Re: Practice Transformation

[Guest guest]

You say you are " only " seeing 25 patient's per day? I have not seen that

many since I opened 2 years ago, and am still averaging probably about 12

patients per day. I'm not getting rich but I'm certain not doing too bad

either. I generally have a low overhead practice, though not nearly to the

extremes that some on this list do (my overhead sounds more similar to your

practice). However, I came into town on a hospital income guarantee and

that allowed me to have all of the " bells and whistles " such as a nice EMR,

tables, etc. There is no way I would have started out in solo practice

right out of residency any other way.

It sounds to me like you really need to start limiting some of the payors

you accept. Do you currently take Medicaid? If so, that would be the first

place I would start. It is critical to work smarter and not necessarily

harder and that usually translates into only taking patients you know you're

going to get paid well for, and eliminating the bottom paying companies

sooner rather than later. Also, I'm not a big believer in cash only

practices, mainly just because I know that absolutely would not work in the

community I practice in. I personally would not pay cash for my own health

care and still pay for my own insurance, no matter how wonderful my doctor

was. I am not sure where you are located but if it is any type of rural or

semi-rural area I would be skeptical that cash only would work. Patients

will just take the path of least resistance and go to the other practices in

town that are still taking insurance unless the quality of care that you

offer is so exponentially better as to justify them paying out-of-pocket.

If I took all comers I'm sure I also would be seeing 25 to 40 patients per

day, but I would simply be working harder and not necessarily making a lot

more (at least not in a one-to-one ratio of effort to income). Finally,

looking at other job offers in other locales may be a viable option after

you rule out making it work where you are at.

Practice Transformation

Looking for advice from doctors on the list working alternative

practices. You know how when you hold a piece of paper over a flame

and it starts to turn brown just that instant before it bursts into

flames? That's me right now. I am so close to burn-out.

I have a solo practice with a 32-hr-a-week NP, an MA, and a

receptionist. I have fairly low overhead, but I have it in part

because I do all the office management work, e.g., ordering supplies,

the books, payroll, etc. I practice in an area where there is a lot of

demand. There are now only 4 doctors here providing care to a

population that averages 20,000. The other three doctors have been

here longer and all practice independently as well. (The hospital is

recruiting, but it is hard to find a doctor to come into this

environment.)

I am only seeing 25 patients a day (and the NP averages 15), but I am

only seeing that number by limiting access. I could probably see 40 a

day if I opened the gates. Limiting access is a stressful thing and it

means that I spend another 1.5 hours a day answering emails and phone

messages. (And therefore providing less then adequate care.)

I recognize now that I let it get out of hand. But I am not sure how

to fix it. I cannot fire a third of my patients. Not at a time when

two of the other three doctors are also no longer taking new patients.

In the heat of my burnout, I can only see two solutions. One is to

move. Pull up shop and start over elsewhere. That is the easy way out,

that is for sure. And my stress has my family stressed enough to where

they would probably pull for this option at this point.

The other idea is to change to a cash-based practice. The good thing

about this is I would lower my overhead even further. I could probably

do away with 1 or 2 of my employees. I would likely slow way down. I

could add extra services, evening or weekend hours, if necessary. I

would opt out of Medicare too.

This seems like a smart move, since the area is underserved enough

that it might support it. But I struggle with it on several levels. I

am afraid that I will generate just as much bad karma doing this as I

would by " firing " half of my patients (or leaving town), because

probably that many will still feel like they are now without a doctor.

And I would think that my practice would turn into an urgent care

clinic as people would not come in for wellness visits and only for

sick visits when the other offices are full.

Has anyone made the leap from too-busy practice to cash-based practice

and have any comments? For that matter, has anyone in the group made

the Gordon--Practice-Conversion from a full, too-busy practice?

How do you slow things down once they're out of hand?

Thanks for the advice!

Greg Hinson

[Guest guest]

You say you are " only " seeing 25 patient's per day? I have not seen that

many since I opened 2 years ago, and am still averaging probably about 12

patients per day. I'm not getting rich but I'm certain not doing too bad

either. I generally have a low overhead practice, though not nearly to the

extremes that some on this list do (my overhead sounds more similar to your

practice). However, I came into town on a hospital income guarantee and

that allowed me to have all of the " bells and whistles " such as a nice EMR,

tables, etc. There is no way I would have started out in solo practice

right out of residency any other way.

It sounds to me like you really need to start limiting some of the payors

you accept. Do you currently take Medicaid? If so, that would be the first

place I would start. It is critical to work smarter and not necessarily

harder and that usually translates into only taking patients you know you're

going to get paid well for, and eliminating the bottom paying companies

sooner rather than later. Also, I'm not a big believer in cash only

practices, mainly just because I know that absolutely would not work in the

community I practice in. I personally would not pay cash for my own health

care and still pay for my own insurance, no matter how wonderful my doctor

was. I am not sure where you are located but if it is any type of rural or

semi-rural area I would be skeptical that cash only would work. Patients

will just take the path of least resistance and go to the other practices in

town that are still taking insurance unless the quality of care that you

offer is so exponentially better as to justify them paying out-of-pocket.

If I took all comers I'm sure I also would be seeing 25 to 40 patients per

day, but I would simply be working harder and not necessarily making a lot

more (at least not in a one-to-one ratio of effort to income). Finally,

looking at other job offers in other locales may be a viable option after

you rule out making it work where you are at.

Practice Transformation

Looking for advice from doctors on the list working alternative

practices. You know how when you hold a piece of paper over a flame

and it starts to turn brown just that instant before it bursts into

flames? That's me right now. I am so close to burn-out.

I have a solo practice with a 32-hr-a-week NP, an MA, and a

receptionist. I have fairly low overhead, but I have it in part

because I do all the office management work, e.g., ordering supplies,

the books, payroll, etc. I practice in an area where there is a lot of

demand. There are now only 4 doctors here providing care to a

population that averages 20,000. The other three doctors have been

here longer and all practice independently as well. (The hospital is

recruiting, but it is hard to find a doctor to come into this

environment.)

I am only seeing 25 patients a day (and the NP averages 15), but I am

only seeing that number by limiting access. I could probably see 40 a

day if I opened the gates. Limiting access is a stressful thing and it

means that I spend another 1.5 hours a day answering emails and phone

messages. (And therefore providing less then adequate care.)

I recognize now that I let it get out of hand. But I am not sure how

to fix it. I cannot fire a third of my patients. Not at a time when

two of the other three doctors are also no longer taking new patients.

In the heat of my burnout, I can only see two solutions. One is to

move. Pull up shop and start over elsewhere. That is the easy way out,

that is for sure. And my stress has my family stressed enough to where

they would probably pull for this option at this point.

