Nurse Practitioners, Telehealth, And The Future of The Nurse Practitioner Medical Practice. The Business of Medicine for Residents, Fellows and Nurse Practitioners.
I recently found an interesting study on habit formation. It suggested that a new habit can be developed in as little as 21 days. The average time for full development was 66 days.
After six months of lockdown all of us are forming new habits, getting used to new and changing lifestyles. In medicine the biggest change, now grown beyond a habit to a norm, has to be the emergence of telehealth.
Although CMS continues to tinker with telehealth rules--as late as last week releasing new guidelines that will expand telehealth rules--it’s here to stay. I don’t think anyone expects a return to pre-pandemic restrictions.
This presents a new opportunity for nurse practitioners, and I regularly field calls from them, queries framed around the question, “What do I need to do to start a telehealth practice?” Most callers understand the clinical piece but lack focus on the more important aspects of developing a successful business.
The thing I find lacking most is a clear focus on what the goals and objectives are. Specifically, what market are you going to serve? Leaving an active practice where you’ve had the time to develop a patient base is going to make it easier, but like all medical practices, how do you grow your business to fit your vision?
Market assessment is a critical part of this. What’s the target market? Adding telehealth to a brick and mortar practice as a way to treat your current patient base? Aligning with an overworked family practice physician to ease his load and increase his patient base? Working to develop a presence in the nursing home/assisted living market? Positioning yourself in the underserved rural markets, possibly in partnership with a healthcare system?
What is your market? How do you break in? Can you find both the financial and clinical rewards you’ve defined in your goals and objectives? How long will it take? What is the marketing effort and capital that needs to be executed to establish a presence? Is the return on the cost to do so make it all worthwhile?
In states where NPs must work with a collaborating physician there’s the big question of finding one. I always suggest a sophisticated presentation be developed for presentation to prospective physicians, one that outlines your work experience/history, levels of clinical activity, training, and a summation of your target market. When you are asking someone to work with you at this level, you need to show them that you are not “risky” and have a commensurate level of professionalism they will be comfortable with.
And you need to define just how they are going to get paid.
Find an EHR vendor who has had extensive experience in telehealth and telehealth billing. Understand the costs.
Social media is crucial. Familiarize yourself with DoctorLogic, PatientPOP and other platforms that understand how to integrate them into your business plan.
Starting a telehealth practice is no different than starting a medical practice in almost all ways. For a complete overview of “how to do it” I’d refer you to www.FirstMEDPractice.com, the platform developed specifically for providers entering the world of medical business.
Possibly the most important thing of all: Who will pay you, and how much. State’s oversee telehealth rules, and what’s required can vary from state to state. Compliance is the issue here. Insurers can also be fickle in this area, and issues related to credentialing with payers can be complex (and take months to achieve), especially if you anticipate providing telehealth to patients across state lines. Be sure to follow payment updates too; I expect insurers will be renegotiating telehealth rates after the pandemic.
---Tom Ellis III/September 2020
Three weeks ago the American Association of Medical Colleges very quietly released a document entitled “AAMC Guidance on Peaceful Protests by Medical Students and Residents.”
In response to the growing number of physician voices sounding the alarm about the on-going attack on science, the lack of political leadership during the on-going COVID-19 crisis, attempts to distort and/or hide critical metrics on the spread of the disease, Whitecoats for Black Lives, and other demonstrations by health care workers of all kinds, the AACM spoke.
Making it clear that medical students should feel free to lawfully and peacefully protest, and that they should engage their peers and academic directors in issues related to systemic racism, opening the conversation to find a new and better way to provide healthcare and not be concerned about the consequences of doing so. Medical schools should not see this kind of engagement as a stain on a student’s career, admission to medical school or residency/fellowship, and only asked that students wearing the “white coat” reflect and uphold the “virtues associated with medicine—humility, compassion, integrity, accountability, ethics and humanism” when engaging in protest.
To restate the famous Dylan phrase: The times they are a changin’……..
COVID has certainly thrown the future of how medicine is delivered up in the air, with it’s impact on the healthcare system and the vulnerable in our society creating new dialogue on how the delivery of medicine can be better, more equitable throughout all classes of our society, and more appropriately prepared for pandemics so as to avoid another tragedy like we are experiencing now.
