I too got screwed by a management company. I was lucky in that my contract required me to write them checks (they couldn't attach my receivables without legal action). So after they bled me dry the relationship turned sour and they dropped me (for nonpayment) and left me for dead. I lived the same disaster, but somehow survived. I swore I would never, never give up.
Sorry this happened to you! I think that you should walk away even if you have to assume the debt--your sanity is worth it, and you will make much more money in a group practice, or in a solo practice "owned" by a hospital.
Listen up. I also did this. I had to declare bankruptcy and walk away. The bankruptcy will suck, but you can start over. I would be an employee for someone and start rebuilding your life. You CAN do this. We have medical licenses and can rebuild our lives. I would learn from this experience. I am a doctor NOT a business person.
You truly need to walk away, before you leave what is left of your sanity behind.
Sermo Doc 4, keep in the mind the bankruptcy laws (Chapter 11) have changed. I looked into that option. Some very good attorneys told me the debt will merely be restructured so that I could spend the rest of my life paying it off. Certainly not like starting over. So I continued to slog it out. I would sooner die than take a salaried position.
doctorfurl- you are not alone. Take all this advice and then decide what you want to do. I applaud Sermo Doc 1 for sticking it out, I thought about it and for me I was given another option. I have not kept up with the Bankruptcy laws and my situation was several years ago. Good Luck in whatever you choose. Keep us in the loop
I have closed my practice this past year as well. I agree that the cost of rent, medical supplies, malpractice, employees, and the insurances became totally prohibitive. It was getting to me working all the time doing everything myself, and still making less in the end than I did as a resident. While we definitely got burned in this venture- it is one thing I can cross off my list of things to do. I know what it is like to have a general surgery solo practice, and would never do it again. When the day comes that I choose to not do surgery anymore, I will do something which is actually fun and no longer sucks the life out of me- something fun like dog grooming. They make more money than I do, and have much better hours and customer base.
If somebody manages the practice, I want a salary. Sorry what happened but staying is just making it worse. Delay doesn't help but make the key decisions with a good nights sleep and a good lawyer. The jobs are out there. PM me if you want to move to East Texas and I can connect you to a Hospital run clinic system with a salary.
I would disagree with Sermo Doc 1. I am currently in a salaried position, and I love it. The deal I have is that my salary is guaranteed by the hospital even though I work for a private group not affiliated with the hospital. The good thing is that the hospital protects me. If the doors of the office close tomorrow, or if I decide I am unhappy, the hospital will relocate me within the community. They would not allow the practice I work for to have me sign a non-compete agreement. They pay my salary and all I have to do is work in the community for two extra years to "reimburse" them. I would agree that there are problems with being an employee, but, for me, I don't have the bussiness experience nor the desire to run my own practice. This way I am guaranteed a good income, and I get a production bonus.
The other option is locums work overseas. I have been looking into a company that places physicians in Australia and New Zealand. The contracts are anywhere from 6 months to 2 years. The weather is great, you get paid, and they furnish a car and a house. It's a good way to get away and forget your troubles for a few years.
You've got some potential options which can pay off your debt now - let you work with some very well trained colleagues and work at a slower pace. Email me if you'd like additional information. Best of luck.
I'm getting a bunch of calls from recruiters. My attorney is aprised of my situation and is talking to a hospital group that might buy the practice and make me a salaried employee with a production bonus. I will have to do zero management. Last I heard, though, there were issues about the salary. They only wanted to guarantee 1 year. After a year they want the same scenario I am in now - a cantractual (albeit slightly lower fee). Not an option, won't happen.
Thank you, ladies and gents, for your response. It encourages me on this endeavor, especially to know others have done it. It's not exactly something everyone is talking about in the doctors' lounge. Being in solo practice, I haven't been in a doctors lounge since residency (9 years ago). Even then we avoided it so as not to have too much assigned scut work...
Seriously, thanks. I will be replying to all who offered to PM with me. I will keep this updated daily.
I am a DO also. Years ago I inquired about a Saudi job that didn't "accept DOs" - PLUS, they were only going to pay me HALF of what I was already making.
The AOA should be able to tell you where in the world DOs are accepted - most of the developed nations recognize us as equals.
I would also recommend your just working for a negotiated salary, perhaps with bonuses for production. Running your own practice is a pain--a few highly motivated, ambitious, gung-ho people can do it and make it work. For the average Joe Primary who wants a life outside medicine (i.e., supper at home) and who treats his staff well with reasonable salary, it's hard to make a living. The demand for primary care and hospitalists is so great now, you can write your own ticket in many states. In addition, though you might not have the 100% autonomy you have now, throwing off the bill paying, the taxes, the worries, etc. is well worth the minimal adjustment to a larger structure where you're a worker bee.
As far as salaried positions are concerned, as long as you join a reputable hospital or clinic, you enjoy certain rights. The salary is essentially guaranteed whether it's a slow month or busy month or whether you're on vacation. They pick up things like malpractice, health insurance, life insurance, etc. After a probation period, it is very hard to fire you unless there is just cause. Also, coming from the private sector, you probably will work twice as hard initially as everyone else and see what lazy shmucks everyone else is.
Agree with Sermo Doc 15, but I've never been in solo private practice, or actually any private practice. It seems that if doing private practice, it definitely works better to have partners...solo docs don't seem to do well from what I've seen, but the groups of 4+ seem to do better.
I'm so sorry for your troubles. I would like to hear more from you as you go through this process...just for my learning/knowledge.
I wouldn't worry about the 100k debt too much...if you get a good employed position you can pay that off within 4-5 years easily. It sucks but I think it is better than bankruptcy.
I also speak from the growing number of us in "employed" positions owned by hospital. Fortunately, from what I am hearing, the trend is for hospitals to want to treat their physicians better than in the past so that they develop collaborative relationships and physician loyalty. Honestly the hospital I work for has been very supportive of our practice. Tons of perks/benefits, fair compensation (making above average salary) and home for dinner every night. I'm NEVER asked to sacrifice patient care for increasing volumes (average 23-24 patients per day). We're on pure collections-based salary after a 2 year guarantee. We are trying to recruit more primary care to the area, so if you're interested, send me an email. I am truly happy with the situation. Hang in there and know that there are better options out there. Sorry you're in such a tough spot. Good luck!!
Disney World!!! I already added a Ped who went under on his own, why not another FP? I could be the Betty Ford Center for recovering solo practitioners.
Sermo Doc 14: I've considered the military. I am the only male member of my family to have never been in the Army. My grandfathers were Col.s, uncle a general, and dad a captain when they retired. I've even looked into options of converting to ER. Would have to complete an ER residency. Not a viable option for me. I have 3 kids 4 and under. My wife, a PA-C, has in no uncertain words said "that will not happen. You will not go through a residency with this family." OUch.
