Re: house call/retainer practice

March 12, 2006

Matt ( & all),

Thanks for

your thoughts. I'm definitely still in the stage of figuring it out

& appreciate any & all thoughts.

I will

most likely opt out of Medicare. I'm not sure what you mean by

justifying home visits....I won't bill insurance but some patients will

try to get reimbursed, so I suppose they may not get back the full

fee. So, is it just a matter of figuring out how many people will

pay for the convenience?

Some of

the patients who say they'll follow me have the high deductible/HSA

combination insurance, so it should work for them as long as they are

willing to do home or their place of business visits. It is a

fairly high income area, and I'm hoping to " scholarship " some

patients that cannot afford the retainer fee & /or visit fees.

I have two

daughters, ages 8 & 11, so, while I can be more flexible with them

then when they were younger, I still would like to be pretty available

for them. I would ideally would like to work about 20

hours/week that are flexible depending on their activities, etc. My

income requirements are not too high....hope to end up around $50k

plus. I also have a fear of being tied to a medical assembly line

again after my years of trying to run in place faster & faster.

I'm sure my own office would ensure more flexibility & control, but I

like the idea of not being tied down. (Probably after I drive in

traffic awhile, I'll change my mind.) I also don't know how much

overhead I can support since rent is so expensive here & I don't want

to work " full-time. "

I have

thought about the one room sublet idea, and would probably try to do this

at least some time for physicals, etc.

I am

willing to do my share of frail elderly & disabled, but don't want

this to be my whole practice by any means.

I read the

article about Brand in FM Management this February who does house

calls only in Florida. She markets to baby-boomers, but I don't

know how much of her practice is elderly/disabled. I'm e mailing

her about it & will let you know. I've read that she charges

$100 for any visit up to 30 minutes during business hours.

Her web

site:

http://www.drbrand.medem.com/

FPM

article, " Cashing in on House calls " :

http://www.aafp.org/fpm/20060200/67cash.html

To those

of you who are low volume, do you feel " trapped " in your office

during times when you don't have patients scheduled? Based on my

previous practices, I know there is always plenty to do to keep busy, but

I don't want to feel like I have to be there 9 to 5 or whatever posted

hours I may have. I like the idea of being available by cell

phone. Thoughts please.

Sharon

Siena,

Italy, soon to be back in Irvine, California

At 11:50 PM 3/11/2006, you wrote:

RE Retainer practice, housecalls only.

Thought about that.

Problem is that you'd probably have to opt out of Medicare.

Don't think you can justify home visit on non-home bound pts, or even

make it pay enough.

May be wrong, but others might be able

to affirm.

Depends on what demand would be in place

you want to set up in.

Why do you think that the practice

you're thinking about could do OK in Orange County?

Questions for you--

Dr Matt Levin

Pittsburgh, PA

Solo since Dec 2004

Outpt, no OB

Using SOAPWare since 1997

Grad. 1988

Re: introduction

Hello.

I

would like to introduce myself. I've been " lurking "

on the list-serve one and off for two years now, but I'm about to take

the plunge.

I was

in a group practice in Seattle after finishing residency at

U.W. I worked out of Providence Hospital, where, at the time,

more babies were delivered by us FP's than by OB's. Due

to my husband getting a faculty position at University of California,

Irvine, I reluctantly moved to Orange County in 1995. It was the

center of the crisis of managed care....2 of the 3 groups I considered

joining were out of business within 6 months of my arrival. I

joined one of the few groups of primary care docs where I could continue

to do OB. I had a very busy mostly HMO practice. From 2001 to

2005, I have been in a faculty practice at UC-Irvine.

I am

currently in Siena, Italy while my husband is on sabbatical here.

When we return to Orange County this summer, I am planning to open a solo

practice. For a variety of reasons, including the high cost of

rental office space near my home (the few I looked at before leaving were

$2800-3500/month for about 1200 sq ft. ), the difficulty of arranging a

lease from the distance, and the desire to lower overhead, I am

considering a mostly house-call practice. I may do a retainer fee

that covers email, phone, advice, ready access, long appointments, small

patient panel, and maybe an annual health assessment, etc.. I am

thinking that I may need to do cash based visits, although I would love

to be able to have them included in the annual fee to avoid the whole

messing with money thing on a daily basis.

This

group has inspired me & already taught me a lot...I look forward to

getting to know you better.......and I'll probably pester you with lots

of questions as plans take shape. Thanks.

Sharon

_____________________

Sharon McCoy , M.D.

March 12, 2006

Have you consider blending this type of practice a a nursing home

practice? What type of EMR are you going to use?

Brent

> >RE Retainer practice, housecalls only.

> >

> >Thought about that.

> >Problem is that you'd probably have to opt out of Medicare.

> >Don't think you can justify home visit on non-home bound pts, or

even make

> >it pay enough.

> >

> >May be wrong, but others might be able to affirm.

> >

> >Depends on what demand would be in place you want to set up in.

> >

> >Why do you think that the practice you're thinking about could do

OK in

> >Orange County?

> >

> >Questions for you--

> >

> >Dr Matt Levin

> >Pittsburgh, PA

> >Solo since Dec 2004

> >Outpt, no OB

> >Using SOAPWare since 1997

> >Grad. 1988

> > Re: introduction

> >

> > Hello.

> > I would like to introduce myself. I've been " lurking "

on the

> > list-serve one and off for two years now, but I'm about to take

the plunge.

> > I was in a group practice in Seattle after finishing

residency at

> > U.W. I worked out of Providence Hospital, where, at the time,

more

> > babies were delivered by us FP's than by OB's. Due to my

husband

> > getting a faculty position at University of California, Irvine,

I

> > reluctantly moved to Orange County in 1995. It was the center

of the

> > crisis of managed care....2 of the 3 groups I considered joining

were out

> > of business within 6 months of my arrival. I joined one of the

few

> > groups of primary care docs where I could continue to do OB. I

had a

> > very busy mostly HMO practice. From 2001 to 2005, I have been

in a

> > faculty practice at UC-Irvine.