But what’s most impressive to me is that the AAMC has now given it’s blessing to the engagement of residents and fellows, recommending they become part of the conversation, i.e,, part of the solution to these problems. Although their directive is couched in terms of conversation about these issues, it’s as close as anything I’ve seen suggesting the medical students of all types enter into a discourse that has become distinctly political over the past four months. Bravo to them, and to all of you who remain mindful of what is going on, alert to the issues that will face you when you leave academia and become responsible for patients and the society around you.
All of this has developed as the impact of COVID on the business of medicine has clearly started a new conversation about this as well. There have been developments that sound the bell of evolution to a lethargic medical system. Physicians, normally the quiet class of professionals, afraid to appear to be breaking laws against “unionization,” have been liberated to speak their mind as never before.
New ways of improving healthcare have grown from infancy to maturity in months in the area of telehealth, for example, where care has expanded to include mental health and allowed physicians to practice across state lines. Licensing has been streamlined to allow physicians to be “deployed” in areas that are underserved or need greater physician presence. CMS has moved to push outpatient procedures from hospitals to surgery centers. Direct primary care, a version of concierge medicine, is on the radar of managed care (although the concept needs development in addressing how it helps provide services to the poorer segments of society). And there are more on the way—it appears that the looming physician shortage, and how to provide service to all of our society, will finally be addressed through the shear impact of COVID, George Floyd, the attacks on science, and the new voice that wants a seat at the table—resident, fellows, and other healthcare providers who are the future care in this country.
Bob Dylan also said, “You need something to open up a new door, to show you something you’ve overlooked a hundred times or more.” The door has opened. Engage. Be part of the conversation.
---TOM ELLIS III. July 2020 www.FirstMEDPractice.com
Last month’s blog post (on www.ellisandassoc.com) talked about how the job interview experience would be different as a result of the changes many practices are witnessing as a result of Covid-19, and how a working knowledge of these changes would be so important to make a part of the job interview process. Failure to explore these changes and discuss them with prospective employers would be a major mistake in finding the best job opportunity.
As noted, the importance of social media in marketing a new practice, the rise of telemedicine, creating a secure environment for patient visits, and the possibility of new payment models will be very different in the new normal. The delivery of medicine will change.
But some things won’t change. There will still be a shortage of physicians, especially primary care. Hospitals will still be making efforts to steer surgeries their way, as surgical revenue becomes their mainstay. EHR platforms should still be scrutinized for their ways to reduce physician’s expense of non-compensated time (as opposed to increasing it!). Nurse practitioners will take a greater role in caring for rural populations. Psychiatrists will be in great demand as mental health issues expand in our society (even more-so as the “defund the police” efforts try to remove the police from handling these issues). Working to define a good work-life balance will be an on-going process for physicians and nurses of all kinds.
And, most importantly, the healthcare system will continue to need the input of all providers in preparation for pandemics, both national and local in nature.
What will not change is the ways in which you get paid. Or at least where the money comes from. Insurance companies will still be in control and will be working to find ways to incentivize value, minimize their risk on follow-up visits, create narrow networks of select providers and hospitals. Surgical procedures will continue down the path of “bundling” require all stakeholders to negotiate together—hospitals, surgeons, therapists, ASCs, and insurance companies—to create a fair and equitable pricing structure. Businesses will get more involved in the employee insurance cost issue and look to create their own self-funded insurance plans and negotiate directly with hospitals and physicians on pricing.
Add questions about reimbursements—where from, how much, how they might change—to any conversations you have with potential new employers, or, if you’re currently working for someone, get in the loop on potential changes in the revenue structure of your practice. Although patients still foot most of your bill, the way their money flows to you will come under constant tuning in the future, and it may be constant. Make sure you are part of that information flow!
—TOM ELLIS III. www.firstmedpractice.com
THE BUSINESS OF MEDICINE FOR RESIDENTS, FELLOWS AND NPs: Interview Preparation for the “New Normal.”
In a blog earlier this month I addressed the issue of pandemic regret, i.e., not taking the time to seriously reflect on your practice or career in medicine and to reimagine a new way of practicing in the era of COVID. But what does this mean for residents, fellows and NPs beginning to look at options for a medical career after graduation?