Doctorfurl-- 3 kids 4 and under and a struggling practice...
Hearing the hoofbeats of burnout.... time for an adult time out (and having enough time to be with family)
I'm employed by a big hospital here which is not even close to where I practice. They buy satellite primary care practices that are established and they provide management services. What I get in return is about 90% of what I bring in, beyond my office overhead. What they get from the deal is that theirs surgical specialists spend time here and get referrals from us, which translates to cash for the hospital.
Look into a hospital relationship, not just a small community hospital that will dump you when times are tough though. A practice as big as yours can bring them lots of surgical referrals which is what they like.
I, too, am 39 yrs old, solo FP for 9 yrs, and wondering how long I will be able to keep the doors open. I have a really sweet deal with a couple of local factories that pay cash per hour to provide an on-site clinic for employees and families. This has helped cover the holes during times when ins companies are slow to pay.
The delay and occasionally long periods of time waiting for insurance payments to come in seems to be what gives my practice the biggest problem. (Right now have nearly $200,000 in medicare billing I'm fighting for) When the companies are all paying promptly, I am just barely able to keep things covered. As soon as payments are delayed, then I'm behind in my payments to everyone else again.
I own the building my practice is in, because it is a rural area and there were no buildings that would work for a medical practice available. The bank tried to foreclose once a few years ago during a similar time, but payments came in and we were able to avoid that. So far they are holding off on filing anything this time. If they decide to file before I get the payments in from Medicare, I will be in your position.
Glad to see someone talking about their situation openly. Don't feel like you are alone. Would be happy to commiserate, or offer any help I can.
To the rest of you, whom I'm sure will jump in with questions about the medicare amount...I have gotten both a lawyer involved and the local congressman. Congressman was able to get them to finally process a few claims and send a small check. Senator's help is next on the list. Anyone have other ideas? Anyone know of a physical location to visit to accost Palmetto GBA (Midwest region's medicare provider)?
You are in trouble. Provigil? prescribed by yourself or your physician?Excessive energy drinks..3-4 hours average sleep. 3 young children that never see you. You must make drastic changes now or you are headed to divorce court or your state's physician health program or both
When do doctors learn that management companies are not for us? Get small, small, small. Reduce your overhead. There is no economy of scale for medicine, Ernst and Young has said so for 20 years.
Who is telling you guys to use these management companies and get lots of staff?
I believe that I am in practice today 20 years later because I did not hire a practice management company. I suppose some would argue that it is the reason that I'm not rich.
In response to Sermo Doc 24- I am small and doing OK. The exception is big groups doing in house MRI, etc are doing better than me. So big can work but it needs to be well run and at least 50 doctors. I have done practice consulting also but it has been a while.
Sad, sad, sad. I hope that you can find a way out. Don't be afraid to look at all options, but it all depends on what you really want. I am in practice 10 yrs now. Started solo, but added NPs and it does help. I am in no way rich and there are definitely better ways to make money. but, I love what i do. I am my own boss and I have the freedom to do what i want. But, I sacrifice $ for it. It's all about what will make you happy. Some days working at Target looks really good. They have good benefits and you get a discount! They teach us none of this stuff in school. I wish you the best. Get some support from Docs around you if you can. You are not alone
I am also trying to figure out what to do. Each month I feel I work harder, but make less. We collect pretty close to all we are supposed to collect. Maryland is the lowest reimbursed state in the union it seems. I was born here, my family lives here, my kids were born here. I don't want to leave. I am not sure how to keep it going though. We are doing our taxes now and despite paying estimateds all year, it looks like I will have to come up with another $5000-8000 dollars. Unfortunately there is not really any money in savings. Not sure where it will come from.
If your lawyer can't (or won't) help you get out of this mess, get another lawyer. You have a good case for breach of contract. Besides, if you can't practice, they get 25% of nothing and, for them, putting you out of business woud be a pyrrhic victory. I had an untenable practice situation of different circumstances which forced me to walk away from a contract . I got sued for an enormous ridiculous amount but went into binding arbitration. I "lost" the suit but settled for $29,000. With a good legal strategy, you might win a breach of contract suit. They squeezed me for every dollar they could but that's all they could get. It was a net loss for me but I didn't have to declare bankruptcy and was able to pick up the pieces. Alternatively, you could close your practice, find a locum tenens (put up your resume on locumtenens.com) or an employment opportunity and gradually pay off your practice debt. Consider it a student loan to the school of hard knocks. But please, do something fast. Your medical license, your health, your marriage, your patients' health and that of everyone you share the road with are ALL in jeopardy. Au courage.
Ventotj: I'm doing that right now. I'm not sure I will make it (meaning, pay my mortgage, major bills at home, etc) before the hospital system I've been talking to will decide to buy me out, take me on, etc. That's why I am concurrently looking for work elsewhere. Good suggestion, though. Cbland: had similar problems with Medicare when I wasn't with a practice management company. It was one of the driving forces for me to join with them. I feel your pain, too. I would rather not commiserate (thanks for the offer, though), but instead focus on solutions for you, me, and everyone else. That's why I am responding on the post and not by PM. One idea I have - do you have a billing company? They often have a much better relationship with a warm-body-behind-a-desk-at-the-Medicare-office. Sometimes that's all that is needed, a contact to expedite (or at least minimize delays). I had a nurse a few years ago who worked for CMS, and said that kind of arrangement definitely helps. Sucks you of 8% (at least), but it might be worth it for you. I can tell you it wouldn't be for me. I have stopped all new Medicare patients in my office. They suck too much time for the reimbursement and in fact take me away from higher paying patient plans. Ellie1: Agree with you entirely. Provigil is from the sample closet. I've taken a long hard look at myself and situation, and limit Provigil to use only after shift work. Still sneaking a Red Bull or two per day... Lawdoc: Other docs have sworn by use of management companies. In retrospect, they were all in large groups... DoctorSH: Agree with you, too. I shouldn't be in solo practice. I am actively looking for a group practice. The hospital system I'm talking too is interested in making my solo practice a group. Drmomof3: Thanks. I appreciate your kind words... Stargirl65: I'm right with you on taxes. One thing that has worked for me: instead of escrow, I set up an online ING savings account that gets about 3% interest versus the 0.25% I get from a local bank. Not much still, but when you subtract escrow fees and add in the additional interest earned, it's way better. I've set it to auto-withdraw bimonthly, so at the end of the year there is enough for our home taxes. I'm sure you could set that up for other taxes as well. I get the message, though. Income is not enough to offset the taxes incurred. Sermo Doc 29: Please PM me with the name of the management group you dealt with. Sounds familiar to me... Agree with you, and my lawyer is working on that exact "bailout package" for me in addition to the other strategies and their legal ramifications. I wonder if I could apply for a "bailout" like all these other large companies?