> > I am currently in Siena, Italy while my husband is on

sabbatical

> > here. When we return to Orange County this summer, I am

planning to open

> > a solo practice. For a variety of reasons, including the high

cost of

> > rental office space near my home (the few I looked at before

leaving were

> > $2800-3500/month for about 1200 sq ft. ), the difficulty of

arranging a

> > lease from the distance, and the desire to lower overhead, I am

> > considering a mostly house-call practice. I may do a retainer

fee that

> > covers email, phone, advice, ready access, long appointments,

small

> > patient panel, and maybe an annual health assessment, etc.. I

am

> > thinking that I may need to do cash based visits, although I

would love

> > to be able to have them included in the annual fee to avoid the

whole

> > messing with money thing on a daily basis.

> > This group has inspired me & already taught me a lot...I

look

> > forward to getting to know you better.......and I'll probably

pester you

> > with lots of questions as plans take shape. Thanks.

> > Sharon

> >

> >_____________________

> >Sharon McCoy , M.D.

> >

March 12, 2006

RE House calls only.

1) The Florida doc practices in a very small geographical area, on an island. Suspect this restricts access to docs anyway. May not be "transportable" to other areas with more availability.

2) I'd bet California INSISTS on malpractice insurance, where Florida doesn't. MOST states do. Assett protection insurance really doesn't help with malpractice claims and defense, according to my understanding.

3) Health insurance for YOURSELF. This expense is a REALITY unless you have a spouse, etc who supplies it, or another income, parttime source.

4) Volume-- traveling around will REDUCE your pt volume. Be aware of this.

I do NOT want to be a "wet blanket" on your idea, but I'd suspect this is very demographic dependent. And if a Medicare pt cannot apply costs of the visit to their medicare insurance (ie, if you opt out of Medicare, THEY cannot submit to Medicare for reimbursement!) you really can't rely on this population.

Small volume practice may work, but you must be clear about

1) Barriers and availability.

2) Demographics and needs in your target community.

3) Income stream and minimal overheads.

Wish you well, keep us informed.

Dr Matt Levin

FP; 2 FTE support

Outpt practice

Solo since Dec 2004; finished residency in 1988.

Soapware user since 1997

Full point of care EMR since 2006

Re: introduction

Hello.

I would like to introduce myself. I've been "lurking" on the list-serve one and off for two years now, but I'm about to take the plunge.

I was in a group practice in Seattle after finishing residency at U.W. I worked out of Providence Hospital, where, at the time, more babies were delivered by us FP's than by OB's. Due to my husband getting a faculty position at University of California, Irvine, I reluctantly moved to Orange County in 1995. It was the center of the crisis of managed care....2 of the 3 groups I considered joining were out of business within 6 months of my arrival. I joined one of the few groups of primary care docs where I could continue to do OB. I had a very busy mostly HMO practice. From 2001 to 2005, I have been in a faculty practice at UC-Irvine.

I am currently in Siena, Italy while my husband is on sabbatical here. When we return to Orange County this summer, I am planning to open a solo practice. For a variety of reasons, including the high cost of rental office space near my home (the few I looked at before leaving were $2800-3500/month for about 1200 sq ft. ), the difficulty of arranging a lease from the distance, and the desire to lower overhead, I am considering a mostly house-call practice. I may do a retainer fee that covers email, phone, advice, ready access, long appointments, small patient panel, and maybe an annual health assessment, etc.. I am thinking that I may need to do cash based visits, although I would love to be able to have them included in the annual fee to avoid the whole messing with money thing on a daily basis.

This group has inspired me & already taught me a lot...I look forward to getting to know you better.......and I'll probably pester you with lots of questions as plans take shape. Thanks.

Sharon

_____________________

Sharon McCoy , M.D.