As I noted in that blog, much of the practice of medicine is not going to change. The payers—government and managed care—are not going away. Although there is still a move to bundled payments for surgeries and other treatments, fee-for-service and RVU forms of reimbursement will be the norm for procedures for most medical specialties. Quality will be reimbursed in the form of bonuses/rewards. Patient satisfaction will be of the utmost importance.
The evaluation of potential jobs and employers will require all of what is outlined in my platform, www.FirstMEDPractice.com. But there will be some new things to find out and analyze, especially if you are in primary care, IM or OB/Gyn. Here’s a short list.
Telemedicine: Although telemed has been a huge success during the last few months of COVID, total visits have started to level off as the extent of what can be done has come into focus. The last number I saw indicated it was leveling off at about 40% of the primary care group. But it’s here to stay and should be discussion topic and evaluated when looking at any job opportunity. How much of your proforma is based on telemed? What are the requirements in your daily workload? Afterhours? What are the reimbursements like among managed care payers?
How will telemed patients be followed up? Doctor visit? NP? Who will make sure medications are taken, review and evaluate tests, and get back to the patients with this information? How HIPPA compliant is the current telemed operation? And what do the state laws say about telemed and it’s future?
And the biggest question: What happens to my proforma projections if Medicare decides not to continue reimbursing for telemed at the end of the crisis that brought about their decision to do so? What will managed care payers do? Asking this question, and its answer, will give you a very good indication of the kind of financial planning and leadership a prospective employer has in place: Have they planned for a change?
Social Media: Is an absolutely must have. My clients are working with PatientPOP and DoctorLogic to help them integrate into Facebook, Instagram, etc. In fact, some are now working with branding agencies to help them establish their “brand” name even more quickly than the software platforms mentioned above. This has to be part of any employment relationship, no questions asked. If it’s not, be wary.
Patient Scheduling/Flow: By now you’ve heard about the various ways practices are dealing with patient visits as a result of COVID, restricting the use of waiting rooms, etc. Be sure you completely understand their new normal here. How will this impact your ability to maximize visits? Also, ask what will be done with the waiting room if it proves obsolete; unused rental space is expensive and you will be apportioned it as part of practice costs.
Capitation/Direct Primary Care: All traditional primary care practices have been hit hard by COVID. There is a recovery underway, and certainly a lot of pent-up patient demand, as well as great concern among the medical community that patients are foregoing necessary care now and will end up in emergency rooms or catch health issues before they become critical. There is talk among many experts that during this primary care crisis the government needs to step in and help primary care office stay open. Certainly, the US does not need to reduce the number of practicing primary care doctors.
Some have suggested that to solve this problem we need to return to capitation, a model where primary care doctors are paid a monthly fee for each of their patients whether they see them or not. This is similar in some ways to direct primary care, where physicians align them selves with insurers under a similar capitated model; they also can contract with patients directly (in some ways DPC is very similar to concierge medicine, but the physicians have an office). Both fit the private practice model, although both take time to mature because you have to access new patients.
I bring these up because if you are just starting out you will need some time to evolve your practice, and that will require your employer funding your practice for some time. Be sure to ask lots of questions about how your practice will grow and whether or not you will be responsible to repay any monies advanced for this purpose (i.e., they are a loan).
The healthcare business and market is undergoing changes almost weekly. I’ll continue to provide analysis as it pertains to future employment issues. Stay tuned.—TOM ELLIS III 5/24/20. www.FirstMEDPractice.com
Last week I listened to a podcast by Dallas-based corporate strategist Robin Pau. During the broadcast Robin coined a phrase new to me that applies across the board to many businesses: Pandemic Regret.
His podcast was built around three activities necessary to make sure that at the end of the virus onslaught you don’t suddenly realize you have not used some of the downtime impacting many medical businesses to plan for the future (i.e. suffer from pandemic regret).
Those activities are:
If you are a resident, fellow, or NP still in your training, don’t be confused with phrases like “medicine will never be the same.” Many aspects of the business of medicine and running a practice are not going to change much at all, at least not without a longer evolutionary timeline. Payers will remain present, and dealing with them will continue much as is. Programs to reward providers for excellent patient care will grow. Dealing with most of the important issues of running the business of a practice, as outlined in my FirstMEDPractice platform will still require that you understand how your practice is developed, managed and how those aspects will directly contribute to clinical and job satisfaction.