The other idea is to change to a cash-based practice. The good thing

about this is I would lower my overhead even further. I could probably

do away with 1 or 2 of my employees. I would likely slow way down. I

could add extra services, evening or weekend hours, if necessary. I

would opt out of Medicare too.

This seems like a smart move, since the area is underserved enough

that it might support it. But I struggle with it on several levels. I

am afraid that I will generate just as much bad karma doing this as I

would by " firing " half of my patients (or leaving town), because

probably that many will still feel like they are now without a doctor.

And I would think that my practice would turn into an urgent care

clinic as people would not come in for wellness visits and only for

sick visits when the other offices are full.

Has anyone made the leap from too-busy practice to cash-based practice

and have any comments? For that matter, has anyone in the group made

the Gordon--Practice-Conversion from a full, too-busy practice?

How do you slow things down once they're out of hand?

Thanks for the advice!

Greg Hinson

[Guest guest]

Greg,

I feel for you, and I am concerned for you very much.I think the best thing from

all this is that you recognize what is happening and that you are reaching out.

You say in your posting that, " I am afraid that I will generate just as much bad

karma doing this as I

would by 'firing' half of my patients.... " How does the karma feel right now?

And most imporantly, there's that word, " afraid, " a very intuitive and, in your

situation, powerful force in how you have ended up in your current situation.

I do not have specific, logistical, practical answers to your questions. I have

opted out of Medicare and everything else, but I am just getting started; I am

not that busy right now. In fact, I am experimenting with several dietary and

nutritional approaches to help me counsel my patients and I am studying for the

boards in holistic medicine. And I'm putting together a large two-day CME event

in my area, etc., etc.

I did a lot of soul-searching recently, and most was focused on my fears and

assumptions of what medicine, my profession, my life, etc. are all about. Once I

felt I understood where my balance is, that is, who I am ultimately, I was able

to start answering those difficult questions.

My first, intuitive, suggestions mentally to you were: practice Qi

Gong/meditation/pray. Eat healthier. Exercise some. Take time off. The world

will not collapse without you. You and your family need you, not the doctor you,

or the whatever you, but you. Focus on this. I know it sounds unproductive, and

perhaps you can make a few changes that can help your immediate situation, but

eventually, you will need to divert all your attention inward and redefine who

you are. Once you feel some comfort with this, then some, and eventually all, of

the answers will be self-evident. And you won't be afraid anymore. Then you

cannot make a wrong decision.

Good luck; I will pray for you. And I look forward to the wisdom that I know

your appeal will generate among our good colleagues.

Charlie Vargas

New Mountain Medicine

lin, NC

newmountainmedicine.familydoctors.net

Date: Tue Feb 28 11:06:58 CST 2006

To:

Subject: Practice Transformation

Looking for advice from doctors on the list working alternative

practices. You know how when you hold a piece of paper over a flame

and it starts to turn brown just that instant before it bursts into

flames? That's me right now. I am so close to burn-out.

I have a solo practice with a 32-hr-a-week NP, an MA, and a

receptionist. I have fairly low overhead, but I have it in part

because I do all the office management work, e.g., ordering supplies,

the books, payroll, etc. I practice in an area where there is a lot of

demand. There are now only 4 doctors here providing care to a

population that averages 20,000. The other three doctors have been

here longer and all practice independently as well. (The hospital is

recruiting, but it is hard to find a doctor to come into this

environment.)

I am only seeing 25 patients a day (and the NP averages 15), but I am

only seeing that number by limiting access. I could probably see 40 a

day if I opened the gates. Limiting access is a stressful thing and it

means that I spend another 1.5 hours a day answering emails and phone

messages. (And therefore providing less then adequate care.)

I recognize now that I let it get out of hand. But I am not sure how

to fix it. I cannot fire a third of my patients. Not at a time when

two of the other three doctors are also no longer taking new patients.

In the heat of my burnout, I can only see two solutions. One is to

move. Pull up shop and start over elsewhere. That is the easy way out,

that is for sure. And my stress has my family stressed enough to where

they would probably pull for this option at this point.

The other idea is to change to a cash-based practice. The good thing

about this is I would lower my overhead even further. I could probably

do away with 1 or 2 of my employees. I would likely slow way down. I

could add extra services, evening or weekend hours, if necessary. I

would opt out of Medicare too.

This seems like a smart move, since the area is underserved enough

that it might support it. But I struggle with it on several levels. I

am afraid that I will generate just as much bad karma doing this as I

would by " firing " half of my patients (or leaving town), because

probably that many will still feel like they are now without a doctor.

And I would think that my practice would turn into an urgent care

clinic as people would not come in for wellness visits and only for

sick visits when the other offices are full.

Has anyone made the leap from too-busy practice to cash-based practice

and have any comments? For that matter, has anyone in the group made

the Gordon--Practice-Conversion from a full, too-busy practice?

How do you slow things down once they're out of hand?

Thanks for the advice!

Greg Hinson

[Guest guest]

Greg,

I feel for you, and I am concerned for you very much.I think the best thing from

all this is that you recognize what is happening and that you are reaching out.

You say in your posting that, " I am afraid that I will generate just as much bad

karma doing this as I

would by 'firing' half of my patients.... " How does the karma feel right now?

And most imporantly, there's that word, " afraid, " a very intuitive and, in your

situation, powerful force in how you have ended up in your current situation.

I do not have specific, logistical, practical answers to your questions. I have

opted out of Medicare and everything else, but I am just getting started; I am

not that busy right now. In fact, I am experimenting with several dietary and

nutritional approaches to help me counsel my patients and I am studying for the

boards in holistic medicine. And I'm putting together a large two-day CME event

in my area, etc., etc.

I did a lot of soul-searching recently, and most was focused on my fears and

assumptions of what medicine, my profession, my life, etc. are all about. Once I

felt I understood where my balance is, that is, who I am ultimately, I was able

to start answering those difficult questions.

My first, intuitive, suggestions mentally to you were: practice Qi

Gong/meditation/pray. Eat healthier. Exercise some. Take time off. The world

will not collapse without you. You and your family need you, not the doctor you,

or the whatever you, but you. Focus on this. I know it sounds unproductive, and

perhaps you can make a few changes that can help your immediate situation, but

eventually, you will need to divert all your attention inward and redefine who

you are. Once you feel some comfort with this, then some, and eventually all, of

the answers will be self-evident. And you won't be afraid anymore. Then you

cannot make a wrong decision.

Good luck; I will pray for you. And I look forward to the wisdom that I know

your appeal will generate among our good colleagues.

