Your Opinion On Startup Options

[Guest guest]

You may send any response directly to my email account or you may

post for the group.

I have been considering a solo practice in Illinois. Currently, my

wife and I our both internists. She will attempt to work 1/2 time as

we have two small boys ages 14 months and 3.5v years old. When we

started our search we were employed by a large multispecialty

clinic. She was shareholder and I was pending shareholder status.

, my wife, needed to go 1/2 time because full time medicine for

both of us left little time for ADAM and was on they way.

Besides re-writting all the job sharing and other " less " than

fulltime contracts, the board and administration changed the terms to

make my wife pay her healthcare and malpractice insurance and asked

her to resign her shareholder status to have 20 contact hours instead

of 34. Needless to say this was unattractive. We were told we were

not covering our overhead and needed to be more productive.

Compensation was purely based on production. Target was 40th

percentile MGMA to begin then raised to 50th percentile and now since

we have left they are targeting 65th percentile for each shareholder

and cost accounting each department. Needless to say we both did not

want to see 24-28 patients per day to make things work for the next

30 years.

We started to look for solo practice opportunities in the area, but

we ran into non-compete difficulties. Long stary short there was a

15 mile restrictive area around each clinic and two hospitals. Both

solo opportunities were on the 15 mile border. Attornies fees and 6

months later, we may have a compromise forced by a local judge for 15

mile driving distance rather tha3n radius which was not specified in

the contract. This leaves one of the opportunities intact.

The opportunity is in a small town of 9000 served by a hospital

recently bought by the large and distant county health system. They

have a hospital about 30 min away. 50000 people are in the service

area. They have recently invested 15 million to renovate the local

hospital. This helped them obtain JACCO status at 99% and three year

term. They only have a census of 11 which is predominantly OB and

some elective ortho cases. The local primary care doctors often

transfer to two additional hospitals 15 to 20 minutes away. My

impression is that the administration wants to attract more inpatient

business and needs someone willing to manage patients in the local

hospital. ( This is one of my primary concerns with the opportunity.

Does the hospital have the necessary subspecialty support?) I think

they are looking to me to bridge the gap to the subspecialists.

Otherwise the area needs several internists, but may be saturated

with other primary doctors. Financial support is one year income and

practice expense guaranttee minus net receipts, loan forgiveness to

$42000 additional. These " loans " are forgiven in years two and three.

I think I have convinced them to allow me to start with minimal

overhead and only add resources as needed. But the lack of " backup "

weighs on my mind.

I think I would have already tken the noncompete settlement and the

support for the solo practice above if I had not received another

offer from a rescected physician 30 miles away in my hometown.

Despite the inablitity to obtain new malpractice coverage with a

clean record, I may have considered a solo practice there as well.

The physican has practiced for forty years and his son has joined him

there for the last two years. He is looking to retire and has asked

me to join his son in practice. Terms are less appealing than the

other opportunity and overheas is already close to $200,000.

Malpractice is out of hand with first year policy at $15000 and 5

year mature rates vary 33-53,000. This would push overhead to

240,000+. However, they claim to be making ends meet seeing 2-3

hospital, 2 new, and 12 returns/day over a 4.5 day week. (I know back

to the hamster wheel, but certainly less than 24-28 patients/day).

In addition, the local hospitals both have excellent cardiothoracic

services with excellent outcomes for bypass. Subspecialty services

are not those of a residency program, but much better than the other

opportunity. (Things change though and several pulmonologists had to

leave town secondary to nonrenewal of their malpractice coverage.

Also, the local neurosurgeon lost a malpractice case which topped his

insurance and he was forced to sell his house and practice. Needless

to say we no longer enjoy a level one trauma center in town secondary

to the loss of neurosurgical services.

I think I know what most of you will say, but am interested in your

perspectives. Each of you has helped various memebers of the group

at different times. I could use your opinions on solo with financial

support without a subspecialty net vs. 2 person group practice with

high overhead (ie possibly retrofit the low overhead model over time)

with plenty of local patient services and subspecialty support.