Don’t throw up your hands thinking the that medicine will never be the same. Most of it will be the same for doctors working to make a good living, run the business of their practice, and find fulfillment. If you are entering the time in your education when graduation is nearing, and recruiters are contacting you, it is still critically important to understand the business of medicine and how that knowledge will impact practice success.
Finally, one other thing. Be prepared to develop your own brand, regardless of whether you are in private practice of “corporate” medicine. Understand how social media works and make sure it’s a critical part of your first year in practice. Work with recognized firms in this area and look to them to provide you with examples of how successful practices are branding themselves as fits your specialty.
Don’t end up with pandemic regret. Use this time to wisely consider your future, either in your first job or in the continuation of your private practice. Take Robin Pau’s suggestion seriously. Reflect. Reimagine. Reset. Then reap the rewards.—Tom Ellis III. 5/1/20. WWW.FirstMEDPractice.com
Scary story: A few years ago I heard about a physician who wanted to open his own office. He had a great patient following, reputation, and didn’t have to deal with a non-compete with his current group, some of whom were retiring (they all practiced under a single Tax ID#). Anxious to set out on his own he found a great location, negotiated a three-year lease and started to hire staff for an opening 60 days out. The office space needed only minor repairs so there would be no delay in taking occupancy and adding all the furnishings and equipment he needed, which he purchased for delivery a week before opening.
For the next few weeks he was busy but was apparently on top of getting the office ready for launch. Staff was hired, software selected, furnishings and equipment purchased, and a marketing campaign underway.
But one month from that date he had a rude awakening:
He had forgotten about credentialing with the managed care payers.
Naïve to the ways of these payers, he mistakenly thought he could just call them up, deliver a new address and start to see their patients as of opening day. He had his new Tax ID# and everything necessary, or so he thought.
Here’s what he heard: 90 days to get on the plans. Maybe longer for some.
Translation: At least 60 days of overhead—rent, staff salaries, interest on any practice loans, marketing, etc.—and NO managed care patients. No charges could be filed with them. No A/R.
Yes, it all does revolve around credentialing when you are setting up a practice, either as a new employee, or as the owner of a private practice.
But it’s also a matter of who is going to provide the credentialing service.
My experience is that credentialing requires a lot more energy than just filling out and submitting the forms to payers. You need to have someone “bird-dog” it, literally from start to finish. Payers are busy, and usually are overwhelmed with credentialing applications, and you have to press them with friendly reminders. Respond immediately to their needs, especially when it comes to getting them all the paperwork they need. Make friendly calls to check in on progress. Ask for completion dates when you can start seeing patients. Be at their beck and call. It’s how you speed up the process.
And it’s best to have someone who knows the ropes. This isn’t a task for an office employee who’s never done it before. Seek out a company or person who has had multiple years of experience. If you have an IPA in your area, seriously consider joining and turning this over to them—credentialing is usually an IPA strength, and they will be able to give you an accurate reading on on-going progress and an effective date you can start billing for patient visits.
And then key everything around those end dates. You want your costs to dovetail with your first patient visits. Be sure to allow enough time for training and move-in, which should be two weeks from your opening day. Minimize non-revenue days.
With the sources at hand today there’s no reason for a repeat of the scary story above.—Tom Ellis, February 2020
Tom is the Founder of www.FirstMEDPractice.com, a platform for fellows, residents and nurse practitioners entering the job market that addresses key business of medicine issues related to vetting job offers and structuring a first practice.
THE BUSINESS OF MEDICINE FOR RESIDENTS AND FELLOWS: Salaries Offers, How They Are Derived, And How To Analyze These Sources
By Tom Ellis/FirstMEDPractice.com blog
In late 2019 Modern Healthcare published its annual Physician Compensation report, a comparison of average compensation ranges as reported by a variety of different groups for 23 select medical specialties. Included were Cardiology, Dermatology, Pediatrics, Internal Medicine and a host of specialties that see patients under a wide range of business models. The salary ranges presented were gleaned from ten different source--a mix of recruitment agencies and healthcare organizations that track this data for their memberships.
