Re: money

[Guest guest]

Dear ,

The website pages on " Benefactors " , " How it Works " and " FAQ's "

really covers this fairly well. The reason the concept is difficult

is that the uninsured pay nothing -- zip, zero, nada. On average

they donate about $9 per visit at last count.

We don't bill any insurance or any patient (insured or otherwise)

anything except the once annual fee. ONLY the insured " Benefactors "

pay the fee. RJ and I have at total of about 550 of them. Our cap

with the IRS is 600, but frankly we think 550 is about right. The

Benefactors pay on average $1K per year. All the rates are posted on

the website.

For example, Benefactors in the hospital or for whom we assist at

surgery are charged nothing additional. We have no insurance billing

apparatus at all. It keeps the overhead low...

Bob

> > >

> > > Recently I have had money on my mind. After 2 years in my new

> > > practice I an finally close to making $150,000 which is still

> less

> > > than I made at my old job. However I am finding it difficult

to

> > > figure out how to make anymore than that since I don't think

> that I

> > > can see any more patients in a day. The median income of FP's

is

> > over

> > > $160.000/yr. How many of you are making more than the median

FP

> > > income and what are you doing to make that much. If the

> > micropractice

> > > model is not capable of producing enough income to provide at

> least

> > > the median income it is probably not going to be a viable

model.

> > > Larry Lindeman MD

> > >

> >

>

[Guest guest]

Bob: I like your model. This makes sense of what I see is the cost of healthcare at about a dollar per day per patient. 550 patients pay 1000 you take care of 1500 patients. No administration for billing and receivables for those insured or uninsured. Bob Forester MD wrote: Dear ,The website pages on "Benefactors", "How it Works" and "FAQ's" really covers this fairly well. The reason the concept

is difficult is that the uninsured pay nothing -- zip, zero, nada. On average they donate about $9 per visit at last count. We don't bill any insurance or any patient (insured or otherwise) anything except the once annual fee. ONLY the insured "Benefactors" pay the fee. RJ and I have at total of about 550 of them. Our cap with the IRS is 600, but frankly we think 550 is about right. The Benefactors pay on average $1K per year. All the rates are posted on the website. For example, Benefactors in the hospital or for whom we assist at surgery are charged nothing additional. We have no insurance billing apparatus at all. It keeps the overhead low... Bob> > >> > > Recently I have had money on my mind. After 2 years in my

new > > > practice I an finally close to making $150,000 which is still > less > > > than I made at my old job. However I am finding it difficult to > > > figure out how to make anymore than that since I don't think > that I > > > can see any more patients in a day. The median income of FP's is > > over > > > $160.000/yr. How many of you are making more than the median FP > > > income and what are you doing to make that much. If the > > micropractice > > > model is not capable of producing enough income to provide at > least > > > the median income it is probably not going to be a viable model.> > > Larry Lindeman MD> > >> >>

Stay in the know. Pulse on the new Yahoo.com. Check it out.

[Guest guest]

Bob: I like your model. This makes sense of what I see is the cost of healthcare at about a dollar per day per patient. 550 patients pay 1000 you take care of 1500 patients. No administration for billing and receivables for those insured or uninsured. Bob Forester MD wrote: Dear ,The website pages on "Benefactors", "How it Works" and "FAQ's" really covers this fairly well. The reason the concept

is difficult is that the uninsured pay nothing -- zip, zero, nada. On average they donate about $9 per visit at last count. We don't bill any insurance or any patient (insured or otherwise) anything except the once annual fee. ONLY the insured "Benefactors" pay the fee. RJ and I have at total of about 550 of them. Our cap with the IRS is 600, but frankly we think 550 is about right. The Benefactors pay on average $1K per year. All the rates are posted on the website. For example, Benefactors in the hospital or for whom we assist at surgery are charged nothing additional. We have no insurance billing apparatus at all. It keeps the overhead low... Bob> > >> > > Recently I have had money on my mind. After 2 years in my

new > > > practice I an finally close to making $150,000 which is still > less > > > than I made at my old job. However I am finding it difficult to > > > figure out how to make anymore than that since I don't think > that I > > > can see any more patients in a day. The median income of FP's is > > over > > > $160.000/yr. How many of you are making more than the median FP > > > income and what are you doing to make that much. If the > > micropractice > > > model is not capable of producing enough income to provide at > least > > > the median income it is probably not going to be a viable model.> > > Larry Lindeman MD> > >> >>

Stay in the know. Pulse on the new Yahoo.com. Check it out.

[Guest guest]

sounds like it's essentially a micro single payer system, supported through "taxes", combined with "from each according to ability, to each according to need". it's socialized communism!! LOL! LLBob Forester MD wrote: Dear ,The website pages on "Benefactors", "How it Works" and "FAQ's" really covers this fairly well. The reason the concept is difficult is that the uninsured pay nothing -- zip, zero, nada. On average they

donate about $9 per visit at last count. We don't bill any insurance or any patient (insured or otherwise) anything except the once annual fee. ONLY the insured "Benefactors" pay the fee. RJ and I have at total of about 550 of them. Our cap with the IRS is 600, but frankly we think 550 is about right. The Benefactors pay on average $1K per year. All the rates are posted on the website. For example, Benefactors in the hospital or for whom we assist at surgery are charged nothing additional. We have no insurance billing apparatus at all. It keeps the overhead low... Bob> > >> > > Recently I have had money on my mind. After 2 years in my new > > > practice I an

finally close to making $150,000 which is still > less > > > than I made at my old job. However I am finding it difficult to > > > figure out how to make anymore than that since I don't think > that I > > > can see any more patients in a day. The median income of FP's is > > over > > > $160.000/yr. How many of you are making more than the median FP > > > income and what are you doing to make that much. If the > > micropractice > > > model is not capable of producing enough income to provide at > least > > > the median income it is probably not going to be a viable model.> > > Larry Lindeman MD> > >> >>

Talk is cheap. Use Yahoo! Messenger to make PC-to-Phone calls. Great rates starting at 1¢/min.

[Guest guest]

Dear Larry,

I prefer to think of it as private philanthropy.

Bob

> > > >

> > > > Recently I have had money on my mind. After 2 years in my

new

> > > > practice I an finally close to making $150,000 which is

still

> > less

> > > > than I made at my old job. However I am finding it difficult

> to

> > > > figure out how to make anymore than that since I don't think

> > that I

> > > > can see any more patients in a day. The median income of

FP's

> is

> > > over

> > > > $160.000/yr. How many of you are making more than the median

> FP

> > > > income and what are you doing to make that much. If the

> > > micropractice

> > > > model is not capable of producing enough income to provide

at

> > least

> > > > the median income it is probably not going to be a viable

> model.

> > > > Larry Lindeman MD

> > > >

> > >

> >

>

>

>

>

>

>

> ---------------------------------

> Talk is cheap. Use Yahoo! Messenger to make PC-to-Phone calls.

Great rates starting at 1¢/min.

>

[Guest guest]

Dear Larry,

I prefer to think of it as private philanthropy.

Bob

> > > >

> > > > Recently I have had money on my mind. After 2 years in my

new

> > > > practice I an finally close to making $150,000 which is

still

> > less

> > > > than I made at my old job. However I am finding it difficult

> to

> > > > figure out how to make anymore than that since I don't think

> > that I

> > > > can see any more patients in a day. The median income of

FP's

> is

> > > over

> > > > $160.000/yr. How many of you are making more than the median

> FP

> > > > income and what are you doing to make that much. If the

> > > micropractice

> > > > model is not capable of producing enough income to provide

at

> > least

> > > > the median income it is probably not going to be a viable

> model.

> > > > Larry Lindeman MD

> > > >

> > >

> >

>

>

>

>

>

>

> ---------------------------------

> Talk is cheap. Use Yahoo! Messenger to make PC-to-Phone calls.

Great rates starting at 1¢/min.

>

[Guest guest]

I was wondering if your model, which I think is very exciting, would work in my

area, a small/medium size town in rural NC.

What general numbers could you share? Percent Medicare, Medicaid, private, etc.

Even though you don't take any of these, it would be helpful to know if your

demographics are comparable. Did you do a feasibility study? If so, through

whom?

Was the 200K you mentioned earlier your take home for each of the two of you, or

gross for the practice?

Thanks

Charlie Vargas

lin, NC

[Guest guest]

Bob- I love the Robin Hood concept institutionalized.

Bob-

I love the 'Robin Hood, institutional', version! I'm wondering about how

your non benefactor patients get the medications/radiology/labwork that they

need. I have a bunch of under insured/noninsured patients and frankly it is

not my $20- 40 fee that is holding up their health care, but the $50-500 lab

fees, the $100- $3000 radiology fees, and the outrageous prices that the

pharmaceutical companies are foisting off on the Americaan public, even for

so-called 'generics'.

Does your organization address this in any way?

