taxes, etc. Any pitfalls you would watch out for (DocB and anyone else)?

Being an IC is not a bad deal, it's just different than employee status. To really come out ahead as an IC you need to either know a lot about finance and taxes or you need a good accountant. That is to take advantage of the write offs and to not get introuble with the IRS. You've got to make sure you kow exactly what things you will have to pay for. Most groups pay your med mal. It's good to ask how they do it. Some pay you the premium amount and you pay the insurer. Others pay the insurer for you but you still have to claim the amount as taxable income. However it's set up it results in tax consequences so again have a good accountant. You likley have to pay all your own benefits like health insurance, etc. Those sort of things are what make for the big numbers up front. You should also check into what various people in the group make. Is it just the director that makes $33K/mo or is that standart across the group? Is there a buy in? Is there a servitude period where you make less and work the bad shifts? Always ask about the last several people that joined the group. If the last 5 people they hired are all gone they may be screwing the new guys.

The most important thing to know about job hunting for EM is that cash on the bottom line is not the end of the story. A job that pays a ton but gives no benefits may not be better than a job that pays less but has more perks.

 

[spyderdoc]

One of the groups I interviewed with witholds 7.5% of the group's annual pay if core measure compliance is not above 90% (they have not yet held anything back). I'm not sure how tthey go about ensuring compliance during daily operations though. This thread couldn't come at a better time. I'm considering joining a very lucrative fee-for-service practice (gross pay around 33k per month) and am wondering how much of this income will fluctuate on a month-to-month basis. Additionally, I would be employed as an independent contractor, meaning quarterly taxes, etc. Any pitfalls you would watch out for (DocB and anyone else)?

I am in a FFS group like this, and gross a bit more than that due to good payor mix. I am completely happy, although it took 3 months to get a decent paycheck. THe good part is that if I leave, I will get money rolling in for several months after I leave. My income has fluctuated a bit from month to month, but not enought to affect whether or not I get to put my $4000/mo into the SEP or pay my bills.. I just started here 8 mos ago, I am told it will eventually stabilize a bit.

You will have to pay quarterly taxes, but that is no big deal. As an independent contractor, you have to pay the full amount of Medicare and Social Security taxes that an employer would have paid otherwise.

A very good point of being a fee-for-service is that any money that you generate, you keep. All the benefits that you would get anywhere else, such as vacation pay, bonuses for performance, you get in cash.

Other expenses for me include malpractice insurance, which in California is relatively cheap. A scary thing though is that if I leave in less than 15 years, I will have to pay tail coverage. Tail coverage is waived by the malpractice insurance company if you stay longer than 15 years. This can be very expensive, usually 2.5 times the annual rate. So I would be careful in selecting a job like this and if in your mind you know it is going to be temporary, like for two or three years. In this case, it may not be worth it to make all the extra cash because your malpractice tail coverage is going to be huge.

I pay for my life and disability insurance. My wife gets our medical/dental benefits through her job.

Another thing that you have to think about in a fee-for-service position is working with the other docs. It have to keep an eye out for the cherry pickers who will pick out the charts of the insured patients, and leave you with the self pay or Medicaid patients. Our group has a nice solution for this and that we only have one physician in each part of the ED. There is no way for cherry picking to occur. Make sure that if you go into a group like this, that the patient will be divided via a good system to prevent cherry picking.

Another thing that you have to consider any fee-for-service job is the "buy in". My buy in has two portions. One is a large proportion of overnights. I am required to do five to six overnight per month out of the required minimum of 12 shifts per month. I usually do 14 to 15 shifts, because that is what I am comfortable doing. The overnights can be a drag obviously. This is especially true when you see the senior partners not working any overnights. On all mind to the overnights, and the overnight nurses tend to be awesome and a fun crew to work with. The other portion of the buy in is money. Basically, for the first six months my group collects 20% of my fees. Each six months, my collections increase by 5% until I hit the two-year mark. At two years, I collect 100% of my collections. The only costs that I have our group overhead costs, malpractice, and billing company fees. Even after all of this, I'm still grossing much more (more than double) of what I made at my previous salaried job.

Fee-for-service is definitely not for everybody. It is a completely different mindset when you're at work. You want to see more volume, because if you don't see patients, you don't make money.

Unfortunately, what SanDiegoSOD said:

Of course, the unintended consequences of that payment structure means that the homeless and uninsured get less treatment time than the paying customers.

Has some truth, although I would have worded it differently. I do not think I or any of us would spend any "less treatment time than medically indicated, or treat the non-paying patients differently than paying patients. I will see every patient and treat them appropriately and like a human being. BUT, I don't have to be thrilled to death when I see this patient that is not going to pay me.

