year end financial/quality stuff

[Guest guest]

Group- I wanted to post summaries of my financial and practice quality

information for the past year, those two duelling forces that settle my practice where it lies. If you are squeamish about viewing the financial underwear or the quality corsets of my practice, then skip this post! I am attaching a year end summary of

expenses/income so you can see the details, but I would appreciate it

if you did not circulate the financial information outside of the listserv. On the other hand. if you have questions about what the HowsYourHealth summary shows, fire away and you can post that summary anywhere you'd like, bathroom wall graffitti, other listservs, etc. I

wanted to put this information out on our list because I wanted to show

that it is possible to run a solely insurance based no fee practice IMP and survive, maybe

even have a somewhat reasonable income, and I wanted to round out the picture of IMP financial models that are survival feasible with other viewpoints/models discussed on the listserv. Generally, I think I am practicing in a zone

which has somewhat low reimbursements, 10% less than neighboring MA and

CT, way less than parts of Oregon, (for 99214 (BCBS $100.08,

second highest medicare at $92.78, United at $85.19, managed medicare

$79.70- 72.07, managed medicaid $50's - $60's, it is too depressing to pull the actual number, lowest medicaid at $25) ), middle- high malpractice

rates, high rents, and great quality of life.Despite this, RI does

not appear to be a completely dead zone, as far as I can tell. Billing

E/M codes about 89% 99214 and 10% 99213. (Tried to do the

calculation that Kathy had suggested in the apples and oranges

thread, but got a low of $57.70 per visit and a high of $125 per

visit. I imagine I am not doing it right. My practice management will

not pull out visits alone, only by procedure codes, and I don't want to

go through my EMR and count them up by hand, though I suppose I could.

The $125 is just using all E and M codes no shots or shot visits only (

for which I am paid only $4.50- 8.50, and which I did 300 of this

fall), or other procedures (biopsies cryos EKG alone etc). The low

number is using all procedures ekgs shots cryos which were performed

during a visit or freestanding, which are bundled or not, etc.)This year it

looks like I will make in salary $72K, health insurance benefits ($3K

as flexible spending account directly to me, and corporation pays for health/dental insurance premiums) , retirement $15K,

remaining profit to me about $53K. Total income for me

in the $143K range. Overhead about 25% and gross collections about $190K. This year out of the profit, I paid back my startup money to me, (well the part of it the accountant said I could, 18K of 20K with 6% interest)I am

still seeing an increase each year in revenues as my billing and office

efficiency improve, but currently I am putting in way too many hours right now -

I think I overshot, added new patients in the fall - so I am resolved

over the next year to crank down, either the patient work at the expense of

income, or keep visits at the same level but keep working on efficiency

issues to work less time. I am seeing between 40-50 patients a

week, working around 45-70 hours a week, maybe 25 clinical hours per week taking about 2-3 weeks of

vacation CME/year, practice had remaining 737 active patients when I

went through the list last week and dropped a bunch of inactive

registrants. First half of the year was slow, maybe averaged 35

patients a week, past 3 months am mostly in the 45-50 range of patient

visits per week. Average payment for 99214 over the past year - all payers: $81 and

for 99213 $52; all claims bundled in RI , so no preventive + E/M,

and you often can't bill a surgical procedure + OV .Still no

office staff but I do have a back office biller, and I do hire my kid

to clean the office (with lots of supervision, though he's improving).

Some background information on the money:Seems like the

average starting salary for FP hospital based practice in RI is about

$120K. For people in practice longer, I think the average salary is

higher but I can't tell you how much higher. It's taken me some time

to get to this amount of revenue for sure. Approximate time frame: first 15

months, $40K, year 2, $70 something K, year 3, $107K or thereabouts,

year 4 - seems like $140K range. Had I been more focused on making

money, I think I would made more sooner, but I am not and no regrets.Some big financial mistakes that I made:Renting

too big a space at first 1600 sq ft, about $1850/month with utilities,

after 2 years moved to a 800 sq ft space, $1066/month with utilities, much more doable.Getting

way behind on billing and going with paper - took about a year to get

out of the hole/backlog (or maybe 2 years) and become electronic,

lost piles of money that I should have collected.Still am not collecting the way I should. However, one can't be perfect. I am definitely not going to tell you guys what my AR% is so don't even ask me.The most important thing I did and continue to do financially:Keeping choices stringently in line with low overhead (including EMR,

limiting fancy medical diagnostic/treatment bells and whistles,

limiting staff, being miserly about office hardware software and space).A winner in the recent basket of cheap technology:Since

the beginning of last December when I started virtual visits, I've

logged 38 visits, charged $25 each, payment 23.90, through Paypal

online, total income about $1000.Costs : my time, about 5-15

minutes per visit, Brinkster webhosting and site $10 per year for

domain name and about $45 for web site hosting. Great addition for

me and my patients. Before using eVisits, I would just have done this work for free. (cost of IMH is $50/month but I was using it

before I started virtual visits so I am not counting it against this

income, if I did it would pay for IMH still have $350 to spare)Big picture items:Practice best things-Quality

of interaction with patients at the practice ( due to unloading of time

constraints), documented courtesy of HowsYourHealth, see attached. In the transparency of a micropractice setting it is especially obvious that quality of care and income earned (sadly equals 'visits seen') are the major duelling players, and both impact MY quality of life a huge amount which in the long run is what matters the most to me - requires a fine balance, which I have not found yet. This group, and connections made through this group - no, there is NO way I would have been able to survive/thrive without you all. Autonomy: (the little tyrant in me rejoices!) I do it ALL the way I want to, ALL the time, just subject to market forces and restraints of my conscience. No boss, no partners, no staff, all ME.Patients at my

practice: they are great!- supportive of the model and the

idiosyncratic way I do things; we didn't know exactly where we were

going at first, but they came for the ride anyway and have stayed (and

we have FUN too).Pretending to be a technogeek (though I'm not).Practice worst things-Autonomy/responsibility

is ALL ME, never lets up, no allowance for off days, tired, lazy, bad

attitude etc. There is no respite, so don't get your hopes up.Work, work, WORK! The constant barrage of high level multitasking makes my brain tired. Dealing with the dysfunction of the current insurance mess we are in. Some things that I want/see/worry about for the future:I

want to work less. I don't see myself working 60+ hours a week 5 years

from now for this income level, but I think I can continue this level

of productivity by continuing to realize efficiency gains. My

efficiency is still improving at a good clip and that seems to be

continuing even as I see it now, with room to move. Other options if

efficiency is maxed out and I am still working too much- I'll limit

my practice size more severely, drop my lowest payors. I also don't

mind working less AND making less but it's hard to calibrate exactly

where the line should be. In RI: internecine insurance

and hospital wars ongoing; these guys are playing with an eye to

vaporize the competition. If BCBS gets knocked out the market and

United has the major market share, that will be a strong impetus to me

to drop all insurances and go to a cash pay system.As in every

place in the US - the dysfunctional system continues to cost all of us

more and more, and as administrative burden increases, and insurances

pay less, I wonder about the survival of even my very lean practice. To

improve quality, I am still chasing after patient activation,

self-efficacy, confidence. I think this is the most important thing I

can do to improve the care I deliver, and I am both lucky and grateful

to have the Wasson/ crowd leading the way.So that's the

summary. Hoping you rich guys in parts of Oregon and Colorado are not

falling off your seats laughing saying things like - 'Geez, she works

like a dog, and she ONLY makes $xxx, haha!', and I hope the information

is useful for you raising-up IMPs.Go IMPS!Lynn HoWindows Live™: Keep your life in sync. Check it out.