March 12, 2006

Sharon-I think you really may enjoy and thrive in a part time solo/solo type practice such as mine. I spend less than 15 hours a week in my office usually (see 20-25 pts per week) and do all my admin stuff at my home office so I can hang out and take cae of pets, husband, garden. I think this is an INCREDIBLE option for Part Timers who have kids. You would only be away a few half days per week. I never SIT in my office and wait. They come to me on time and that's it!!I'll include the final write up from my grand rounds presentation below which really outlines how possible it is to THRIVE, not just SURVIVE in the LOVE model.... (read on)CREATE YOUR IDEAL MEDICAL PRACTICE: Thrive Don't Just SurvivePamela L. Wible, MDLearning Objectives: 1) Understand why self employment may be the best option for realizing YOUR personal, professional, and financial objectives 2) List benefits of low overhead volume practices and best methods to limit overhead. 3) Master the calculation of overhead as days needed to work (DNW) and number needed to treat (NNT) 4) Learn how to activate your community in designing & marketing your practice for you. LOVE: Low Overhead Volume Employment : an experiment in finances and work volumeLow Overhead Volume Employment (LOVE) vs. High Overhead Volume Employment (HOVE) Ultralight Practice Typical Housecall MDs "Assembly Line" Boutique Practices Large Corporate My LOVE story 2000-2002 2005-current Employee/partnership potential Self EmployedFull Time Part Time4 full days/ week 3 half days/ week 112 pts/wk 28/d 25 pts/wk 8/d2500 + patient panel 300-400 patient panel$130 K/ yr (110K + "bonus?") $130 K/ yr370K/ yr OH 10 K / yr OH> 30 K mo OH <1K mo OH My Yearly "Ultralight" Overhead (OH) rent @ 300/mo 3600 Personal health ins. 2200 Malpractice (@ 60% off) 1230 Supplies 1000 Phone cell + land 700 Hospital/society Dues 600 Office liability insurance 500 9830 < 10K/yr Get Your Malpractice Discounts! * 5 year maturity on claims made policies = steep discounts first 4 years * "Fresh out of residency discounts" x 3 years * Loss prevention credits (7.5% discount) * Part time discounts (up to 50% off!) * Board certified (2.5% discount) (The LOVE practice makes your malpractice risk close to nil)Control Overhead and THRIVE (3 simple calculations that will save YOUR life) 1) Your OH / Total Revenue/yr => % OH 2) #1 x # days/yr worked => DNW 3) #2 x avg # pts/day => NNT My Salary 1) HOVE 440K - 330K OH --> 110 K base 500-440K x 33% --> 20 K production "bonus?" ---> 130K (5432 pt visits, $2577 day collected, $92/per pt.) 2) LOVE projected 140K - 10K OH ---> 130K (1250 pt visits/yr, $930/half day, $112/ per pt.) OH! OH NO! The BIG SURPRISE! Yearly Overhead (OH!) as % of Total Revenue 1) HOVE 370K/500K -> 74 % (MGMA 2000 avg 60%) 2) LOVE 10K/140K -> 7 % DNW (Days Needed to Work) to pay OH 1) HOVE @ 194 X 74% --> 143 FULL days (> 8 months) 2) LOVE @ 150 half days x 7% --> 11 HALF days (< 1 month) NNT (Numbers Needed to Treat) to pay OH HOVE @ 143 x 28 --> 4004 LOVE @ 11 x 8.3 --> 91 This is news to me! Recruiters, MGMA, medical organizations, and stakeholders give statistics based on HOVE practices. LOVE practices were the norm 50 years ago, but most docs are not exposed to LOVE data in training, journals or elsewhere and are heavily marketed with HOVE "opportunities" My Professional Goals --> My Professional Climax Bike to work Bike to work 1 mile Work part time 2-3 days/week WorK PT 3 half days/week Positive environment Positive & empowering environment Minimal call / hospital work Minimal inpt. (2 in 11 months) Manageable call Noninvasive call (<2/mo) Flexible vacation Vacation whenever I want Appreciative patients Appreciative patients Excellent collection rate Unexpected Benefits Time for medical volunteerism (Katrina disaster relief) - see articles Medical journalism - I love to write and have published multiple articles Academically stimulating (time to research medical mysteries, attend consultant visits) Local/regional fame/admiration (colleagues, patients, health plans) Why Community Involvement in Clinic Design? They are your eventual patients They have great ideas and insights you may value They serve as a a business consultant They are a built in patient panel on day one of your practice They become a network of loyal patients who market your practice for you Why Solo/Solo? Why not? Will staff add value? No staff = Low overhead = Less HAs Flexibility & spontaneity No micromanaging others, embezzlement concerns The business of medicine no longer a delegated mystery Become a coding expert Simple with today's technology LOVE : An experiment in finances and work volume The RESULTS are in.. * same salary BUT... * 23% (1/4th) work volume by total pt visits yearly * 3.8% (1/26th) of work volume as DNW to pay OH * 2% (1/50th) of the work volume by NNT to pay OH Who should consider self-employment? Everyone but especially physicians who... *have independent spirit *are creative and "out of the box" thinkers *value balance (part timers, moms, dads) *value high quality leisurely interaction with patients *want to pursue other interests *may exceed there wildest financial expectations Sounds great, but how do I start? Transitioning from HOVE to LOVE Jumping from residency to LOVE OPEN LOVE in 4 Steps1) OPEN your mind on a RETREAT to envision your ideal practice2) PLAN your model (You made it through med school. It's not rocket science) 3) EXPLORE Locums, UC, part time jobs (great for checking out various locales) Hospital recruitment package with guarantee for setting up solo practice NEVER, EVER sign a NON COMPETE clause!4) NEED HELP? Contact me with questions.Pamela L. Wible, MDPhone # Email: roxywible@...Webpage: www.idealmedicalpractice.orgOn Mar 12, 2006, at 1:53 AM, Sharon McCoy wrote: Matt ( & all), Thanks for your thoughts. I'm definitely still in the stage of figuring it out & appreciate any & all thoughts. I will most likely opt out of Medicare. I'm not sure what you mean by justifying home visits....I won't bill insurance but some patients will try to get reimbursed, so I suppose they may not get back the full fee. So, is it just a matter of figuring out how many people will pay for the convenience? Some of the patients who say they'll follow me have the high deductible/HSA combination insurance, so it should work for them as long as they are willing to do home or their place of business visits. It is a fairly high income area, and I'm hoping to "scholarship" some patients that cannot afford the retainer fee & /or visit fees. I have two daughters, ages 8 & 11, so, while I can be more flexible with them then when they were younger, I still would like to be pretty available for them. I would ideally would like to work about 20 hours/week that are flexible depending on their activities, etc. My income requirements are not too high....hope to end up around $50k plus. I also have a fear of being tied to a medical assembly line again after my years of trying to run in place faster & faster. I'm sure my own office would ensure more flexibility & control, but I like the idea of not being tied down. (Probably after I drive in traffic awhile, I'll change my mind.) I also don't know how much overhead I can support since rent is so expensive here & I don't want to work "full-time." I have thought about the one room sublet idea, and would probably try to do this at least some time for physicals, etc. I am willing to do my share of frail elderly & disabled, but don't want this to be my whole practice by any means. I read the article about Brand in FM Management this February who does house calls only in Florida. She markets to baby-boomers, but I don't know how much of her practice is elderly/disabled. I'm e mailing her about it & will let you know. I've read that she charges $100 for any visit up to 30 minutes during business hours. Her web site: http://www.drbrand.medem.com/ FPM article, "Cashing in on House calls": http://www.aafp.org/fpm/20060200/67cash.html To those of you who are low volume, do you feel "trapped" in your office during times when you don't have patients scheduled? Based on my previous practices, I know there is always plenty to do to keep busy, but I don't want to feel like I have to be there 9 to 5 or whatever posted hours I may have. I like the idea of being available by cell phone. Thoughts please. Sharon Siena, Italy, soon to be back in Irvine, California At 11:50 PM 3/11/2006, you wrote: RE Retainer practice, housecalls only. Thought about that. Problem is that you'd probably have to opt out of Medicare. Don't think you can justify home visit on non-home bound pts, or even make it pay enough. May be wrong, but others might be able to affirm. Depends on what demand would be in place you want to set up in. Why do you think that the practice you're thinking about could do OK in Orange County? Questions for you-- Dr Matt Levin Pittsburgh, PA Solo since Dec 2004 Outpt, no OB Using SOAPWare since 1997 Grad. 1988 Re: introduction Hello. I would like to introduce myself. I've been "lurking" on the list-serve one and off for two years now, but I'm about to take the plunge. I was in a group practice in Seattle after finishing residency at U.W. I worked out of Providence Hospital, where, at the time, more babies were delivered by us FP's than by OB's. Due to my husband getting a faculty position at University of California, Irvine, I reluctantly moved to Orange County in 1995. It was the center of the crisis of managed care....2 of the 3 groups I considered joining were out of business within 6 months of my arrival. I joined one of the few groups of primary care docs where I could continue to do OB. I had a very busy mostly HMO practice. From 2001 to 2005, I have been in a faculty practice at UC-Irvine. I am currently in Siena, Italy while my husband is on sabbatical here. When we return to Orange County this summer, I am planning to open a solo practice. For a variety of reasons, including the high cost of rental office space near my home (the few I looked at before leaving were $2800-3500/month for about 1200 sq ft. ), the difficulty of arranging a lease from the distance, and the desire to lower overhead, I am considering a mostly house-call practice. I may do a retainer fee that covers email, phone, advice, ready access, long appointments, small patient panel, and maybe an annual health assessment, etc.. I am thinking that I may need to do cash based visits, although I would love to be able to have them included in the annual fee to avoid the whole messing with money thing on a daily basis. This group has inspired me & already taught me a lot...I look forward to getting to know you better.......and I'll probably pester you with lots of questions as plans take shape. Thanks. Sharon _____________________ Sharon McCoy , M.D.