I appreciate your time in advance and thank you for any advice you

can give based on your personal views and experience in medicine.

Standing at the fork in the road.

Ready to forget the path not taken.

Sincerely,

D. Egly, M.D.

[Guest guest]

The hospital support would be nice. Having several primary care

doctors in the area could work in your favor if they are FP. I am

an FP and more than willing to consult a local internist when

needed. The local internist usually have more than they want of IP

care.

You could then do a minimalist type of practice with inpatient and

op care , visit local nursing homes etc. and keep your costs down.

Beware of joining the practice with father and son. It will never be

yours.

Brent

> You may send any response directly to my email account or you may

> post for the group.

>

>

> I have been considering a solo practice in Illinois. Currently,

my

> wife and I our both internists. She will attempt to work 1/2 time

as

> we have two small boys ages 14 months and 3.5v years old. When we

> started our search we were employed by a large multispecialty

> clinic. She was shareholder and I was pending shareholder

status.

> , my wife, needed to go 1/2 time because full time medicine

for

> both of us left little time for ADAM and was on they way.

> Besides re-writting all the job sharing and other " less " than

> fulltime contracts, the board and administration changed the terms

to

> make my wife pay her healthcare and malpractice insurance and

asked

> her to resign her shareholder status to have 20 contact hours

instead

> of 34. Needless to say this was unattractive. We were told we

were

> not covering our overhead and needed to be more productive.

> Compensation was purely based on production. Target was 40th

> percentile MGMA to begin then raised to 50th percentile and now

since

> we have left they are targeting 65th percentile for each

shareholder

> and cost accounting each department. Needless to say we both did

not

> want to see 24-28 patients per day to make things work for the

next

> 30 years.

>

> We started to look for solo practice opportunities in the area,

but

> we ran into non-compete difficulties. Long stary short there was

a

> 15 mile restrictive area around each clinic and two hospitals.

Both

> solo opportunities were on the 15 mile border. Attornies fees and

6

> months later, we may have a compromise forced by a local judge for

15

> mile driving distance rather tha3n radius which was not specified

in

> the contract. This leaves one of the opportunities intact.

>

> The opportunity is in a small town of 9000 served by a hospital

> recently bought by the large and distant county health system.

They

> have a hospital about 30 min away. 50000 people are in the

service

> area. They have recently invested 15 million to renovate the

local

> hospital. This helped them obtain JACCO status at 99% and three

year

> term. They only have a census of 11 which is predominantly OB and

> some elective ortho cases. The local primary care doctors often

> transfer to two additional hospitals 15 to 20 minutes away. My

> impression is that the administration wants to attract more

inpatient

> business and needs someone willing to manage patients in the local

> hospital. ( This is one of my primary concerns with the

opportunity.

> Does the hospital have the necessary subspecialty support?) I

think

> they are looking to me to bridge the gap to the subspecialists.

> Otherwise the area needs several internists, but may be saturated

> with other primary doctors. Financial support is one year income

and

> practice expense guaranttee minus net receipts, loan forgiveness

to

> $42000 additional. These " loans " are forgiven in years two and

three.

> I think I have convinced them to allow me to start with minimal

> overhead and only add resources as needed. But the lack

of " backup "

> weighs on my mind.

>

> I think I would have already tken the noncompete settlement and

the

> support for the solo practice above if I had not received another

> offer from a rescected physician 30 miles away in my hometown.

> Despite the inablitity to obtain new malpractice coverage with a

> clean record, I may have considered a solo practice there as well.

>

> The physican has practiced for forty years and his son has joined

him

> there for the last two years. He is looking to retire and has

asked

> me to join his son in practice. Terms are less appealing than the

> other opportunity and overheas is already close to $200,000.

> Malpractice is out of hand with first year policy at $15000 and 5

> year mature rates vary 33-53,000. This would push overhead to

> 240,000+. However, they claim to be making ends meet seeing 2-3

> hospital, 2 new, and 12 returns/day over a 4.5 day week. (I know

back

> to the hamster wheel, but certainly less than 24-28

patients/day).