OK, I don't have anymore energy to type anymore. I do have more to say, and will post more later....

M

 

[southerndoc]

spyderdoc, a couple questions for you:

1. When paying the full social security/Medicare taxes, what is the percentage you pay?

2. Since your employer pays for your malpractice insurance, must you claim this as income on your taxes?

3. How does fee-for-service being paid by amount paid by patients compare to amount billed by the provider? In other words, I have an offer on the table that is a fee-for-service, but compensation is paid based on what is billed rather than collected. Basically 31% of all physician charges billed to the patient are provided as salary to the emergency physician.

4. Why did you go with an SEP-IRA as opposed to a Self-employed 401(k)?

 

[NYMDinMI]

A friend of mine told me that he applied to a group where it was hourly salary plus quarterly bonus based on collections. When he was going through the fine print it said that if you didn't meet a certain level of collections that they actually deducted from your paycheck.

 

[docB]

3. How does fee-for-service being paid by amount paid by patients compare to amount billed by the provider? In other words, I have an offer on the table that is a fee-for-service, but compensation is paid based on what is billed rather than collected. Basically 31% of all physician charges billed to the patient are provided as salary to the emergency physician.

I know this was for Spyder but let me take a stab until he checks back. It sounds like they have devised a way to avoid penalizing docs for seeing the uninsured. That's basically what any program that pays performance bonuses based on billing is. They have most likely picked 31% because it reflects what they can give you based on their payor mix. I would expect that that 31% could change (over the long term) to reflect changes in that payor mix.

 

[NinerNiner999]

Thanks for the replies - the job I'm considering is working between two hospitals, one 60k volume and the other 25k. Both in a very desirable coastal location. This is as assistant director, with 2-year director track and higher monthly stipend. This location is one of 17 contracts held by a large regional group. Currently, this will include 12 shifts per month (12 hour shifts), equal scheduling (1/3 nights, 1/4 weekends, 2/3 at higher volume hospital). This also includes midlevel providers who see patients. I would sign the charts and bill for their patients as mine, in addition to the other patients I see.

Malpractice with tail is included, but I don't know the details of the tail coverage. I am a partner from day one, with the option to invest in the corporation's private ventures after two years (currently they are developing their own malpractice company and have real estate in several major cities). There is no profit sharing that I am aware of. Physicians recieve 83% of total money collected from patient services, which I assume means there will be a few months until I get my full salary rolling in. How long can it take before I get paid after starting a job such as this?

Also, there is a minimum $120 per hour rate should patient volume drop below average levels, meaning I won't "go broke" on a fee-for-service basis. What are some of the downsides to fee-for service pay under this system? Can anyone suggest other things I should research as I continue to pursue this job?

 

[NinerNiner999]

Oh, and how much should I expect to pay each month for health/dental insurance (two adults), disability insurance, and life insurance?

I've been doing the math comparing IC and Employee and I'm getting the same take-home. What is the "huge" advantage I keep hearing about as an independent contractor?

Also, I hear I can invest up to 42k annually pre-tax as an IC, but I can't substantiate this. Can someone with IC experience give me a breakdown of what I can expect to earn after taxes. For simplicity sake, please use the following numbers:

$400k annual gross
$50k in annual deductions
Married, filing jointly

I'm having a hard time deciding if independent contractor status or employee status is best for me. I know that nobody here is a financial planner, but I'd like the wisdom of those who have used this system before. Thanks in advance!

 

[southerndoc]

Also, I hear I can invest up to 42k annually pre-tax as an IC, but I can't substantiate this.

You can create a SEP-IRA and invest up to 25% of your income (up to $205,000) or $44,000.

You can also create a self-employed IRA and get additional contribution limits.

People who moonlight as independent contractors can also contribute to SEP-IRA's while residents.

 

[NinerNiner999]

Does this all get deducted pre-tax? In other words, does my pre-tax income start at (400-44k or 356k).

Here's what I've got so far:

400k-16k (FICA/Medicare) - 44k (SEP) - 50k (deductions like home interest, etc).

Taxable income = $290k

Is this right?

 

[docB]

Physicians recieve 83% of total money collected from patient services, which I assume means there will be a few months until I get my full salary rolling in. How long can it take before I get paid after starting a job such as this?

Also, there is a minimum $120 per hour rate should patient volume drop below average levels, meaning I won't "go broke" on a fee-for-service basis. What are some of the downsides to fee-for service pay under this system? Can anyone suggest other things I should research as I continue to pursue this job?