March 12, 2006

Sharon-I think you really may enjoy and thrive in a part time solo/solo type practice such as mine. I spend less than 15 hours a week in my office usually (see 20-25 pts per week) and do all my admin stuff at my home office so I can hang out and take cae of pets, husband, garden. I think this is an INCREDIBLE option for Part Timers who have kids. You would only be away a few half days per week. I never SIT in my office and wait. They come to me on time and that's it!!I'll include the final write up from my grand rounds presentation below which really outlines how possible it is to THRIVE, not just SURVIVE in the LOVE model.... (read on)CREATE YOUR IDEAL MEDICAL PRACTICE: Thrive Don't Just SurvivePamela L. Wible, MDLearning Objectives: 1) Understand why self employment may be the best option for realizing YOUR personal, professional, and financial objectives 2) List benefits of low overhead volume practices and best methods to limit overhead. 3) Master the calculation of overhead as days needed to work (DNW) and number needed to treat (NNT) 4) Learn how to activate your community in designing & marketing your practice for you. LOVE: Low Overhead Volume Employment : an experiment in finances and work volumeLow Overhead Volume Employment (LOVE) vs. High Overhead Volume Employment (HOVE) Ultralight Practice Typical Housecall MDs "Assembly Line" Boutique Practices Large Corporate My LOVE story 2000-2002 2005-current Employee/partnership potential Self EmployedFull Time Part Time4 full days/ week 3 half days/ week 112 pts/wk 28/d 25 pts/wk 8/d2500 + patient panel 300-400 patient panel$130 K/ yr (110K + "bonus?") $130 K/ yr370K/ yr OH 10 K / yr OH> 30 K mo OH <1K mo OH My Yearly "Ultralight" Overhead (OH) rent @ 300/mo 3600 Personal health ins. 2200 Malpractice (@ 60% off) 1230 Supplies 1000 Phone cell + land 700 Hospital/society Dues 600 Office liability insurance 500 9830 < 10K/yr Get Your Malpractice Discounts! * 5 year maturity on claims made policies = steep discounts first 4 years * "Fresh out of residency discounts" x 3 years * Loss prevention credits (7.5% discount) * Part time discounts (up to 50% off!) * Board certified (2.5% discount) (The LOVE practice makes your malpractice risk close to nil)Control Overhead and THRIVE (3 simple calculations that will save YOUR life) 1) Your OH / Total Revenue/yr => % OH 2) #1 x # days/yr worked => DNW 3) #2 x avg # pts/day => NNT My Salary 1) HOVE 440K - 330K OH --> 110 K base 500-440K x 33% --> 20 K production "bonus?" ---> 130K (5432 pt visits, $2577 day collected, $92/per pt.) 2) LOVE projected 140K - 10K OH ---> 130K (1250 pt visits/yr, $930/half day, $112/ per pt.) OH! OH NO! The BIG SURPRISE! Yearly Overhead (OH!) as % of Total Revenue 1) HOVE 370K/500K -> 74 % (MGMA 2000 avg 60%) 2) LOVE 10K/140K -> 7 % DNW (Days Needed to Work) to pay OH 1) HOVE @ 194 X 74% --> 143 FULL days (> 8 months) 2) LOVE @ 150 half days x 7% --> 11 HALF days (< 1 month) NNT (Numbers Needed to Treat) to pay OH HOVE @ 143 x 28 --> 4004 LOVE @ 11 x 8.3 --> 91 This is news to me! Recruiters, MGMA, medical organizations, and stakeholders give statistics based on HOVE practices. LOVE practices were the norm 50 years ago, but most docs are not exposed to LOVE data in training, journals or elsewhere and are heavily marketed with HOVE "opportunities" My Professional Goals --> My Professional Climax Bike to work Bike to work 1 mile Work part time 2-3 days/week WorK PT 3 half days/week Positive environment Positive & empowering environment Minimal call / hospital work Minimal inpt. (2 in 11 months) Manageable call Noninvasive call (<2/mo) Flexible vacation Vacation whenever I want Appreciative patients Appreciative patients Excellent collection rate Unexpected Benefits Time for medical volunteerism (Katrina disaster relief) - see articles Medical journalism - I love to write and have published multiple articles Academically stimulating (time to research medical mysteries, attend consultant visits) Local/regional fame/admiration (colleagues, patients, health plans) Why Community Involvement in Clinic Design? They are your eventual patients They have great ideas and insights you may value They serve as a a business consultant They are a built in patient panel on day one of your practice They become a network of loyal patients who market your practice for you Why Solo/Solo? Why not? Will staff add value? No staff = Low overhead = Less HAs Flexibility & spontaneity No micromanaging others, embezzlement concerns The business of medicine no longer a delegated mystery Become a coding expert Simple with today's technology LOVE : An experiment in finances and work volume The RESULTS are in.. * same salary BUT... * 23% (1/4th) work volume by total pt visits yearly * 3.8% (1/26th) of work volume as DNW to pay OH * 2% (1/50th) of the work volume by NNT to pay OH Who should consider self-employment? Everyone but especially physicians who... *have independent spirit *are creative and "out of the box" thinkers *value balance (part timers, moms, dads) *value high quality leisurely interaction with patients *want to pursue other interests *may exceed there wildest financial expectations Sounds great, but how do I start? Transitioning from HOVE to LOVE Jumping from residency to LOVE OPEN LOVE in 4 Steps1) OPEN your mind on a RETREAT to envision your ideal practice2) PLAN your model (You made it through med school. It's not rocket science) 3) EXPLORE Locums, UC, part time jobs (great for checking out various locales) Hospital recruitment package with guarantee for setting up solo practice NEVER, EVER sign a NON COMPETE clause!4) NEED HELP? Contact me with questions.Pamela L. Wible, MDPhone # Email: roxywible@...Webpage: www.idealmedicalpractice.orgOn Mar 12, 2006, at 1:53 AM, Sharon McCoy wrote: Matt ( & all), Thanks for your thoughts. I'm definitely still in the stage of figuring it out & appreciate any & all thoughts. I will most likely opt out of Medicare. I'm not sure what you mean by justifying home visits....I won't bill insurance but some patients will try to get reimbursed, so I suppose they may not get back the full fee. So, is it just a matter of figuring out how many people will pay for the convenience? Some of the patients who say they'll follow me have the high deductible/HSA combination insurance, so it should work for them as long as they are willing to do home or their place of business visits. It is a fairly high income area, and I'm hoping to "scholarship" some patients that cannot afford the retainer fee & /or visit fees. I have two daughters, ages 8 & 11, so, while I can be more flexible with them then when they were younger, I still would like to be pretty available for them. I would ideally would like to work about 20 hours/week that are flexible depending on their activities, etc. My income requirements are not too high....hope to end up around $50k plus. I also have a fear of being tied to a medical assembly line again after my years of trying to run in place faster & faster. I'm sure my own office would ensure more flexibility & control, but I like the idea of not being tied down. (Probably after I drive in traffic awhile, I'll change my mind.) I also don't know how much overhead I can support since rent is so expensive here & I don't want to work "full-time." I have thought about the one room sublet idea, and would probably try to do this at least some time for physicals, etc. I am willing to do my share of frail elderly & disabled, but don't want this to be my whole practice by any means. I read the article about Brand in FM Management this February who does house calls only in Florida. She markets to baby-boomers, but I don't know how much of her practice is elderly/disabled. I'm e mailing her about it & will let you know. I've read that she charges $100 for any visit up to 30 minutes during business hours. Her web site: http://www.drbrand.medem.com/ FPM article, "Cashing in on House calls": http://www.aafp.org/fpm/20060200/67cash.html To those of you who are low volume, do you feel "trapped" in your office during times when you don't have patients scheduled? Based on my previous practices, I know there is always plenty to do to keep busy, but I don't want to feel like I have to be there 9 to 5 or whatever posted hours I may have. I like the idea of being available by cell phone. Thoughts please. Sharon Siena, Italy, soon to be back in Irvine, California At 11:50 PM 3/11/2006, you wrote: RE Retainer practice, housecalls only. Thought about that. Problem is that you'd probably have to opt out of Medicare. Don't think you can justify home visit on non-home bound pts, or even make it pay enough. May be wrong, but others might be able to affirm. Depends on what demand would be in place you want to set up in. Why do you think that the practice you're thinking about could do OK in Orange County? Questions for you-- Dr Matt Levin Pittsburgh, PA Solo since Dec 2004 Outpt, no OB Using SOAPWare since 1997 Grad. 1988 Re: introduction Hello. I would like to introduce myself. I've been "lurking" on the list-serve one and off for two years now, but I'm about to take the plunge. I was in a group practice in Seattle after finishing residency at U.W. I worked out of Providence Hospital, where, at the time, more babies were delivered by us FP's than by OB's. Due to my husband getting a faculty position at University of California, Irvine, I reluctantly moved to Orange County in 1995. It was the center of the crisis of managed care....2 of the 3 groups I considered joining were out of business within 6 months of my arrival. I joined one of the few groups of primary care docs where I could continue to do OB. I had a very busy mostly HMO practice. From 2001 to 2005, I have been in a faculty practice at UC-Irvine. I am currently in Siena, Italy while my husband is on sabbatical here. When we return to Orange County this summer, I am planning to open a solo practice. For a variety of reasons, including the high cost of rental office space near my home (the few I looked at before leaving were $2800-3500/month for about 1200 sq ft. ), the difficulty of arranging a lease from the distance, and the desire to lower overhead, I am considering a mostly house-call practice. I may do a retainer fee that covers email, phone, advice, ready access, long appointments, small patient panel, and maybe an annual health assessment, etc.. I am thinking that I may need to do cash based visits, although I would love to be able to have them included in the annual fee to avoid the whole messing with money thing on a daily basis. This group has inspired me & already taught me a lot...I look forward to getting to know you better.......and I'll probably pester you with lots of questions as plans take shape. Thanks. Sharon _____________________ Sharon McCoy , M.D.

