Re: Breakpoint patient visits for ultralite practices

[Guest guest]

I agree.The other part of the equation is what a person " needs " to

make for their bills/debt/lifestyle.Personally, two years ago, as I was

crunching the numbers, I felt that I couldn't do it financially without staff but

then was concerned for the slippery slope of adding more appts, etc.That was

what led me to the hybrid model of solo-solo family medicine (6-10 appts/d, about

4.5 d/wk) with aesthetics (laser, products, botox... 2-4 appts/d). Goals

are being approached currently and the money, though still tough right now, is

improving and trending toward my projections. The balance is the cash-flow of

aesthetics is better and the pay per hour is better. So it balances the health

insurance hassles of family medicine thus allowing me to see whoever I please until

I'm full.I like it, and I'm back to loving being a doctor and

controlling how I relate to anyone who enters my office ... but still put in too

many hours. Am stiving to add efficiencies like Lynn Ho has.Greatest piece of advise... do today's work today. Now, if I can

consistently do that, all will be fine!Tim

Malia, M.D.

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Road

Perinton Square Mall

Fairport, NY 14450

585- 223-2880 (phone/fax)

www.relayhealth.com/doc/DrMalia

www.SkinSenseLaser.com

On Tue, July 10, 2007 7:34 am

EDT, Dr Levin wrote:

RE Ultralite practice patient burden level

Seems to me, both posting and lurking here for about 1 year now, that if you have 0-1 staff, 10 pts appears to be about the " magic number " beyond which it is increasingly difficult to " get

the job done today. "

Meaning, if you have 10 pts seen, the time to take

care of all of the admin work will overwhelm you so that " 0-staff "

becomes the point of diminishing returns.

This is very useful information -- meaning, you must be able to calculate your fixed overhead expenses as well as average return

monetarily on a pt visit, then you can decide if you can survive on the difference.

Ex:

Income (pt visits x recovery in $ per visit)

Overhead (rent, malpractice, consumables, EMR costs)

Difference is your take home.

You need to decide if this generates enough income. If it doesn't, you need to either:

1) Supplement income by moonlighting, teaching, alternative work in office (botox, etc).

2) Hire staff (or family) to increase volume.

Thoughts?

Dr Matt Levin

Solo since Dec 2004

EMR SOAPware since 1997

Residency FP completed 1988

Burden of medical home>Date: Mon, 9 Jul 2007 23:50:39 -0400>>Today was not a

bad Monday. Pretty average actually. Saw 10 patients,>admitted one of

them. But here it is, going on midnight, and I am still>trying to

finish up. Has anyone done any studies about what all we do>besides

see patients? A quick count just now: besides the 10 I saw (and>had

to write notes for, schedule referrals and fax orders for (3) a also>had to review results and send letters to 11 (8 lab, 3 radiology);

provide>records for 4 (2 specialist, 1 hospitalist, 1 jail (and the

jail request >was>for a 79 year old diabetic-they wouldn't

tell me what in the world landed>her in jail); Seven consultants

notes requiring update of med lists and PMH>reviewed; and 14 phone

calls from patients, each requiring documentation>(other than to

schedule appointments) mostly with questions like " my sister>just found out she has an ulcer; could I have one too? " or " is

it OK to>take Claritin with my Allegra? And one from a pharmacist

asking if it was >OK>to give her father three Arthrotec to

hold him over until his mail order>arrives.>>So I

saw 10, but took care of stuff for a total of just under 50 patients>today....is there any objective data out there about the cost to us

of>providing all that extra care (like 4:1) 'cause it is sure wearing

me out >to>do all that.>> L. Skaggs,

MD>Lexington, KY>www.fayettefamilymed.com>>>>__________________________________________________________Local listings, incredible imagery, and driving directions - all in one place! http://maps.live.com/?wip=69 & FORM=MGAC01