Stargirl, you can ask the IRS for a payment plan so you pay that extra money over several months at a not unreasonable rate of interest. I fear that I will be doing the same as I have been working a lot of locums the last few months while transitioning jobs.
A farmer thought that he could teach his horse not to eat if he did it slow enough. but ever time the horse learned, it died. the horse is now the independent practitionier. As I am quitting a practice that has netted between 10,000 and -5,000 a year for the last 6 year since stopping in patient work. I never got a letter lessening my work load or increasing my remuneration,
If you run the numbers, e.g., apply the E&M codes the way they are specified, there is no way that anyone in primary care can be making a living. Ergo, everyone who is doing well is effectively "upcoding", not through increasing to a higher CPT level, but rather by cutting the time and faking the level of service provided. In short, anyone who is billing 6+ (or even 5-6) level 3 visits in an hour is cheating. The sad truth is that in order to prosper in primary care, or now even survive, one now has to commit insurance fraud on a daily basis.
To DOCTORFURLThe "management group" I worked with was actually a hospital with whom I had a "salary guarantee." The physician I partnered with was embezzling from my escrot account with them (whom I stupidly trusted to handle the finances) and, when the money ran out and the hospital said "it's only a guarantee if you do well,", I confronted my "partner". He threatened to "beat the shi**" out of me if he ever saw me again and, being forced to leave the practice quickly, the hospital sued me for breach of contract for not staying for another 2 years. So, while the resolution was similar, the circumstances are different. Still I truly do feel your pain and am confident that, with good legal advice and personal support, you will ultimately land on your feet.
If we all stop accpeting insurance and get off of all plans together, the reimbursement will have to change. Write your concerns to change.gov. Maybe the new team will hear us if we all scream together.
I believe in this day and age, VA primary care jobs are perfect balance of work and life.
You have to deal wit a little bit of beurocracy but lot less heartaches and headaches that you describe. You see pt's from 8-4 and go home, relaxed. What more, you have
weekends to yourself. VA has all electronic medical records which is the jewel. Once
you get used to EMR's, you will not go back to paper records for any amount of money.
You practice best medicine for pt's without worrying about whether they can pay for certain test or meds or not. And NO billing headaches. It is win-win situation.
You need to do whatever you have to to get rid of the management company. If that means declaring bankruptcy, then so be it. You are young. Chalk it up to experience and move on. Do not work for someone else because they will screw you too. YOU need to learn to play the bureaucratic billing game that has been imposed upon us by the government. If you don't learn to play this stupid game, it is going to cost you big time. It will be the difference between thriving or going broke. If you learn to play the game and are busy, then there is no reason you shouldn't make at least 250K. I know plenty of primary care guys who are doing way better than that. If you think you are too important to learn to play this game (I doubt you are after this experience) then you deserve to go broke. YOU have to be the billing expert in your office. YOU have to be the Medicare expert in your office. YOU have to be the charting expert in your office. YOU have to decide which CPT and ICD9 codes are to be submitted for each note that you write. The ones who don't understand this are the ones who go broke. The billing software and the people behind it are also critical. I can direct you to someone who has developed billing software and is an expert in this stupid game you have to play. It will save your financial ass. It did mine and several other people I know (including a family practice doc.).
I am a pediatrician who was in solo private practice for 16 years. In 2000, I closed my practice, filed Chapter 13 (I was an unincorporated sole proprietor), worked locums for about 6 months, and then got an employed position as a hospitalist/peds ER doc with a medium-sized hospital group. I work less and earn more, I have benefits, and I wonder why the hell I ever tried to be a businessman. I just wanted to take care of kids--not worry about whether to make payroll or pay taxes, much less buy health insurance for my family.
Nowadays it seems that the only way to keep your head above water as a physician is to let somebody else do the BS so that i can do patient care.
Happened to me too. My last year of full time IM I probably didn't make as much as most carpenters. Fortunately for me I used to be certified in EM and the Amer Bd of Emerg Medicine allows you to recert if you allowed your boards to lapse. I hit the books, got part time work in an ED that was desperate, and recertified after a 10 yr lapse in my boards and almost 20 yrs outside of EM. I am now full time EM, with its own attendant problems, but at least I'm making a living.
I gave away my practice for nothing to a local hospital. The only thing I got in return was their committment to handle all the charts and copying in the hopes that the pts would stay at their hosp owned practices.
My wife and I sold our office building and made some money there but that has since evaporated in the stock market.
The coup de grace was when the management company told me I owed them $10,000 bucks after everything was settled. I sent them a five page letter, through my attorney, detailing how they violated the letter and spirit of the contract and threatened to sue them for a large sum. They dropped it ASAP and I haven't heard from them since. That was in 2004.
add my empathy. the system continues to worsen. in the western world, the US is at or near the bottom in all categories. we spend too much and get too little. very little time is actual clinical medicine. generally, physicians office's are woefully inefficient with overheads surpassing 50-70%! when it should be closer to 40 even 30%. but the system requires a full time manager just to keep on top of billing, collections and staying on the approved lists. oft times they, oops, drop off docs, and you are screwed until the next book comes out next year. someone in another city or state dictates what you can and not do; I experienced the 'you can't do that' and presented the situation and asked what was permissible and got another 'you can't do that'. I know many who walk away and want to do so. There are companies that can place physicians in other fields of interest while maintaining contact with medicine. drop the bad habits and live your life and be with your family. don't die for this job. perhaps look at moving somewhere with a better lifestyle (mountains, beach) and good schools. can you teach? the job is not worth your life, or that of your family. keep on truckin'.
I am so sorry to hear about your circumstances. Please remember what is truly important in life - your health and well-being and your loved ones. Nothing is worth sacrificing them and you are doing the right thing by fighting for those things. It may seem like you are giving up a practice but in actuality, you are saving a life - yours!
I have the utmost respect for primary care docs no matter what the specialty. My doc is FP and she is fantastic in so many respects. When I have patients ask me "why didn't my doctor explain that?" I tell them that is why they are seeing me. I take a few minutes out to explain that we are the only professionals in the country who have no control over our fees, etc. And I make sure they understand noone hates it more than their doc, who went into primary care to get to know the whole patient and care for them that way. It is a travesty. Yet another example of our third party payer system being penny wise and pound foolish. Invest in good primary care and preventative medicine and people will have better health....
