Re: IMP types/Practice Models/Style

[Guest guest]

Tonya--It's great for you to step up and ask for help. You are about to get a

bunch of emails with a bunch of good advise from people are have been in , or are

working out of, your similar situation. Some info will seem to conflict. The most

important thing is that you start moving in better directions little by little at

least, and by big bounds when you can.My quick take on a complex

situation you outlined... you are overwhelmed and over-heated --- stop taking ALL

new patients, spend 6 hrs a week (at least) just doing the old notes you can bill

for (last 3 months most often depending on your insurance contracts), if you are not

comfortable with the financial balance (accounts/insurance/bills/etc) get a really

good accountant.Remember, " perfect is the enemy of good " .

Procrastination is often related to wanting to do things perfectly, so it gets put

off until " I have more time to do it right " but that anticipated time

later is eaten up by other priorities. And, thus a paid 99213 note that could

have been coded a 99214 appt but was kept real simple is still better than no

payment for that appt ... of course the best thing of all is a system that allows a

99214 bill to be paid for a 99214 appt, but right now you need ANY payments you can

get!Get you notepad ready as I suspect you'll be getting a bunch of

ideas and opinions thrown your way.Good luck,TimOn Sun, November 4, 2007 10:32 am EST, Tonya S. Little

wrote:

While I’m not sure it’s adebate, I for one would like to hear more about Matt’s three itemsbelow.

Does an Ideal Practice have to be Micro?

What about Mini? Or even Medium?

I’ve been going over and over

theseposts in my mind and trying to find my own philosophy/ way of practice

/business model, or whatever you want to call it but I’m so completely

torn. I hear so much frustration andangst in our posts. We are supportive

and provide each other with specificinformation about how to be better.

I’ve learned a lot from this list andfrom Bachman and Wenner’s

High Performance Physicians workshop. But I’mnot sure I’m at the

“viable and sustainable” point thatGordon has brought up. I need

to know at what point I can slow down, stoptaking new patients, and remain

sustainable. Somewhere I got on the hamsterwheel and am afraid to get

off.

I want to remain solo, with no midlevels.

I don’t want to work without staff because I would be uncomfortable

being alone with some of my patients. Ihave a great staff and want to keep

them; two were with me at my old hospitalowned practice and we left together. Patients seem pretty happy overall but I’mgetting too busy. I work

in an underserved area and my next new pt opening isJanuary. This is awful. People are frantic to find a doctor that will seethem. Social workers call

and beg me to take difficult pts. My familymembers are approached and asked

if I’ll take ‘one more’. I’ve stopped accepting new

Medicaid and stopped those on Medicare whodon’t have a supplement. I

need to stop accepting new patients, butwhere are these people going to go? Am I seeing enough to stop accepting newones? How are small, but not micro,

practices doing? What numbers aresustainable for them? Are we no longer

Ideal if I see 20+ patients a day?

Can we talk about the real numbers here? For the record, I have 30min new pt appts and 15min established pts; no

limitto the number of either per day. I see pts 7:30 to 12:30 and 1:30 to 5

Mon– Thursday and ½ day on Fridays. We have Open Access if folks

callbefore lunch, else they need to comein the next day. Hospitalists

do adult admissions, I do my own peds admissions(very few). Most of my visits

are level 3s and 4s, about evenly split. Myonly level 1 visits are regular

monthly warfarin checks (have machine) andDepoProvera injections. Currently I

have 2100 active patients. I saw 438 ptslast month and get 4-6 new pts

calling looking for a doctor on any given day. Ihave 3.5 FTE (in line with

MGMA data) and while 4155 patient visits per yearper family physician is

median per MGMA (or so I’ve been told),I’ve had 3934 office visits

so far this year and have two more months togo in 2007. I quit all

advertising after the first year.

We all have Achilles’ heels and

mineis in completing the office note soI can send out the bill. I am

embarrassed to say this but I am 800+ visitsbehind. My efficiencies are in

having a great biller, good staff, and I cansee people pretty quickly. I

have a large EMR/EPM that takes a ton ofcustomization (NextGen) but I

can’t seem to slow down long enough totweak it enough. When I started

in 2005 with this practice, I made a mistakeand used a reseller/ASP and nearly

lost it all; I now use NextGen directly andthat has saved me. However, I got

so far behind. While I’m improvingI still spend way too much time

trying to get a decent note generated from thetemplate based EMR. This is

worsened by the large number of patients thatwant to be seen each day and my

own OCD traits about documenting every littlething. I’m currently

working on a lab interface with Spectrum whichwill make me a lot more

efficient and have two training sessions set up tospeed up my notes so I can

try to finish notes same day. The EPM side ofthings are fantastic; NextGen

can bill almost instantly once I generate acharge from my note. It has a

built in coder. One day I’ll like to setup Virtual Office Visits and

use Instant Medical History, but I can’tstop for that just

now.

I can’t calculate my overhead

untilI get my books balanced and can’t figure out the total income until

all the bills are sent out. I know Ipay too much for my employees health

insurance but I think I do well with theirsalaries and my office space (

3100/month for a rather large office in a greatlocation). Yet I only took

home 40K last year.

This may be far more information thananybody cares about, and I may get booted out of the IMP club, but I like this

‘debate’on practice business analysis.

Tonya Little, MD

NC

Solo since 2005.

From: [mailto: ]On Behalf Of Dr LevinSent: Saturday, November 03, 20074:06 PMTo: Subject: Re: Re debates

/Practiceimprovement/buttoning and practicestyel

RE

Debates

OK,

if no debate, what about workshops competing--

1)

tools to make ultralite practice work better.

2)

tools to keep micropractice overhead low, and promotepatient

continuity.

3)

Final workshop on practice business analysis, when tochange from 1) to 2) or

2) to 1) in order to be viable.

alternative revenue streams.

trends in malpractice and methods toirmprove practice

But

I didn't go to the first retreat, so was some of thiscovered? Or should we

still do the Debate??

Matt

from Western PA

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[Guest guest]

Tonya,

Two comments:

1)

You sound like you have too many patients, not doing today’s

work today.

2)

Get your notes done, get your bills out otherwise you won’t

be able to pay yourself or your staff anything.  You can’t possibly

remember the visits at this point so just code them and bill them.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Tonya S.

Little

Sent: Sunday, November 04, 2007 10:32 AM

To:

Subject: IMP types/Practice Models/Style

While

I’m not sure it’s a debate, I for one would like to hear more about

Matt’s three items below.

Does an

Ideal Practice have to be Micro? What about Mini? Or even

Medium?

I’ve

been going over and over these posts in my mind and trying to find my own

philosophy/ way of practice / business model, or whatever you want to call it

but I’m so completely torn. I hear so much frustration and angst in

our posts. We are supportive and provide each other with specific

information about how to be better. I’ve learned a lot from this list and

from Bachman and Wenner’s High Performance Physicians

workshop. But I’m not sure I’m at the “viable and

sustainable” point that Gordon has brought up. I need to know at

what point I can slow down, stop taking new patients, and remain

sustainable. Somewhere I got on the hamster wheel and am afraid to

get off.

I want to

remain solo, with no midlevels. I don’t want to work without staff

because I would be uncomfortable being alone with some of my patients. I

have a great staff and want to keep them; two were with me at my old hospital

owned practice and we left together. Patients seem pretty happy

overall but I’m getting too busy. I work in an

underserved area and my next new pt opening is January. This is awful.

People are frantic to find a doctor that will see them.

Social workers call and beg me to take difficult pts. My family

members are approached and asked if I’ll take ‘one

more’. I’ve stopped accepting new Medicaid and stopped those

on Medicare who don’t have a supplement. I need to stop

accepting new patients, but where are these people going to go? Am I

seeing enough to stop accepting new ones? How are small, but not micro,

practices doing? What numbers are sustainable for them? Are we no

longer Ideal if I see 20+ patients a day?