Lynn Ho

>

>Reply-To:

>To:

>Subject: Re: money

>Date: Fri, 06 Oct 2006 18:42:27 -0000

>

>Dear ,

>The website pages on " Benefactors " , " How it Works " and " FAQ's "

>really covers this fairly well. The reason the concept is difficult

>is that the uninsured pay nothing -- zip, zero, nada. On average

>they donate about $9 per visit at last count.

>We don't bill any insurance or any patient (insured or otherwise)

>anything except the once annual fee. ONLY the insured " Benefactors "

>pay the fee. RJ and I have at total of about 550 of them. Our cap

>with the IRS is 600, but frankly we think 550 is about right. The

>Benefactors pay on average $1K per year. All the rates are posted on

>the website.

>For example, Benefactors in the hospital or for whom we assist at

>surgery are charged nothing additional. We have no insurance billing

>apparatus at all. It keeps the overhead low...

>Bob

>

>

> > > >

> > > > Recently I have had money on my mind. After 2 years in my new

> > > > practice I an finally close to making $150,000 which is still

> > less

> > > > than I made at my old job. However I am finding it difficult

>to

> > > > figure out how to make anymore than that since I don't think

> > that I

> > > > can see any more patients in a day. The median income of FP's

>is

> > > over

> > > > $160.000/yr. How many of you are making more than the median

>FP

> > > > income and what are you doing to make that much. If the

> > > micropractice

> > > > model is not capable of producing enough income to provide at

> > least

> > > > the median income it is probably not going to be a viable

>model.

> > > > Larry Lindeman MD

> > > >

> > >

> >

>

>

>

>

[Guest guest]

"Necessity is the mother of invention." author? As I read this particular thread, I am excited and dsimayed. Excited because both Tim and Bob have engineered a way to treat an underserved population through Robin Hood tactics and have come up with a creative way to do so. I am dismayed because they had to do so in order to practice the way they want: that we don't have a system in place that actually financially covers under and uninsured patients. That on my hampster wheel day job, I do have to treat patients differently based on their insurance coverage...where they can go, who they can see. It makesd me angry the money that can be saved just by all the duplication of services that each insurance company has and the layers of buerocracy(sp) consumers of health care pay for in these companies. That being said, what is our role as not only IMP's, but concerned citizens, consumers of

health care ourselves to get real change occurring, not just lip service. " Malia, MD" wrote: Bob --It's great to hear from you on the list. You may not know it, but you gaveme the final push to jump ship from my old practice and start my imp. Wemet briefly at the SF assembly last year and hearing you speak helped mefit together the last pieces of the puzzle I had in my head... yes, "robinhood practice"

stood out in my mind.I happen to know sign language and have provided medical care for hundredsof Deaf patients... about 30% of my patients are Deaf (Rochester has ahuge Deaf community, deaf college, etc). Many of them are undereducatedand have received lousy care for years (today, met new Deaf man... 51 yo,24 yrs diabetic on insulin but not taking aspirin... he said he'd neverbeen told that a diabetic has increased risk of heart disease and hadnever had a fasting blood test!!!!!... I got tons of examples likethat...)... anyway, many of the Deaf have medicare and medicaid. But whenI did my financial calculations I worried I'd have to drop medicare andmedicaid to make the office float. But that didn't sit right with mepersonally and I wondered what cI ould do.... Robin Hood model came alongand I decided to take a part of my practice and add aesthetic services sowith the financial support of that I could keep practicing

medicine theway I want for the patients I want! So far, so good and I'm soon to entera new stage as I may close to new family med patients and am about totrain in botox and Restylane.So, thanks for developing your model and helping me know I could stilloffer a special, though low paying, service to patients who need primarycare AND still make money for comfort. ... and, about the money, I'mstill working to improve t as I'm not yet making a great salary but thinkthat by my 1 yr anniversary (March) I'll be where I need to be.Have a good weekendTim> Dear ,> Thank you for your interest. We really dislike the semantics> of "retainer", "boutique" and "concierge" practices to try and> describe what we do. Basically, among imps and non-profit do-gooder> folks they are pejoritive terms -- but hey, it's the jargon we have.> More to my liking is Gordon's label of "a Robin Hood

practice.">> We are an imp that uses an annual pre-payment to fund care to the> uninsured. It wouldn't work for every community, but certainly it will> work for more than just ours. Our primary focus is free care to the> uninsured. In California, there are many who have no coverage. No> MediCal (MedicAid), no MIA (Medically Indigent Adults Program), no> nothing -- those folks are the primary recipients of our> practice.>> We fund our practice by providing "boutique" type payment for great> service -- the same kind of service you are all providing to your> patients utilizing an imp model. We are in the enviable setting of> having:> 1. Solid, established (10-15 year) reputations in a medium-sized> community (200K).> 2. Living in a relatively primary care doctor deficient area with a> history of less than optimal customer service to patients.> 3. The

support of our local Catholic and do-gooder community.> 4. A Board of Directors.> 5. A favorable 501©(3) ruling from the IRS after a protracted> process.>> , I am not surprised that you have never heard of a medical> office operating as a 501©(3) before; because as far as we know from> discussions with many imps, do-gooder groups and the IRS, none of them> have either. However, with the help of our Board,> Benefactors and Donors we have set the precedent. Now the challenge is> up to a few of you to adopt, adapt and improve the model to help worthy> causes (like the uninsured) your communities and carve out a> sustainable lifestyle and practice high-quality imp medicine at the> same time too.>> Again, please take a look at our website www.stlukesfp.org. On> the "News" page in the left hand column, you will be able to read the> articles from

the Modesto Bee about how the community perceives and> supports our practce. Soon we will post the recent article from> Catholic Digest (July 2006). You may also view our IRS ruling> letter.>> I look forward to trying to answer your further questions as it may> help me form my thoughts for future presentations and publications.>> Bob Forester>> >> >>> > Recently I have had money on my mind. After 2 years in my new>> practice I an finally close to making $150,000 which is still> less>> > than I made at my old job. However I am finding it difficult to>> figure out how to make anymore than that since I don't think> that I>> > can see any more patients in a day. The median income of FP's is>> over>> > $160.000/yr. How many of you are making more than the median FP>> income and what are you doing to make that much.

If the>> micropractice>> > model is not capable of producing enough income to provide at> least>> > the median income it is probably not going to be a viable model.>> Larry Lindeman MD>> >>>>>>>>>>>

[Guest guest]

It's from Plato's " Republic " ...

And this, plus thoughts of mission/vision statements, reminds me of

Socrates great one-liner, " An unexamined life is not worth living " ...

And the modern perspective -- " an unlived life is not worth examining " !!

Anyway... we all make choices based on where we want our life to lead. BUT

we have to be realistic and accept the world we are in.

If our priority is to change a large system the goals/objectives will be

very different than if we prioritize family and helping the lives of those

we touch at work.

If one has debt or lives in an area where insurance ain't paying well, IMP

alone would be tough choice (that is my opinion based on what I believe is

reality).

But if one wants a " good " income and great flexibility and enjoy

life/work, IMP may be perfect.

And... if one wants a bit of both (what I judge is my reality), more ideas

from " outside the box " have to become reality.

Another perspective is the little bit I know about the health care system

in Bolivia (my wife's native country and to which I have professional

ties). Basically, all the docs have to serve the national system for the

poor by working in clinics in the mornings. Then there is the midday break

where most everyone goes home from about 12 to about 3. Then all the docs

go to their private offices/ private clinics (like mini-hospitals) and

they work until about 8 really making their money.

That's a whole different world where the docs and the country have

different priorities than we have, but it's the reality those folks live

in.

Tim

> " Necessity is the mother of invention. " author?

>

> As I read this particular thread, I am excited and dsimayed. Excited

> because both Tim and Bob have engineered a way to treat an underserved

> population through Robin Hood tactics and have come up with a creative

> way to do so. I am dismayed because they had to do so in order to

> practice the way they want: that we don't have a system in place that

> actually financially covers under and uninsured patients. That on my

> hampster wheel day job, I do have to treat patients differently based

> on their insurance coverage...where they can go, who they can see.

> It makesd me angry the money that can be saved just by all the

> duplication of services that each insurance company has and the layers

> of buerocracy(sp) consumers of health care pay for in these companies.

> That being said, what is our role as not only IMP's, but concerned

> citizens, consumers of health care ourselves to get real change

> occurring, not just lip service.

>

>

> " Malia, MD " wrote:

> Bob --

>

> It's great to hear from you on the list. You may not know it, but you

> gave me the final push to jump ship from my old practice and start my

> imp. We met briefly at the SF assembly last year and hearing you speak

> helped me fit together the last pieces of the puzzle I had in my head...

> yes, " robin hood practice " stood out in my mind.

>

> I happen to know sign language and have provided medical care for

> hundreds of Deaf patients... about 30% of my patients are Deaf

> (Rochester has a huge Deaf community, deaf college, etc). Many of them

> are undereducated and have received lousy care for years (today, met new

> Deaf man... 51 yo, 24 yrs diabetic on insulin but not taking aspirin...