Charlie Vargas

New Mountain Medicine

lin, NC

newmountainmedicine.familydoctors.net

Date: Tue Feb 28 11:06:58 CST 2006

To:

Subject: Practice Transformation

Looking for advice from doctors on the list working alternative

practices. You know how when you hold a piece of paper over a flame

and it starts to turn brown just that instant before it bursts into

flames? That's me right now. I am so close to burn-out.

I have a solo practice with a 32-hr-a-week NP, an MA, and a

receptionist. I have fairly low overhead, but I have it in part

because I do all the office management work, e.g., ordering supplies,

the books, payroll, etc. I practice in an area where there is a lot of

demand. There are now only 4 doctors here providing care to a

population that averages 20,000. The other three doctors have been

here longer and all practice independently as well. (The hospital is

recruiting, but it is hard to find a doctor to come into this

environment.)

I am only seeing 25 patients a day (and the NP averages 15), but I am

only seeing that number by limiting access. I could probably see 40 a

day if I opened the gates. Limiting access is a stressful thing and it

means that I spend another 1.5 hours a day answering emails and phone

messages. (And therefore providing less then adequate care.)

I recognize now that I let it get out of hand. But I am not sure how

to fix it. I cannot fire a third of my patients. Not at a time when

two of the other three doctors are also no longer taking new patients.

In the heat of my burnout, I can only see two solutions. One is to

move. Pull up shop and start over elsewhere. That is the easy way out,

that is for sure. And my stress has my family stressed enough to where

they would probably pull for this option at this point.

The other idea is to change to a cash-based practice. The good thing

about this is I would lower my overhead even further. I could probably

do away with 1 or 2 of my employees. I would likely slow way down. I

could add extra services, evening or weekend hours, if necessary. I

would opt out of Medicare too.

This seems like a smart move, since the area is underserved enough

that it might support it. But I struggle with it on several levels. I

am afraid that I will generate just as much bad karma doing this as I

would by " firing " half of my patients (or leaving town), because

probably that many will still feel like they are now without a doctor.

And I would think that my practice would turn into an urgent care

clinic as people would not come in for wellness visits and only for

sick visits when the other offices are full.

Has anyone made the leap from too-busy practice to cash-based practice

and have any comments? For that matter, has anyone in the group made

the Gordon--Practice-Conversion from a full, too-busy practice?

How do you slow things down once they're out of hand?

Thanks for the advice!

Greg Hinson

[Guest guest]

Greg,Sorry to hear about your situation. It sounds like a lot of your time is spent on non-patient care/admin stuff that is not reimbursed. I have 2 ideas: 1) delegate some or all of this to someone else, either by training your receptionist or MA to do more of this stuff or letting one of them go so you can hire someone who would be able to do the combined duties of an office manager.2) or you could start charging an administration fee/retainer fee that could be used to either pay for that office manager position, or to supplement your income so you don't have to see as many patients/day. It would also have the net effect of reducing your demand as patients would self-select which ones are willing to pay the extra fee. This way you don't have to fire any patients. This could also be a transition towards a completely cash-only practice. Best of luck! SetoSouth Pasadena, CA Looking for advice from doctors on the list working alternative practices. You know how when you hold a piece of paper over a flame and it starts to turn brown just that instant before it bursts into flames? That's me right now. I am so close to burn-out. I have a solo practice with a 32-hr-a-week NP, an MA, and a receptionist. I have fairly low overhead, but I have it in part because I do all the office management work, e.g., ordering supplies, the books, payroll, etc. I practice in an area where there is a lot of demand. There are now only 4 doctors here providing care to a population that averages 20,000. The other three doctors have been here longer and all practice independently as well. (The hospital is recruiting, but it is hard to find a doctor to come into this environment.) I am only seeing 25 patients a day (and the NP averages 15), but I am only seeing that number by limiting access. I could probably see 40 a day if I opened the gates. Limiting access is a stressful thing and it means that I spend another 1.5 hours a day answering emails and phone messages. (And therefore providing less then adequate care.) I recognize now that I let it get out of hand. But I am not sure how to fix it. I cannot fire a third of my patients. Not at a time when two of the other three doctors are also no longer taking new patients. In the heat of my burnout, I can only see two solutions. One is to move. Pull up shop and start over elsewhere. That is the easy way out, that is for sure. And my stress has my family stressed enough to where they would probably pull for this option at this point. The other idea is to change to a cash-based practice. The good thing about this is I would lower my overhead even further. I could probably do away with 1 or 2 of my employees. I would likely slow way down. I could add extra services, evening or weekend hours, if necessary. I would opt out of Medicare too. This seems like a smart move, since the area is underserved enough that it might support it. But I struggle with it on several levels. I am afraid that I will generate just as much bad karma doing this as I would by "firing" half of my patients (or leaving town), because probably that many will still feel like they are now without a doctor. And I would think that my practice would turn into an urgent care clinic as people would not come in for wellness visits and only for sick visits when the other offices are full. Has anyone made the leap from too-busy practice to cash-based practice and have any comments? For that matter, has anyone in the group made the Gordon--Practice-Conversion from a full, too-busy practice? How do you slow things down once they're out of hand? Thanks for the advice! Greg Hinson

[Guest guest]

Greg,Sorry to hear about your situation. It sounds like a lot of your time is spent on non-patient care/admin stuff that is not reimbursed. I have 2 ideas: 1) delegate some or all of this to someone else, either by training your receptionist or MA to do more of this stuff or letting one of them go so you can hire someone who would be able to do the combined duties of an office manager.2) or you could start charging an administration fee/retainer fee that could be used to either pay for that office manager position, or to supplement your income so you don't have to see as many patients/day. It would also have the net effect of reducing your demand as patients would self-select which ones are willing to pay the extra fee. This way you don't have to fire any patients. This could also be a transition towards a completely cash-only practice. Best of luck! SetoSouth Pasadena, CA Looking for advice from doctors on the list working alternative practices. You know how when you hold a piece of paper over a flame and it starts to turn brown just that instant before it bursts into flames? That's me right now. I am so close to burn-out. I have a solo practice with a 32-hr-a-week NP, an MA, and a receptionist. I have fairly low overhead, but I have it in part because I do all the office management work, e.g., ordering supplies, the books, payroll, etc. I practice in an area where there is a lot of demand. There are now only 4 doctors here providing care to a population that averages 20,000. The other three doctors have been here longer and all practice independently as well. (The hospital is recruiting, but it is hard to find a doctor to come into this environment.) I am only seeing 25 patients a day (and the NP averages 15), but I am only seeing that number by limiting access. I could probably see 40 a day if I opened the gates. Limiting access is a stressful thing and it means that I spend another 1.5 hours a day answering emails and phone messages. (And therefore providing less then adequate care.) I recognize now that I let it get out of hand. But I am not sure how to fix it. I cannot fire a third of my patients. Not at a time when two of the other three doctors are also no longer taking new patients. In the heat of my burnout, I can only see two solutions. One is to move. Pull up shop and start over elsewhere. That is the easy way out, that is for sure. And my stress has my family stressed enough to where they would probably pull for this option at this point. The other idea is to change to a cash-based practice. The good thing about this is I would lower my overhead even further. I could probably do away with 1 or 2 of my employees. I would likely slow way down. I could add extra services, evening or weekend hours, if necessary. I would opt out of Medicare too. This seems like a smart move, since the area is underserved enough that it might support it. But I struggle with it on several levels. I am afraid that I will generate just as much bad karma doing this as I would by "firing" half of my patients (or leaving town), because probably that many will still feel like they are now without a doctor. And I would think that my practice would turn into an urgent care clinic as people would not come in for wellness visits and only for sick visits when the other offices are full. Has anyone made the leap from too-busy practice to cash-based practice and have any comments? For that matter, has anyone in the group made the Gordon--Practice-Conversion from a full, too-busy practice? How do you slow things down once they're out of hand? Thanks for the advice! Greg Hinson