I wish you the best of luck and hope that this dark time is just before the dawn of a wonderful new beginning for you and those you love.
>>Nowadays it seems that the only way to keep your head above water as a physician is to let somebody else do the BS so that i can do patient care.<<
This is exactly the attitude that will make you go broke. You are running a business and you better learn all of the ins and outs or it will bite you in the ass.
really sorry this has happened to you. it is criminal when hardworking docs cannot make ends meet in a busy practice.
just my 2 cents, but if there is any true wrongdoing, don't be shy about seeing a lawyer to sue as there is enough money involved for it to be done on consignment.
I am very happy being employed and make good money. I am very sorry for your situation, but give the idea of being employed more thought. There are many of us who are very happy.
Although I will never be rich, and my salary is laughable for a specialist, I hang on, albeit barely.
Green Lantern, it is possible to do so without committing fraud. But not if you sign insurance contracts. I bill insurance, but I am no one's preferred provider. That way, I can balance bill. It's the only way to survive--legally and ethically.
stargirl, not sure about Maryland, but I know that Oregon and Washington are 50th and 49th in the Union for Medicare reimbursement rates. Our private payors are not much better. Hope you can figure out a plan. It's sad when it comes down to this for so many of us.
I know Sermo Doc 34's advice is not what you want to hear when you're hanging in the wind, but he tells it like it is. I've been in solo private practice since '77, and much as I didn't want to, learning to play the system by knowing all the rules and how to document efficiently saved my butt many a time. Do what you have to for the short term, but his advice will serve you well in the long run.
Wow. You're all freaking me out. I just gave notice to my group - which is owned and operated by our hospital - so that I can go solo. I am tired of paying 8% Dean's tax, 10% for billing (oh, yeah, 10%), and 55% of what's left to the hospital, and not being able to buy a pencil without a committe meeting to approve it. I long for the autonomy of being solo. I know it will be long hours and new concerns I never had to bother with as a salaried physician, but I want to be answerable only to me and my patients (and ok the bank I have to get a line of credit from).
Now, after reading your posts I'm suddenly even more anxious than I already was.
I am sorry to hear you have reached the point that you have but I cant help but wonder what is going on with your cash flow. I had a solo pediatric practice with a patient base of 1500, at least half medicaid, and managed to get by, though not comfortably. My biggest debt was due to getting into a bad EMR/PM lease and maintenance deal that, with my current experience, I feel could have been avoided. (th soft ware worked great but every other aspect of the EMR company was overpriced and ineffective-still fighting with them to get back money they owe me). Medicaid pays much less than medicare and has some equally complex patients. If you had the patience or resources I would recommend auditing your cash flow to make sure you have the appropriate number of employees, are actually getting paid for what you bill(not writing off because of 'incorrect' billing), etc.. I enjoyed the freedom that solo practice allowed for me to spend as much time getting to know my patients as I felt necessary and also balancing my time to get everything done. I managed my own office and was able to get by with one employee and the occasional 'extern' from local medical assitant programs, a local payroll service handled my payroll checks and payroll taxes, and I used a local accountant with knowledge of medical practices for annual taxes(he was always available for giving advice at no or low rates as well). The most ouside management help I needed was a once yearly 'consult' with a local practice management consultant who came and looked at my practice(no contract-just a once a year thing that i scheduled when I had time and interest) and gave tips on where I might want to consider changes and where I might be able to make things more efficient and less costly-well worth the low hourly rate she charged. I closed because a change in personal life situations that did not allow me to stay in my same location. Now I am employed with a much higher salary but missing the personal relationship I had with all of my patients before. I no longer can spend a lot of time with them and often am seeing other physicians patients for their acute visits so I don't know the patients at all. Solo practice can be done and can be rewarding but you have to understand what you are getting into and what is involved in running a business from day one-otherwise it rapidly becomes overwhelming and takes over the rest of your life.
From the way you describe your work it sounds like doing another residency would actually be a pay raise and fewer hours for you.
mlgoungmd, head this way, we have a several month wait to see endocrine around here, and you can rent space in my office, alleviating my mortgage problems :)
Hang in there, doctorfurl. You have in here a lot of experienced docs willing to lend a hand. Certainly there are a lot here more experienced than me.
Just stick to the basics- yes, you got screwed by a management co. It's really an irony in itself if you look back when you started solo and then took on a management co. When you decided to be solo, you basically "announced" (in a way) that you want control over your affairs. the co. took you on knowing it can push you against the wall, which it did.
But, hey- that's water under the bridge. You can still make a go of this. You just have to kick the co. out. There has to be a loophole somewhere.
Then, get a trustworthy office manager, one that won't screw you (no Freudian implications, pls.), AND an honest-to goodness billing company (yes there are still some). If you can't, then I agree with locums- the way to go, and it may even be therapeutic for you.
At any rate, good luck. Remember that they can never take what you truly are- hardworking, professional, competent...unless you let them.
(How can I say all of the above? Had been with a big group before, and had high overhead- 25 employees for 4 docs, we rented a big space at 6K a month back in 1998. We each had to see a minimum of 40 pts/day, 5 days a week, aside from inpatients averaging 4-8 per doc per week, PLUS nursing home.
then I went solo in 2001. am still solo, am "in the red" 10 out of 30 days in a month, so I guess that's okay. Can I take on a new partner? I wished.)
The failure of the practice is not your fault. We closed our practice while still well "in the black". I could see us going downstream toward the falls for a few years, mainly the past 3 years. The solo practice of medicine is a nonviable occupation due to all the factors we are all too familiar with, so I won't list them. Working harder does not help; it only hurts you. At your age, I would recommend finding an employed position so that the "management" aspect is taken over by someone else. You will make more than you are now, and will hopefully find a position that works on shifts. When you are done, you are FREE. I never in my life thought that medicine would decay to this point, but, here we are. Hopefully, you will earn enough in an employed position to live well, and you will get some life back. Who I really have pity on are all the medical students, residents, and "doctors to be". They have no clue that they will never get out of debt. So be the process of evolution. Once the medical system collapses, we all may find appropriate compensation and maybe even some respect, when the populace becomes willing to pay for our valuable services. I have been in your shoes and respect you.
The practice management company depends on YOU to survive. YOU are helping them pay THEIR bills. If you quit, they end up with nothing, so seems to me it would be in their interest to renegotiate the terms of the contract with you...reduce their share to 10% (I know a management company that takes this).
Also, you really need to TAKE A BREAK. I know it will cost you the coverage, but you need to STOP and take a rest, to allow yourself the energy to find a creative solution to this stressful situation. Easier said than done, I realize, but just do it!
Slowly reduce the energy drinks, take a daily 30 minute walk, and get a locum for a week.