For residents and fellows these salary surveys are important, whether you are dealing with hospital attached employers or private group practices. Upon examination you’ll find there can be significant swings in the salaries reported for each given specialty. Analyzing pertinent results for your specialty and understanding the way the information presented has been gathered is important as you consider and counter salary offers as part of your negotiations.
Most employers utilize salary data like this as they compile offers, usually as a requirement of regulations and/or justification for salary offers. It’s important that you understand why there are significant swings in the salary amounts reported by the sources, how to read changes as reflected from the prior year, and how sample size impacts the value of reported data.
For example, let’s look at information reported for OB/Gyns. The top salary was reported by Sullivan Cotter, an organization, and reflects the salary within a group practice of $376,000. That reflected a 2.4% increase from the prior reporting year. Sullivan also reported a salary of $357,000 for private practice, a jump of .34%. The lowest salary was $297,000, reported by recruiting agency Pinnacle Health Group, a 7% increase for the prior year (no mention of whether this was group or private practice).
Let’s break that down. First, let’s look at the change from year to year. The 2.4% change reflected in the group practice salary is significantly more than the .34% change in private practice salaries; the latter might reflect stagnant growth in the private sector. However, the 7% increase reported by Pinnacle is a big jump but means that in the prior year the reported salary was $276,000, far less than what Sullivan-Cotter reported for group and private practice this year or the year prior.
And then there’s the total difference between Sullivan and Pinnacle—Sullivan is almost $80,000 higher than Pinnacle. That’s a difference of well over 20%. Which salary would you prefer?
And it’s also important to know the sample size of those contributing to each listing. You’ll usually find that organizations like Sullivan and the MGMA have a sample size that is significant (in fact, they can usually provide region specific data as well); they pride themselves on giving accurate “national” data. Conversely, the recruiting firms rely on a much smaller in sample size, and report primarily from the placement activity they have had. Which isn’t necessarily a bad thing. Sometimes they have a number that’s higher.
Urology might point this out. Sullivan shows a salary of $497,000, a .72% change upward. But Pinnacle Health group, a recruiter, shows a salary of $210,000, a 51% drop from the prior year. Obviously, there is an issue with their sample size as compared to Sullivan. If your potential employer told you they relied on Pinnacle to set your salary as a urologist, you might want to take a few steps to examine other reporting data!
My read is that, in general, the organizations will report a larger sample size and that usually their data reflects higher salaries. But you have to look at all. Knowing the sample size, and especially where the majority of respondents are located geographically, is important to your analytics. You’ll probably find that certain areas of the US pay more or less, depending on the specialty.
You can also use this data as an example of salary potential. If you’re being offered a starting salary as a urologist of $350,000, current reporting numbers of a $497,000 average imply some significant upside when your practice matures (remember that the salary numbers shown are averages, not maximums).
Finally, if you’re trying to decide on what specialty to pursue, these income numbers may be of help.
There are other ways to slice and dice this information, but you must ask lots of questions about how salary offers are determined when looking at job offers.
Tom is the Founder of www.FirstMEDPractice.com, a platform for residents and fellows entering the job market, that addresses key business of medicine issues related to vetting job offers and structuring a first practice.
THE BUSINESS OF MEDICINE FOR RESIDENTS AND FELLOWS: The Patient Visit, Your Revenue Stream and Metrics Useful in Job Negotiation—PART II.
In the first part of this two part blog I addressed the patient visit, looking at the amount of time spent with patients and how it can be affected by the visit reimbursement. The more money for the visit, the more opportunity to break from the 15 minutes per patient model (I am still unable to find how the 15 minute visit time limit was devised, and if doctors had any input.).
In this second part, I’ll discuss how scheduling affects this, as well as the impact of both on patient engagement and satisfaction.
There’s a non-ending amount of information that has emerged about patient relationships, and the entire patient experience has been parsed into a range of specific topics. “Patient engagement” seems to be the umbrella over these, incorporating all or some depending on the approach. From my perspective, patient engagement starts with the first contact a patient makes with a physician office and ends after the visit(and/or follow-up visits) and patient issue solved.