[Guest guest]

Greg, I feel your pain! I switched from a too busy, overstaffed " traditional "

office to a minimalist (Gordon ) practice. I was seeing about 20-25

patients a day, staying late to keep up with documentation/e-mails/refill

requets. The first thing you need to do is assess insurance reimbursement, and

your own convictions. I identified my 3 lowest reimbursing insurance companies

with the intent of eliminating them. They turned out to be , medicare,

medicaid(straight medicaid, and a " comercially run " ), and a local private

insurer. I didn't feel comfortable eliminating medicare. I did eliminate the

comercial medicaid, and the local insurer. I explained to patients that I was

sorry, but was unable to negotiate a suitable contract with these payors. The

next thing I did was identify the patients that just weren't working out. You

know the ones, you groan when you see their name on the schedule. They got 30

day letters. I am not completely solo, I have a part time person to help with

billing and phones. Anyway, the point is, if your system isn't working for you,

trust me, it's not working for the patients either. HTH. Boyce.---- Greg

& Amy Hinson wrote:

> Looking for advice from doctors on the list working alternative

> practices. You know how when you hold a piece of paper over a flame

> and it starts to turn brown just that instant before it bursts into

> flames? That's me right now. I am so close to burn-out.

>

> I have a solo practice with a 32-hr-a-week NP, an MA, and a

> receptionist. I have fairly low overhead, but I have it in part

> because I do all the office management work, e.g., ordering supplies,

> the books, payroll, etc. I practice in an area where there is a lot of

> demand. There are now only 4 doctors here providing care to a

> population that averages 20,000. The other three doctors have been

> here longer and all practice independently as well. (The hospital is

> recruiting, but it is hard to find a doctor to come into this

> environment.)

>

> I am only seeing 25 patients a day (and the NP averages 15), but I am

> only seeing that number by limiting access. I could probably see 40 a

> day if I opened the gates. Limiting access is a stressful thing and it

> means that I spend another 1.5 hours a day answering emails and phone

> messages. (And therefore providing less then adequate care.)

>

> I recognize now that I let it get out of hand. But I am not sure how

> to fix it. I cannot fire a third of my patients. Not at a time when

> two of the other three doctors are also no longer taking new patients.

>

> In the heat of my burnout, I can only see two solutions. One is to

> move. Pull up shop and start over elsewhere. That is the easy way out,

> that is for sure. And my stress has my family stressed enough to where

> they would probably pull for this option at this point.

>

> The other idea is to change to a cash-based practice. The good thing

> about this is I would lower my overhead even further. I could probably

> do away with 1 or 2 of my employees. I would likely slow way down. I

> could add extra services, evening or weekend hours, if necessary. I

> would opt out of Medicare too.

>

> This seems like a smart move, since the area is underserved enough

> that it might support it. But I struggle with it on several levels. I

> am afraid that I will generate just as much bad karma doing this as I

> would by " firing " half of my patients (or leaving town), because

> probably that many will still feel like they are now without a doctor.

> And I would think that my practice would turn into an urgent care

> clinic as people would not come in for wellness visits and only for

> sick visits when the other offices are full.

>

> Has anyone made the leap from too-busy practice to cash-based practice

> and have any comments? For that matter, has anyone in the group made

> the Gordon--Practice-Conversion from a full, too-busy practice?

> How do you slow things down once they're out of hand?

>

> Thanks for the advice!

>

> Greg Hinson

>

>

>

>

>

>

>

[Guest guest]

Greg, I feel your pain! I switched from a too busy, overstaffed " traditional "

office to a minimalist (Gordon ) practice. I was seeing about 20-25

patients a day, staying late to keep up with documentation/e-mails/refill

requets. The first thing you need to do is assess insurance reimbursement, and

your own convictions. I identified my 3 lowest reimbursing insurance companies

with the intent of eliminating them. They turned out to be , medicare,

medicaid(straight medicaid, and a " comercially run " ), and a local private

insurer. I didn't feel comfortable eliminating medicare. I did eliminate the

comercial medicaid, and the local insurer. I explained to patients that I was

sorry, but was unable to negotiate a suitable contract with these payors. The

next thing I did was identify the patients that just weren't working out. You

know the ones, you groan when you see their name on the schedule. They got 30

day letters. I am not completely solo, I have a part time person to help with

billing and phones. Anyway, the point is, if your system isn't working for you,

trust me, it's not working for the patients either. HTH. Boyce.---- Greg

& Amy Hinson wrote:

> Looking for advice from doctors on the list working alternative

> practices. You know how when you hold a piece of paper over a flame

> and it starts to turn brown just that instant before it bursts into

> flames? That's me right now. I am so close to burn-out.

>

> I have a solo practice with a 32-hr-a-week NP, an MA, and a

> receptionist. I have fairly low overhead, but I have it in part

> because I do all the office management work, e.g., ordering supplies,

> the books, payroll, etc. I practice in an area where there is a lot of

> demand. There are now only 4 doctors here providing care to a

> population that averages 20,000. The other three doctors have been

> here longer and all practice independently as well. (The hospital is

> recruiting, but it is hard to find a doctor to come into this

> environment.)

>

> I am only seeing 25 patients a day (and the NP averages 15), but I am

> only seeing that number by limiting access. I could probably see 40 a

> day if I opened the gates. Limiting access is a stressful thing and it

> means that I spend another 1.5 hours a day answering emails and phone

> messages. (And therefore providing less then adequate care.)

>

> I recognize now that I let it get out of hand. But I am not sure how

> to fix it. I cannot fire a third of my patients. Not at a time when

> two of the other three doctors are also no longer taking new patients.