> In addition, the local hospitals both have excellent

cardiothoracic

> services with excellent outcomes for bypass. Subspecialty

services

> are not those of a residency program, but much better than the

other

> opportunity. (Things change though and several pulmonologists had

to

> leave town secondary to nonrenewal of their malpractice coverage.

> Also, the local neurosurgeon lost a malpractice case which topped

his

> insurance and he was forced to sell his house and practice.

Needless

> to say we no longer enjoy a level one trauma center in town

secondary

> to the loss of neurosurgical services.

>

> I think I know what most of you will say, but am interested in

your

> perspectives. Each of you has helped various memebers of the

group

> at different times. I could use your opinions on solo with

financial

> support without a subspecialty net vs. 2 person group practice

with

> high overhead (ie possibly retrofit the low overhead model over

time)

> with plenty of local patient services and subspecialty support.

>

> I appreciate your time in advance and thank you for any advice you

> can give based on your personal views and experience in medicine.

>

>

> Standing at the fork in the road.

> Ready to forget the path not taken.

>

> Sincerely,

>

> D. Egly, M.D.

[Guest guest]

Greetings,

It seems to be the attitude of this group that replies to a post of this sort, should be here on the listserv, so that we can all share in the information, as well as share our collective "wisdom". Besides that, I don't know how to find your email addy.

That being said.

I can't really talk about IM practice being an FP, but I have been a rural physician for the past 10 years, except for the last 18 months. And will be doing so again. I also was on the executive committee of the Texas State Agency, Center for Rural Health Initiatives. Why do I mention all this?

It relates to your question about subspecialty support. Throughout my Rural ED experiences, and Rural clinic experiences, I have rarely missed having in-town specialty support. One was a 3y/o accidentally run over by her mother. We flew her out of the ED as quickly as we could get her stabilized and get the helicopter there, but she didn't make it. Could she have made it at a level 1 trauma center? Possibly, perhaps probably, but the closest one was an hour away by car. It is a reality in rural healthcare, you don't have all the resources of a big city, but folks there need care as well. You do what you can.

On a positive note, subspecialty care of a sort has always been available. I have always found many subspecialist more than willing to take my phone calls and discuss questions about patient care, even when it may seem a stupid question to a subspecialist. But heh, I am an FP, I know alot about alot of things, but not everything about everything. Also, in general, when there are more than one physician in town, we will unofficially subspecialize, each becoming more knowledgeable in a certain subspecialty.

Anyway to make my long (usual) story short. Don't let the lack of in-town subspecialists be your deciding factor on where to practice. Help is a phone call away in most cases. And it sounds like, if I have the right mental picture, that subspecialists are not a too terribly long way away, that patients can be sent to, or a tertiary hospital to transfer to. In many places in Texas, those things can be several hours away by land, and even a few hours away by plane. Will all patients get the necessary care in time to recieve the best outcomes? No, resources are limited, especially in the rural setting, see the example above. But, I believe that outcomes would be even worse were we not there at all.

A question from me: Being a rural FP, I see how Gordon's model works well for me. Not knowing the scope of practice you envision, but from the sound of it, not primary care. How does this model work for non-primary care, with all the extra costs that seem to go with it? This pertains to Tim's posts as well.

Sincerely,

TAS

PS: <I think I have convinced them to allow me to start with minimal overhead and only add resources as needed.> Be careful of this one, I thought the same thing. And I do still have the local hospital CEO convinced, however, he was unable to convince the corporate owners (a nearby big city hospital). And so, we went from the offer from the CEO of $120k a year for two years guarantee, plus $7k sign-on bonus, to the loan of a few pieces of office equipment. The reason? The owning hospital would rather spend that money on an employeed physician they can control to see 28+ patients a day, even though they lose $50k per year per practice, for the hospital revenue obtained. ($150k of guarantee then $50k a year) They were unable to see that spending $50k one time, would garner them 1/3 of the revenue for many years.