> he said he'd never been told that a diabetic has increased risk of heart

> disease and had never had a fasting blood test!!!!!... I got tons of

> examples like that...)... anyway, many of the Deaf have medicare and

> medicaid. But when I did my financial calculations I worried I'd have to

> drop medicare and medicaid to make the office float. But that didn't sit

> right with me personally and I wondered what cI ould do.... Robin Hood

> model came along and I decided to take a part of my practice and add

> aesthetic services so with the financial support of that I could keep

> practicing medicine the way I want for the patients I want! So far, so

> good and I'm soon to enter a new stage as I may close to new family med

> patients and am about to train in botox and Restylane.

>

> So, thanks for developing your model and helping me know I could still

> offer a special, though low paying, service to patients who need primary

> care AND still make money for comfort. ... and, about the money, I'm

> still working to improve t as I'm not yet making a great salary but

> think that by my 1 yr anniversary (March) I'll be where I need to be.

>

> Have a good weekend

> Tim

>

>> Dear ,

>> Thank you for your interest. We really dislike the semantics

>> of " retainer " , " boutique " and " concierge " practices to try and

>> describe what we do. Basically, among imps and non-profit do-gooder

>> folks they are pejoritive terms -- but hey, it's the jargon we have.

>> More to my liking is Gordon's label of " a Robin Hood practice. "

>>

>> We are an imp that uses an annual pre-payment to fund care to the

>> uninsured. It wouldn't work for every community, but certainly it will

>> work for more than just ours. Our primary focus is free care to the

>> uninsured. In California, there are many who have no coverage. No

>> MediCal (MedicAid), no MIA (Medically Indigent Adults Program), no

>> nothing -- those folks are the primary recipients of our

>> practice.

>>

>> We fund our practice by providing " boutique " type payment for great

>> service -- the same kind of service you are all providing to your

>> patients utilizing an imp model. We are in the enviable setting of

>> having:

>> 1. Solid, established (10-15 year) reputations in a medium-sized

>> community (200K).

>> 2. Living in a relatively primary care doctor deficient area with a

>> history of less than optimal customer service to patients.

>> 3. The support of our local Catholic and do-gooder community.

>> 4. A Board of Directors.

>> 5. A favorable 501©(3) ruling from the IRS after a protracted

>> process.

>>

>> , I am not surprised that you have never heard of a medical

>> office operating as a 501©(3) before; because as far as we know from

>> discussions with many imps, do-gooder groups and the IRS, none of them

>> have either. However, with the help of our Board,

>> Benefactors and Donors we have set the precedent. Now the challenge is

>> up to a few of you to adopt, adapt and improve the model to help

>> worthy causes (like the uninsured) your communities and carve out a

>> sustainable lifestyle and practice high-quality imp medicine at the

>> same time too.

>>

>> Again, please take a look at our website www.stlukesfp.org. On

>> the " News " page in the left hand column, you will be able to read the

>> articles from the Modesto Bee about how the community perceives and

>> supports our practce. Soon we will post the recent article from

>> Catholic Digest (July 2006). You may also view our IRS ruling

>> letter.

>>

>> I look forward to trying to answer your further questions as it may

>> help me form my thoughts for future presentations and publications.

>>

>> Bob Forester

>>

>>

>>> >

>>> > Recently I have had money on my mind. After 2 years in my new

>>> practice I an finally close to making $150,000 which is still

>> less

>>> > than I made at my old job. However I am finding it difficult to

>>> figure out how to make anymore than that since I don't think

>> that I

>>> > can see any more patients in a day. The median income of FP's is

>>> over

>>> > $160.000/yr. How many of you are making more than the median FP

>>> income and what are you doing to make that much. If the

>>> micropractice

>>> > model is not capable of producing enough income to provide at

>> least

>>> > the median income it is probably not going to be a viable model.

>>> Larry Lindeman MD

>>> >

>>>

>>

>>

>>

>>

>>

>>

>>

>>

[Guest guest]

It's from Plato's " Republic " ...

And this, plus thoughts of mission/vision statements, reminds me of

Socrates great one-liner, " An unexamined life is not worth living " ...

And the modern perspective -- " an unlived life is not worth examining " !!

Anyway... we all make choices based on where we want our life to lead. BUT

we have to be realistic and accept the world we are in.

If our priority is to change a large system the goals/objectives will be

very different than if we prioritize family and helping the lives of those

we touch at work.

If one has debt or lives in an area where insurance ain't paying well, IMP

alone would be tough choice (that is my opinion based on what I believe is

reality).

But if one wants a " good " income and great flexibility and enjoy

life/work, IMP may be perfect.

And... if one wants a bit of both (what I judge is my reality), more ideas

from " outside the box " have to become reality.

Another perspective is the little bit I know about the health care system

in Bolivia (my wife's native country and to which I have professional

ties). Basically, all the docs have to serve the national system for the

poor by working in clinics in the mornings. Then there is the midday break

where most everyone goes home from about 12 to about 3. Then all the docs

go to their private offices/ private clinics (like mini-hospitals) and

they work until about 8 really making their money.

That's a whole different world where the docs and the country have

different priorities than we have, but it's the reality those folks live

in.

Tim

> " Necessity is the mother of invention. " author?

>

> As I read this particular thread, I am excited and dsimayed. Excited

> because both Tim and Bob have engineered a way to treat an underserved

> population through Robin Hood tactics and have come up with a creative

> way to do so. I am dismayed because they had to do so in order to

> practice the way they want: that we don't have a system in place that

> actually financially covers under and uninsured patients. That on my

> hampster wheel day job, I do have to treat patients differently based

> on their insurance coverage...where they can go, who they can see.

> It makesd me angry the money that can be saved just by all the

> duplication of services that each insurance company has and the layers

> of buerocracy(sp) consumers of health care pay for in these companies.

> That being said, what is our role as not only IMP's, but concerned

> citizens, consumers of health care ourselves to get real change

> occurring, not just lip service.

>

>

> " Malia, MD " wrote:

> Bob --

>

> It's great to hear from you on the list. You may not know it, but you

> gave me the final push to jump ship from my old practice and start my

> imp. We met briefly at the SF assembly last year and hearing you speak

> helped me fit together the last pieces of the puzzle I had in my head...

> yes, " robin hood practice " stood out in my mind.

>

> I happen to know sign language and have provided medical care for

> hundreds of Deaf patients... about 30% of my patients are Deaf

> (Rochester has a huge Deaf community, deaf college, etc). Many of them

> are undereducated and have received lousy care for years (today, met new

> Deaf man... 51 yo, 24 yrs diabetic on insulin but not taking aspirin...

> he said he'd never been told that a diabetic has increased risk of heart

> disease and had never had a fasting blood test!!!!!... I got tons of

> examples like that...)... anyway, many of the Deaf have medicare and

> medicaid. But when I did my financial calculations I worried I'd have to

> drop medicare and medicaid to make the office float. But that didn't sit

> right with me personally and I wondered what cI ould do.... Robin Hood

> model came along and I decided to take a part of my practice and add

> aesthetic services so with the financial support of that I could keep

> practicing medicine the way I want for the patients I want! So far, so

> good and I'm soon to enter a new stage as I may close to new family med

> patients and am about to train in botox and Restylane.

>

> So, thanks for developing your model and helping me know I could still

> offer a special, though low paying, service to patients who need primary

> care AND still make money for comfort. ... and, about the money, I'm

> still working to improve t as I'm not yet making a great salary but

> think that by my 1 yr anniversary (March) I'll be where I need to be.

>

> Have a good weekend

> Tim

>

>> Dear ,

>> Thank you for your interest. We really dislike the semantics

>> of " retainer " , " boutique " and " concierge " practices to try and

>> describe what we do. Basically, among imps and non-profit do-gooder

>> folks they are pejoritive terms -- but hey, it's the jargon we have.

>> More to my liking is Gordon's label of " a Robin Hood practice. "

>>

>> We are an imp that uses an annual pre-payment to fund care to the

>> uninsured. It wouldn't work for every community, but certainly it will

>> work for more than just ours. Our primary focus is free care to the

>> uninsured. In California, there are many who have no coverage. No

>> MediCal (MedicAid), no MIA (Medically Indigent Adults Program), no

>> nothing -- those folks are the primary recipients of our

>> practice.

>>

>> We fund our practice by providing " boutique " type payment for great

>> service -- the same kind of service you are all providing to your

>> patients utilizing an imp model. We are in the enviable setting of

>> having:

>> 1. Solid, established (10-15 year) reputations in a medium-sized

>> community (200K).

>> 2. Living in a relatively primary care doctor deficient area with a

>> history of less than optimal customer service to patients.

>> 3. The support of our local Catholic and do-gooder community.

>> 4. A Board of Directors.

>> 5. A favorable 501©(3) ruling from the IRS after a protracted

>> process.

>>

>> , I am not surprised that you have never heard of a medical

>> office operating as a 501©(3) before; because as far as we know from

>> discussions with many imps, do-gooder groups and the IRS, none of them

>> have either. However, with the help of our Board,

>> Benefactors and Donors we have set the precedent. Now the challenge is

>> up to a few of you to adopt, adapt and improve the model to help

>> worthy causes (like the uninsured) your communities and carve out a

>> sustainable lifestyle and practice high-quality imp medicine at the

>> same time too.