Ask yourself what you really value most....your family? your health? your sanity? and do whatever it takes to preserve these precious commodities.
You will get through this difficult period, but you need to take care of yourself first.
Take a week off. Spend it with your family. Call the state medical association and ask for help to sue the practice management firm, or at least get legal assistance to let the rest of the docs in the state know what they have done to you. Set some daily hours that you can live with, and make yourself stick to them. Don't get killed on the road from being too tired. When you are able to, get a group of docs in your area to start a Finding Meaning in Medicine group, which is to share the meaning of our work, and what you will find is that you suddenly have friends and colleagues who deeply understand you, and can help you to figure out the next step which will fit you best. Best of luck, and it makes me so angry that so many docs are being screwed by these bad working conditions and situations. But you MUST take care of yourself first, in order to take care of others.
All, the problem is with reimburstment for cognitive based specialties. The SGR and the amount that is paid for CPT codes favor procedural based specialties. The SGR board that determines the amount paid is dominated by specialists who don't want to give the primary care provider as much money for their 99914-99215 visits. That needs to be changed. Where in the world besides the US can an orthopedic physician make $500,000 a year? Do they may that much in China or Russia? How much more do they make than prmary care in those countries? Does anyone even know? The payment screme for procedural specialists a a large bubble, like the real estate one, and it will end at somepoint and it will be ugly, for them and for medicine in the US. All the medical students are not selecting primary care due to payments. At some point primary care will get their day and payments will go us as the crisis worsens but even bubbles can go on for long times before something happens. As a military endocrinology fellow, I have a set pay. I would consider the VA as someone mentioned. At least until you get your bills in order, you can always quit and don't have to worry about getting deployed.
Also, I'm interested in those running a cash based practice only. Is that viable? I figured after retiring from the military and doing at as an endocrinologist. If I only see several a day, so be it, I will be retired with a pension afterall and I won't be working too vigorously.
Sorry that you are going through this. Sad. I would take the 15 minutes and write Obama at Change.gov about it. Maybe it will cure of few "nonbelievers" about the state of medical reimbursements. And, what was that rumor about "primary care shortage" - excuse me? How does shortage go with going bankrupt?
I saw many good comments above. I also would not be afraid of bankruptcy if it gets you out of the claws of the management company.
The fact that you have a panel of 5000 patients is great! Can't you switch to cash only as Doctor SH did? I would at least consider it. having experience, being in private practice for 5-10 years and having a large following is THE precondition for success in cash only. And, the "management company" would be superfluous, since there is minimal billing required. Cash in advance. No collectons required.
"Amazing Charts" offers an EMR for only 1200 and they do you billing for 8%, using the data you enter into the EMR. Sounds like a good offer.
It obviously depends on your personal circumstances, on your running expenses, mortage, family etc, but an adventure into Business as Cash only might be worth it. What do you have to lose?
I understand what you are going through. I am 61 years old and am broke. I opened an office 9 years ago, because jobs were hard to get. We have PA's and nurse practitioners everywhere. I lost my three other state licenses, because I couldn't pay the fees every year. My office has never made any money. Everyone who has worked for me was either incompetent or dishonest. I have been robbed and lied to. I was trained as a physician and not a businessman....and not an insurance coder. Prior to 2000 I never had any debt, except a small mortgage. Now I am hopelessly in debt, have bill collectors calling me daily. I feel like I'm at the end of the line. I don't see any future for medicine in this country. It will collapse. As long as people are satisfied with allowing insurance companies to make decisions about their health, there is no hope.
First I would like to say so sorry for your predicament! After reading your story, I was immediately concerned for your mental and physical well-being as it seems that you are spiraling down into a deep abyss. The anxiety level that I sensed seems on the verge of mania and your wife, it seems, is attempting to corral your urges to enter ER residency. Just that comment alone was a red flag that you are truely reaching anxiously and aimlessly about. Quit the modafinil and whatever else you may be indulging in as you need to climb out of this hole with a sane and clear mind.
I have been in a solo psychiatry practice intermittently for six years. Had been in groups, we were eaten alive by "managed care penetration" (translated bend over, guys). Got out of group after disasters with management company, mismanagement in the office, two partners with cancer, one with a boundary violation and malpractice, criminal litigation, bankruptcy, etc. After three years in solo practice, decided to take a job, closed my practice, moved. Fourth day on new job, they changed my verbal contract, sixth day on job they fired the medical director who recruited me, I lasted two months, had to take two half-days off because I had developed renal failure, got fired. Now back in solo practice, adding an associate, struggling with payer mix, etc. Have all ready fired one billing company, new one somewhat better. The point is, you can and will survive. Please, please consider seeing a therapist, psychiatrist, etc. to help with stress management/depression/etc. (If I had not done this, I would probably have done something stupid). Physicians are really bad at doing this, don't be stupid. Don't prescribe your own Provigil or take your own samples. When looking at any contract, read the out clause first. If you are working with any billing/management company that does not allow you access to your EOBs and payments, run away fast. Learn how to read EOBs and take the time to do this so you can actually pay attention to your payer mix. Any time you see the word "manage", automatically assume that the correct translation is "mismanage". Educate your patients about their insurance companies (I find that making preauth calls whle the patient is in the appointment is more effective than any other approach). In your current situation, you may want to consider some locums tenens work to bail you out while you decide what to do. Take care of yourself. Don't view bankruptcy as failure if it comes to that. I ask myself whether practicing medicine is really what I want to do and recognise that even at 50 I certainly have the ability to make a living doing something else. Unfortunately, my current retirement plan is to get long-term care insurance before I develop dementia and then work until my short-term memory fails. Eventually, the pendulum will swing somewhere and things will either improve or we will all be doing cash practices (sometimes I think that I might eat better working for chickens and vegetables). Hang in there.
It has taken me 3 years, but I have a Fully booked Cash only Psychiatry practice.
Too many physicians lead lives of self torture and quiet desperation. Most high earning specialists make money because they have high fixed costs, but times are changing. Low overhead and fixed cost are the keys to success. If you are a PCP, you can run on low fixed cost. Patients will always pay for quality, caring, and genuine physicians.
I suggest reading Rich Dad, Poor Dad and rereading the House of God.