Your Opinion On Startup Options

You may send any response directly to my email account or you may post for the group.I have been considering a solo practice in Illinois. Currently, my wife and I our both internists. She will attempt to work 1/2 time as we have two small boys ages 14 months and 3.5v years old. When we started our search we were employed by a large multispecialty clinic. She was shareholder and I was pending shareholder status. , my wife, needed to go 1/2 time because full time medicine for both of us left little time for ADAM and was on they way. Besides re-writting all the job sharing and other "less" than fulltime contracts, the board and administration changed the terms to make my wife pay her healthcare and malpractice insurance and asked her to resign her shareholder status to have 20 contact hours instead of 34. Needless to say this was unattractive. We were told we were not covering our overhead and needed to be more productive. Compensation was purely based on production. Target was 40th percentile MGMA to begin then raised to 50th percentile and now since we have left they are targeting 65th percentile for each shareholder and cost accounting each department. Needless to say we both did not want to see 24-28 patients per day to make things work for the next 30 years.We started to look for solo practice opportunities in the area, but we ran into non-compete difficulties. Long stary short there was a 15 mile restrictive area around each clinic and two hospitals. Both solo opportunities were on the 15 mile border. Attornies fees and 6 months later, we may have a compromise forced by a local judge for 15 mile driving distance rather tha3n radius which was not specified in the contract. This leaves one of the opportunities intact. The opportunity is in a small town of 9000 served by a hospital recently bought by the large and distant county health system. They have a hospital about 30 min away. 50000 people are in the service area. They have recently invested 15 million to renovate the local hospital. This helped them obtain JACCO status at 99% and three year term. They only have a census of 11 which is predominantly OB and some elective ortho cases. The local primary care doctors often transfer to two additional hospitals 15 to 20 minutes away. My impression is that the administration wants to attract more inpatient business and needs someone willing to manage patients in the local hospital. ( This is one of my primary concerns with the opportunity. Does the hospital have the necessary subspecialty support?) I think they are looking to me to bridge the gap to the subspecialists. Otherwise the area needs several internists, but may be saturated with other primary doctors. Financial support is one year income and practice expense guaranttee minus net receipts, loan forgiveness to $42000 additional. These "loans" are forgiven in years two and three.I think I have convinced them to allow me to start with minimal overhead and only add resources as needed. But the lack of "backup" weighs on my mind.I think I would have already tken the noncompete settlement and the support for the solo practice above if I had not received another offer from a rescected physician 30 miles away in my hometown. Despite the inablitity to obtain new malpractice coverage with a clean record, I may have considered a solo practice there as well.The physican has practiced for forty years and his son has joined him there for the last two years. He is looking to retire and has asked me to join his son in practice. Terms are less appealing than the other opportunity and overheas is already close to $200,000. Malpractice is out of hand with first year policy at $15000 and 5 year mature rates vary 33-53,000. This would push overhead to 240,000+. However, they claim to be making ends meet seeing 2-3 hospital, 2 new, and 12 returns/day over a 4.5 day week. (I know back to the hamster wheel, but certainly less than 24-28 patients/day). In addition, the local hospitals both have excellent cardiothoracic services with excellent outcomes for bypass. Subspecialty services are not those of a residency program, but much better than the other opportunity. (Things change though and several pulmonologists had to leave town secondary to nonrenewal of their malpractice coverage. Also, the local neurosurgeon lost a malpractice case which topped his insurance and he was forced to sell his house and practice. Needless to say we no longer enjoy a level one trauma center in town secondary to the loss of neurosurgical services.I think I know what most of you will say, but am interested in your perspectives. Each of you has helped various memebers of the group at different times. I could use your opinions on solo with financial support without a subspecialty net vs. 2 person group practice with high overhead (ie possibly retrofit the low overhead model over time) with plenty of local patient services and subspecialty support.I appreciate your time in advance and thank you for any advice you can give based on your personal views and experience in medicine.Standing at the fork in the road.Ready to forget the path not taken.Sincerely, D. Egly, M.D.

[Guest guest]

Another option, if you want to follow Gordon's model even more closely. Instead of joining the practice, rent a room from them and practice solo in their facility, leaving the high overhead to them.