>>

>> Again, please take a look at our website www.stlukesfp.org. On

>> the " News " page in the left hand column, you will be able to read the

>> articles from the Modesto Bee about how the community perceives and

>> supports our practce. Soon we will post the recent article from

>> Catholic Digest (July 2006). You may also view our IRS ruling

>> letter.

>>

>> I look forward to trying to answer your further questions as it may

>> help me form my thoughts for future presentations and publications.

>>

>> Bob Forester

>>

>>

>>> >

>>> > Recently I have had money on my mind. After 2 years in my new

>>> practice I an finally close to making $150,000 which is still

>> less

>>> > than I made at my old job. However I am finding it difficult to

>>> figure out how to make anymore than that since I don't think

>> that I

>>> > can see any more patients in a day. The median income of FP's is

>>> over

>>> > $160.000/yr. How many of you are making more than the median FP

>>> income and what are you doing to make that much. If the

>>> micropractice

>>> > model is not capable of producing enough income to provide at

>> least

>>> > the median income it is probably not going to be a viable model.

>>> Larry Lindeman MD

>>> >

>>>

>>

>>

>>

>>

>>

>>

>>

>>

[Guest guest]

Here, here, I tried to find a low cost/free MRI for a pt who I suspected had MS.

Called everywhere, and even using Simple Care(reduced fees for cash pt) could

find nothing lower than $4000 for brain MRI. In the end sent pt to a local

Community hospital knowing that eventually they could " write it off " . However,

they threatened collections etc, this pt was a working insurance salesman,

living on limited commissions, and kept getting told, " no sliding fee " , she just

needed to pay the balance. Also recently had a teen land a jump on a BMX bike

poorly, driving handle bars into his upper thigh, near groin. Went to

Harborview our local trauma hospital, got cleaned out, sutured, packed, IV

antibiotics, and was supposed to spend night, didn't. Cost of XR, surgeons, ER

fee, labs, and ambulance ride for 1 d, $130,000! This is generally thought of

as a hospital of last resort for anyone who can't pay. Working, divorced

father, who does construction, no health insurance. Is being dunn

ed to pay this exhorbitant(sp) amt, " to not ruin his credit rating " . In this

state your health debt isn't even allowed to show on your credit. The current

state of health care in this country and how it gets paid for is crazy. As we

have been saying on these posts for yrs. For both pt I urged them to stand their

ground, speak to financial counsellors at hospitals, show their income, and

plead for debt reduction/write off. For the first it eventually happened, for

the second still to early to know.

--------- Re: money

> >Date: Fri, 06 Oct 2006 18:42:27 -0000

> >

> >Dear ,

> >The website pages on " Benefactors " , " How it Works " and " FAQ's "

> >really covers this fairly well. The reason the concept is difficult

> >is that the uninsured pay nothing -- zip, zero, nada. On average

> >they donate about $9 per visit at last count.

> >We don't bill any insurance or any patient (insured or otherwise)

> >anything except the once annual fee. ONLY the insured " Benefactors "

> >pay the fee. RJ and I have at total of about 550 of them. Our cap

> >with the IRS is 600, but frankly we think 550 is about right. The

> >Benefactors pay on average $1K per year. All the rates are posted on

> >the website.

> >For example, Benefactors in the hospital or for whom we assist at

> >surgery are charged nothing additional. We have no insurance billing

> >apparatus at all. It keeps the overhead low...

> >Bob

> >

> >

> > > >

> > > > Recently I have had money on my mind. After 2 years in my new

> > > > practice I an finally close to making $150,000 which is still

> > less

> > > > than I made at my old job. However I am finding it difficult

>to

> > > > figure out how to make anymore than that since I don't think

> > that I

> > > > can see any more patients in a day. The median income of FP's

>is

> > > over

> > > > $160.000/yr. How many of you are making more than the median

>FP

> > > > income and what are you doing to make that much. If the

> > > micropractice

> > > > model is not capable of producing enough income to provide at

> > least

> > > > the median income it is probably not going to be a viable

>model.

> > > > Larry Lindeman MD

> > > >

> > >

> >

>

>

>

>

[Guest guest]

Dear Lynn,

My apologies for the delay, but I had a very busy October since

beginning the answer to your question.

You are absolutely correct. Primary care cognitive services are not

the big expense to modern health care! But fear of expense and

actually getting into the primary care doctor's office is often the

first and most important stumbling block.

Getting labs and medicines is an ongoing problem. First of all,

remember that the poorest of the poor citizens will virtually always

qualify for Medicaid and will be seen elsewhere. Our uninsureds are

typically working poor and are usually happy to pay what they can.

The unemployed AND undocumented (illegals) are our biggest headache

because they are broke and have no Medicaid eligibility in

California except for " Emergency Only " immediate threat to life or

limb. But still, that is a help to get people emergency treatment

when our patients have acute cholecystitis, cancer or an MI. The

other neat part is that once they suffer their inpatient malady, we

are happy to communicate with the hospital doctors and caseworkers

and get the patients appropriate follow up care.

Regarding the labs and diagnostic studies:

Typically, by having the ability to see patients more frequently.

And with more time we are able to require fewer lab tests and rely

more on our clinical skills. I assume that all IMP's are having the

same experience compared to their former lives at 4-6 patients/hr.

We perform UA micro, wet mount, KOH, BS, HgbA1c, urine pregnancy,

hematocrit and EKG in the office. We pay for all the supplies and

charge nothing for the tests. We send patients to the County

Facility to pay cash for labs (CBC $15, CMP $30, Lipid $38, FT4

$27). For radiographs our patients get a 50% break at a local

radiology office for cash pay at the time of service. Most plain

radiographs are $30-100. An upper GI is only about $120. Pelvic and

abdominal sonos are about $100-120. Most CT's are about $300 w/o

contrast, and we do far more of them than MRI's on our uninsured

Recipients. (C'mon Lynn, you're old enough, like me, to remember way

back to the days when upper GI's and CT scans used to be good

studies?) Also, we try to develop and maintain relationships with

the local hospitals, consultants, DME providers to provide a few

freebies. We get a cheapo endoscopy or colonoscopy now and then.

Earlier this year we convinced a local hospital to " comp " a TURP to

an undocumented alien.

One of next year's goals is to repeat a coordinated " marketing

campaign " that was quite successful in 2003-04 at our start-up. We

will again use local newspaper and TV coverage and speak to lots of

local service clubs and churches. We hope to build up a little

bigger war chest to help fund these types of expenses. A local

medical supply company (with a very strong sense of Christian

commitment) donated almost $15,000 of used equipment at our start-

up. Last year, Omega Nu bought us an EKG. And this year they paid

for some additional surgical equipment and HgbA1c tests. We'll hit

up other service clubs (Rotary, Kiwanis's, Lion's, etc.) and

hospitals for bigger ticket items: sigmoidoscope, electronic scale,

automated BP cuffs, software, etc. We have found that the service

clubs love having engaging speakers for their meetings and rarely

have physicians among their ranks.

Another plan is to help defray part of the cost of some diagnostic

studies through accounts " donated " by local diagnostic service

providers. Here's how it would work. The provider (hospital,

diagnostic imaging center or pathology group) would donate an

account to St. Luke's with a positive balance. We would negotiate

with the provider for a favorable rate (i.e. Medicaid or Medicare)

rather than often exorbitant " retail " prices. As we deemed

necessary we would order pathology, labs and X-rays on our patients.

The uninsured have a cash co-payment (e.g. $25) at the time of

service at the diagnostic provider's office, and with that the

provider would perform the test. The balance of the cost of the test

minus the co-payment would be " deducted " from our account. That

would allow several good things to happen:

1. The donor facility would get a little positive cash flow.

2. The donor facility wouldn't be required to put out any cash for

the donation.

3. The donor facility would be able always know the cash value of

their donation to a 501©(3).

3. It would keep the bookkeeping simple (no insurance to bill keeps

their costs low).

4. The uninsured would bear a modest cost and gain a greater sense

of partnership in the provision of their health care.

Regarding Medications:

Because we are able to think about patient care a little longer than

traditional docs, I would hope that all of us IMP's are striving to

stay away from polypharmacy. Attempting an EBM approach should lead

to fewer and usually cheaper meds for all our patients. I have had a

few Medicare Benefactors paying out of pocket for meds and

previously naïve to the drug class in consideration, who I have

switched (i.e. from Lexapro to fluoxetine and from Cozaar to

lisinopril) on their first visit. Those moves alone basically saved

an entire years ($1500) Benefactor fee! And the savings will

continue. I have become more aggressive about discontinuing

medications because I can call and follow up closely.

Remember, our uninsured patients are not usually indigent (unless

undocumented) and can easily pay $35 per month for metformin, but

not the $800+ per month insurance premium.