March 12, 2006

Sharon-I think you really may enjoy and thrive in a part time solo/solo type practice such as mine. I spend less than 15 hours a week in my office usually (see 20-25 pts per week) and do all my admin stuff at my home office so I can hang out and take cae of pets, husband, garden. I think this is an INCREDIBLE option for Part Timers who have kids. You would only be away a few half days per week. I never SIT in my office and wait. They come to me on time and that's it!!I'll include the final write up from my grand rounds presentation below which really outlines how possible it is to THRIVE, not just SURVIVE in the LOVE model.... (read on)CREATE YOUR IDEAL MEDICAL PRACTICE: Thrive Don't Just SurvivePamela L. Wible, MDLearning Objectives: 1) Understand why self employment may be the best option for realizing YOUR personal, professional, and financial objectives 2) List benefits of low overhead volume practices and best methods to limit overhead. 3) Master the calculation of overhead as days needed to work (DNW) and number needed to treat (NNT) 4) Learn how to activate your community in designing & marketing your practice for you. LOVE: Low Overhead Volume Employment : an experiment in finances and work volumeLow Overhead Volume Employment (LOVE) vs. High Overhead Volume Employment (HOVE) Ultralight Practice Typical Housecall MDs "Assembly Line" Boutique Practices Large Corporate My LOVE story 2000-2002 2005-current Employee/partnership potential Self EmployedFull Time Part Time4 full days/ week 3 half days/ week 112 pts/wk 28/d 25 pts/wk 8/d2500 + patient panel 300-400 patient panel$130 K/ yr (110K + "bonus?") $130 K/ yr370K/ yr OH 10 K / yr OH> 30 K mo OH <1K mo OH My Yearly "Ultralight" Overhead (OH) rent @ 300/mo 3600 Personal health ins. 2200 Malpractice (@ 60% off) 1230 Supplies 1000 Phone cell + land 700 Hospital/society Dues 600 Office liability insurance 500 9830 < 10K/yr Get Your Malpractice Discounts! * 5 year maturity on claims made policies = steep discounts first 4 years * "Fresh out of residency discounts" x 3 years * Loss prevention credits (7.5% discount) * Part time discounts (up to 50% off!) * Board certified (2.5% discount) (The LOVE practice makes your malpractice risk close to nil)Control Overhead and THRIVE (3 simple calculations that will save YOUR life) 1) Your OH / Total Revenue/yr => % OH 2) #1 x # days/yr worked => DNW 3) #2 x avg # pts/day => NNT My Salary 1) HOVE 440K - 330K OH --> 110 K base 500-440K x 33% --> 20 K production "bonus?" ---> 130K (5432 pt visits, $2577 day collected, $92/per pt.) 2) LOVE projected 140K - 10K OH ---> 130K (1250 pt visits/yr, $930/half day, $112/ per pt.) OH! OH NO! The BIG SURPRISE! Yearly Overhead (OH!) as % of Total Revenue 1) HOVE 370K/500K -> 74 % (MGMA 2000 avg 60%) 2) LOVE 10K/140K -> 7 % DNW (Days Needed to Work) to pay OH 1) HOVE @ 194 X 74% --> 143 FULL days (> 8 months) 2) LOVE @ 150 half days x 7% --> 11 HALF days (< 1 month) NNT (Numbers Needed to Treat) to pay OH HOVE @ 143 x 28 --> 4004 LOVE @ 11 x 8.3 --> 91 This is news to me! Recruiters, MGMA, medical organizations, and stakeholders give statistics based on HOVE practices. LOVE practices were the norm 50 years ago, but most docs are not exposed to LOVE data in training, journals or elsewhere and are heavily marketed with HOVE "opportunities" My Professional Goals --> My Professional Climax Bike to work Bike to work 1 mile Work part time 2-3 days/week WorK PT 3 half days/week Positive environment Positive & empowering environment Minimal call / hospital work Minimal inpt. (2 in 11 months) Manageable call Noninvasive call (<2/mo) Flexible vacation Vacation whenever I want Appreciative patients Appreciative patients Excellent collection rate Unexpected Benefits Time for medical volunteerism (Katrina disaster relief) - see articles Medical journalism - I love to write and have published multiple articles Academically stimulating (time to research medical mysteries, attend consultant visits) Local/regional fame/admiration (colleagues, patients, health plans) Why Community Involvement in Clinic Design? They are your eventual patients They have great ideas and insights you may value They serve as a a business consultant They are a built in patient panel on day one of your practice They become a network of loyal patients who market your practice for you Why Solo/Solo? Why not? Will staff add value? No staff = Low overhead = Less HAs Flexibility & spontaneity No micromanaging others, embezzlement concerns The business of medicine no longer a delegated mystery Become a coding expert Simple with today's technology LOVE : An experiment in finances and work volume The RESULTS are in.. * same salary BUT... * 23% (1/4th) work volume by total pt visits yearly * 3.8% (1/26th) of work volume as DNW to pay OH * 2% (1/50th) of the work volume by NNT to pay OH Who should consider self-employment? Everyone but especially physicians who... *have independent spirit *are creative and "out of the box" thinkers *value balance (part timers, moms, dads) *value high quality leisurely interaction with patients *want to pursue other interests *may exceed there wildest financial expectations Sounds great, but how do I start? Transitioning from HOVE to LOVE Jumping from residency to LOVE OPEN LOVE in 4 Steps1) OPEN your mind on a RETREAT to envision your ideal practice2) PLAN your model (You made it through med school. It's