---------------------------------------- Malia, MD Malia Family Medicine & Skin Sense Laser 6720 Pittsford-Palmyra Rd. Perinton Square Mall Fairport, NY 14450 (phone /

fax) www.relayhealth.com/doc/DrMalia www.SkinSenseLaser.com -- Confidentiality Notice -- This email message, including all the

attachments, is for the sole use of the intended recipient(s) and contains

confidential information. Unauthorized use or disclosure is prohibited. If you are

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information. If you are not the intended recipient, please contact the sender

immediately by reply email and destroy all copies of the original message, including

attachments. ----------------------------------------

---------------------------------------- Malia, MD Malia Family Medicine

& Skin Sense Laser 6720 Pittsford-Palmyra Rd. Perinton Square Mall Fairport, NY

14450 (phone / fax) www.relayhealth.com/doc/DrMalia

www.SkinSenseLaser.com -- Confidentiality Notice -- This email message, including

all the attachments, is for the sole use of the intended recipient(s) and contains

confidential information. Unauthorized use or disclosure is prohibited. If you are

not the intended recipient, you may not use, disclose, copy or disseminate this

information. If you are not the intended recipient, please contact the sender

immediately by reply email and destroy all copies of the original message, including

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[Guest guest]

Matt:

We believe with increased technology leverage, (ie website, patient portal, secure e-mail, voice recognition, Electronic remittance advice, online scheduling, and possibly a low cost statement service or merchant services) that we could have a sweet spot somewhere between 12-18/day without staff. We will be making that investment this next year. At 18/day we would likely generate inexcess of $300-360,000 gross revenue. This would easily pay us over 200K per year. At that point I might splurge and hire someone.

PS one FTE at $20K per year should increase our profitability. To do so we would have to see 20-24 patients per day ( up from 10-12) to maintain the efficiency of our current system at about 35% overhead. We could sacrifice efficiency and still be more prifitable, but we currently chose the highest efficiency to maximize time with patients and our family. I understand that we are two physicians splitting a practice 1 FTE, while you are the one FTE in your practice. I like to think I could invest $20,000 each year in technology instead of an employee. I invested in my EMR up front and have needed no employees for 3+ years. It is not to say that I would never invest in an employee, but not just yet.

[Practiceimprovemen t1] Burden of medical home>Date: Mon, 9 Jul 2007 23:50:39 -0400>>Today was not a bad Monday. Pretty average actually. Saw 10 patients,>admitted one of them. But here it is, going on midnight, and I am still>trying to finish up. Has anyone done any studies about what all we do>besides see patients? A quick count just now: besides the 10 I saw (and>had to write

notes for, schedule referrals and fax orders for (3) a also>had to review results and send letters to 11 (8 lab, 3 radiology); provide>records for 4 (2 specialist, 1 hospitalist, 1 jail (and the jail request >was>for a 79 year old diabetic-they wouldn't tell me what in the world landed>her in jail); Seven consultants notes requiring update of med lists and PMH>reviewed; and 14 phone calls from patients, each requiring documentation>(other than to schedule appointments) mostly with questions like "my sister>just found out she has an ulcer; could I have one too?" or "is it OK to>take Claritin with my Allegra? And one from a pharmacist asking if it was >OK>to give her father three Arthrotec to hold him over until his mail order>arrives.>>So I saw 10, but took care of stuff for a total of just under 50 patients>today....is there any objective data out there about the cost

to us of>providing all that extra care (like 4:1) 'cause it is sure wearing me out >to>do all that.>> L. Skaggs, MD>Lexington, KY>www.fayettefamilym ed.com>>><< winmail.dat >>____________ _________ _________ _________ _________ _________ _Local listings, incredible imagery, and driving directions - all in one place! http://maps. live.com/ ?wip=69 & FORM= MGAC01

Ready for the edge of your seat? Check out tonight's top picks on Yahoo! TV.