Scheduling can be extremely problematic. When you consider the time it can take to adequately diagnose a patient’s condition, along with regular problems like late arrivals, more than the allotted time needed for a diagnosis, regular interruptions like unpredicted hospital visits, medical emergencies, procedures or surgeries that run long, etc., it’s easy to see why practices often struggle to minimize or eliminate all of the problems that arise when patients stack up in the waiting room.
Obviously, if you are looking at an average reimbursement per patient visit, easily converted into a revenue/day amount, you are also, de facto, arriving at a revenue per day based on a total time you spend on visits. But there’s more to consider: If, for example, you’re an FP doc, seeing patients all day, you will have some non-reimbursed time spent during the day—the goal should be to minimize this by tracking it, analyzing it, and seeing how to compress it through making it part of your overall daily schedule.
What you’re looking for here is doctor satisfaction: Predictability of how your day will flow! Maximized revenue for the total time you spend working. How can a practice/employer help you improve workflow and still get you out of the office and home to your family? When and how is this reviewed? Who oversees this issue within the practice? And how are they looking at ways to minimize the physical and emotional drain of extensive non-reimbursed time, a major contributor to fatigue and burnout?
This kind of information can be built back into your patient schedule to minimize wait times. There is nothing more detrimental to patient engagement than long wait times. Patients have expectations and have frequently had to schedule much further in advance of their appointment date than they would have liked. Given the importance of social media in your reputation, and your total lack of control over it, you have to address all of this, and keep it on the radar.
Although most patient satisfaction studies ask generic questions about wait and visit times, it’s worthwhile to do more focused analysis with a small patient group. Large studies often don’t really address all of the questions necessary for a practice to get the granular data needed to help. To solve these kinds of problems a ranking system of one to five stars will usually need a higher level of explanation and specificity.
But don’t forget that all of this should be driven by the desire to improve both—patient and doctor satisfaction, with emphasis on efficient utilization of your time. The latter will have a concurrent impact on patient satisfaction (and revenue).
Telemedicine, in it’s infancy, will certainly serve as a balm and possibly a cure to this situation, especially by involving mid-levels in the review of patient records (submitted by the patient) and their interaction by phone to deal with frequent ailments like colds, flu, etc. But it is going to require more clarity from payers and, in my opinion, more definition of the medical protocols. Regardless, you should look for practices that are engaging in telemedicine. And if they are not, ask why. I recently saw an advertisement from a large healthcare system pushing telemedicine of late; the ad read, “You can now eliminate the hassle of visiting the doctor’s office.” This was the first time I’ve seen this kind of diminution from a big player. But it certainly charts the future (oddly, while deriding the value an office visit!).
Of course, there are other important factors in the patient engagement and satisfaction equation. More on those in a future blog entry. ---TOM ELLIS
Tom is the Founder of www.FirstMEDPractice.com, a platform for resident and fellows entering the job market, that addresses key business of medicine issues related to vetting job offers and structuring a first practice.
THE BUSINESS OF MEDICINE FOR RESIDENTS AND FELLOWS: The Patient Visit, Your Revenue Stream and Metrics Useful in Job Negotiations.
Over the past year or two I’ve spoken to a number of physicians who have left their current jobs, transitioning away in variety of directions. Some have moved into the “business” of medicine or joined med-tech firms. Others, complaining about the “corporatization” of medicine have moved to smaller, private practices. And, of course, everyone is aware of the growth of concierge medicine, as well as the steady flow of doctors to Functional Medicine or it’s more wholistic relatives.
Most have come from primary care, IM, or OB/Gyn. All have complaints and issues that led to their decisions. But one reason that has been echoing through medicine for over a decade now (and I always hear from them) is the inability to spend more time with patients. They chafe at the current formula that visits not exceed 15 minutes or less and are worn out by the way this plays havoc on their desire to have real patient relationships and the emotional and physical demands of seeing an average of 30-40 patients a day.
I have tried to find out just who established the 15 minute rule, but there seems to be no evidence or study that supports it (and where did new patient visits and annuals fit in?). More likely it’s one of the holdovers from the HMO days, when employed doctors came under the control of bean counters. If I’m right, you can be assured there was little or no physician input.