>

> In the heat of my burnout, I can only see two solutions. One is to

> move. Pull up shop and start over elsewhere. That is the easy way out,

> that is for sure. And my stress has my family stressed enough to where

> they would probably pull for this option at this point.

>

> The other idea is to change to a cash-based practice. The good thing

> about this is I would lower my overhead even further. I could probably

> do away with 1 or 2 of my employees. I would likely slow way down. I

> could add extra services, evening or weekend hours, if necessary. I

> would opt out of Medicare too.

>

> This seems like a smart move, since the area is underserved enough

> that it might support it. But I struggle with it on several levels. I

> am afraid that I will generate just as much bad karma doing this as I

> would by " firing " half of my patients (or leaving town), because

> probably that many will still feel like they are now without a doctor.

> And I would think that my practice would turn into an urgent care

> clinic as people would not come in for wellness visits and only for

> sick visits when the other offices are full.

>

> Has anyone made the leap from too-busy practice to cash-based practice

> and have any comments? For that matter, has anyone in the group made

> the Gordon--Practice-Conversion from a full, too-busy practice?

> How do you slow things down once they're out of hand?

>

> Thanks for the advice!

>

> Greg Hinson

>

>

>

>

>

>

>

[Guest guest]

Greg, sounds pretty rough.

One of the pillars of practice is broken and you're in burnout

mode. Somehow you've got to achieve balance between work and the

rest of your life. The ideal is that the practice is joyful and

within reasonable bounds. I hope that you can create a practice

capable of delivering superb care in a way that is exciting and

sustainable for you.

Something has to give, but what gives?

One of the issues we face as clinicians is the desire to serve.

Sometimes our recognition of need and desire to serve puts us in the

terrible spot of serving more that we can sustain (Greg) or we have to

serve only some of those with need.

There are several possibilities:

Shrink your current practice

This can be accomplished by dropping some insurance carriers and those

patients, by charging cash only and dropping all insurance, or by

dropping some segment of your current practice while still accepting all

insurance carriers.

Grown your current practice

You could try to hire another NP or a PA

You could add other staff to create a high flow practice capable of

delivering great care

You've already mentioned how difficult it is to hire MDs to your

locale.

None of these ideas comes without pain. Moving and starting fresh

comes with pain as well, and continuing on the same path appears

unsustainable.

So what can you do?

One idea is to go to your community with the problem. " Folks,

I'm in burnout mode. Here are several options, none really

palatable, and darned if I know which is the right one. I know for

certain that I can't continue as I am. "

The ultimate problem is not one that can be solved by you alone.

The community needs more than you can give. I suspect that they

would eventually see that some of you is better than none and would look

for ways to help, even if it meant sharing the pain.

I think it is time that we start discussing really different financing

models for primary care, as the current models are not working.

More on this in a separate email.

Gordon

At 12:45 PM 2/28/2006, you wrote:

You say you are

" only " seeing 25 patient's per day? I have not seen

that

many since I opened 2 years ago, and am still averaging probably about

12

patients per day. I'm not getting rich but I'm certain not doing

too bad

either. I generally have a low overhead practice, though not nearly

to the

extremes that some on this list do (my overhead sounds more similar to

your

practice). However, I came into town on a hospital income guarantee

and

that allowed me to have all of the " bells and whistles " such as

a nice EMR,

tables, etc. There is no way I would have started out in solo

practice

right out of residency any other way.

It sounds to me like you really need to start limiting some of the

payors

you accept. Do you currently take Medicaid? If so, that would

be the first

place I would start. It is critical to work smarter and not

necessarily

harder and that usually translates into only taking patients you know

you're

going to get paid well for, and eliminating the bottom paying

companies

sooner rather than later. Also, I'm not a big believer in cash

only

practices, mainly just because I know that absolutely would not work in

the

community I practice in. I personally would not pay cash for my own

health

care and still pay for my own insurance, no matter how wonderful my

doctor

was. I am not sure where you are located but if it is any type of

rural or

semi-rural area I would be skeptical that cash only would work.

Patients

will just take the path of least resistance and go to the other practices

in

town that are still taking insurance unless the quality of care that

you

offer is so exponentially better as to justify them paying

out-of-pocket.

If I took all comers I'm sure I also would be seeing 25 to 40 patients

per

day, but I would simply be working harder and not necessarily making a

lot

more (at least not in a one-to-one ratio of effort to income).

Finally,

looking at other job offers in other locales may be a viable option

after

you rule out making it work where you are at.

Practice Transformation

Looking for advice from doctors on the list working alternative

practices. You know how when you hold a piece of paper over a flame

and it starts to turn brown just that instant before it bursts into

flames? That's me right now. I am so close to burn-out.

I have a solo practice with a 32-hr-a-week NP, an MA, and a

receptionist. I have fairly low overhead, but I have it in part

because I do all the office management work, e.g., ordering

supplies,

the books, payroll, etc. I practice in an area where there is a lot

of

demand. There are now only 4 doctors here providing care to a

population that averages 20,000. The other three doctors have been

here longer and all practice independently as well. (The hospital is

recruiting, but it is hard to find a doctor to come into this

environment.)

I am only seeing 25 patients a day (and the NP averages 15), but I

am

only seeing that number by limiting access. I could probably see 40

a

day if I opened the gates. Limiting access is a stressful thing and

it

means that I spend another 1.5 hours a day answering emails and

phone

messages. (And therefore providing less then adequate care.)

I recognize now that I let it get out of hand. But I am not sure how

to fix it. I cannot fire a third of my patients. Not at a time when

two of the other three doctors are also no longer taking new

patients.

In the heat of my burnout, I can only see two solutions. One is to

move. Pull up shop and start over elsewhere. That is the easy way

out,

that is for sure. And my stress has my family stressed enough to

where

they would probably pull for this option at this point.

The other idea is to change to a cash-based practice. The good thing

about this is I would lower my overhead even further. I could

probably

do away with 1 or 2 of my employees. I would likely slow way down. I

could add extra services, evening or weekend hours, if necessary. I

would opt out of Medicare too.

This seems like a smart move, since the area is underserved enough

that it might support it. But I struggle with it on several levels.

I

am afraid that I will generate just as much bad karma doing this as

I

would by " firing " half of my patients (or leaving town),

because

probably that many will still feel like they are now without a

doctor.

And I would think that my practice would turn into an urgent care

clinic as people would not come in for wellness visits and only for

sick visits when the other offices are full.

Has anyone made the leap from too-busy practice to cash-based

practice

and have any comments? For that matter, has anyone in the group made

the Gordon--Practice-Conversion from a full, too-busy practice?

How do you slow things down once they're out of hand?

Thanks for the advice!

Greg Hinson

[Guest guest]

Greg, sounds pretty rough.