[Guest guest]

Right now, I am averaging 15-18 patients, starting at 8:30am -5:00 or 6:00 MWF. On Tues, Thurs, I do admin stuff and ill care if I need to. Also Sat, Sun if I need to. I often have patients do what I call 'reverse house calls' off-hours. Since I live in a town of 7,000 most folks know where I live. I have them come over and I see them in my front room, or out on the porch if they are ill (my 5 yr old is on chemo for ALL). People haven't seemed to mind and I bill them the regular level as well as the after hours code. I have one FTE plus my billing and accounting are contracted out for now. My receptionist is interested in learning coding/billing, so will bring that in-house over the next year. All and all, this number is quite doable with this schedule. I also still do hospital work and about 25 obs a year.

I have a question on a different topic however. My husband's group (my former group) is becoming less of a match for him also. The residency up the road has a full-time faculty position open. Anyone formally affiliated with a residency? I've thought we could job share both spots (IMP and faculty). That would allow us access to healthcare...one of our major concerns, but continue to provide care for our rural communtiy. Any thoughts or comments are welcome.

Lynette I Iles MD 214 South Iowa Ste 3 Washington IA 52353 Flexible Family Care'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

[Guest guest]

Agreed. 10 is easy with no staff. I can do 20 a day if some are allergy shots

and blood draws, but I do not get the work done. About 15 a day is fine and

allows all the other work to get done with no employees and similar gross.

I did calculate the time spend in bench work about a year ago when I gave a talk

to STFM on practice models, but I think it has changed. I will try to do this

again and post it, since someone asked earlier today.

I tend to loose track, since I do some of it on the fly between patients while I

am in the EMR. I will try to count every minute and come up with a percentage of

time. If all did that, it would really interesting. Should we count time

ordering supplies, changing out rooms, or just the medical things like refills

and charting?

________________________________

From: on behalf of Egly

Sent: Tue 7/10/2007 2:00 PM

To:

Subject: Re: Breakpoint patient visits for ultralite

practices

Matt:

We believe with increased technology leverage, (ie website, patient portal,

secure e-mail, voice recognition, Electronic remittance advice, online

scheduling, and possibly a low cost statement service or merchant services) that

we could have a sweet spot somewhere between 12-18/day without staff. We will

be making that investment this next year. At 18/day we would likely generate

inexcess of $300-360,000 gross revenue. This would easily pay us over 200K per

year. At that point I might splurge and hire someone.

PS one FTE at $20K per year should increase our profitability. To do so we

would have to see 20-24 patients per day ( up from 10-12) to maintain the

efficiency of our current system at about 35% overhead. We could sacrifice

efficiency and still be more prifitable, but we currently chose the highest

efficiency to maximize time with patients and our family. I understand that we

are two physicians splitting a practice 1 FTE, while you are the one FTE in your

practice. I like to think I could invest $20,000 each year in technology

instead of an employee. I invested in my EMR up front and have needed no

employees for 3+ years. It is not to say that I would never invest in an

employee, but not just yet.

[Practiceimprovemen t1] Burden of medical home

>Date: Mon, 9 Jul 2007 23:50:39 -0400

>

>Today was not a bad Monday. Pretty average actually. Saw 10 patients,

>admitted one of them. But here it is, going on midnight, and I am still

>trying to finish up. Has anyone done any studies about what all we do

>besides see patients? A quick count just now: besides the 10 I saw (and

>had to! write notes for, schedule referrals and fax orders for (3) a also

>had to review results and send letters to 11 (8 lab, 3 radiology); provide

>records for 4 (2 specialist, 1 hospitalist, 1 jail (and the jail request

>was

>for a 79 year old diabetic-they wouldn't tell me what in the world landed

>her in jail); Seven consultants notes requiring update of med lists and PMH

>reviewed; and 14 phone calls from patients, each requiring documentation

>(other than to schedule appointments) mostly with questions like " my sister

>just found out she has an ulcer; could I have one too? " or " is it OK to

>take Claritin with my Allegra? And one from a pharmacist asking if it was

>OK

>to give her father three Arthrotec to hold him over until his mail order

>arrives.