First of all, hang on in there! Try to remind yourself that your first and foremost responsibility is to yourself and your family, most tangibly by just being there for them, not strung out on Provigil and caffeine, and not falling asleep behind the wheel. The next step would be to get out of that highway robbery so aptly called "practice management company". Confer with your lawyer, with your State medical society, perhaps with a local/state consumer protection agency or BBB. Only after all of the above, start looking at different business scenarios. Perhaps having your practice bought out with resulting salaried status and profit-sharing is the most viable option for you. Or you may consider staying in your solo practice, but rethinking and perhaps expanding your business model. You mentioned your wife is a PA... perhaps there is an option of her joining your practice and applying her skills to the betterment of the family business? Or consider adding cash-only services, such as vein treatments, Botox etc. Perhaps you could start advertising concierge services to some of your patients? Or maybe consider advertising yourself as an immediate care provider, ready to see patients at their convenience, perhaps at a higher premium.
In any case, please remember that you owe it to yourself and your family to stay healthy, sane, and available to them. Nothing else is more important than this.
I am a solo practitioner in NY, I cover two offices to keep bills paid, I used to work 4 jobs including moonlighting twice a week, I never got to see my kids both under 10, and me a single parent, here's the deal,first get a good lawyer and see if you can negotiate an exit from those leeches,tell them you are willing to be reasonable and they should remember as we say back home cows get milked ,pigs get slaughtered ,don't be a pig, let them know that if you close the practice they get jack, and you can always start elsewhere, what you are aiming for is a negotiated settlement preferably for a reasonably low sum,i think max 10k and a handshake, get the agreement in writing, secondly be prepared to play hardball, close the bank account they have access to, open a new one, inform all the plans that you have a NEW billing address, if you are thinking of closing it what can they do, sue you, it will still come to money and time on both sides, try and put stuff in writing cc the president of the company, explaining your position, so that if it goes to court you show the david v goliath aspect, and that you have tried to be reasonable, next , do your own billing from now on, if there is one thing that separates the practice that is doing well from one that flounders it is that, I had a biller that cost me tens of thousands, I took over, I use an online co, they charge $75 /mo and I input the data, I try to buy my equipment used from ebay, starting afresh always use a pc or llc, dont put your ass on the line, that way if they sue , they sue your legal entity, not you, try to keep expenses down, and remember people, money then things, 10, 15 yrs from now , what do you think your kids will remember, what would you lke them to remember?. Good luck and God Bless
i have been lucky in my professional life as a connecticut pediatrician, having a good, loyal patient base and lucky enough to have made money. i like all of you feel worried about some of these terrible stories. doctorfurl sounds stuck..hopefully some of the advice here will help him move forward. i started out solo and stayed that way for 22 years. 10 years ago i joined with 10 other practices to have centralized everything including billing. because out billing system worked so well for our practices, we opened a billing company to other docs and have helped them earn more money and free them of all those worries which has been a common theme in some of these comments. our billing company also helps with coding and other office processes. i am telling you all of this because we are always looking for new clients and any physician is welcome to contact me. because we are physicians, we bend over backward to be fair to our clients. i hope none of you are offended by this pitch, but since unloading many of the business aspects of running my office, my life has become much more simple..
Consider the following books (if it is not too late for that)
1.Marketing Your Clinical ... Third Edition by Neil Baum, Hardcover - April 2004. $77 This book contains the sum of all other advice that I had ever heard before. It is an absolut must for private practice.
2 Practice Management: A P... by Christian Rainer. Paperback - April 2004, $28.00. Very practical, basic, down to earth, easy to read, written by a physician. Since it is short, you may have time to read THIS. If you only have time for one book, this should be it.
3. Think Business! Medical Practice Quality, Efficiency, Profits, Paperback, 2007 by Owen Dahl, 225 pages, by Greenbranch Publishing. $64 and worth it. Looking at the topic more from a much more economical and business perspective. Written by an office manager with a talent for teaching. More complicated, kind of an MBA for the office.
4. The Successful Physician: A Productivity Handbook for Practitioners. Paperback, $40 by Marshall Zaslove. More of a great guide to personal productivity and happiness, which of course will have an impact in your practice. Very good.
5. Also consider Steven Knoop "Concierge Medicine". - a great intro into cash only medicine. Might just be the solution for you!
The "Guerilla Marketing" Series. I would start with the basic or or two books. Most of them are very good, and inexpensive. It inspires and motivates you, makes you creative, gives you ideas.
Please be very very very very careful with physician recruiters!!!!!! They represent only a very small segment of the available positions, and the recruiter positions usually are the less desirable ones! Please check the blog "A Physician on Job Search and Practice" for tips on how to find a job. Also look on WikiHow "Hot to find a physician job" Physician recruiters are salespeople that DO NOT have your best interests in mind. They routinely fudge over the drawbacks of job just to sell them. And , since they are not physicians, and since they have not walked in our shoes, they do not know as well as we do what matters and what doesn't. And a recruiter that speaks for 10-15 minutes with a potential employer will not be able to tell you much about a job anyway
There is no way a general practice can generate enough. Reimbursements are so much higher for procedures that you have to join a group practice and benefit from echos, Holters, TST's, bone densities, not to mention laboratory work. Billings for procedures are 6-8 x higher than for 9921x services. Join a group
I add my sympathies to those expressed by others. It's very difficult to have a solo practice. It's also very difficuilt to have a life with some balance. It's important to have someone who might help you out with the psychological stresses, whether it be another FP, a psychiatrist, and/or therapist- especially the former if meds are involved. It will be one less burden that you have to try to manage on your own. Best wishes.
Silvamber: I'm pretty good at the game. I've had charting review done by the blood-sucking management company, and they can't find much in the way of additional or "more correct" coding. I learned early on to code appropriately and diligently. I don't think that is the problem. The problem is the actual getting out of the contract. It's a David vs. Goliath legal battle that I just don't have the money to fight. I thank god for the attorney/patient that has been willing to trade services to help me out of this predicament. Huberetal: I'm glad you are in a good situation now. Looks like I'm headed down that path... clinped: Good advice. Thanks for words of encouragement. I hadn't thought about teaching, but I'll look into it... Sermo Doc 38: Thanks. You've lifted my spirits with your comments. haystack: Already in the planning. When I started realizing that this was going to happen (about 2 months ago) I contacted an attorney who wanted to have my involvement in a law suit involving about 10 other doctors against the management company. My personal attorney advised against it, as it may affect our ability to sell this practice, or have it taken over by a larger entity. "No one will buy into this if there is a lawsuit pending." I'm waiting for the dust to clear to go back to the attorney and have him work his magic. He estimated that the case would last about 1-2 years, and said I can join it if I decide later. migrainemaven: Agree, balance billing is a must. How did it ever happen that all contracts don't allow primary care physicians to balance bill? It chapped my ass royally recently, when I had to pay balance billing for anesthesia services on my kid's myringotomy tube placement. I said to my PA-C wife, "Why in the hell can't we do that?"
mlgyoungmd: I think it would be ok to go solo as an endocrinologist. You can still do a lot of hospital work, and your office overhead can be real low if you send out all labs (I can't think of what you would have to spend on supply-wise, so that leaves rent and employees. Please look into the writings of Gordon Moore, M.D. in American Family Physician, Family Practice Managment, and Medical Economics. He advocates the "low overhead" model that I wish I would have implemented at the beginning of my office...)
klong72: I'm laughing, genuinely. I probably would be making more money in residency, especially if I could moonlight.
daverey60: good ideas, thanks for the comments and I'll keep at it..
wplummer: I knew there would be other people on Sermo with my or similar situation. I never thought I would find so many willing to tell me about their experience. This whole post has been therapeutic for me. I agree with your comment. Also, there is a pre-med student that is the daughter of one of our medical assistants. I have told her not to go into primary care, or even medicine for that matter. She wants to be a surgeon. "Go into anything but family, as you can't subspecialize much in family practice."