Can we

talk about the real numbers here? For the record, I have 30min new

pt appts and 15min established pts; no limit to the number of either per

day. I see pts 7:30 to 12:30 and 1:30 to 5 Mon – Thursday and ½ day

on Fridays. We have Open Access if folks call before lunch, else they

need to come in the next day. Hospitalists do adult admissions, I do my

own peds admissions (very few). Most of my visits are level 3s and 4s,

about evenly split. My only level 1 visits are regular monthly warfarin

checks (have machine) and DepoProvera injections. Currently I have 2100

active patients. I saw 438 pts last month and get 4-6 new pts calling

looking for a doctor on any given day. I have 3.5 FTE (in line with MGMA

data) and while 4155 patient visits per year per family physician is median per

MGMA (or so I’ve been told), I’ve had 3934 office visits so far

this year and have two more months to go in 2007. I quit all advertising

after the first year.

We all

have Achilles’ heels and mine is in completing the office note so I can

send out the bill. I am embarrassed to say this but I am 800+ visits

behind. My efficiencies are in having a great biller, good staff, and I

can see people pretty quickly. I have a large EMR/EPM that takes a

ton of customization (NextGen) but I can’t seem to slow down long enough

to tweak it enough. When I started in 2005 with this practice, I made a

mistake and used a reseller/ASP and nearly lost it all; I now use NextGen

directly and that has saved me. However, I got so far

behind. While I’m improving I still spend way too much time

trying to get a decent note generated from the template based EMR.

This is worsened by the large number of patients that want to be seen each day

and my own OCD traits about documenting every little thing.

I’m currently working on a lab interface with Spectrum which will make me

a lot more efficient and have two training sessions set up to speed up my notes

so I can try to finish notes same day. The EPM side of things are

fantastic; NextGen can bill almost instantly once I generate a charge from my

note. It has a built in coder. One day I’ll like to set

up Virtual Office Visits and use Instant Medical History, but I can’t

stop for that just now.

I

can’t calculate my overhead until I get my books balanced and can’t

figure out the total income until all the bills are sent out. I

know I pay too much for my employees health insurance but I think I do well

with their salaries and my office space ( 3100/month for a rather large office

in a great location). Yet I only took home 40K last year.

This may

be far more information than anybody cares about, and I may get booted out of

the IMP club, but I like this ‘debate’ on practice business

analysis.

Tonya

Little, MD

NC

Solo since

2005.

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Saturday, November 03, 2007 4:06 PM

To:

Subject: Re: Re debates /Practiceimprovement/buttoning

and practice styel

RE Debates

OK, if no debate,

what about workshops competing--

1) tools to make

ultralite practice work better.

2) tools to keep

micropractice overhead low, and promote patient continuity.

3) Final workshop on

practice business analysis, when to change from 1) to 2) or 2) to 1) in order

to be viable.

alternative revenue streams.

trends in malpractice and methods to irmprove practice

But I didn't go to

the first retreat, so was some of this covered? Or should we still do the

Debate??

Matt from Western PA

[Guest guest]

Practice size and staffing are means to the end, not the end in an of

itself.

The goal is to deliver superb care in a vital and sustainable

practice.

If you're wondering why your practice is not sustainable (as I suspect

from your post below), look at revenue and expense, recognizing that some

of the issues may be outside your control (average primary care payment

in your region, malpractice costs, cost of living).

Revenue:

Being behind in billing certainly hurts you and you'll need to catch

up.

You might find that average payment in your region does not support good

primary care (some regions of the country establish average primary care

payment that only rewards the worst churning behavior).

You may find that it is impossible to remain viable while serving the

full mix of insurers in your region. You can keep doing it, but

you'll suffer.

Expense:

Don't wonder about this. Look at benchmark data from the IMP

practices (see the overhead table in the FPM article:

http://www.aafp.org/fpm/20070900/20thei.html )

Efficiency:

Sounds like you're caught a cord short with winter coming on. You

can keep sawing with all your strength or you can stop to sharpen the

saw.

Caring for all of those with need:

An individual physician practice has an upper limit of patient

volume. You can increase the volume by putting together a great

team, using great tools, and being very efficient, but eventually even

the great will reach a limit.

The skill set needed to put together a great team is not common -

especially in doctors; individual autonomy and non-team behavior is the

norm, which is why great teams are rare in health care.

At some point every individual or team reaches the limit of their

capacity. At that point, continuing to accept patients into the

practice results in degraded outcomes for all.

Outcomes in the U.S. are bad enough, let's not add to them through the

false notion of helping by continuing to accept patients beyond our

capacity to deliver good care. We care deeply for those we serve,

we know that our assistance may make a real difference in the lives of

those we serve, but why must we continue to delude ourselves and our

communities with this absurd notion that we can endlessly enroll new

patients while not providing adequate care for those already in our

practices?

Unmet community need must be addressed by fixing the fundamental problems

that afflict health care in the U.S. We need adequate funding for

primary care, that funding must result in adequate and attractive income

targets to attract more into primary care, and we need payment systems

that reflect the real work of primary care and not

" visits. "

Gordon

At 10:32 AM 11/4/2007, you wrote:

While I’m not sure it’s a debate, I for one would like to hear more about

Matt’s three items below.

Does an Ideal Practice have to be

Micro? What about Mini? Or even Medium?

I’ve been going over and over these posts in

my mind and trying to find my own philosophy/ way of practice / business

model, or whatever you want to call it but I’m so completely torn.

I hear so much frustration and angst in our posts. We are

supportive and provide each other with specific information about how to

be better. I’ve learned a lot from this list and from Bachman and

Wenner’s High Performance Physicians workshop. But I’m not

sure I’m at the “viable and sustainable” point that Gordon has brought

up. I need to know at what point I can slow down, stop taking new

patients, and remain sustainable. Somewhere I got on the

hamster wheel and am afraid to get off.

I want to remain solo, with no

midlevels. I don’t want to work without staff because I would be

uncomfortable being alone with some of my patients. I have a great

staff and want to keep them; two were with me at my old hospital owned

practice and we left together. Patients seem pretty happy

overall but I’m getting too busy. I work in an

underserved area and my next new pt opening is January. This is

awful. People are frantic to find a doctor that will see

them. Social workers call and beg me to take difficult

pts. My family members are approached and asked if I’ll take

‘one more’. I’ve stopped accepting new Medicaid and stopped those

on Medicare who don’t have a supplement. I need to stop

accepting new patients, but where are these people going to go? Am

I seeing enough to stop accepting new ones? How are small, but not

micro, practices doing? What numbers are sustainable for

them? Are we no longer Ideal if I see 20+ patients a day?

Can we talk about the real numbers

here? For the record, I have 30min new pt appts and 15min

established pts; no limit to the number of either per day. I see

pts 7:30 to 12:30 and 1:30 to 5 Mon – Thursday and ½ day on

Fridays. We have Open Access if folks call before lunch, else they

need to come in the next day. Hospitalists do adult admissions, I

do my own peds admissions (very few). Most of my visits are level

3s and 4s, about evenly split. My only level 1 visits are regular

monthly warfarin checks (have machine) and DepoProvera injections.

Currently I have 2100 active patients. I saw 438 pts last month and

get 4-6 new pts calling looking for a doctor on any given day. I

have 3.5 FTE (in line with MGMA data) and while 4155 patient visits per

year per family physician is median per MGMA (or so I’ve been told), I’ve

had 3934 office visits so far this year and have two more months to go in

2007. I quit all advertising after the first year.

We all have Achilles’ heels and mine is in

completing the office note so I can send out the bill. I am

embarrassed to say this but I am 800+ visits behind. My

efficiencies are in having a great biller, good staff, and I can see

people pretty quickly. I have a large EMR/EPM that takes a

ton of customization (NextGen) but I can’t seem to slow down long enough

to tweak it enough. When I started in 2005 with this practice, I

made a mistake and used a reseller/ASP and nearly lost it all; I now use

NextGen directly and that has saved me. However, I got so far

behind. While I’m improving I still spend way too much time

trying to get a decent note generated from the template based

EMR. This is worsened by the large number of patients that

want to be seen each day and my own OCD traits about documenting every

little thing. I’m currently working on a lab interface with

Spectrum which will make me a lot more efficient and have two training

sessions set up to speed up my notes so I can try to finish notes same

day. The EPM side of things are fantastic; NextGen can bill

almost instantly once I generate a charge from my note. It has a

built in coder. One day I’ll like to set up Virtual Office

Visits and use Instant Medical History, but I can’t stop for that just

now.