One of the pillars of practice is broken and you're in burnout

mode. Somehow you've got to achieve balance between work and the

rest of your life. The ideal is that the practice is joyful and

within reasonable bounds. I hope that you can create a practice

capable of delivering superb care in a way that is exciting and

sustainable for you.

Something has to give, but what gives?

One of the issues we face as clinicians is the desire to serve.

Sometimes our recognition of need and desire to serve puts us in the

terrible spot of serving more that we can sustain (Greg) or we have to

serve only some of those with need.

There are several possibilities:

Shrink your current practice

This can be accomplished by dropping some insurance carriers and those

patients, by charging cash only and dropping all insurance, or by

dropping some segment of your current practice while still accepting all

insurance carriers.

Grown your current practice

You could try to hire another NP or a PA

You could add other staff to create a high flow practice capable of

delivering great care

You've already mentioned how difficult it is to hire MDs to your

locale.

None of these ideas comes without pain. Moving and starting fresh

comes with pain as well, and continuing on the same path appears

unsustainable.

So what can you do?

One idea is to go to your community with the problem. " Folks,

I'm in burnout mode. Here are several options, none really

palatable, and darned if I know which is the right one. I know for

certain that I can't continue as I am. "

The ultimate problem is not one that can be solved by you alone.

The community needs more than you can give. I suspect that they

would eventually see that some of you is better than none and would look

for ways to help, even if it meant sharing the pain.

I think it is time that we start discussing really different financing

models for primary care, as the current models are not working.

More on this in a separate email.

Gordon

At 12:45 PM 2/28/2006, you wrote:

You say you are

" only " seeing 25 patient's per day? I have not seen

that

many since I opened 2 years ago, and am still averaging probably about

12

patients per day. I'm not getting rich but I'm certain not doing

too bad

either. I generally have a low overhead practice, though not nearly

to the

extremes that some on this list do (my overhead sounds more similar to

your

practice). However, I came into town on a hospital income guarantee

and

that allowed me to have all of the " bells and whistles " such as

a nice EMR,

tables, etc. There is no way I would have started out in solo

practice

right out of residency any other way.

It sounds to me like you really need to start limiting some of the

payors

you accept. Do you currently take Medicaid? If so, that would

be the first

place I would start. It is critical to work smarter and not

necessarily

harder and that usually translates into only taking patients you know

you're

going to get paid well for, and eliminating the bottom paying

companies

sooner rather than later. Also, I'm not a big believer in cash

only

practices, mainly just because I know that absolutely would not work in

the

community I practice in. I personally would not pay cash for my own

health

care and still pay for my own insurance, no matter how wonderful my

doctor

was. I am not sure where you are located but if it is any type of

rural or

semi-rural area I would be skeptical that cash only would work.

Patients

will just take the path of least resistance and go to the other practices

in

town that are still taking insurance unless the quality of care that

you

offer is so exponentially better as to justify them paying

out-of-pocket.

If I took all comers I'm sure I also would be seeing 25 to 40 patients

per

day, but I would simply be working harder and not necessarily making a

lot

more (at least not in a one-to-one ratio of effort to income).

Finally,

looking at other job offers in other locales may be a viable option

after

you rule out making it work where you are at.

Practice Transformation

Looking for advice from doctors on the list working alternative

practices. You know how when you hold a piece of paper over a flame

and it starts to turn brown just that instant before it bursts into

flames? That's me right now. I am so close to burn-out.

I have a solo practice with a 32-hr-a-week NP, an MA, and a

receptionist. I have fairly low overhead, but I have it in part

because I do all the office management work, e.g., ordering

supplies,

the books, payroll, etc. I practice in an area where there is a lot

of

demand. There are now only 4 doctors here providing care to a

population that averages 20,000. The other three doctors have been

here longer and all practice independently as well. (The hospital is

recruiting, but it is hard to find a doctor to come into this

environment.)

I am only seeing 25 patients a day (and the NP averages 15), but I

am

only seeing that number by limiting access. I could probably see 40

a

day if I opened the gates. Limiting access is a stressful thing and

it

means that I spend another 1.5 hours a day answering emails and

phone

messages. (And therefore providing less then adequate care.)

I recognize now that I let it get out of hand. But I am not sure how

to fix it. I cannot fire a third of my patients. Not at a time when

two of the other three doctors are also no longer taking new

patients.

In the heat of my burnout, I can only see two solutions. One is to

move. Pull up shop and start over elsewhere. That is the easy way

out,

that is for sure. And my stress has my family stressed enough to

where

they would probably pull for this option at this point.

The other idea is to change to a cash-based practice. The good thing

about this is I would lower my overhead even further. I could

probably

do away with 1 or 2 of my employees. I would likely slow way down. I

could add extra services, evening or weekend hours, if necessary. I

would opt out of Medicare too.

This seems like a smart move, since the area is underserved enough

that it might support it. But I struggle with it on several levels.

I

am afraid that I will generate just as much bad karma doing this as

I

would by " firing " half of my patients (or leaving town),

because

probably that many will still feel like they are now without a

doctor.

And I would think that my practice would turn into an urgent care

clinic as people would not come in for wellness visits and only for

sick visits when the other offices are full.

Has anyone made the leap from too-busy practice to cash-based

practice

and have any comments? For that matter, has anyone in the group made

the Gordon--Practice-Conversion from a full, too-busy practice?

How do you slow things down once they're out of hand?

Thanks for the advice!

Greg Hinson

[Guest guest]

Dear Greg and colleagues,

As Gordon so adeptly outlined, your choices are to

shrink it or adjust your business model. Due to good

service and growth the practice is admittedly

overheated and what you have created is a moderate

volume, low overhead, understaffed traditional FP

practice. I would have to poll the group, but I'm

pretty sure you won't go to FP solo practice hell for

it. You will be more than welcome in this forum if

you don't practice out of one room in an

Neuro-optho-dermatologist's closet.

If you can't bring yourself to shrink your practice to

cash only micropractice level my thoughts are to do

some strategic hiring. A slippery slope, but

preferable to a narrow ledge. It will add variable

costs, but if done right you will gain efficiency and

enhance profitability. Being understaffed at your

volume of services is a value trap. I've been there.

Pay to get good people to help you achieve your health

vision for your community. They should be among the

best in town or forget it. Partner with standout

performers that can give good service and think on

their feet, but don't try to over-manage average

performers in hopes of creating ideal employees.

Won't happen. Be careful with hiring and let sub par

performers go as sooner rather than later. Build an

audit trail of performance concerns, warnings and

efforts at remediation for anyone who is marginally

effective, but not really working out before letting

them go.(A hard lesson I learned at my expense.)

It is my observation that you are understaffed in the

back office.