>

>So I saw 10, but took care of stuff for a total of just under 50 patients

>today....is there any objective data out there about the cost to us of

>providing all that extra care (like 4:1) 'cause it is sure wearing me out

>to

>do all that.

>

> L. Skaggs, MD

>Lexington, KY

>www.fayettefamilym ed.com

>

>

><< winmail.dat >>

____________ _________ _________ _________ _________ _________ _

Local listings, incredible imagery, and driving directions - all in one

place! http://maps. live.com/ ?wip=69 & FORM= MGAC01

<http://maps.live.com/?wip=69 & FORM=MGAC01>

________________________________

Ready for the edge of your seat? Check out tonight's top picks

<http://us.rd.yahoo.com/evt=48220/*http://tv.yahoo.com/> on Yahoo! TV.

[Guest guest]

RE Generation and overhead

This is possible, surely, but the effort to maintain the technology MUST be figured into the overhead.

Software for "clean claims" has a learning curve, as well as an investment in maintenance of interface.

For me, still worth the fee of 6-8% on the collected dollar instead of investment of my time to do my billing and follow up of my claims, or my 1.5 FTE, for this interaction.

Suspect it may also be due to my population of 65+ year olds who need more assistance to get evaluations and testing done (estimation of 60% of my pts) ; I'm diverting all pts who have internet access to email me on the day of their testing (lab, X-rays available on-line from hospital database) and can get them results same day which of course has received great response!

So the "split point" of overhead when must consider adding staff depends on pt population as well as automation capabilities to reduce overhead.

Curious how we think our practices are very similar, when 1,2 factors through off the model.

Dr Matt Levin

[Practiceimprovemen t1] Burden of medical home>Date: Mon, 9 Jul 2007 23:50:39 -0400>>Today was not a bad Monday. Pretty average actually. Saw 10 patients,>admitted one of them. But here it is, going on midnight, and I am still>trying to finish up. Has anyone done any studies about what all we do>besides see patients? A quick count just now: besides the 10 I saw (and>had to write notes for, schedule referrals and fax orders for (3) a also>had to review results and send letters to 11 (8 lab, 3 radiology); provide>records for 4 (2 specialist, 1 hospitalist, 1 jail (and the jail request >was>for a 79 year old diabetic-they wouldn't tell me what in the world landed>her in jail); Seven consultants notes requiring update of med lists and PMH>reviewed; and 14 phone calls from patients, each requiring documentation>(other than to schedule appointments) mostly with questions like "my sister>just found out she has an ulcer; could I have one too?" or "is it OK to>take Claritin with my Allegra? And one from a pharmacist asking if it was >OK>to give her father three Arthrotec to hold him over until his mail order>arrives.>>So I saw 10, but took care of stuff for a total of just under 50 patients>today....is there any objective data out there about the cost to us of>providing all that extra care (like 4:1) 'cause it is sure wearing me out >to>do all that.>> L. Skaggs, MD>Lexington, KY>www.fayettefamilym ed.com>>><< winmail.dat >>____________ _________ _________ _________ _________ _________ _Local listings, incredible imagery, and driving directions - all in one place! http://maps. live.com/ ?wip=69 & FORM= MGAC01

Ready for the edge of your seat? Check out tonight's top picks on Yahoo! TV.

[Guest guest]

RE 15-18 pts three days a week

This works out to 48-54 pts a week, so my estimate still fits.

Glad you worked out the novel approach of doing the admin T/Th; very interesting.

Sorry to hear about your daughter's leukemia and hope treatment goes well.

Dr Matt Levin

Re: Breakpoint patient visits for ultralite practices

Right now, I am averaging 15-18 patients, starting at 8:30am -5:00 or 6:00 MWF. On Tues, Thurs, I do admin stuff and ill care if I need to. Also Sat, Sun if I need to. I often have patients do what I call 'reverse house calls' off-hours. Since I live in a town of 7,000 most folks know where I live. I have them come over and I see them in my front room, or out on the porch if they are ill (my 5 yr old is on chemo for ALL). People haven't seemed to mind and I bill them the regular level as well as the after hours code. I have one FTE plus my billing and accounting are contracted out for now. My receptionist is interested in learning coding/billing, so will bring that in-house over the next year. All and all, this number is quite doable with this schedule. I also still do hospital work and about 25 obs a year.