You may not have to wait 90 days for a check. Some of the big groups pay you based on what they expect your collections to be. In my group we call the larger corporation "the bank" because they essentially front the money and then take the collections down the line.

I don't see any big downsides to the $120/hr base with additional pay for performance over the base. That's very similar to the system I work under and I'm very happy with it. If you get killed you know you'll get some extra cash. If it's dead then you get an easy shift and make your base which is still pretty good. Find out if your performance portion is based on billing or collections for the reasons discussed previously.

 

[southerndoc]

Does this all get deducted pre-tax? In other words, does my pre-tax income start at (400-44k or 356k).

Here's what I've got so far:

400k-16k (FICA/Medicare) - 44k (SEP) - 50k (deductions like home interest, etc).

Taxable income = $290k

Is this right?

That's the way I understand it. Then again, I'm still trying to figure out all the ins and outs of SEP-IRA's and self-employed 401(k)'s.

 

[southerndoc]

Oh, don't forget you have to pay a self-employment tax in addition to the income tax.

 

[SanDiegoSOD]

Are you sure you'll owe only $16k for FICA/Medicare? As an IC you pay both your share and what your employer would pay, 12.4% up to $94,200 for SS and 2.9% of your gross for Medicare. With a gross of $400k, that would be $11681 and $11600, respectively, for a total of $23281. Probably not a big deal in an end, just dont spend that $7k in your mind yet

 

[spyderdoc]

spyderdoc, a couple questions for you:

Sorry I took so long to reply. I am on a string of overnights, so basically work, chart, and sleep....

1. When paying the full social security/Medicare taxes, what is the percentage you pay?

From the IRS website: http://www.irs.gov/businesses/small/article/0,,id=98846,00.html

What is Self-Employment Tax?

Self-employment tax (SE tax) is a social security and Medicare tax primarily for individuals who work for themselves. It is similar to the social security and Medicare taxes withheld from the pay of most wage earners.

You figure SE tax yourself using Schedule SE (Form 1040). Social security and Medicare taxes of most wage earners are figured by their employers. Also you can deduct half of your SE tax in figuring your adjusted gross income. Wage earners cannot deduct social security and Medicare taxes.

SE tax rate. The self-employment tax rate is 15.3%. The rate consists of two parts: 12.4% for social security (old-age, survivors, and disability insurance) and 2.9% for Medicare (hospital insurance).

Maximum earnings subject to SE tax. Only the first $94,200 of your combined wages, tips, and net earnings in 2006 is subject to any combination of the 12.4% social security part of SE tax, social security tax, or railroad retirement (tier 1) tax.

All your combined wages, tips, and net earnings in 2006 are subject to any combination of the 2.9% Medicare part of SE tax, social security tax, or railroad retirement (tier 1) tax.

Fiscal year filer. If you use a tax year other than the calendar year, you must use the tax rate and maximum earnings limit in effect at the beginning of your tax year. Even if the tax rate or maximum earnings limit changes during your tax year, continue to use the same rate and limit throughout your tax year.

Self-employment tax deduction. You can deduct half of your SE tax in figuring your adjusted gross income. This deduction only affects your income tax. It does not affect either your net earnings from self-employment or your SE tax.

2. Since your employer pays for your malpractice insurance, must you claim this as income on your taxes?

Actually, I pay for my own malpractice. It is deductible off my "pre-tax" income.

3. How does fee-for-service being paid by amount paid by patients compare to amount billed by the provider? In other words, I have an offer on the table that is a fee-for-service, but compensation is paid based on what is billed rather than collected. Basically 31% of all physician charges billed to the patient are provided as salary to the emergency physician.

This could be either a good deal or a bad deal based on your payor mix. If you are seeing a large indigent/self pay population, this may be good. My guess is that this 31% will be less than what is actually collected, so you won't be getting all of your collections. Where will the extra money go if your collections are greater than 31%? If they go towards group overhead expenses and your malpractice, then is fine. If you still have to pay these expenses, then the extra money most likely is being divided amongst the partners.

My group pays me based on my collections. They deduct group overhead expenses as well as my malpractice. Otherwise, what I collect is mine.

4. Why did you go with an SEP-IRA as opposed to a Self-employed 401(k)?

Actually, this is all I was really aware of. Blame my ignorance I guess, but I don't know much, if anything about the 401k.

I do know that I can but about $44k/yr of PRETAX money into the SEP-IRA. Fidelity has a great service with no fees.

Well, hope this helps. Good luck!
Mark