BeReal: Agree with the need for rest. I'm likely to get a locums soon, but will have to work elsewhere in the meantime (I'm a month behind on my mortgage...)
martina: noted your comments, thanks. Greatly appreciated.
Sermo Doc 50: see my first response above on this comment...
abc1530: Amazingly, there is no noncompete or restrictive covenant in the contract. They just make it so hard to leave, and sue your ass if you do before hand, that most people can't afford to fight it. An insider told me once, that whenever they are in a lawsuit, they ask "how is this guy fighting this?" Not, "does he have any case, " or "what did we do wrong?", hell no. They use the court to strong-arm their docs. I hadn't thought of the cash only thing. I worry about using that model in this area, as most of these folks are young, middle class, live paycheck to paycheck (hell, that's me). I'll definitely look into it.
Sermo Doc 51: Awesome reading list! I think I have read the shorter one. More importantly, I really appreciate the advice about the recruiters. I will definitely check into the posting you mentioned.
To ALL: Thank you for your responses. I'm a little behind in responding, so if I missed you, It is still greatly appreciated. It's now 3:30 am, and I need to get my usual 3-4 hours of beauty rest so I can move the meat tomorrow. Thanks for the great advice and helping me find hope in this horrible predicament.
doctorfurl It is difficult to manage your scenerio on the meds both Rx and OTC that you consume. You are constantly pushing, pushing, pushing. Stop. Patiently finish your ER obligations. Save as much as you can. Decrease your expenses both personal and business temporarily. Just because your management company wants controversy, doesn't mean you have to hire legal advice and pay pay pay for probably nothing. Let them pay pay pay for legal advice and when they are finished then you can stand up and address their issues and requests. In the meantime, take two weeks off from your private practice. Private practice includes management whether we like it or not.. Several good books have been mentioned above. Your 5,000 charts might need to be checked to see who didn't follow up. Man, I know many can work as employee for people or companies who want to make money from them but it takes a lot of visits per day to pay for that many salaries. It seems we can't make as much in private solo practice but working for others means no or little autonomy in how you want to practice. Think about it. Take time to stop and ascertain your situation and where you think you should be in this endeavor. I have been there and done that more than once. Currently struggling to keep doors open in solo private practice. Recent economy has hurt hard and heavy locally. But, lo and behold starting to pick back up. Good luck to you.
I have been through a lot of the same stuff over a very extended time period - mostly for different reasons. Practicing medicine "gave me up" in 1999. It was very tough before and after as well. I had my own weaknesses and shortcomings in trying to do primary care, but rarely got much understanding or help, which would I believe have spelled the difference between "alleged" failure and success. Political correctness - or its lack is often the basis. I was once told my annual receipts had to be $230,000 AFTER expenses to justify my position in a practice network - nothing less than a pipe dream! I have pursued non-clinical work with varying success - many have left practice like I had to.
UPDATE: to clarify, I do have a noncompete, just no restrictive covenant in my current contract. If I leave and set up a new shop down the road, I will be in violation. If the contract chronologically terminates, I can stay in the same place, or move, and continue to practice.
Today, I got two more contacts on potentially joining a group. My hopes are to potentially set up a bidding war, have the principals bid up on a salary or bonus and/or benefits, etc, until my debts are paid off or I get a really good salary. I can still hope.
Another factor that is weighing on my head is my wife has MS. She does well, is working, and doing fine on Copaxone. I've got to have a job with good (as it gets) health insurance. Hence the need to look for large groups. The stress of all of this is not good for her condition or for my hypertension. My dad died of a heart attack at the age of 57. I do control my bp and LDL with meds quite well, and he was a smoker (I'm not), but suffice it to say my FamHx worries me at times. I'm keeping my fingers crossed and saying prayers every day.
Does anyone happen to know anything about how to sell a practice to known entities? Meaning, I already have about 3 or 4 potential hospital systems, large single and multispecialty groups considering my practice for sale. I know there are professionals out there willing to help me sell it, but if I've already done the major leg work on this, shouldn't I be able to lower their rates? What's reasonable, in your opinion?
Tell you wife what is going on so she fully understands (if she doesn't already). She needs to know how bad things have really gotten. And as much as everyone likes to blame MS flares on stress, there are no studies that demonstrate it, so stop "protecting" her and start working as a team with her. Yes, the meds are expensive and she'll need continuous insurance coverage unless you want to pay ~$1500/month for meds out of pocket.
The kids are young, and aren't in school. Move to a state with tort reform and a low cost of living and a reasonable public school district.
Hang in there. As a group, physicians are undercompensated in this country and treated with disdain by most politicians (who are mostly lawyers). I have been in a salaried position for the last 14 years and am very content, especially with the lifestyle. I would recommend this, whether ER shift work or some other setting with defined hours and compensation. The next few years are going to be turbulent for our profession and it would be good to be in a safe haven until the dust settles.
>>The problem is the actual getting out of the contract. <<
Then let your lawyer handle it so you can get a fresh start. Hopefully, others in here will see the mess a "management company" put you in. Work for yourself or join a successful practice elsewhere where you can become a partner. Don't trust any middleman with respect to your career. Good luck.
A non-compete clause will not hold up in court, California. Check with your attorney or do your own research to avoid cost of attorneys. Goal is to minimize office overhead. I use ringcentral for phones- web based system 50.00 per month. My EHR- Office Ally 30.00 per month. Billing is through office ally No fee service they are a clearing house paid by insurance Co. Don't get ripped off by other EHR. They should all be low cost or free. Office staff of 2 - 1 front office and 1 MA. Only contract with efficient good paying PPO. Emphasize Cash up front payment. Provide discount to cash patient.s. I charge 80.00 per OV for cash at time of service. Dispense generics to cash patients. It is profitable and appreciated by patients. I use PDRx. Accommodate Cash patients with Appointments within 48 hours. May want to consider following your patient in hospital and SNF. Don't need to moonlight you will be busy with your own patients. Its hard, it can be done. Please seek help from an FP/Internist regarding Provigil and other issues. We are trying to survive. There is little support from other physicians in local community. I think we are just too proud to express our situations and emotions. Realize that your health and your family is the top priority in your life.