I have a question on a different topic however. My husband's group (my former group) is becoming less of a match for him also. The residency up the road has a full-time faculty position open. Anyone formally affiliated with a residency? I've thought we could job share both spots (IMP and faculty). That would allow us access to healthcare...one of our major concerns, but continue to provide care for our rural communtiy. Any thoughts or comments are welcome. Lynette I Iles MD 214 South Iowa Ste 3 Washington IA 52353 Flexible Family Care'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

[Guest guest]

RE counting time.

Count only if it takes time from regular pt care?

Dr Levin

[Practiceimprovemen t1] Burden of medical home>Date: Mon, 9 Jul 2007 23:50:39 -0400>>Today was not a bad Monday. Pretty average actually. Saw 10 patients,>admitted one of them. But here it is, going on midnight, and I am still>trying to finish up. Has anyone done any studies about what all we do>besides see patients? A quick count just now: besides the 10 I saw (and>had to! write notes for, schedule referrals and fax orders for (3) a also>had to review results and send letters to 11 (8 lab, 3 radiology); provide>records for 4 (2 specialist, 1 hospitalist, 1 jail (and the jail request >was>for a 79 year old diabetic-they wouldn't tell me what in the world landed>her in jail); Seven consultants notes requiring update of med lists and PMH>reviewed; and 14 phone calls from patients, each requiring documentation>(other than to schedule appointments) mostly with questions like "my sister>just found out she has an ulcer; could I have one too?" or "is it OK to>take Claritin with my Allegra? And one from a pharmacist asking if it was >OK>to give her father three Arthrotec to hold him over until his mail order>arrives.>>So I saw 10, but took care of stuff for a total of just under 50 patients>today....is there any objective data out there about the cost to us of>providing all that extra care (like 4:1) 'cause it is sure wearing me out >to>do all that.>> L. Skaggs, MD>Lexington, KY>www.fayettefamilym ed.com>>><< winmail.dat >>____________ _________ _________ _________ _________ _________ _Local listings, incredible imagery, and driving directions - all in one place! http://maps. live.com/ ?wip=69 & FORM= MGAC01 <http://maps.live.com/?wip=69 & FORM=MGAC01> ________________________________Ready for the edge of your seat? Check out tonight's top picks <http://us.rd.yahoo.com/evt=48220/*http://tv.yahoo.com/> on Yahoo! TV.

[Guest guest]

I agree. That " 10 " sounds like a tiny bit of information, but I don't

know of anywhere else on the planet someone trying to start doing what

we do could get this kind of information. Hooray for democratization

and the Internet.

Haresch

>

> RE Ultralite practice patient burden level

>

> Seems to me, both posting and lurking here for about 1 year now,

that if you have 0-1 staff, 10 pts appears to be about the " magic

number " beyond which it is increasingly difficult to " get the job done

today. "

>

> Meaning, if you have 10 pts seen, the time to take care of all of

the admin work will overwhelm you so that " 0-staff " becomes the point

of diminishing returns.

>

> This is very useful information -- meaning, you must be able to

calculate your fixed overhead expenses as well as average return

monetarily on a pt visit, then you can decide if you can survive on

the difference.

>

> Ex:

>

> Income (pt visits x recovery in $ per visit)

> Overhead (rent, malpractice, consumables, EMR costs)

>

> Difference is your take home.

>

> You need to decide if this generates enough income. If it doesn't,

you need to either:

> 1) Supplement income by moonlighting, teaching, alternative work in

office (botox, etc).

> 2) Hire staff (or family) to increase volume.

>

> Thoughts?

>

> Dr Matt Levin

> Solo since Dec 2004

> EMR SOAPware since 1997

> Residency FP completed 1988