We maintain relationships with our local drug reps that allow them

scheduled access to both doctors uninterrupted attention for five

minutes every few months (about 3 reps per week). The deal is that

they need to keep us in samples, or at least able to call for

samples as needed. A volunteer retired RN comes in once every week

or two to straighten the samples in the cabinet. They are grouped by

drug class and packaging is reduced sharply. When name brand drugs

are required, we sample generously and use www.helpingpatients.org,

a pharmaceutical manufacturer's website that includes all the

patient assistance programs rolled into one portal. The most

important drugs for this are TZD's, statins, ARB's, antidepressants,

atypical antipsychotics, nasal steroids, and quinolones.

And finally, a local pharmacy donates big stock bottles of a few

common meds to use with the indigent (doxycycline, atenolol,

metformin, hydrochlorothiazide, glyburide).

It isn't perfect, but it seems to be working better than nothing and

doesn't take up too much of our time. I can't wait to see the " How's

Your Health " responses on our Recipients before and after having our

practice!

Bob

> > > > >

> > > > > Recently I have had money on my mind. After 2 years in my

new

> > > > > practice I an finally close to making $150,000 which is

still

> > > less

> > > > > than I made at my old job. However I am finding it

difficult

> >to

> > > > > figure out how to make anymore than that since I don't

think

> > > that I

> > > > > can see any more patients in a day. The median income of

FP's

> >is

> > > > over

> > > > > $160.000/yr. How many of you are making more than the

median

> >FP

> > > > > income and what are you doing to make that much. If the

> > > > micropractice

> > > > > model is not capable of producing enough income to provide

at

> > > least

> > > > > the median income it is probably not going to be a viable

> >model.

> > > > > Larry Lindeman MD

> > > > >

> > > >

> > >

> >

> >

> >

> >

>

[Guest guest]

Sounds great! Wish I were there. Bob Forester MD wrote: Dear Lynn,My apologies for the delay, but I had a very busy October since beginning the answer to your question. You are absolutely correct. Primary care cognitive services are not the big expense to modern health care! But fear of expense and actually getting into the primary care doctor's office is often the first and most important

stumbling block. Getting labs and medicines is an ongoing problem. First of all, remember that the poorest of the poor citizens will virtually always qualify for Medicaid and will be seen elsewhere. Our uninsureds are typically working poor and are usually happy to pay what they can. The unemployed AND undocumented (illegals) are our biggest headache because they are broke and have no Medicaid eligibility in California except for "Emergency Only" immediate threat to life or limb. But still, that is a help to get people emergency treatment when our patients have acute cholecystitis, cancer or an MI. The other neat part is that once they suffer their inpatient malady, we are happy to communicate with the hospital doctors and caseworkers and get the patients appropriate follow up care. Regarding the labs and diagnostic studies:Typically, by having the ability to see patients more frequently. And with more

time we are able to require fewer lab tests and rely more on our clinical skills. I assume that all IMP's are having the same experience compared to their former lives at 4-6 patients/hr. We perform UA micro, wet mount, KOH, BS, HgbA1c, urine pregnancy, hematocrit and EKG in the office. We pay for all the supplies and charge nothing for the tests. We send patients to the County Facility to pay cash for labs (CBC $15, CMP $30, Lipid $38, FT4 $27). For radiographs our patients get a 50% break at a local radiology office for cash pay at the time of service. Most plain radiographs are $30-100. An upper GI is only about $120. Pelvic and abdominal sonos are about $100-120. Most CT's are about $300 w/o contrast, and we do far more of them than MRI's on our uninsured Recipients. (C'mon Lynn, you're old enough, like me, to remember way back to the days when upper GI's and CT scans used to be good studies?) Also, we try to

develop and maintain relationships with the local hospitals, consultants, DME providers to provide a few freebies. We get a cheapo endoscopy or colonoscopy now and then. Earlier this year we convinced a local hospital to "comp" a TURP to an undocumented alien. One of next year's goals is to repeat a coordinated "marketing campaign" that was quite successful in 2003-04 at our start-up. We will again use local newspaper and TV coverage and speak to lots of local service clubs and churches. We hope to build up a little bigger war chest to help fund these types of expenses. A local medical supply company (with a very strong sense of Christian commitment) donated almost $15,000 of used equipment at our start-up. Last year, Omega Nu bought us an EKG. And this year they paid for some additional surgical equipment and HgbA1c tests. We'll hit up other service clubs (Rotary, Kiwanis's, Lion's, etc.) and hospitals for

bigger ticket items: sigmoidoscope, electronic scale, automated BP cuffs, software, etc. We have found that the service clubs love having engaging speakers for their meetings and rarely have physicians among their ranks. Another plan is to help defray part of the cost of some diagnostic studies through accounts "donated" by local diagnostic service providers. Here's how it would work. The provider (hospital, diagnostic imaging center or pathology group) would donate an account to St. Luke's with a positive balance. We would negotiate with the provider for a favorable rate (i.e. Medicaid or Medicare) rather than often exorbitant "retail" prices. As we deemed necessary we would order pathology, labs and X-rays on our patients. The uninsured have a cash co-payment (e.g. $25) at the time of service at the diagnostic provider's office, and with that the provider would perform the test. The balance of the cost of the

test minus the co-payment would be "deducted" from our account. That would allow several good things to happen:1. The donor facility would get a little positive cash flow.2. The donor facility wouldn't be required to put out any cash for the donation.3. The donor facility would be able always know the cash value of their donation to a 501©(3).3. It would keep the bookkeeping simple (no insurance to bill keeps their costs low).4. The uninsured would bear a modest cost and gain a greater sense of partnership in the provision of their health care.Regarding Medications:Because we are able to think about patient care a little longer than traditional docs, I would hope that all of us IMP's are striving to stay away from polypharmacy. Attempting an EBM approach should lead to fewer and usually cheaper meds for all our patients. I have had a few Medicare Benefactors paying out of pocket for meds and

previously naïve to the drug class in consideration, who I have switched (i.e. from Lexapro to fluoxetine and from Cozaar to lisinopril) on their first visit. Those moves alone basically saved an entire years ($1500) Benefactor fee! And the savings will continue. I have become more aggressive about discontinuing medications because I can call and follow up closely.Remember, our uninsured patients are not usually indigent (unless undocumented) and can easily pay $35 per month for metformin, but not the $800+ per month insurance premium. We maintain relationships with our local drug reps that allow them scheduled access to both doctors uninterrupted attention for five minutes every few months (about 3 reps per week). The deal is that they need to keep us in samples, or at least able to call for samples as needed. A volunteer retired RN comes in once every week or two to straighten the samples in the cabinet.

They are grouped by drug class and packaging is reduced sharply. When name brand drugs are required, we sample generously and use www.helpingpatients.org, a pharmaceutical manufacturer's website that includes all the patient assistance programs rolled into one portal. The most important drugs for this are TZD's, statins, ARB's, antidepressants, atypical antipsychotics, nasal steroids, and quinolones.And finally, a local pharmacy donates big stock bottles of a few common meds to use with the indigent (doxycycline, atenolol, metformin, hydrochlorothiazide, glyburide).It isn't perfect, but it seems to be working better than nothing and doesn't take up too much of our time. I can't wait to see the "How's Your Health" responses on our Recipients before and after having our practice!Bob> > > > >> > > > > Recently I have had money on my mind. After 2 years in my new> > > > > practice I an finally close to making $150,000 which is still> > > less> > > > > than I made at my old job. However I am finding it difficult> >to> > > > > figure out how to make anymore than that since I don't think> > > that I> > > > > can see any more patients in a day. The median income of FP's> >is> > > > over> > > > > $160.000/yr. How many of you are making more than the

median> >FP> > > > > income and what are you doing to make that much. If the> > > > micropractice> > > > > model is not capable of producing enough income to provide at> > > least> > > > > the median income it is probably not going to be a viable> >model.> > > > > Larry Lindeman MD> > > > >> > > >> > >> >> >> >> >>

Check out the New Yahoo! Mail - Fire up a more powerful email and get things done faster.

[Guest guest]

I'm more than intreged. I love this idea! Any chance of a lecture (or three) or file or anything if any of us others out here would like to 'me too'? Are you coming to our possible gathering next spring? -- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353

Flexible Family Care

'Modern medicine the old-fashioned way'

[Guest guest]

I'm more than intreged. I love this idea! Any chance of a lecture (or three) or file or anything if any of us others out here would like to 'me too'? Are you coming to our possible gathering next spring? -- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353

Flexible Family Care

'Modern medicine the old-fashioned way'

[Guest guest]

Dear Lynette, This string is too long. Are you directing your comments to me? Bob Forester St. Luke's Modesto aka "Robin Hood"ote: I'm more than intreged. I love this idea! Any chance of a lecture (or three) or file or anything if any of us others out here would like to 'me too'? Are you coming to our possible gathering next spring? -- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern

medicine the old-fashioned way'

We have the perfect Group for you. Check out the handy changes to Yahoo! Groups.