For physicians finalizing residency or a fellowship there may not be many options to make significant changes. And income is a major factor with medical school debt to deal with. But don’t agree to anything without doing some shopping and comparisons. You’ll probably see as many as 50 offers, and you have real leverage to get ALL the information you need to make a good decision.
You need to understand the patient visit formula of a prospective employer and go beyond it to understand how this relates to your revenue stream, the scheduling process and the important issue of patient satisfaction. These key components of any practice need to be discussed and fully understood.
Let’s start with the revenue piece. Request the average reimbursement for the top five codes you will use in your practice as well as the payer mix of the potential employer. With this in hand, ask for a history of the average gross reimbursement amount per patient visit over the last 3-5 years. Has it increased? Decreased? Why? What about the payer mix? How has it changed?
Has the practice made any attempt to renegotiate pay rates (this would apply to RVUs as well)? Is there a mechanism to do so within the practice? Is there an IPN or other entity that would provide negotiating leverage?
These questions will give you an idea about a practice’s attention to income. Now ask about costs. What is the cost for the average patient visit? Has it increased or decreased during that 3-5 year term. If it’s increased, what actions have been taken to minimize the increase? Who chases “costs” and is responsible for this extremely important metric?
Your time is the way you generate income. What you want to do, obviously, is to engage with an employer who has a terrific net revenue per patient total. Compare this amount among the offers you receive. What you find may surprise you; for example, it may be that smaller, private practices are competitive and more with the larger employer groups.
And if you have more revenue per patient visit, you may be able to adjust the 15 minute rule upward, and get more time in the exam room to develop the kind of doctor/patient relationship you want. An extra five minutes can be extremely rewarding.
If all is running smoothly, and net revenue is being realized, try to find out what kind of salary or income a full-time doc in your specialty should expect. Compare this to your offer, or the salary your employer projects you can make when your practice has matured.
Scheduling can play a very important role in all of this. And then there’s the issue of how all of this can impact patient satisfaction. In Part 2 of this blog we’ll address these subjects. ---TOM ELLIS
Tom is the Founder of wwwFirstMedPractice.com, a platform for residents and fellows entering the job market that address key business of medicine issues related to vetting job offers and structuring a first practice.
By Tom Ellis/FirstMEDPractice.com blog
Autonomy is a word that has taken on a life of its own in medical circles. Depending on who you talk to, it seems to be injected into the conversation surrounding many different aspects of medicine, clinical to operational to the business thereof. The generic definition always revolves around issues of “control” starting with the most basic: That a physician can implement their diagnoses and control the way he or she cares for their patients. This matter seems to come up more and more as medicine becomes more corporatized.
However, when the desire for control comes up in other areas—especially those related to HR, staff oversight, scheduling, facility usage, payers, marketing, etc.—it seems that physicians may have the cart ahead of the horse.
For over twenty years one of the resounding phrases I’ve heard is, “Doctors are terrible at business.” But I don’t agree.
Physicians aren’t bad at business. They are just UNDEREDUCATED about it.
Physicians are smart people. The rigors of med-school training are intellectually demanding. But there is little or no educational training that provides the basics of how medical practices work as required course work.
I believe autonomy, defined as “control,” needs to be based on education commencing as early as possible, best before the final year of training, when the end of residency or fellowship is in sight. Rounding in the final year is a tremendous opportunity to examine, up close, the variety of different business models employed by different specialties and have access to the administrative types that are responsible for the operations of each practice.
Almost as valuable, it gives the graduates a chance to discuss practice governance and how it’s deals with long range planning and implementation.
Building this knowledge base is necessary preparation for fielding and analyzing the flood of job offers that will soon come. It’s the antidote to the anxiety when literally dozens of employers start making contact (most graduates receive at least 50 offers).
Which brings us back to autonomy. True autonomy comes with knowledge. The path to autonomy starts before entering practice, by having the necessary knowledge to make a good first choice or employer and practicing environment, where business education can continue and be offered and continued. A choice that isn’t filled with anxiety due to undereducation on these topics
In their busy schedules, residents and fellows, preparing for their first practice, shouldn’t overlook the importance of business education. It’s the building block of autonomy and a successful career.---TOM ELLIS
I welcome your comments and thought. Please send to me at firstname.lastname@example.org