I can’t calculate my overhead until I get my

books balanced and can’t figure out the total income until all the bills

are sent out. I know I pay too much for my employees health

insurance but I think I do well with their salaries and my office space (

3100/month for a rather large office in a great location). Yet I

only took home 40K last year.

This may be far more information than

anybody cares about, and I may get booted out of the IMP club, but I like

this ‘debate’ on practice business analysis.

Tonya Little, MD

NC

Solo since 2005.

From:

[

mailto: ] On Behalf Of Dr

Levin

Sent: Saturday, November 03, 2007 4:06 PM

To:

Subject: Re: Re debates

/Practiceimprovement/buttoning and practice styel

RE Debates

OK, if no debate, what about workshops competing--

1) tools to make ultralite practice work better.

2) tools to keep micropractice overhead low, and promote

patient continuity.

3) Final workshop on practice business analysis, when to

change from 1) to 2) or 2) to 1) in order to be viable.

alternative revenue streams.

trends in malpractice and methods to

irmprove practice

But I didn't go to the first retreat, so was some of this

covered? Or should we still do the Debate??

Matt from Western PA

[Guest guest]

Dear Tonya,Of course you are welcome here! You can be "ideal" at 20+ patients a day, but you can't do it by yourself. You do have staff, so you could do it. You can't be an Ideal Micropractice, but you can be an Ideal Medical Practice. By being 800 charts behind, I think you might not be there yet, as you can't possibly be sustainable when you can't get your billing done. But you are definitely working toward it.My advice, for what it's worth, is to close to new patients. Or at least close to all but the best payers. Slow down. Get caught up. You are no good to all those needy people if you can't catch your breath. As much as those people need doctors and people call you and beg you, you have to take care of yourself first. When you get caught up you can open again. It is sad, but it is not your responsibility to figure out where all those people will go. Maybe you

could take off another half day a week for a while to catch up if you weren't taking new patients? Good luck with this, it sounds really hard.Lonna"Tonya S. Little" wrote: While I’m not sure it’s a debate, I for one would like to hear more about Matt’s three items below. Does an Ideal Practice have to be Micro? What about Mini? Or even Medium? I’ve been going over and over these posts in my mind and trying to find my own philosophy/ way of practice / business model, or whatever you want to call it but I’m so completely torn. I hear so much frustration and angst in our posts. We are supportive and provide each other with specific information

about how to be better. I’ve learned a lot from this list and from Bachman and Wenner’s High Performance Physicians workshop. But I’m not sure I’m at the “viable and sustainable” point that Gordon has brought up. I need to know at what point I can slow down, stop taking new patients, and remain sustainable. Somewhere I got on the hamster wheel and am afraid to get off. I want to remain solo, with no midlevels. I don’t want to work without staff because I would be uncomfortable being alone with some of my patients. I have a great staff and want to keep them; two were with me at my old hospital owned practice

and we left together. Patients seem pretty happy overall but I’m getting too busy. I work in an underserved area and my next new pt opening is January. This is awful. People are frantic to find a doctor that will see them. Social workers call and beg me to take difficult pts. My family members are approached and asked if I’ll take ‘one more’. I’ve stopped accepting new Medicaid and stopped those on Medicare who don’t have a supplement. I need to stop accepting new patients, but where are these people going to go? Am I seeing enough to stop accepting new ones? How are small, but not micro, practices doing? What numbers are sustainable for them? Are we no longer Ideal if I see 20+ patients a day? Can we talk about the real numbers here? For the record, I have 30min new pt appts and 15min established pts; no limit to the number of either per day. I see pts 7:30 to 12:30 and 1:30 to 5 Mon – Thursday and ½ day on Fridays. We have Open Access if folks call before lunch, else they need to come in the next day. Hospitalists do adult admissions, I do my own peds admissions (very few). Most of my visits are level 3s and 4s, about evenly split. My only level 1 visits are regular monthly warfarin checks (have machine) and DepoProvera injections. Currently I have 2100 active patients. I saw 438 pts last month and get 4-6 new pts calling looking for a doctor on any given day. I have 3.5 FTE (in line with MGMA data) and while 4155 patient

visits per year per family physician is median per MGMA (or so I’ve been told), I’ve had 3934 office visits so far this year and have two more months to go in 2007. I quit all advertising after the first year. We all have Achilles’ heels and mine is in completing the office note so I can send out the bill. I am embarrassed to say this but I am 800+ visits behind. My efficiencies are in having a great biller, good staff, and I can see people pretty quickly. I have a large EMR/EPM that takes a ton of customization (NextGen) but I can’t seem to slow down long enough to tweak it enough. When I started in 2005 with

this practice, I made a mistake and used a reseller/ASP and nearly lost it all; I now use NextGen directly and that has saved me. However, I got so far behind. While I’m improving I still spend way too much time trying to get a decent note generated from the template based EMR. This is worsened by the large number of patients that want to be seen each day and my own OCD traits about documenting every little thing. I’m currently working on a lab interface with Spectrum which will make me a lot more efficient and have two training sessions set up to speed up my notes so I can try to finish notes same day. The EPM side of things are fantastic; NextGen can bill almost instantly once I generate a charge from my note. It has a built in coder. One day I’ll like to set up Virtual Office Visits and use Instant Medical History, but I can’t stop for that just now. I can’t calculate my overhead until I get my books balanced and can’t figure out the total income until all the bills are sent out. I know I pay too much for my employees health insurance but I think I do well with their salaries and my office space ( 3100/month for a rather large office in a great location). Yet I only took home 40K last year. This

may be far more information than anybody cares about, and I may get booted out of the IMP club, but I like this ‘debate’ on practice business analysis. Tonya Little, MD NC Solo since

2005. From: [mailto: ] On Behalf Of Dr Levin Sent: Saturday, November 03, 2007 4:06 PM To:

Subject: Re: Re debates /Practiceimprovement/buttoning and practice styel RE Debates OK, if no debate, what about workshops competing-- 1) tools to make ultralite practice work better. 2) tools to keep micropractice overhead low, and promote patient continuity. 3) Final workshop on practice business analysis, when to change from 1)

to 2) or 2) to 1) in order to be viable. alternative revenue streams. trends in malpractice and methods to irmprove practice But I didn't go to the first retreat, so was some of this covered? Or should we still do the Debate?? Matt from Western PA __________________________________________________

[Guest guest]

Tonya,

1) Take your ½ day this week and meditate on everything. What do you

want? How can you continue to provide good or even great care to your patients?

How do you feel about your practice? Is it possible to change or should you go

through the pain of restarting? Read Lynn Ho’s

article in Family Practice Management (Sept 2007) and see if any of her

solutions can be applied to your practice.

2) Prioritize—Organize things into a high medium and low

priorities and start with the high priority stuff

3) Meet with your employees initially and the often (q2 weeks until

things are stable). Let them know where the business stands financially and ask

them to pitch in whenever possible outside their “job description.”

Ask them to offer suggestions as to how to improve efficiencies. Although a lot

of business owners don’t like doing this, good employees long to be heard

and make things better. Be honest, be upfront. Ask for help and they likely

will do whatever they can.

4) Stop the bleeding. Close to all new patients for now. NO

exceptions. Tell patients-“I would love to accept your friend, but that

would give me less time to focus on the patients I currently have and will

decrease my ability to provide quality.” Most will understand.