not rocket science) 3) EXPLORE Locums, UC, part time jobs (great for checking out various locales) Hospital recruitment package with guarantee for setting up solo practice NEVER, EVER sign a NON COMPETE clause!4) NEED HELP? Contact me with questions.Pamela L. Wible, MDPhone # Email: roxywible@...Webpage: www.idealmedicalpractice.orgOn Mar 12, 2006, at 1:53 AM, Sharon McCoy wrote: Matt ( & all), Thanks for your thoughts. I'm definitely still in the stage of figuring it out & appreciate any & all thoughts. I will most likely opt out of Medicare. I'm not sure what you mean by justifying home visits....I won't bill insurance but some patients will try to get reimbursed, so I suppose they may not get back the full fee. So, is it just a matter of figuring out how many people will pay for the convenience? Some of the patients who say they'll follow me have the high deductible/HSA combination insurance, so it should work for them as long as they are willing to do home or their place of business visits. It is a fairly high income area, and I'm hoping to "scholarship" some patients that cannot afford the retainer fee & /or visit fees. I have two daughters, ages 8 & 11, so, while I can be more flexible with them then when they were younger, I still would like to be pretty available for them. I would ideally would like to work about 20 hours/week that are flexible depending on their activities, etc. My income requirements are not too high....hope to end up around $50k plus. I also have a fear of being tied to a medical assembly line again after my years of trying to run in place faster & faster. I'm sure my own office would ensure more flexibility & control, but I like the idea of not being tied down. (Probably after I drive in traffic awhile, I'll change my mind.) I also don't know how much overhead I can support since rent is so expensive here & I don't want to work "full-time." I have thought about the one room sublet idea, and would probably try to do this at least some time for physicals, etc. I am willing to do my share of frail elderly & disabled, but don't want this to be my whole practice by any means. I read the article about Brand in FM Management this February who does house calls only in Florida. She markets to baby-boomers, but I don't know how much of her practice is elderly/disabled. I'm e mailing her about it & will let you know. I've read that she charges $100 for any visit up to 30 minutes during business hours. Her web site: http://www.drbrand.medem.com/ FPM article, "Cashing in on House calls": http://www.aafp.org/fpm/20060200/67cash.html To those of you who are low volume, do you feel "trapped" in your office during times when you don't have patients scheduled? Based on my previous practices, I know there is always plenty to do to keep busy, but I don't want to feel like I have to be there 9 to 5 or whatever posted hours I may have. I like the idea of being available by cell phone. Thoughts please. Sharon Siena, Italy, soon to be back in Irvine, California At 11:50 PM 3/11/2006, you wrote: RE Retainer practice, housecalls only. Thought about that. Problem is that you'd probably have to opt out of Medicare. Don't think you can justify home visit on non-home bound pts, or even make it pay enough. May be wrong, but others might be able to affirm. Depends on what demand would be in place you want to set up in. Why do you think that the practice you're thinking about could do OK in Orange County? Questions for you-- Dr Matt Levin Pittsburgh, PA Solo since Dec 2004 Outpt, no OB Using SOAPWare since 1997 Grad. 1988 Re: introduction Hello. I would like to introduce myself. I've been "lurking" on the list-serve one and off for two years now, but I'm about to take the plunge. I was in a group practice in Seattle after finishing residency at U.W. I worked out of Providence Hospital, where, at the time, more babies were delivered by us FP's than by OB's. Due to my husband getting a faculty position at University of California, Irvine, I reluctantly moved to Orange County in 1995. It was the center of the crisis of managed care....2 of the 3 groups I considered joining were out of business within 6 months of my arrival. I joined one of the few groups of primary care docs where I could continue to do OB. I had a very busy mostly HMO practice. From 2001 to 2005, I have been in a faculty practice at UC-Irvine. I am currently in Siena, Italy while my husband is on sabbatical here. When we return to Orange County this summer, I am planning to open a solo practice. For a variety of reasons, including the high cost of rental office space near my home (the few I looked at before leaving were $2800-3500/month for about 1200 sq ft. ), the difficulty of arranging a lease from the distance, and the desire to lower overhead, I am considering a mostly house-call practice. I may do a retainer fee that covers email, phone, advice, ready access, long appointments, small patient panel, and maybe an annual health assessment, etc.. I am thinking that I may need to do cash based visits, although I would love to be able to have them included in the annual fee to avoid the whole messing with money thing on a daily basis. This group has inspired me & already taught me a lot...I look forward to getting to know you better.......and I'll probably pester you with lots of questions as plans take shape. Thanks. Sharon _____________________ Sharon McCoy , M.D.