TAS

Your Opinion On Startup Options

You may send any response directly to my email account or you may post for the group.I have been considering a solo practice in Illinois. Currently, my wife and I our both internists. She will attempt to work 1/2 time as we have two small boys ages 14 months and 3.5v years old. When we started our search we were employed by a large multispecialty clinic. She was shareholder and I was pending shareholder status. , my wife, needed to go 1/2 time because full time medicine for both of us left little time for ADAM and was on they way. Besides re-writting all the job sharing and other "less" than fulltime contracts, the board and administration changed the terms to make my wife pay her healthcare and malpractice insurance and asked her to resign her shareholder status to have 20 contact hours instead of 34. Needless to say this was unattractive. We were told we were not covering our overhead and needed to be more productive. Compensation was purely based on production. Target was 40th percentile MGMA to begin then raised to 50th percentile and now since we have left they are targeting 65th percentile for each shareholder and cost accounting each department. Needless to say we both did not want to see 24-28 patients per day to make things work for the next 30 years.We started to look for solo practice opportunities in the area, but we ran into non-compete difficulties. Long stary short there was a 15 mile restrictive area around each clinic and two hospitals. Both solo opportunities were on the 15 mile border. Attornies fees and 6 months later, we may have a compromise forced by a local judge for 15 mile driving distance rather tha3n radius which was not specified in the contract. This leaves one of the opportunities intact. The opportunity is in a small town of 9000 served by a hospital recently bought by the large and distant county health system. They have a hospital about 30 min away. 50000 people are in the service area. They have recently invested 15 million to renovate the local hospital. This helped them obtain JACCO status at 99% and three year term. They only have a census of 11 which is predominantly OB and some elective ortho cases. The local primary care doctors often transfer to two additional hospitals 15 to 20 minutes away. My impression is that the administration wants to attract more inpatient business and needs someone willing to manage patients in the local hospital. ( This is one of my primary concerns with the opportunity. Does the hospital have the necessary subspecialty support?) I think they are looking to me to bridge the gap to the subspecialists. Otherwise the area needs several internists, but may be saturated with other primary doctors. Financial support is one year income and practice expense guaranttee minus net receipts, loan forgiveness to $42000 additional. These "loans" are forgiven in years two and three.I think I have convinced them to allow me to start with minimal overhead and only add resources as needed. But the lack of "backup" weighs on my mind.I think I would have already tken the noncompete settlement and the support for the solo practice above if I had not received another offer from a rescected physician 30 miles away in my hometown. Despite the inablitity to obtain new malpractice coverage with a clean record, I may have considered a solo practice there as well.The physican has practiced for forty years and his son has joined him there for the last two years. He is looking to retire and has asked me to join his son in practice. Terms are less appealing than the other opportunity and overheas is already close to $200,000. Malpractice is out of hand with first year policy at $15000 and 5 year mature rates vary 33-53,000. This would push overhead to 240,000+. However, they claim to be making ends meet seeing 2-3 hospital, 2 new, and 12 returns/day over a 4.5 day week. (I know back to the hamster wheel, but certainly less than 24-28 patients/day). In addition, the local hospitals both have excellent cardiothoracic services with excellent outcomes for bypass. Subspecialty services are not those of a residency program, but much better than the other opportunity. (Things change though and several pulmonologists had to leave town secondary to nonrenewal of their malpractice coverage. Also, the local neurosurgeon lost a malpractice case which topped his insurance and he was forced to sell his house and practice. Needless to say we no longer enjoy a level one trauma center in town secondary to the loss of neurosurgical services.I think I know what most of you will say, but am interested in your perspectives. Each of you has helped various memebers of the group at different times. I could use your opinions on solo with financial support without a subspecialty net vs. 2 person group practice with high overhead (ie possibly retrofit the low overhead model over time) with plenty of local patient services and subspecialty support.I appreciate your time in advance and thank you for any advice you can give based on your personal views and experience in medicine.Standing at the fork in the road.Ready to forget the path not taken.Sincerely, D. Egly, M.D.