5) Finish off the notes and get off the billing!!! We only get paid if

the billing gets done. Do today’s work today and start working on the

other notes. Be careful, if they are not submitted by 90 days from date of

service, some insurances will reject them outright.

Figure out ways of getting the notes done quicker so they are done as soon as

you walk out of the exam room (if not template, can you use dragon natural speaking

or something like that?).

6) Increase income: organize your coumadin

rechecks into certain time slots of the day or all in one block. Look at the

PT/INR and tell the patient yourself what to do. Although this may take one

more minute, it becomes a 99212 visit. If you discuss their cold or sugar, it

is a 99213. Very fast stuff, but increases reimbursement (this goes even faster

if you have a premade template saying you were there and

saw the patient). Figure out other ways for you to increase reimbursement by

better utilizing what you have (read as not further increasing your overhead).

7) Remember: The system sucks and as most of us are working on a very

thin margin, any small issue can tip us over. You are the norm not the

exception. You should not be making $40K/year with the kind of volume you see

and the situation you are in is not just a reflection of you but of our broken

health care system. However, it can be better and it should be better. Figure

out where you want to go and how to get there. Good luck!!

B

Re:

Re debates /Practiceimprovement/buttoning and practice styel

RE Debates

OK, if no debate, what about workshops competing--

1) tools to make ultralite practice work better.

2) tools to keep micropractice overhead low, and promote

patient continuity.

3) Final workshop on practice business analysis, when to

change from 1) to 2) or 2) to 1) in order to be viable.

alternative revenue streams.

trends in malpractice and methods to

irmprove practice

But I didn't go to the first retreat, so was some of this

covered? Or should we still do the Debate??

Matt from Western PA

[Guest guest]

Tonya

do everything JOhn Brady says!

1. you need what we call breathing room.

stop taking new patietns!!

AND extend length of time between new visits

AND delegate some of what would have been folow up viists to a nurse call

( who c ares if there is no money in this if you are not now doing your

billing you are getting no money anyway)

get rid of back log

hire a locums of you have to.

2.recognize what has done in Colordaod in an area where she is

the only provider she met with town officials She is not required to solve

the world's health care issues by working til she- or you- drop and giving

more and more bad care

3. so when we get breathing room

we can offer fabulous access and

continuity and

great quality

And then the practice is sustainable becsasue when redesigned you will be

able to do what Kathy says-- do today's work today NO backlog.

YOur task is get rid of the backlog and take a breath.

then be thinking about how not to get into this mess agian.

In the future you may decide to have less staff to reduce your overlhead to

spend more time with patietns.

Or

You may decied to ask for help and be rescued and hire help and then

continue on as is.

Sometimes a volunteer can do scanning or filing things

let us know.

Re: Re debates

/Practiceimprovement/buttoning and practice styel

RE Debates

OK, if no debate, what about workshops competing--

1) tools to make ultralite practice work better.

2) tools to keep micropractice overhead low, and promote patient

continuity.

3) Final workshop on practice business analysis, when to change from 1)

to 2) or 2) to 1) in order to be viable.

alternative revenue streams.

trends in malpractice and methods to irmprove practice

But I didn't go to the first retreat, so was some of this covered? Or

should we still do the Debate??

Matt from Western PA

[Guest guest]

Tonya-

I would like to answer your question in a slightly different way, but

with similar intent-it enables you to come to a conclusion yourself

and hopefully implement a solution. I believe when we have

generalizable concepts and people come to their own conclusion and

path, things tend to work out much better.

The first concept is that of personal and office happiness and

effectiveness. I think the overriding discovery of the physicians on

this list paradoxically is not that of patient care although this is

very important-it's that to achieve effective patient care you and/or

your office must be happy and effective. If you're not, whatever

you're doing is not sustainable and therefore excellent patient care

will not be sustainable. Note that this concept says nothing about

absolute numbers of patients, numbers of staff or how your office is

constructed specifically. It's just about being happy and effective

at your work.

The second concept I'd like to introduce is one of " constraints " . We

as physicians and specifically family medicine physicians live in a

world full of constraints. I like to think of these constraints as

external and internal constraints.

For example, external constraints might be the area in which you live,

reimbursement issues, overhead issues, staff issues, insurance issues

and the list goes on. Other important external constraints are those

that involve your family life-spouse, children, community involvement

and the list goes on here as well.

Internal constraints involve how we think as family medicine

physicians about our jobs, our everyday experience and how we take

care of our patients. How good a job do we need to do? How many

patients do we need to see per day? What is our internal obligation

to our family, patients, community, medical system etc.. These

internal constraints are COGNITIVE, how we think about what we do.

They can be as daunting or perhaps more daunting than the external

constraints.The third constraint of course is time. We only have so

much time allotted to what we want to do and in fact our life in

general and we need to make decisions.

Finally, the fourth concept is that many (but not all) constraints

cannot be abolished completely but only managed. It is important to

abolish the constraints that can be abolished, but the more important

thing is to effectively manage most of the constraints that can only

be managed.

So, to get down to brass tacks and concrete-certainly now you're not

constrained by the amount of patients who want to see you-life is

good!-you're in demand. Perhaps that is leading to other constraints

such as difficulty billing, difficulty seeing every body, difficulty

doing the job you want to do.

So...... you need to manage the constraints or they will certainly

manage you (sometimes right out of business). What you need to do

specifically-in the end you must decide.

By the way, I'd be glad to discuss this with you on the telephone as

we have previously and/or come down for a visit as I used to practice

in Oxford North Carolina and still have a number of acquaintances in

the area.

Lou

Louis Spikol M.D.

Senior Healthcare Information Technology Consultant

Center for Health Information Technology

American Academy of Family Physicians

-mobile

-office

lspikol@...

>

> >While I'm not sure it's a debate, I for one

> >would like to hear more about Matt's three items below.

> >

> >

> >

> >Does an Ideal Practice have to be Micro? What about Mini? Or even

Medium?

> >

> >

> >

> >I've been going over and over these posts in my

> >mind and trying to find my own philosophy/ way

> >of practice / business model, or whatever you

> >want to call it but I'm so completely torn. I

> >hear so much frustration and angst in our

> >posts. We are supportive and provide each other

> >with specific information about how to be

> >better. I've learned a lot from this list and

> >from Bachman and Wenner's High Performance

> >Physicians workshop. But I'm not sure I'm at

> >the " viable and sustainable " point that Gordon

> >has brought up. I need to know at what point I

> >can slow down, stop taking new patients, and

> >remain sustainable. Somewhere I got on the

> >hamster wheel and am afraid to get off.

> >

> >

> >

> >I want to remain solo, with no midlevels. I

> >don't want to work without staff because I would

> >be uncomfortable being alone with some of my

> >patients. I have a great staff and want to keep

> >them; two were with me at my old hospital owned

> >practice and we left together. Patients seem

> >pretty happy overall but I'm getting too

> >busy. I work in an underserved area and my

> >next new pt opening is January. This is

> >awful. People are frantic to find a doctor

> >that will see them. Social workers call and beg

> >me to take difficult pts. My family members

> >are approached and asked if I'll take `one

> >more'. I've stopped accepting new Medicaid and

> >stopped those on Medicare who don't have a

> >supplement. I need to stop accepting new

> >patients, but where are these people going to

> >go? Am I seeing enough to stop accepting new

> >ones? How are small, but not micro, practices

> >doing? What numbers are sustainable for

> >them? Are we no longer Ideal if I see 20+ patients a day?