[Guest guest]

Thanks Bob- I see that you clearly have a safety net set up to try to

provide for your working poor population, though the whole she-bang

definitely consumes some resources from the practice side. I'm wondering if

my solo solo IMP practice can co-opt any of your strategies on a small scale

for my working poor patients; I'm going to incubate some of your ideas.

Lynn

>

>Reply-To:

>To:

>Subject: Re: money

>Date: Tue, 31 Oct 2006 06:15:01 -0000

>

>Dear Lynn,

>My apologies for the delay, but I had a very busy October since

>beginning the answer to your question.

>

>You are absolutely correct. Primary care cognitive services are not

>the big expense to modern health care! But fear of expense and

>actually getting into the primary care doctor's office is often the

>first and most important stumbling block.

>

>Getting labs and medicines is an ongoing problem. First of all,

>remember that the poorest of the poor citizens will virtually always

>qualify for Medicaid and will be seen elsewhere. Our uninsureds are

>typically working poor and are usually happy to pay what they can.

>The unemployed AND undocumented (illegals) are our biggest headache

>because they are broke and have no Medicaid eligibility in

>California except for " Emergency Only " immediate threat to life or

>limb. But still, that is a help to get people emergency treatment

>when our patients have acute cholecystitis, cancer or an MI. The

>other neat part is that once they suffer their inpatient malady, we

>are happy to communicate with the hospital doctors and caseworkers

>and get the patients appropriate follow up care.

>

>Regarding the labs and diagnostic studies:

>

>Typically, by having the ability to see patients more frequently.

>And with more time we are able to require fewer lab tests and rely

>more on our clinical skills. I assume that all IMP's are having the

>same experience compared to their former lives at 4-6 patients/hr.

>We perform UA micro, wet mount, KOH, BS, HgbA1c, urine pregnancy,

>hematocrit and EKG in the office. We pay for all the supplies and

>charge nothing for the tests. We send patients to the County

>Facility to pay cash for labs (CBC $15, CMP $30, Lipid $38, FT4

>$27). For radiographs our patients get a 50% break at a local

>radiology office for cash pay at the time of service. Most plain

>radiographs are $30-100. An upper GI is only about $120. Pelvic and

>abdominal sonos are about $100-120. Most CT's are about $300 w/o

>contrast, and we do far more of them than MRI's on our uninsured

>Recipients. (C'mon Lynn, you're old enough, like me, to remember way

>back to the days when upper GI's and CT scans used to be good

>studies?) Also, we try to develop and maintain relationships with

>the local hospitals, consultants, DME providers to provide a few

>freebies. We get a cheapo endoscopy or colonoscopy now and then.

>Earlier this year we convinced a local hospital to " comp " a TURP to

>an undocumented alien.

>

>One of next year's goals is to repeat a coordinated " marketing

>campaign " that was quite successful in 2003-04 at our start-up. We

>will again use local newspaper and TV coverage and speak to lots of

>local service clubs and churches. We hope to build up a little

>bigger war chest to help fund these types of expenses. A local

>medical supply company (with a very strong sense of Christian

>commitment) donated almost $15,000 of used equipment at our start-

>up. Last year, Omega Nu bought us an EKG. And this year they paid

>for some additional surgical equipment and HgbA1c tests. We'll hit

>up other service clubs (Rotary, Kiwanis's, Lion's, etc.) and

>hospitals for bigger ticket items: sigmoidoscope, electronic scale,

>automated BP cuffs, software, etc. We have found that the service

>clubs love having engaging speakers for their meetings and rarely

>have physicians among their ranks.

>

>Another plan is to help defray part of the cost of some diagnostic

>studies through accounts " donated " by local diagnostic service

>providers. Here's how it would work. The provider (hospital,

>diagnostic imaging center or pathology group) would donate an

>account to St. Luke's with a positive balance. We would negotiate

>with the provider for a favorable rate (i.e. Medicaid or Medicare)

>rather than often exorbitant " retail " prices. As we deemed

>necessary we would order pathology, labs and X-rays on our patients.

>The uninsured have a cash co-payment (e.g. $25) at the time of

>service at the diagnostic provider's office, and with that the

>provider would perform the test. The balance of the cost of the test

>minus the co-payment would be " deducted " from our account. That

>would allow several good things to happen:

>1. The donor facility would get a little positive cash flow.

>2. The donor facility wouldn't be required to put out any cash for

>the donation.

>3. The donor facility would be able always know the cash value of

>their donation to a 501©(3).

>3. It would keep the bookkeeping simple (no insurance to bill keeps

>their costs low).

>4. The uninsured would bear a modest cost and gain a greater sense

>of partnership in the provision of their health care.

>

>Regarding Medications:

>

>Because we are able to think about patient care a little longer than

>traditional docs, I would hope that all of us IMP's are striving to

>stay away from polypharmacy. Attempting an EBM approach should lead

>to fewer and usually cheaper meds for all our patients. I have had a

>few Medicare Benefactors paying out of pocket for meds and

>previously naïve to the drug class in consideration, who I have

>switched (i.e. from Lexapro to fluoxetine and from Cozaar to

>lisinopril) on their first visit. Those moves alone basically saved

>an entire years ($1500) Benefactor fee! And the savings will

>continue. I have become more aggressive about discontinuing

>medications because I can call and follow up closely.

>

>Remember, our uninsured patients are not usually indigent (unless

>undocumented) and can easily pay $35 per month for metformin, but

>not the $800+ per month insurance premium.

>

>We maintain relationships with our local drug reps that allow them

>scheduled access to both doctors uninterrupted attention for five

>minutes every few months (about 3 reps per week). The deal is that

>they need to keep us in samples, or at least able to call for

>samples as needed. A volunteer retired RN comes in once every week

>or two to straighten the samples in the cabinet. They are grouped by

>drug class and packaging is reduced sharply. When name brand drugs

>are required, we sample generously and use www.helpingpatients.org,

>a pharmaceutical manufacturer's website that includes all the

>patient assistance programs rolled into one portal. The most

>important drugs for this are TZD's, statins, ARB's, antidepressants,

>atypical antipsychotics, nasal steroids, and quinolones.

>

>And finally, a local pharmacy donates big stock bottles of a few

>common meds to use with the indigent (doxycycline, atenolol,

>metformin, hydrochlorothiazide, glyburide).

>

>It isn't perfect, but it seems to be working better than nothing and

>doesn't take up too much of our time. I can't wait to see the " How's

>Your Health " responses on our Recipients before and after having our

>practice!

>

>Bob

>

>

> > > > > >

> > > > > > Recently I have had money on my mind. After 2 years in my

>new

> > > > > > practice I an finally close to making $150,000 which is

>still

> > > > less

> > > > > > than I made at my old job. However I am finding it

>difficult

> > >to

> > > > > > figure out how to make anymore than that since I don't

>think

> > > > that I

> > > > > > can see any more patients in a day. The median income of

>FP's

> > >is

> > > > > over

> > > > > > $160.000/yr. How many of you are making more than the

>median

> > >FP

> > > > > > income and what are you doing to make that much. If the

> > > > > micropractice

> > > > > > model is not capable of producing enough income to provide

>at

> > > > least

> > > > > > the median income it is probably not going to be a viable

> > >model.

> > > > > > Larry Lindeman MD

> > > > > >

> > > > >

> > > >

> > >

> > >

> > >

> > >

> >

>

>

>

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[Guest guest]

Thanks Bob- I see that you clearly have a safety net set up to try to

provide for your working poor population, though the whole she-bang

definitely consumes some resources from the practice side. I'm wondering if

my solo solo IMP practice can co-opt any of your strategies on a small scale

for my working poor patients; I'm going to incubate some of your ideas.

Lynn

>

>Reply-To:

>To:

>Subject: Re: money

>Date: Tue, 31 Oct 2006 06:15:01 -0000

>

>Dear Lynn,

>My apologies for the delay, but I had a very busy October since

>beginning the answer to your question.

>

>You are absolutely correct. Primary care cognitive services are not

>the big expense to modern health care! But fear of expense and

>actually getting into the primary care doctor's office is often the

>first and most important stumbling block.

>

>Getting labs and medicines is an ongoing problem. First of all,

>remember that the poorest of the poor citizens will virtually always

>qualify for Medicaid and will be seen elsewhere. Our uninsureds are

>typically working poor and are usually happy to pay what they can.

>The unemployed AND undocumented (illegals) are our biggest headache

>because they are broke and have no Medicaid eligibility in

>California except for " Emergency Only " immediate threat to life or

>limb. But still, that is a help to get people emergency treatment

>when our patients have acute cholecystitis, cancer or an MI. The

>other neat part is that once they suffer their inpatient malady, we

>are happy to communicate with the hospital doctors and caseworkers

>and get the patients appropriate follow up care.

>

>Regarding the labs and diagnostic studies:

>

>Typically, by having the ability to see patients more frequently.

>And with more time we are able to require fewer lab tests and rely

>more on our clinical skills. I assume that all IMP's are having the

>same experience compared to their former lives at 4-6 patients/hr.