March 12, 2006

Pamela---

I think your situation may work well for me. You don't feel like

the office needs to have " office hours " where it is always

open? My expenses would be more for rent (lots more) &

malpractice (my quote for a part-time is $6500/year), but I may still be

able to do it. What kind of office do you have for

$300/month?

Matt--

I would never go without malpractice insurance. I'm

lucky to have a tenured UC professor husband who gets good benefits,

including health insurance for the family. It is hard to know

how much the house call concept is just one that hasn't been

promoted/offered very widely recently & could catch on, or there

really isn't a need except for those who cannot get out easily.

What do you think of trying it out for 6 months or so and seeing if

patients like it? I guess there is a risk of attracting patients

who wouldn't want to transition to an office-based practice and losing

some of my patients who don't want to try it.

Brent--

I didn't have any nursing home patients when I left, but it is a

possibility for me to consider. Makes sense. Definitely want

to use an EMR on a laptop, but haven't chosen one yet....one of my next

research projects....

Sharon

At 05:25 PM 3/12/2006, you wrote:

Sharon-

I think you really may enjoy and thrive in a part time solo/solo type

practice such as mine. I spend less than 15 hours a week in my

office usually (see 20-25 pts per week) and do all my admin stuff at my

home office so I can hang out and take cae of pets, husband, garden. I

think this is an INCREDIBLE option for Part Timers who have kids. You

would only be away a few half days per week. I never SIT in my office and

wait. They come to me on time and that's it!!