> >

> >

> >

> >Can we talk about the real numbers here? For

> >the record, I have 30min new pt appts and 15min

> >established pts; no limit to the number of

> >either per day. I see pts 7:30 to 12:30 and

> >1:30 to 5 Mon – Thursday and ½ day on

> >Fridays. We have Open Access if folks call

> >before lunch, else they need to come in the next

> >day. Hospitalists do adult admissions, I do my

> >own peds admissions (very few). Most of my

> >visits are level 3s and 4s, about evenly

> >split. My only level 1 visits are regular

> >monthly warfarin checks (have machine) and

> >DepoProvera injections. Currently I have 2100

> >active patients. I saw 438 pts last month and

> >get 4-6 new pts calling looking for a doctor on

> >any given day. I have 3.5 FTE (in line with

> >MGMA data) and while 4155 patient visits per

> >year per family physician is median per MGMA (or

> >so I've been told), I've had 3934 office visits

> >so far this year and have two more months to go

> >in 2007. I quit all advertising after the first year.

> >

> >

> >

> >We all have Achilles' heels and mine is in

> >completing the office note so I can send out the

> >bill. I am embarrassed to say this but I am

> >800+ visits behind. My efficiencies are in

> >having a great biller, good staff, and I can see

> >people pretty quickly. I have a large EMR/EPM

> >that takes a ton of customization (NextGen) but

> >I can't seem to slow down long enough to tweak

> >it enough. When I started in 2005 with this

> >practice, I made a mistake and used a

> >reseller/ASP and nearly lost it all; I now use

> >NextGen directly and that has saved

> >me. However, I got so far behind. While I'm

> >improving I still spend way too much time trying

> >to get a decent note generated from the template

> >based EMR. This is worsened by the large

> >number of patients that want to be seen each day

> >and my own OCD traits about documenting every

> >little thing. I'm currently working on a lab

> >interface with Spectrum which will make me a lot

> >more efficient and have two training sessions

> >set up to speed up my notes so I can try to

> >finish notes same day. The EPM side of things

> >are fantastic; NextGen can bill almost instantly

> >once I generate a charge from my note. It has a

> >built in coder. One day I'll like to set up

> >Virtual Office Visits and use Instant Medical

> >History, but I can't stop for that just now.

> >

> >

> >

> >I can't calculate my overhead until I get my

> >books balanced and can't figure out the total

> >income until all the bills are sent out. I

> >know I pay too much for my employees health

> >insurance but I think I do well with their

> >salaries and my office space ( 3100/month for a

> >rather large office in a great location). Yet I only took home 40K

last year.

> >

> >

> >

> >This may be far more information than anybody

> >cares about, and I may get booted out of the IMP

> >club, but I like this `debate' on practice business analysis.

> >

> >

> >

> >Tonya Little, MD

> >

> > NC

> >

> >Solo since 2005.

> >

> >

> >

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

> >From:

> >[mailto: ] On Behalf Of Dr Levin

> >Sent: Saturday, November 03, 2007 4:06 PM

> >To:

> >Subject: Re: Re debates

> >/Practiceimprovement/buttoning and practice styel

> >

> >

> >

> >RE Debates

> >

> >

> >

> >OK, if no debate, what about workshops competing--

> >

> >

> >

> >1) tools to make ultralite practice work better.

> >

> >

> >

> >2) tools to keep micropractice overhead low, and promote patient

continuity.

> >

> >

> >

> >3) Final workshop on practice business analysis,

> >when to change from 1) to 2) or 2) to 1) in order to be viable.

> >

> > alternative revenue streams.

> >

> > trends in malpractice and methods to irmprove practice

> >

> >

> >

> >But I didn't go to the first retreat, so was

> >some of this covered? Or should we still do the Debate??

> >

> >

> >

> >Matt from Western PA

> >

> >

> >

> >

> >

>

[Guest guest]

RE overhead calculation, finishing notes.

I think I started this thread and am glad I did.

First off:

1) IMP does not mean no staff; we beat up this concept at my insistence about a month ago, and think we can all put this behind us.

2) Overhead calculation does NOT need to wait until the "end of the year"; means -- add up ALL your bills paid for the month, including salaries, and you'll have an approximate number. That's it, not perfect, but a reasonable goal. DO NOT put in any figure for yourself!!

3) Getting notes finished in your EMR. I think you've tried to be paperless, not sure, but suspect the biggest part of things for you is to finish the Subjective (CC, HPI) part in the computer. When I get overloaded, I HANDW RITE THE CC, HPI!! yes, this isn't pretty, but can readily be done. THE REST OF THE NOTE is much more easily boilerplated. This is truely possible, even if you had a circle template, and scanned it in.

Don't let the EMR issues stop your billing -- the only time you need to submit a note is when it is requested! Now if you're letting your EMR code for you, well, 800 visits back is a large number.

You should also try to calculate what it's costing you to run the Protime machine -- it may be that it's COSTING YOU to do this. In my area, I would not run a machine as my costs would not get paid, and pts don't want to pay copays for each protime. You could just NOT BILL for the protime, and just see the pt, doing the Protime "for free" as it's helpful to YOU, but you'd still have to run the controls.

I agree with the others, you need to just focus on your pts that you see now, and see where you're going.

Also look at the most adminstratively aggravating pts, and you may have to CUT some programs (I take no new Medicaid AT ALL since July, almost 3 years in, but I have many fewer pts than you).

Bottom line is that if you have to struggle to make payroll every 2 weeks, you have a cash flow problem which can be resolved either by:

1) getting the bills out NOW.

2) reducing the overhead.

My opinion, yours?

Matt in Western PA

Solo since Dec 2004

Residency FP trained completed 1988 (1 year after Lou different place, didn't know you worked in NC Lou)

FTE 1.75

SOAPware EMR (since 1997 even when working for a hospital without EMR)

Appointment Quest scheduling (since May 2007)

RelayHealth for confidential email (since Oct 2007)

Using another FP for admissions, am on staff at 1 local hospital but I don't go in

On call 24/7 for all my pts.

Advanced open access scheduling (same day/next day appts all pts)

See kids under 5, but not for regular care

Gave flu shots for first time this year on a schedule ahead basis

IMP types/Practice Models/Style

While I’m not sure it’s a debate, I for one would like to hear more about Matt’s three items below.

Does an Ideal Practice have to be Micro? What about Mini? Or even Medium?

I’ve been going over and over these posts in my mind and trying to find my own philosophy/ way of practice / business model, or whatever you want to call it but I’m so completely torn. I hear so much frustration and angst in our posts. We are supportive and provide each other with specific information about how to be better. I’ve learned a lot from this list and from Bachman and Wenner’s High Performance Physicians workshop. But I’m not sure I’m at the “viable and sustainable” point that Gordon has brought up. I need to know at what point I can slow down, stop taking new patients, and remain sustainable. Somewhere I got on the hamster wheel and am afraid to get off.

I want to remain solo, with no midlevels. I don’t want to work without staff because I would be uncomfortable being alone with some of my patients. I have a great staff and want to keep them; two were with me at my old hospital owned practice and we left together. Patients seem pretty happy overall but I’m getting too busy. I work in an underserved area and my next new pt opening is January. This is awful. People are frantic to find a doctor that will see them. Social workers call and beg me to take difficult pts. My family members are approached and asked if I’ll take ‘one more’. I’ve stopped accepting new Medicaid and stopped those on Medicare who don’t have a supplement. I need to stop accepting new patients, but where are these people going to go? Am I seeing enough to stop accepting new ones? How are small, but not micro, practices doing? What numbers are sustainable for them? Are we no longer Ideal if I see 20+ patients a day?

Can we talk about the real numbers here? For the record, I have 30min new pt appts and 15min established pts; no limit to the number of either per day. I see pts 7:30 to 12:30 and 1:30 to 5 Mon – Thursday and ½ day on Fridays. We have Open Access if folks call before lunch, else they need to come in the next day. Hospitalists do adult admissions, I do my own peds admissions (very few). Most of my visits are level 3s and 4s, about evenly split. My only level 1 visits are regular monthly warfarin checks (have machine) and DepoProvera injections. Currently I have 2100 active patients. I saw 438 pts last month and get 4-6 new pts calling looking for a doctor on any given day. I have 3.5 FTE (in line with MGMA data) and while 4155 patient visits per year per family physician is median per MGMA (or so I’ve been told), I’ve had 3934 office visits so far this year and have two more months to go in 2007. I quit all advertising after the first year.