>We perform UA micro, wet mount, KOH, BS, HgbA1c, urine pregnancy,

>hematocrit and EKG in the office. We pay for all the supplies and

>charge nothing for the tests. We send patients to the County

>Facility to pay cash for labs (CBC $15, CMP $30, Lipid $38, FT4

>$27). For radiographs our patients get a 50% break at a local

>radiology office for cash pay at the time of service. Most plain

>radiographs are $30-100. An upper GI is only about $120. Pelvic and

>abdominal sonos are about $100-120. Most CT's are about $300 w/o

>contrast, and we do far more of them than MRI's on our uninsured

>Recipients. (C'mon Lynn, you're old enough, like me, to remember way

>back to the days when upper GI's and CT scans used to be good

>studies?) Also, we try to develop and maintain relationships with

>the local hospitals, consultants, DME providers to provide a few

>freebies. We get a cheapo endoscopy or colonoscopy now and then.

>Earlier this year we convinced a local hospital to " comp " a TURP to

>an undocumented alien.

>

>One of next year's goals is to repeat a coordinated " marketing

>campaign " that was quite successful in 2003-04 at our start-up. We

>will again use local newspaper and TV coverage and speak to lots of

>local service clubs and churches. We hope to build up a little

>bigger war chest to help fund these types of expenses. A local

>medical supply company (with a very strong sense of Christian

>commitment) donated almost $15,000 of used equipment at our start-

>up. Last year, Omega Nu bought us an EKG. And this year they paid

>for some additional surgical equipment and HgbA1c tests. We'll hit

>up other service clubs (Rotary, Kiwanis's, Lion's, etc.) and

>hospitals for bigger ticket items: sigmoidoscope, electronic scale,

>automated BP cuffs, software, etc. We have found that the service

>clubs love having engaging speakers for their meetings and rarely

>have physicians among their ranks.

>

>Another plan is to help defray part of the cost of some diagnostic

>studies through accounts " donated " by local diagnostic service

>providers. Here's how it would work. The provider (hospital,

>diagnostic imaging center or pathology group) would donate an

>account to St. Luke's with a positive balance. We would negotiate

>with the provider for a favorable rate (i.e. Medicaid or Medicare)

>rather than often exorbitant " retail " prices. As we deemed

>necessary we would order pathology, labs and X-rays on our patients.

>The uninsured have a cash co-payment (e.g. $25) at the time of

>service at the diagnostic provider's office, and with that the

>provider would perform the test. The balance of the cost of the test

>minus the co-payment would be " deducted " from our account. That

>would allow several good things to happen:

>1. The donor facility would get a little positive cash flow.

>2. The donor facility wouldn't be required to put out any cash for

>the donation.

>3. The donor facility would be able always know the cash value of

>their donation to a 501©(3).

>3. It would keep the bookkeeping simple (no insurance to bill keeps

>their costs low).

>4. The uninsured would bear a modest cost and gain a greater sense

>of partnership in the provision of their health care.

>

>Regarding Medications:

>

>Because we are able to think about patient care a little longer than

>traditional docs, I would hope that all of us IMP's are striving to

>stay away from polypharmacy. Attempting an EBM approach should lead

>to fewer and usually cheaper meds for all our patients. I have had a

>few Medicare Benefactors paying out of pocket for meds and

>previously naïve to the drug class in consideration, who I have

>switched (i.e. from Lexapro to fluoxetine and from Cozaar to

>lisinopril) on their first visit. Those moves alone basically saved

>an entire years ($1500) Benefactor fee! And the savings will

>continue. I have become more aggressive about discontinuing

>medications because I can call and follow up closely.

>

>Remember, our uninsured patients are not usually indigent (unless

>undocumented) and can easily pay $35 per month for metformin, but

>not the $800+ per month insurance premium.

>

>We maintain relationships with our local drug reps that allow them

>scheduled access to both doctors uninterrupted attention for five

>minutes every few months (about 3 reps per week). The deal is that

>they need to keep us in samples, or at least able to call for

>samples as needed. A volunteer retired RN comes in once every week

>or two to straighten the samples in the cabinet. They are grouped by

>drug class and packaging is reduced sharply. When name brand drugs

>are required, we sample generously and use www.helpingpatients.org,

>a pharmaceutical manufacturer's website that includes all the

>patient assistance programs rolled into one portal. The most

>important drugs for this are TZD's, statins, ARB's, antidepressants,

>atypical antipsychotics, nasal steroids, and quinolones.

>

>And finally, a local pharmacy donates big stock bottles of a few

>common meds to use with the indigent (doxycycline, atenolol,

>metformin, hydrochlorothiazide, glyburide).

>

>It isn't perfect, but it seems to be working better than nothing and

>doesn't take up too much of our time. I can't wait to see the " How's

>Your Health " responses on our Recipients before and after having our

>practice!

>

>Bob

>

>

> > > > > >

> > > > > > Recently I have had money on my mind. After 2 years in my

>new

> > > > > > practice I an finally close to making $150,000 which is

>still

> > > > less

> > > > > > than I made at my old job. However I am finding it

>difficult

> > >to

> > > > > > figure out how to make anymore than that since I don't

>think

> > > > that I

> > > > > > can see any more patients in a day. The median income of

>FP's

> > >is

> > > > > over

> > > > > > $160.000/yr. How many of you are making more than the

>median

> > >FP

> > > > > > income and what are you doing to make that much. If the

> > > > > micropractice

> > > > > > model is not capable of producing enough income to provide

>at

> > > > least

> > > > > > the median income it is probably not going to be a viable

> > >model.

> > > > > > Larry Lindeman MD

> > > > > >

> > > > >

> > > >

> > >

> > >

> > >

> > >

> >

>

>

>

_________________________________________________________________

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[Guest guest]

Lynn & all,

I think

this is a great topic....how to help serve the under served in our

practices. I'm just starting....saw my first patient in my home

office yesterday. I have been doing some house calls, but this was

the first one here. It was fun. She is 82, huge list of meds,

was thrilled I was willing to sit down & talk about each one &

consider options to lower costs. Still have lots of organizing to

do and some painting trim work and supply purchasing to be fully

functional, but it is exciting to get started. She loved the

printed prescriptions from Amazing Charts and the fact that I faxed them

to her pharmacy. She couldn't believe I called the pharmacy to

check availability of a medication for her. I did learn I need a

hand rail on the three steps up to my door....some things you don't learn

until you start.

Anyway, my

goal is to see a portion of patients without fees. I guess this is

a Robin Hood approach, and you could argue that the paying patients are

paying more than they would otherwise. But they are paying less

than at other practices for the service I provide because of lower

overhead, so I think everyone will be happy. It doesn't answer the

questions of how to provide labs, X-rays, specialists for these

patients. Keeping track of ways to get those free or the cheapest

is a major project that I won't have time for. But if everyone

helps a little, at least we are doing something. I feel strongly

that I needed to step out of the predominant health system and stop

helping to prop it up.

It is

wonderful to be a part of this group.....thanks for all the help in the

planning of this adventure. It would have been much harder without

you guys, and I'm not sure I would have had the courage.

Sharon

Sharon McCoy , M.D.

Renaissance Family Medicine

The

Rebirth of Personal Healthcare

www.SharonMD.com

Phone Fax (949)

281-2197

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[Guest guest]

Lynn & all,

I think

this is a great topic....how to help serve the under served in our

practices. I'm just starting....saw my first patient in my home

office yesterday. I have been doing some house calls, but this was

the first one here. It was fun. She is 82, huge list of meds,

was thrilled I was willing to sit down & talk about each one &

consider options to lower costs. Still have lots of organizing to

do and some painting trim work and supply purchasing to be fully

functional, but it is exciting to get started. She loved the

printed prescriptions from Amazing Charts and the fact that I faxed them

to her pharmacy. She couldn't believe I called the pharmacy to

check availability of a medication for her. I did learn I need a

hand rail on the three steps up to my door....some things you don't learn

until you start.

Anyway, my

goal is to see a portion of patients without fees. I guess this is

a Robin Hood approach, and you could argue that the paying patients are

paying more than they would otherwise. But they are paying less

than at other practices for the service I provide because of lower

overhead, so I think everyone will be happy. It doesn't answer the

questions of how to provide labs, X-rays, specialists for these

patients. Keeping track of ways to get those free or the cheapest

is a major project that I won't have time for. But if everyone

helps a little, at least we are doing something. I feel strongly

that I needed to step out of the predominant health system and stop

helping to prop it up.

It is

wonderful to be a part of this group.....thanks for all the help in the

planning of this adventure. It would have been much harder without

you guys, and I'm not sure I would have had the courage.

Sharon

Sharon McCoy , M.D.

Renaissance Family Medicine

The

Rebirth of Personal Healthcare

www.SharonMD.com

Phone Fax (949)

281-2197

No virus found in this outgoing message.

Checked by AVG Free Edition.