I know this because I have been understaffed in the

back office. Hire an accountant to do your payroll

processing and taxes. You need a book keeper to do

the bill paying, medical billing and collecting

functions. Not just a bookkeeper, but someone who

knows exactly what they're doing with medical billing.

Often these hidden gems are working for someone else,

but haven't had their salary compensated at fair

market value for awhile or their current work

environment is toxic for some reason. If you are

outsourcing billing, you are likely paying too much.

If you add a partner seeing 20 patients per day and

taking insurance, you will need two billers, not 1.

You may need an additional staff person in clinical

role of MA or LPN to assist patients. For a long time

I had an efficient LPN in the clinical role. Between

my NP and I, we saw 35-40 patients per day. I think

overly relying on her led to her burnout and slowed

the growth of my business over time. When she quit,

my NP and I saw 600 patients per month for 4 months

ultralight style + hospital + nursing home care for 30

+ OB. My overhead went down a little, but my practice

didn't grow much and wasn't much fun. When we found

qualified replacements we hired two. Our business

grew 25% in one year after that against essentially

the same fixed costs. Then I found a partner. Then

this year we are adding another partner -In a rural

area, in a malpractice crisis state (IL).

My practice overhead is 40-42% of collections entering

my 9th year of practice. I see about 20-25 patients

per day with my EMR and do hospital work, some NH and

50-60 deliveries per year. I have an NP, a nurse

midwife and an FP partner that share my vision of

country doctoring. We share 2 front desk people, 2

LPNs and 2 biller/book keepers at my main office. A

ratio of 1.5 FTE support staff: provider.

My best to all,

Ben Brewer MD

Forrest, IL

__________________________________________________

[Guest guest]

Dear Greg and colleagues,

As Gordon so adeptly outlined, your choices are to

shrink it or adjust your business model. Due to good

service and growth the practice is admittedly

overheated and what you have created is a moderate

volume, low overhead, understaffed traditional FP

practice. I would have to poll the group, but I'm

pretty sure you won't go to FP solo practice hell for

it. You will be more than welcome in this forum if

you don't practice out of one room in an

Neuro-optho-dermatologist's closet.

If you can't bring yourself to shrink your practice to

cash only micropractice level my thoughts are to do

some strategic hiring. A slippery slope, but

preferable to a narrow ledge. It will add variable

costs, but if done right you will gain efficiency and

enhance profitability. Being understaffed at your

volume of services is a value trap. I've been there.

Pay to get good people to help you achieve your health

vision for your community. They should be among the

best in town or forget it. Partner with standout

performers that can give good service and think on

their feet, but don't try to over-manage average

performers in hopes of creating ideal employees.

Won't happen. Be careful with hiring and let sub par

performers go as sooner rather than later. Build an

audit trail of performance concerns, warnings and

efforts at remediation for anyone who is marginally

effective, but not really working out before letting

them go.(A hard lesson I learned at my expense.)

It is my observation that you are understaffed in the

back office.

I know this because I have been understaffed in the

back office. Hire an accountant to do your payroll

processing and taxes. You need a book keeper to do

the bill paying, medical billing and collecting

functions. Not just a bookkeeper, but someone who

knows exactly what they're doing with medical billing.

Often these hidden gems are working for someone else,

but haven't had their salary compensated at fair

market value for awhile or their current work

environment is toxic for some reason. If you are

outsourcing billing, you are likely paying too much.

If you add a partner seeing 20 patients per day and

taking insurance, you will need two billers, not 1.

You may need an additional staff person in clinical

role of MA or LPN to assist patients. For a long time

I had an efficient LPN in the clinical role. Between

my NP and I, we saw 35-40 patients per day. I think

overly relying on her led to her burnout and slowed

the growth of my business over time. When she quit,

my NP and I saw 600 patients per month for 4 months

ultralight style + hospital + nursing home care for 30

+ OB. My overhead went down a little, but my practice

didn't grow much and wasn't much fun. When we found

qualified replacements we hired two. Our business

grew 25% in one year after that against essentially

the same fixed costs. Then I found a partner. Then

this year we are adding another partner -In a rural

area, in a malpractice crisis state (IL).

My practice overhead is 40-42% of collections entering

my 9th year of practice. I see about 20-25 patients

per day with my EMR and do hospital work, some NH and

50-60 deliveries per year. I have an NP, a nurse

midwife and an FP partner that share my vision of

country doctoring. We share 2 front desk people, 2

LPNs and 2 biller/book keepers at my main office. A

ratio of 1.5 FTE support staff: provider.

My best to all,

Ben Brewer MD

Forrest, IL

__________________________________________________

[Guest guest]

Hi Everyone,

I wanted to share with you a story about a phone call I got recently. A lady

called for a new appointment for family medicine (I have to ask now, since some

call for acupuncture). She said she read about me in a newspaper article and

decided to she wanted to switch to me. I asked her if she looked at my website

(newmountainmedicine.familydoctors.net), and her answer was, " Yes--that is why I

am calling you to make an appointment. "

So I asked if she had a current PCP. She said she sees a P.A. in a nearby town,

but she is so busy, she has a hard time getting in to see her. I was surprised

to hear about a P.A. who is so popular. " Why is she so busy? " I asked. " Because

she listens, " the woman replied.

Wow. That's how I am being perceived, and that is cool. And encouraging. She

will be my fourth family practice patient. That is 400% over my threshhold for

success!

I think it helps me to have severl income sources, even though each one is not

enought support me alone. I serve as medical director of our local hospice at

$75 per hour, and I put in about 10+ hours per week. I also write a weekly

health column in the paper. And I have my medical acupuncture practice that pays

most of my bills. So my family practice is my newest addition, and even though

it warrants my full attention when I do it because I want to offer high quality

care, it is only one of the many things I like to do.

And I resolved to myself, after I discovered, again, that I am, ultimately an

artist, and not a doctor, that I will do family practice again only if I can

design a practice environment that appeals to me and allows me to practice the

way I feel is right for my patients.

I also know that I am excited about my upcoming bass guitar lessons, sculpture

classes, Qi Gong classes, and my future career in documentary film making. I

also have a few books to write.

My point is: there is a lot more to me than doctoring. Or, doctoring, to me, is

not just about clinical work. The meaning of the word doctor is teaching, after

all; I am just expanding my role as I discover new ways to do it.

My life feels like an opportunity to realize myself, instead of a race to finish

first in some weird daily competition. And the most important roles I have found

are that of child of God, husband and father, in that order.

I dream of opening a learning center where people can experience various methods

of self-awareness and expression. I call it The Little Drummer Boy Institute. It

feels really, really good when I think and dream about it. It is probably a long

way off, but that's OK. My roles of physician, father, artist, etc. have more

time, then, to prepare for this more important work. And my goal is not to have

it up and running; my goal is to work toward fulfilling who I am, which also

means realizing my relationship with God, so that someday I might experience the

role at the Institute.