We all have Achilles’ heels and mine is in completing the office note so I can send out the bill. I am embarrassed to say this but I am 800+ visits behind. My efficiencies are in having a great biller, good staff, and I can see people pretty quickly. I have a large EMR/EPM that takes a ton of customization (NextGen) but I can’t seem to slow down long enough to tweak it enough. When I started in 2005 with this practice, I made a mistake and used a reseller/ASP and nearly lost it all; I now use NextGen directly and that has saved me. However, I got so far behind. While I’m improving I still spend way too much time trying to get a decent note generated from the template based EMR. This is worsened by the large number of patients that want to be seen each day and my own OCD traits about documenting every little thing. I’m currently working on a lab interface with Spectrum which will make me a lot more efficient and have two training sessions set up to speed up my notes so I can try to finish notes same day. The EPM side of things are fantastic; NextGen can bill almost instantly once I generate a charge from my note. It has a built in coder. One day I’ll like to set up Virtual Office Visits and use Instant Medical History, but I can’t stop for that just now.

I can’t calculate my overhead until I get my books balanced and can’t figure out the total income until all the bills are sent out. I know I pay too much for my employees health insurance but I think I do well with their salaries and my office space ( 3100/month for a rather large office in a great location). Yet I only took home 40K last year.

This may be far more information than anybody cares about, and I may get booted out of the IMP club, but I like this ‘debate’ on practice business analysis.

Tonya Little, MD

NC

Solo since 2005.

From: [mailto: ] On Behalf Of Dr LevinSent: Saturday, November 03, 2007 4:06 PMTo: Subject: Re: Re debates /Practiceimprovement/buttoning and practice styel

RE Debates

OK, if no debate, what about workshops competing--

1) tools to make ultralite practice work better.

2) tools to keep micropractice overhead low, and promote patient continuity.

3) Final workshop on practice business analysis, when to change from 1) to 2) or 2) to 1) in order to be viable.

alternative revenue streams.

trends in malpractice and methods to irmprove practice

But I didn't go to the first retreat, so was some of this covered? Or should we still do the Debate??

Matt from Western PA

[Guest guest]

Tonya -I read your post and began to feel slightly breathless. When I got to

the '800 notes behind' part I actually began to have palpitations. I totally

empathize with where you are right now because I've been there (but really not

quite as there are you are, I think...) First of all, if it makes you feel any

better, right now I am also about 3 weeks behind in my new billing because I

upgraded my billing program and despite great help from listserv users, still

cannot get the billing straight because what is required is so state-specific.

I won't even talk about my old billing (, cover your eyes...)Great big

picture analysis from Lou for the spiritual look at where you are/want to be,

and that would be worth considering now, but the macro health care snapshot

whether micro mini or medium or ideal really doesn't and shouldn't matter to

you right now- how could you even have time to think about it? You just really

need to dig out from where you are. When I was running really behind, I gave

over on the practice improvement/IMP cohort stuff - suspended working on it-

until I could get my efficiency act together and only after then- was more able

to focus on the ideal practice stuff. So microscopically, looking at your

practice details:Can you say more about where in the note generation you are

being held up? Is it History and ROS, PE, plan? I don't know much about

Nextgen. Does nextgen only let you bill the note after it's done? Does it

level the visit for you? Can you use Dragon with Nextgen or does it demand that

you select elements from a pick list? How much data is already extracted in the

saved notes? Can you get around the billing as says by just selecting ICD

9 codes and CPTS and just billing the 800 + old notes without filling them out?

I would just bill them out as 3's and give up on the notes for documentation at

this point. In one of Dr. Bachman's great presentations he goes through how many

words per minute each type of doumentation can cover something like 3000+ per

minute for IMH, 80-100+? for dragon with macros, 60 wpm for dictating, 40? for

templates, 20 for handwriting. (I'm not sure about the exactness of those

numbers though they feel about right - Lou or anyone feel free to correct me -

(I am only good with numbers up to about 40, all others just turn into

factorials. ))So if you are being held up on the histories, IMH is the best and

fastest documenter that there is but takes a SIGNIFICANT learning curve to get

set up and running ( for me in a staffless practice about 3-6 months, I imagine

it would take much longer in a practice with staff.). Probably you won't/don't

have the energy for that one now. Dragon might be your best bet with a much

shorter learning curve and pretty good speed if you are stalled on the

history/ROS parts. If you are being held up by plans, precooked templates for

your top twenty diagnoses might take you 2-3 hours total to write up- if you

don't mind being utterly impersonal, you can just go to familydoctor.org and

copy/load them into your template section. If you are being held up by PE, try

shorthand for windows, relatively short learning curve- fast documenter (though

doesn't Nextgen have pick lists for PE which should be fast?).It is great that

your billing/PM works so seamlessly though- wish mine did!In terms of closing

of to new patients- I am going to repeat this again, even though it is old hat

on this listserv.Closing to new patients was the BEST thing I did to get

breathing room. I LOVED closing to new patients! I closed on the advice from

the listserv when I was about 2/3s full (by my estimation), just taking family

members of existing patients, I have NEVER regretted this. Brady who has

staff and a bigger practice (might be somewhat closer to your model) has closed

and opened at least once? experienced maybe some revenue slowdown, but not

irreversibly so ( correct me if I am wrong). New patients = lots of work!

sick with acute visits and thus more closely scheduled visits at first, steep

training/learning curve for you and them, abstracting old records and populating

a new chart, for me an hour long visit vs a 30 minute visit. I think you need

to close your practice to new now, including family members, maybe permanently.

Isn't a panel of 2100 at least average FM size? Send them to Haresch, is he

anywhere near you? You CAN'T take care of all of the unassigned patients in your

neck of the woods, you are only one person. Try saying NO, squelch that guilt,

the first time is hard but succeeding NOs get easier. Good luck, I feel worried

for you, let us know how it is going...Lynn___

_________________________________________________________________

Windows Live Hotmail and Microsoft Office Outlook – together at last.  Get it

now.

http://office.microsoft.com/en-us/outlook/HA102225181033.aspx?pid=CL100626971033

[Guest guest]

Tonya --As I mentioned this morning, lots of good posts from a bunch of

folks who do care that you are in the most noble profession and not thriving and

joyful. Most, if not all, of us have been in somewhat similar

situations. And it led us to come together and try to design practices that

work better. Each of us has our own formula, but many pieces of each puzzle

are shared.Please stay in touch with the list. Consider updates for us

once or twice a week -- we'll be able to keep giving some pointers from afar. And

hopefully most of them will only help you understand your options and think of

solutions. But also, your lessons will help us too. So teach us as

you rise from the ashes and learn to love being a doctor without martyrdom!You are in a tough situation. But today you may be taking a great stride forward.

There are solutions. They may not be easy, and there may be bumps in the road, but

they are there.Good luck. I'm really looking forward to learning about

your successes as they unfold these next few months.Tim > On Sun, November 4, 2007 7:56 pm EST, Lynn Ho

wrote:> > > > Tonya

-I read your post and began to feel slightly breathless. When I got to the> '800 notes behind' part I actually began to have palpitations. I totally

empathize> with where you are right now because I've been there (but really

not quite as there> are you are, I think...) First of all, if it makes you

feel any better, right now I> am also about 3 weeks behind in my new

billing because I upgraded my billing program> and despite great help from

listserv users, still cannot get the billing straight> because what is

required is so state-specific. I won't even talk about my old> billing

(, cover your eyes...)Great big picture analysis from Lou for the>

spiritual look at where you are/want to be, and that would be worth considering> now, but the macro health care snapshot whether micro mini or medium or ideal

really> doesn't and shouldn't matter to you right now- how could you even

have time to> think about it? You just really need to dig out from where

you are. When I was> running really behind, I gave over on the practice

improvement/IMP cohort stuff -> suspended working on it- until I could get

my efficiency act together and only> after then- was more able to focus on

the ideal practice stuff. So microscopically,> looking at your practice

details:Can you say more about where in the note generation> you are being

held up? Is it History and ROS, PE, plan? I don't know much about>

Nextgen. Does nextgen only let you bill the note after it's done? Does it level> the visit for you? Can you use Dragon with Nextgen or does it demand that you

select> elements from a pick list? How much data is already extracted in

the saved notes? > Can you get around the billing as says by just

selecting ICD 9 codes and CPTS> and just billing the 800 + old notes

without filling them out? I would just bill> them out as 3's and give up

on the notes for documentation at this point. In one of> Dr. Bachman's

great presentations he goes through how many words per minute each> type of

doumentation can cover something like 3000+ per minute for IMH, 80-100+?>

for dragon with macros, 60 wpm for dictating, 40? for templates, 20 for

handwriting.> (I'm not sure about the exactness of those numbers though

they feel about right -> Lou or anyone feel free to correct me - (I am only

good with numbers up to about 40,> all others just turn into factorials.