Version: 7.0.409 / Virus Database: 268.13.32/523 - Release Date: 11/7/2006

[Guest guest]

Congratulations, Sharon! I am envious that you get to practice out of your home. A very short commute, indeed.Looking over your impressive-looking website, I have a few suggestions. I think you need a good photo of yourself on your website. Patients want to know what their potential doctor looks like. I also think you need to mention something about another doctor covering for you when you are away traveling. I think patients want another option besides phone contact and the ER while you are out of town. It took me time to meet other local solo FPs who agreed to cross-cover, but I didn't go out of town for a while when I first started. Also, I think potential patients would want to know upfront what your registration and membership fees are. I couldn't find those listed anywhere. I'm glad to see you referring people to the Micropractice Frappr map. But the link doesn't seem to work. Speaking of the Frappr map (http://www.frappr.com/medicalmicropractices), I noticed a new name on it that I haven't seen before on this listserve: Dr. Albenberg of ton, SC. I found this article about his unique practice: http://www.charlestonbusiness.com/issues/6_14/news/2889-1.html.I assume Dr. Albenberg is part of this listserve, because I don't think anyone else knows about the Frappr map yet. I'm always happy to hear about other physicians adopting a micropractice-type model. It makes me wonder how many others have started their own micropractices whom we haven't even heard about yet. Perhaps we're just the tip of a growing iceberg? SetoSouth Pasadena, CA Lynn & all,         I think this is a great topic....how to help serve the under served in our practices.  I'm just starting....saw my first patient in my home office yesterday.  I have been doing some house calls, but this was the first one here.  It was fun.  She is 82, huge list of meds, was thrilled I was willing to sit down & talk about each one & consider options to lower costs.  Still have lots of organizing to do and some painting trim work and supply purchasing to be fully functional, but it is exciting to get started.  She loved the printed prescriptions from Amazing Charts and the fact that I faxed them to her pharmacy.  She couldn't believe I called the pharmacy to check availability of a medication for her.  I did learn I need a hand rail on the three steps up to my door....some things you don't learn until you start.         Anyway, my goal is to see a portion of patients without fees.  I guess this is a Robin Hood approach, and you could argue that the paying patients are paying more than they would otherwise.  But they are paying less than at other practices for the service I provide because of lower overhead, so I think everyone will be happy.  It doesn't answer the questions of how to provide labs, X-rays, specialists for these patients.  Keeping track of ways to get those free or the cheapest is a major project that I won't have time for.  But if everyone helps a little, at least we are doing something.  I feel strongly that I needed to step out of the predominant health system and stop helping to prop it up.         It is wonderful to be a part of this group.....thanks for all the help in the planning of this adventure.  It would have been much harder without you guys, and I'm not sure I would have had the courage. Sharon Sharon McCoy , M.D. Renaissance Family Medicine The Rebirth of Personal Healthcare www.SharonMD.com  Phone      Fax         No virus found in this outgoing message.Checked by AVG Free Edition.Version: 7.0.409 / Virus Database: 268.13.32/523 - Release Date: 11/7/2006

[Guest guest]

Congratulations, Sharon! I am envious that you get to practice out of your home. A very short commute, indeed.Looking over your impressive-looking website, I have a few suggestions. I think you need a good photo of yourself on your website. Patients want to know what their potential doctor looks like. I also think you need to mention something about another doctor covering for you when you are away traveling. I think patients want another option besides phone contact and the ER while you are out of town. It took me time to meet other local solo FPs who agreed to cross-cover, but I didn't go out of town for a while when I first started. Also, I think potential patients would want to know upfront what your registration and membership fees are. I couldn't find those listed anywhere. I'm glad to see you referring people to the Micropractice Frappr map. But the link doesn't seem to work. Speaking of the Frappr map (http://www.frappr.com/medicalmicropractices), I noticed a new name on it that I haven't seen before on this listserve: Dr. Albenberg of ton, SC. I found this article about his unique practice: http://www.charlestonbusiness.com/issues/6_14/news/2889-1.html.I assume Dr. Albenberg is part of this listserve, because I don't think anyone else knows about the Frappr map yet. I'm always happy to hear about other physicians adopting a micropractice-type model. It makes me wonder how many others have started their own micropractices whom we haven't even heard about yet. Perhaps we're just the tip of a growing iceberg? SetoSouth Pasadena, CA Lynn & all,         I think this is a great topic....how to help serve the under served in our practices.  I'm just starting....saw my first patient in my home office yesterday.  I have been doing some house calls, but this was the first one here.  It was fun.  She is 82, huge list of meds, was thrilled I was willing to sit down & talk about each one & consider options to lower costs.  Still have lots of organizing to do and some painting trim work and supply purchasing to be fully functional, but it is exciting to get started.  She loved the printed prescriptions from Amazing Charts and the fact that I faxed them to her pharmacy.  She couldn't believe I called the pharmacy to check availability of a medication for her.  I did learn I need a hand rail on the three steps up to my door....some things you don't learn until you start.         Anyway, my goal is to see a portion of patients without fees.  I guess this is a Robin Hood approach, and you could argue that the paying patients are paying more than they would otherwise.  But they are paying less than at other practices for the service I provide because of lower overhead, so I think everyone will be happy.  It doesn't answer the questions of how to provide labs, X-rays, specialists for these patients.  Keeping track of ways to get those free or the cheapest is a major project that I won't have time for.  But if everyone helps a little, at least we are doing something.  I feel strongly that I needed to step out of the predominant health system and stop helping to prop it up.         It is wonderful to be a part of this group.....thanks for all the help in the planning of this adventure.  It would have been much harder without you guys, and I'm not sure I would have had the courage. Sharon Sharon McCoy , M.D. Renaissance Family Medicine The Rebirth of Personal Healthcare www.SharonMD.com  Phone      Fax         No virus found in this outgoing message.Checked by AVG Free Edition.Version: 7.0.409 / Virus Database: 268.13.32/523 - Release Date: 11/7/2006

[Guest guest]

Congratulations

Sharon!

I hope you have many more of these

wonderful encounters; it makes it all worth while.

Annie

RE:

Re: money

Lynn & all,

I think this is a great

topic....how to help serve the under served in our practices. I'm just

starting....saw my first patient in my home office yesterday. I have

been doing some house calls, but this was the first one here. It was fun.

She is 82, huge list of meds, was thrilled I was willing to sit down & talk

about each one & consider options to lower costs. Still have lots of

organizing to do and some painting trim work and supply purchasing to be fully

functional, but it is exciting to get started. She loved the printed

prescriptions from Amazing Charts and the fact that I faxed them to her

pharmacy. She couldn't believe I called the pharmacy to check

availability of a medication for her. I did learn I need a hand rail on

the three steps up to my door....some things you don't learn until you start.

Anyway, my goal is to

see a portion of patients without fees. I guess this is a Robin Hood

approach, and you could argue that the paying patients are paying more than

they would otherwise. But they are paying less than at other practices

for the service I provide because of lower overhead, so I think everyone will

be happy. It doesn't answer the questions of how to provide labs, X-rays,

specialists for these patients. Keeping track of ways to get those free

or the cheapest is a major project that I won't have time for. But if

everyone helps a little, at least we are doing something. I feel strongly

that I needed to step out of the predominant health system and stop helping to

prop it up.

It is wonderful to be a

part of this group.....thanks for all the help in the planning of this

adventure. It would have been much harder without you guys, and I'm not

sure I would have had the courage.

Sharon

Sharon McCoy , M.D.

Renaissance

Family Medicine

The Rebirth of Personal Healthcare

www.SharonMD.com

Phone Fax (949)

281-2197

[Guest guest]

Congratulations

Sharon!

I hope you have many more of these

wonderful encounters; it makes it all worth while.

Annie

RE:

Re: money

Lynn & all,

I think this is a great

topic....how to help serve the under served in our practices. I'm just

starting....saw my first patient in my home office yesterday. I have

been doing some house calls, but this was the first one here. It was fun.

She is 82, huge list of meds, was thrilled I was willing to sit down & talk

about each one & consider options to lower costs. Still have lots of

organizing to do and some painting trim work and supply purchasing to be fully

functional, but it is exciting to get started. She loved the printed

prescriptions from Amazing Charts and the fact that I faxed them to her

pharmacy. She couldn't believe I called the pharmacy to check

availability of a medication for her. I did learn I need a hand rail on

the three steps up to my door....some things you don't learn until you start.

Anyway, my goal is to

see a portion of patients without fees. I guess this is a Robin Hood

approach, and you could argue that the paying patients are paying more than

they would otherwise. But they are paying less than at other practices

for the service I provide because of lower overhead, so I think everyone will

be happy. It doesn't answer the questions of how to provide labs, X-rays,

specialists for these patients. Keeping track of ways to get those free

or the cheapest is a major project that I won't have time for. But if

everyone helps a little, at least we are doing something. I feel strongly

that I needed to step out of the predominant health system and stop helping to

prop it up.

It is wonderful to be a

part of this group.....thanks for all the help in the planning of this

adventure. It would have been much harder without you guys, and I'm not

sure I would have had the courage.

Sharon

Sharon McCoy , M.D.

Renaissance

Family Medicine

The Rebirth of Personal Healthcare

www.SharonMD.com

Phone Fax (949)

281-2197