This puts being a physician in a context that earlier in my career would be very

foreign. But because of this, whether my practice succeeds financially or not

does not scare me anymore, at least not like it used to. It took me few years to

do it, but now I have multiple routes of expression and multiple avenues of

income.

Charlie Vargas

lin, NC

[Guest guest]

Hi Everyone,

I wanted to share with you a story about a phone call I got recently. A lady

called for a new appointment for family medicine (I have to ask now, since some

call for acupuncture). She said she read about me in a newspaper article and

decided to she wanted to switch to me. I asked her if she looked at my website

(newmountainmedicine.familydoctors.net), and her answer was, " Yes--that is why I

am calling you to make an appointment. "

So I asked if she had a current PCP. She said she sees a P.A. in a nearby town,

but she is so busy, she has a hard time getting in to see her. I was surprised

to hear about a P.A. who is so popular. " Why is she so busy? " I asked. " Because

she listens, " the woman replied.

Wow. That's how I am being perceived, and that is cool. And encouraging. She

will be my fourth family practice patient. That is 400% over my threshhold for

success!

I think it helps me to have severl income sources, even though each one is not

enought support me alone. I serve as medical director of our local hospice at

$75 per hour, and I put in about 10+ hours per week. I also write a weekly

health column in the paper. And I have my medical acupuncture practice that pays

most of my bills. So my family practice is my newest addition, and even though

it warrants my full attention when I do it because I want to offer high quality

care, it is only one of the many things I like to do.

And I resolved to myself, after I discovered, again, that I am, ultimately an

artist, and not a doctor, that I will do family practice again only if I can

design a practice environment that appeals to me and allows me to practice the

way I feel is right for my patients.

I also know that I am excited about my upcoming bass guitar lessons, sculpture

classes, Qi Gong classes, and my future career in documentary film making. I

also have a few books to write.

My point is: there is a lot more to me than doctoring. Or, doctoring, to me, is

not just about clinical work. The meaning of the word doctor is teaching, after

all; I am just expanding my role as I discover new ways to do it.

My life feels like an opportunity to realize myself, instead of a race to finish

first in some weird daily competition. And the most important roles I have found

are that of child of God, husband and father, in that order.

I dream of opening a learning center where people can experience various methods

of self-awareness and expression. I call it The Little Drummer Boy Institute. It

feels really, really good when I think and dream about it. It is probably a long

way off, but that's OK. My roles of physician, father, artist, etc. have more

time, then, to prepare for this more important work. And my goal is not to have

it up and running; my goal is to work toward fulfilling who I am, which also

means realizing my relationship with God, so that someday I might experience the

role at the Institute.

This puts being a physician in a context that earlier in my career would be very

foreign. But because of this, whether my practice succeeds financially or not

does not scare me anymore, at least not like it used to. It took me few years to

do it, but now I have multiple routes of expression and multiple avenues of

income.

Charlie Vargas

lin, NC

[Guest guest]

Greg,

To be brief as so much good advice has already been given, my 2 cents worth

is to cut back your practice:

1. drop Medicare (can still see Medicare pts, have them sign a waiver,

charge them what you want - I charge them very little). This will decrease

some of your

2. if you are contracted with several insurances, drop the lowest paying

25% of them. This will decrease your number of patients, and increase your

average reimbursement/visit.

3. charge patients for your email and phone care. This is often in lieu of

an office visit, involves a cognitive component, and should be reimbursed.

Good luck in your decision making! I'm pulling for you!

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO 80863

[Guest guest]

I can't believe you are actually able to convince any Medicare patients to

pay you out of pocket. A local doc here has apparently started trying to

that; I know this because most of his Medicare patients are leaving & asking

to transfer here. I know if I was 65 years old with Medicare I sure would

not pay out of pocket when I had worked all of those tears putting $$$ into

Medicare. If I dropped Medicare I would be out of business, period.

RE: Practice Transformation

Greg,

To be brief as so much good advice has already been given, my 2 cents worth

is to cut back your practice:

1. drop Medicare (can still see Medicare pts, have them sign a waiver,

charge them what you want - I charge them very little). This will decrease

some of your

2. if you are contracted with several insurances, drop the lowest paying

25% of them. This will decrease your number of patients, and increase your

average reimbursement/visit.

3. charge patients for your email and phone care. This is often in lieu of

an office visit, involves a cognitive component, and should be reimbursed.

Good luck in your decision making! I'm pulling for you!

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO 80863

[Guest guest]

Thanks everyone for the advice and encouragement. Really some good

advice out there and I knew I could count on this group for help.

A few comments. It doesn't sound like there is a lot of enthusiasm out

there for the idea of changing to a cash-based practice (in spite of

this month's FPM journal). And, the more I think about it, I really

think that it would create much more anger in my current patient

population then actual inconvenience or hardship, enough that I am

beginning to see that this is not the best option. I really like the

idea of having a cash practice that charges a nominal yearly

membership (e.g., maybe $200/yr) and in return for this giving away a

yearly wellness visit (to discourage patients from thinking of the

practice as a use-only-when-you-need-it urgent care clinic). But, I

would upset too many people with the change.

Slowing down, in any other way, is going to be tough. I do not have a

bad plan to drop, with the exception of Medicare and Medicaid. Opting

out of Medicare seems so drastic and I need to learn more about what

happens during the following two years if you change your mind. And my

Medicaid is primarily obstetrics and well child care. Both make up

maybe 30% of my practice. Most of the rest is fee for service BCBS. I

am only contracted with two payors, and they both pay fairly well.

The problem is demand. The only way I can get by with only seeing

25-30 people/day (and another 15 for my NP) is by spending another 1-2

hours a day answering phone messages and email messages (and providing

shoddy care in doing it). Not that the patients are demanding this

free service; they'd all be willing to come in if given a slot.

So it seems like the only answer is going to be to ramp up the

practice. The local hospital is recruiting and has someone in mind

they'd like to join me. We could hire a manager. Bring the billing

in-house. Hire a nurse or two.

But my instincts are telling me that this will all just fuel the fire.

It feels like I should be getting smaller, not bigger.

Although I love where I live, and want to stay, I love the idea of

starting over and doing it right from the beginning. Maybe finding the

right area that would support a cash practice, or even a cash

housecall practice. And, as long as I am dreaming, use our savings as

a safety net while the practice grows by word of mouth alone, by

providing the absolute best possible care!

Anyway, thanks for the advice, I'll keep you all updated as I explore

the option of hiring another physician and trying to tame this beast.