))So if you are being held up on the> histories, IMH is the best and

fastest documenter that there is but takes a> SIGNIFICANT learning curve to

get set up and running ( for me in a staffless> practice about 3-6 months,

I imagine it would take much longer in a practice with> staff.). Probably

you won't/don't have the energy for that one now. Dragon might> be your

best bet with a much shorter learning curve and pretty good speed if you are> stalled on the history/ROS parts. If you are being held up by plans,

precooked> templates for your top twenty diagnoses might take you 2-3 hours

total to write up- > if you don't mind being utterly impersonal, you can

just go to familydoctor.org and> copy/load them into your template section.

If you are being held up by PE, try> shorthand for windows, relatively

short learning curve- fast documenter (though> doesn't Nextgen have pick

lists for PE which should be fast?).It is great that your> billing/PM works

so seamlessly though- wish mine did!In terms of closing of to new>

patients- I am going to repeat this again, even though it is old hat on this> listserv.Closing to new patients was the BEST thing I did to get breathing

room. I> LOVED closing to new patients! I closed on the advice from the

listserv when I was> about 2/3s full (by my estimation), just taking family

members of existing patients,> I have NEVER regretted this. Brady who

has staff and a bigger practice (might be> somewhat closer to your model)

has closed and opened at least once? experienced> maybe some revenue

slowdown, but not irreversibly so ( correct me if I am> wrong). New

patients = lots of work! sick with acute visits and thus more closely>

scheduled visits at first, steep training/learning curve for you and them,>

abstracting old records and populating a new chart, for me an hour long visit vs

a> 30 minute visit. I think you need to close your practice to new now,

including> family members, maybe permanently. Isn't a panel of 2100 at

least average FM size?> Send them to Haresch, is he anywhere near you?

You CAN'T take care of all of> the unassigned patients in your neck of the

woods, you are only one person. Try> saying NO, squelch that guilt, the

first time is hard but succeeding NOs get easier.> Good luck, I feel

worried for you, let us know how it is going...Lynn___> > > > > > > > > >

> > > > > > >

_________________________________________________________________> Windows

Live Hotmail and Microsoft Office Outlook – together at last. Get it now.>

http://office.microsoft.com/en-us/outlook/HA102225181033.aspx?pid=CL100626971033> > >

[Guest guest]

You guys are losing me. We had this mirco, macro discussion a few weeks ago when

certain parts of my anatomy got handed to me. We have decided that it has no

meaning, since it can include 0-10 employees/provider. On the other hand we all

seem to agree on the definition of Idealized Medical practice.

Tonya, If I read your numbers correctly, your overhead could be as high as 80%.

Probably not, since you have 800 bills unsent, that represents $40,000 at 50

bucks a vist, and I hope you get more. As stated many of these may now be not

billable. I agree with the idea of taking the time to slow down and get this

work done. You would improve your bottom line by closing the office for 2 days,

not paying your staff and getting the work done.

I do not want to go through the thought process again on line, but having been

in many practice models over the last 30 years, employees are very expensive. I

have none, see 11 patients a day 3.5-4 days a week and will net out above teh FM

average for the year. The key is to keep the number of patients managable, do

todays work today, get the billing and collection done and not work yourself to

the bone. If you have 3 employees at 25k each (low) that is 31 patients a week!

Yicks, that is almost as many as I see some weeks.

If you have an EMR, be sure it is not just an added cost, but actually saves you

time and money. don't worry where these new patients will go, you do not have to

solve the health care crisis by yourself.

________________________________

From: on behalf of Tonya S. Little

Sent: Sun 11/4/2007 8:32 AM

To:

Subject: IMP types/Practice Models/Style

While I'm not sure it's a debate, I for one would like to hear more about Matt's

three items below.

Does an Ideal Practice have to be Micro? What about Mini? Or even Medium?

I've been going over and over these posts in my mind and trying to find my own

philosophy/ way of practice / business model, or whatever you want to call it

but I'm so completely torn. I hear so much frustration and angst in our posts.

We are supportive and provide each other with specific information about how to

be better. I've learned a lot from this list and from Bachman and Wenner's High

Performance Physicians workshop. But I'm not sure I'm at the " viable and

sustainable " point that Gordon has brought up. I need to know at what point I

can slow down, stop taking new patients, and remain sustainable. Somewhere I

got on the hamster wheel and am afraid to get off.

I want to remain solo, with no midlevels. I don't want to work without staff

because I would be uncomfortable being alone with some of my patients. I have a

great staff and want to keep them; two were with me at my old hospital owned

practice and we left together. Patients seem pretty happy overall but I'm

getting too busy. I work in an underserved area and my next new pt opening is

January. This is awful. People are frantic to find a doctor that will see

them. Social workers call and beg me to take difficult pts. My family members

are approached and asked if I'll take 'one more'. I've stopped accepting new

Medicaid and stopped those on Medicare who don't have a supplement. I need to

stop accepting new patients, but where are these people going to go? Am I

seeing enough to stop accepting new ones? How are small, but not micro,

practices doing? What numbers are sustainable for them? Are we no longer Ideal

if I see 20+ patients a day?

Can we talk about the real numbers here? For the record, I have 30min new pt

appts and 15min established pts; no limit to the number of either per day. I

see pts 7:30 to 12:30 and 1:30 to 5 Mon - Thursday and ½ day on Fridays. We

have Open Access if folks call before lunch, else they need to come in the next

day. Hospitalists do adult admissions, I do my own peds admissions (very few).

Most of my visits are level 3s and 4s, about evenly split. My only level 1

visits are regular monthly warfarin checks (have machine) and DepoProvera

injections. Currently I have 2100 active patients. I saw 438 pts last month

and get 4-6 new pts calling looking for a doctor on any given day. I have 3.5

FTE (in line with MGMA data) and while 4155 patient visits per year per family

physician is median per MGMA (or so I've been told), I've had 3934 office visits

so far this year and have two more months to go in 2007. I quit all advertising

after the first year.

We all have Achilles' heels and mine is in completing the office note so I can

send out the bill. I am embarrassed to say this but I am 800+ visits behind.

My efficiencies are in having a great biller, good staff, and I can see people

pretty quickly. I have a large EMR/EPM that takes a ton of customization

(NextGen) but I can't seem to slow down long enough to tweak it enough. When I

started in 2005 with this practice, I made a mistake and used a reseller/ASP and

nearly lost it all; I now use NextGen directly and that has saved me. However,

I got so far behind. While I'm improving I still spend way too much time

trying to get a decent note generated from the template based EMR. This is

worsened by the large number of patients that want to be seen each day and my

own OCD traits about documenting every little thing. I'm currently working on

a lab interface with Spectrum which will make me a lot more efficient and have

two training sessions set up to speed up my notes so I can try to finish notes

same day. The EPM side of things are fantastic; NextGen can bill almost

instantly once I generate a charge from my note. It has a built in coder. One

day I'll like to set up Virtual Office Visits and use Instant Medical History,

but I can't stop for that just now.