I'll include the final write up from my grand rounds presentation below

which really outlines how possible it is to THRIVE, not just SURVIVE in

the LOVE model.... (read on)

CREATE YOUR IDEAL MEDICAL PRACTICE:

Thrive Don't Just Survive

Pamela L. Wible, MD

Learning Objectives:

1) Understand why self employment may be the best

option for realizing YOUR personal, professional, and financial

objectives

2) List benefits of low overhead volume practices and

best methods to limit overhead.

3) Master the calculation of overhead as days needed

to work (DNW) and number needed to treat (NNT)

4) Learn how to activate your community in designing

& marketing your practice for you.

LOVE:

Low

Overhead

Volume

Employment : an experiment

in finances and work volume

Low Overhead Volume

Employment (LOVE)

vs. High

Overhead Volume Employment

(HOVE)

Ultralight Practice Typical

Housecall MDs " Assembly Line "

Boutique PracticesLarge Corporate

My LOVE story

2000-20022005-current

Employee/partnership potentialSelf Employed

Full Time Part Time

4 full days/ week3 half days/ week

112 pts/wk28/d25 pts/wk 8/d

2500 + patient panel300-400 patient panel

$130 K/ yr (110K + " bonus? " )$130 K/ yr

370K/ yr OH10 K / yr OH

> 30 K mo OH<1K mo OH

My Yearly " Ultralight " Overhead (OH)

rent@ 300/mo3600

Personal health ins.2200

Malpractice (@ 60% off)1230

Supplies 1000

Phone cell + land700

Hospital/society Dues600

Office liability insurance 500

9830 < 10K/yr

Get Your Malpractice Discounts!

* 5 year maturity on claims made policies = steep discounts

first 4 years

* " Fresh out of residency discounts " x 3 years

* Loss prevention credits (7.5% discount)

* Part time discounts (up to 50% off!)

* Board certified (2.5% discount)

(The LOVE practice makes your malpractice risk close to

nil)

Control Overhead and THRIVE

(3 simple calculations that will save YOUR life)

1) Your OH / Total Revenue/yr => %

OH

2) #1 x # days/yr worked =>

DNW

3) #2 x avg # pts/day =>

NNT

My Salary

1) HOVE 440K - 330K OH --> 110 K base

500-440K x 33% --> 20 K production " bonus? "

---> 130K

(5432 pt visits, $2577 day collected,

$92/per pt.)

2) LOVE projected 140K - 10K OH --->

130K

(1250 pt visits/yr, $930/half day, $112/ per pt.)

OH! OH NO! The BIG

SURPRISE!

Yearly Overhead (OH!) as % of Total Revenue

1) HOVE 370K/500K -> 74 %

(MGMA 2000 avg 60%)

2) LOVE 10K/140K -> 7 %

DNW (Days Needed to Work) to

pay OH

1) HOVE @ 194 X 74%

-->143 FULL

days (> 8 months)

2) LOVE @ 150 half days x 7%

-->11 HALF days

(< 1 month)

NNT (Numbers Needed to Treat)

to pay OH

HOVE @ 143 x 28 -->

4004

LOVE @ 11 x 8.3 -->

91

This is news to me!

Recruiters, MGMA, medical organizations, and stakeholders give

statistics based on HOVE practices. LOVE practices were the norm 50 years

ago, but most docs are not exposed to LOVE data in training, journals or

elsewhere and are heavily marketed with HOVE

" opportunities "

My Professional Goals-->My Professional

Climax

Bike to workBike to work 1 mile

Work part time 2-3 days/weekWorK PT 3 half days/week

Positive environmentPositive & empowering environment

Minimal call / hospital workMinimal inpt. (2 in 11 months)

Manageable callNoninvasive call (<2/mo)

Flexible vacationVacation whenever I want

Appreciative patientsAppreciative patients

Excellent collection rate

Unexpected Benefits

Time for medical volunteerism (Katrina disaster

relief) - see articles

Medical journalism - I love to write and have published multiple

articles

Academically stimulating (time to research medical mysteries, attend

consultant visits)

Local/regional fame/admiration (colleagues, patients, health plans)

Why Community Involvement in Clinic Design?

They are your eventual patients

They have great ideas and insights you may value

They serve as a a business consultant

They are a built in patient panel on day one of your practice

They become a network of loyal patients who market your practice for

you

Why Solo/Solo?

Why not? Will staff add value?

No staff = Low overhead = Less HAs

Flexibility & spontaneity

No micromanaging others, embezzlement concerns

The business of medicine no longer a delegated mystery

Become a coding expert

Simple with today's technology

LOVE : An experiment in finances and work

volume

The RESULTS are in..* same salary

BUT...

* 23% (1/4th) work volume by total pt visits yearly

* 3.8% (1/26th) of work volume as DNW to pay OH

* 2% (1/50th) of the work volume by NNT to pay OH

Who should consider self-employment?

Everyone but especially physicians who...

*have independent spirit

*are creative and " out of the box " thinkers

*value balance (part timers, moms, dads)

*value high quality leisurely interaction with patients

*want to pursue other interests

*may exceed there wildest financial expectations

Sounds great, but how do I start?

Transitioning from HOVE to LOVE

Jumping from residency to LOVE

OPEN LOVE in 4 Steps

1)OPEN your mind on a RETREAT

to envision your ideal practice

2) PLAN your model (You

made it through med school. It's not rocket science)

3)EXPLORE Locums, UC, part

time jobs (great for checking out various locales)

Hospital recruitment package with guarantee for setting up solo

practice

NEVER, EVER sign a NON COMPETE clause!

4) NEED HELP? Contact me

with questions.

Pamela L. Wible, MD

Phone #

Email:

roxywible@...

Webpage:

www.idealmedicalpractice.org