I can't calculate my overhead until I get my books balanced and can't figure out

the total income until all the bills are sent out. I know I pay too much for

my employees health insurance but I think I do well with their salaries and my

office space ( 3100/month for a rather large office in a great location). Yet I

only took home 40K last year.

This may be far more information than anybody cares about, and I may get booted

out of the IMP club, but I like this 'debate' on practice business analysis.

Tonya Little, MD

NC

Solo since 2005.

________________________________

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Saturday, November 03, 2007 4:06 PM

To:

Subject: Re: Re debates /Practiceimprovement/buttoning

and practice styel

RE Debates

OK, if no debate, what about workshops competing--

1) tools to make ultralite practice work better.

2) tools to keep micropractice overhead low, and promote patient continuity.

3) Final workshop on practice business analysis, when to change from 1) to 2) or

2) to 1) in order to be viable.

alternative revenue streams.

trends in malpractice and methods to irmprove practice

But I didn't go to the first retreat, so was some of this covered? Or should we

still do the Debate??

Matt from Western PA

[Guest guest]

Tonya,

First, my sympathies that you are using the NextGen EMR! Converting

from paper charts to NextGen was the " straw that broke the camel's

back, " resulting in my complete burnout at my previous employed

position. It is such an unwieldy behemoth, and like you, I found it

took way too much time to generate what I considered to be a decent

note. I'm now working at an urgent care center where notes are all

handwritten, hoping to start my IMP within the next 6 months, and

can't wait to start from scratch with a simpler EMR.

Second, I heartily agree with the poster who reminded you that

" Perfect is the enemy of good. " I, too, have a perfectionism problem,

against which I struggle daily. When/if you do those old notes, just

put in the absolute minimum.

Finally, regarding your guilt at not being able to care for all the

people who would like to see you, I heard a great analogy. When you

are flying in a plane and the cabin loses pressure and the oxygen

masks drop down in front of you, you are reminded to ALWAYS SECURE

YOUR OWN OXYGEN MASK FIRST, THEN HELP THOSE AROUND YOU WHO NEED HELP.

It sounds as if your practice " cabin " is losing pressure, and if

you " pass out " for lack of oxygen (i.e, family time, rest,

recreation), you will not be able to help ANY of the people who need

you. Close to new patients immediately and take a day a week off from

seeing patients to get the old bills sent out. You have already done

the work of seeing those pts., so you will still be earning money on

those days.

Good luck!

Sharlene

-

-- In , " Tonya S. Little "

wrote:

>

> While I’m not sure it’s a debate, I for one would like to hear more

about

> Matt’s three items below.

>

>

>

> Does an Ideal Practice have to be Micro? What about Mini? Or even

Medium?

>

>

>

>

> I’ve been going over and over these posts in my mind and trying to

find my

> own philosophy/ way of practice / business model, or whatever you

want to

> call it but I’m so completely torn. I hear so much frustration and

angst in

> our posts. We are supportive and provide each other with specific

> information about how to be better. I’ve learned a lot from this

list and

> from Bachman and Wenner’s High Performance Physicians workshop.

But I’m

> not sure I’m at the “viable and sustainable” point that Gordon has

brought

> up. I need to know at what point I can slow down, stop taking new

patients,

> and remain sustainable. Somewhere I got on the hamster wheel and

am afraid

> to get off.

>

>

>

> I want to remain solo, with no midlevels. I don’t want to work without

> staff because I would be uncomfortable being alone with some of my

patients.

> I have a great staff and want to keep them; two were with me at my old

> hospital owned practice and we left together. Patients seem pretty

happy

> overall but I’m getting too busy. I work in an underserved area

and my

> next new pt opening is January. This is awful. People are frantic

to find

> a doctor that will see them. Social workers call and beg me to take

> difficult pts. My family members are approached and asked if I’ll take

> ‘one more’. I’ve stopped accepting new Medicaid and stopped those on

> Medicare who don’t have a supplement. I need to stop accepting new

> patients, but where are these people going to go? Am I seeing enough to

> stop accepting new ones? How are small, but not micro, practices doing?

> What numbers are sustainable for them? Are we no longer Ideal if I

see 20+

> patients a day?

>

>

>

> Can we talk about the real numbers here? For the record, I have

30min new

> pt appts and 15min established pts; no limit to the number of either per

> day. I see pts 7:30 to 12:30 and 1:30 to 5 Mon – Thursday and ½ day on

> Fridays. We have Open Access if folks call before lunch, else they

need to

> come in the next day. Hospitalists do adult admissions, I do my own

peds

> admissions (very few). Most of my visits are level 3s and 4s, about

evenly

> split. My only level 1 visits are regular monthly warfarin checks (have

> machine) and DepoProvera injections. Currently I have 2100 active

patients.

> I saw 438 pts last month and get 4-6 new pts calling looking for a

doctor on

> any given day. I have 3.5 FTE (in line with MGMA data) and while 4155

> patient visits per year per family physician is median per MGMA (or

so I’ve

> been told), I’ve had 3934 office visits so far this year and have

two more

> months to go in 2007. I quit all advertising after the first year.

>

>

>

> We all have Achilles’ heels and mine is in completing the office

note so I

> can send out the bill. I am embarrassed to say this but I am 800+

visits

> behind. My efficiencies are in having a great biller, good staff,

and I can

> see people pretty quickly. I have a large EMR/EPM that takes a ton of

> customization (NextGen) but I can’t seem to slow down long enough to

tweak

> it enough. When I started in 2005 with this practice, I made a

mistake and

> used a reseller/ASP and nearly lost it all; I now use NextGen

directly and

> that has saved me. However, I got so far behind. While I’m

improving I

> still spend way too much time trying to get a decent note generated

from the

> template based EMR. This is worsened by the large number of

patients that

> want to be seen each day and my own OCD traits about documenting every

> little thing. I’m currently working on a lab interface with

Spectrum which

> will make me a lot more efficient and have two training sessions set

up to

> speed up my notes so I can try to finish notes same day. The EPM

side of

> things are fantastic; NextGen can bill almost instantly once I

generate a

> charge from my note. It has a built in coder. One day I’ll like

to set up

> Virtual Office Visits and use Instant Medical History, but I can’t

stop for

> that just now.

>

>

>

> I can’t calculate my overhead until I get my books balanced and

can’t figure

> out the total income until all the bills are sent out. I know I

pay too

> much for my employees health insurance but I think I do well with their

> salaries and my office space ( 3100/month for a rather large office in a

> great location). Yet I only took home 40K last year.

>

>

>

> This may be far more information than anybody cares about, and I may get

> booted out of the IMP club, but I like this ‘debate’ on practice

business

> analysis.

>

>

>

> Tonya Little, MD

>

> NC

>

> Solo since 2005.

>

>

>

> _____

>

> From:

> [mailto: ] On Behalf Of Dr Levin

> Sent: Saturday, November 03, 2007 4:06 PM

> To:

> Subject: Re: Re debates

> /Practiceimprovement/buttoning and practice styel

>

>

>

> RE Debates

>

>

>

> OK, if no debate, what about workshops competing--

>

>

>

> 1) tools to make ultralite practice work better.

>

>

>

> 2) tools to keep micropractice overhead low, and promote patient

continuity.

>

>

>

> 3) Final workshop on practice business analysis, when to change from

1) to

> 2) or 2) to 1) in order to be viable.

>

> alternative revenue streams.

>

> trends in malpractice and methods to irmprove practice

>

>

>

> But I didn't go to the first retreat, so was some of this covered? Or

> should we still do the Debate??

>

>

>

> Matt from Western PA

>

[Guest guest]

LOL, Lynn....NC is no RI! We're in the same end of the state but still

a couple of hours away...

Haresch

>

>

permanently. Isn't a panel of 2100 at least average FM size? Send

them to Haresch, is he anywhere near you? You CAN'T take care