Be EXTREMELY careful with selling your practice to a hospital or PMG especially if you are going to stay as a physician!!!!!!!
You have to rely on their accounting and WILL end up in the hole which will make you more dependent on them and perhaps unable to leave due to money owed them!!
I have had some experience with this. One doc in our sold his practice to a hospital and now owes them $200,000 which they say they fronted him tokeep him afloat in his own practice!!
He is still having to moonlight in Urgent Care.
Please just get out (with some money if u can) and go where docs are needed and you will be happy. You can get group insurance for your wife.
Keep O/H down!!!!!!! That is the name of the game today.
A Family Practice (sad to say, and I disagree with this....) is worth just "goodwill" and today has virtually no cash value- unless you're selling assets (building, equipment, etc.). I was in the process of selling my practice about 2 years ago, on my own, and, talking to an attorney-friend (imagine befriending the "dark side"!!), was told primary care practices hardly hold any monetary value (that absolutely sucks). Anyway, the sale didn't go through, as my prospective buyer, coming out of residency, was asking for a "guaranteed income" after I sold the practice- i.e.- that I would pay him the difference in monthly income if he fell short in collections of my average monthly income!!! My take: If you're really intent on leaving the practice, transition your patients to other docs, while still cashing the "aging collectibles". You have to give your patients, by contract with insurance companies, about 2-3 months' notice (depending on the ins. co.) your closing the practice. You should also "advertise" the closure per your state law (in most states, check w/ your lawyer). This should be during the "phasing-in" of your new assignment- hopefully, with a bigger practice, not a hospital entity.
FP practices have no value simply because there is no one to buy them. As I've said before, the "average" FP salary neglects one very big matter - the capitalization of the job itself. It fails to account for the cost of creating the job. In other words, you can get the job - if you can find one.
"But wait", you say, "there are all sorts of FP jobs available that they can't find anyone to fill". True enough, but those are primarily "capitalize as you go" jobs. That is, a hospital may create one, but you'd damn well better be ready to pay them back by means of ordering tests people don't need and making lots of referrals (that will lead to more tests patients don't need). Hospitals aren't looking to create real FP, they're looking to create their own version of primary care, sort of an urgent care/clinic "fill in the gaps and round out our services" dumping ground for patients that they really don't know what to do with after they've done little more than suck them dry of insurance revenue and still not "fixed" them with their expensive diagnostic test driven hospital and specialist centered care.
And, if you don't believe that, then you need to look no further than their replacement of FPs with NP/PAs for a whole lot less money. It's not primary care they want, but the appearance of it, and "mids" can give them that and be more compliant in ordering the testing they want. FPs fail because they offer better outcomes to a provider that wants more process.
The future of FP, if it has one, is in jobs created by the current payers - employers. It's employers who are going to have to capitalize the practices, creating jobs for the FPs whom they need to take care of their employees in a way that focuses on greater efficiency and convenience and better outcome rather than more process. Until then, I'm saving a heck of a lot of money for a whole lot of payers who can't see what I'm doing and don't have to pay for it, while being of less and less value to a hospital centered system that hates me for being good at what I do because they care less and less about the patients and more and more about revenue.
Sermo Doc 20 has hit the nail on the head! Primary care keeps patients away from the whole money pit. No primary care or poor primary care and ED's and hospitals are swarming with customers. If there isn't something serious wrong, there sure as hell will be after a few encounters with the midlevels! Certainly the only ones who care are the payers. Maybe a patient here and there who can figure out what is happening to them.
You're so lucky to have this community. I've reviewed all the input, what a wonderful group of caring docs. What invaluable input. I've learned a lot, and I'm a busy, practicing solo psychiatrist with a very large practice. So many of us care enough to contribute. I've learned a lot from all these very able docs.
i was thinking of opening up a solo practice....some people say its not that bad...but now i'm scared sh**less....
i'm young, single, looking to become "un-single" one day, and want to leave my current academic salaried position....but perhaps this is not the way to go????
I have always been salaried with a 401(k) and good benefits for my family and me. The stock market has made it more like a 101(k) but I'll never complain about being salaried. I don't have to worry about the business aspects, and can focus on my professional activity.
Wow, I really feel for you. There are some really rotten management companies out there. I spent almost a decade working for a pathology company (Ameripath) and what did 10 years of excellent performance reviews, doing the work of two pathologists, participating in Medical Staff affairs (including as Chief of Staff) and showing up for work with pneumonia or a broken leg (can't call in sick if you're the only pathologist at the hospital) get me? Fired at the whim of an asshole who violated my privacy then spread rumors about me. What reason did they give?? They didn't. Just kicked me to the curb at a time when I really really needed support. Thank God for disability insurance (yes they not only violated HIPAA but ADA as well).
What can you do? Nothing, they have the money and lawyers on their side. Maybe consider academics....not perfect but at least you can survive.
Hang in there. The other side may have a "team of attorneys" only because they need them. This company most likely has been sodomizing full tilt for some time and you are one of many. Anyway, if you have a good case (that is for your & your atty. to decide), then nothing can protect them from the truth. Don't take this passively; fight back with all your might. Another possibility is to call in the media and have this company tried in the court of public opinion. You have served your community and 5000 pts. with integrity so you might be surprised at the outpouring of support. For money, consider becoming a Clinical Trial Monitor as a means of support. The classes are not too expensive & its a good fit for physicians. Good luck.
Sad story. What initial motivations/greed/ unrealistic expectations got you into this miserable situation with blinders on as to the potential risks? I think the best option is to work for the military - either as active duty - a great life with lots of benefits (plus, of course the hazard of being deployed; but then, we have already "won the war"), or as a civilian contractor. It is disturbing how far and wide the economic catastrophe is spreading. Medicine is still the greatest business, and if you think there is another golden windfall out there you and your brood will keep on reliving this nightmare until you kick the bucket.
I went through the same experience with a private management/billing service. They made great claims and did nothing. I finally got a new honest private low key biller. She works for about 5 doctors in our community. Asks only 7.5%. She has been a life-saver. I still have to moonlight but my practice base is much smaller than yours. You need to get rid of the management employees and pay hourly wages, no benefits, retirement etc. Cut out the frills for staff that they are collecting your ho-money to pay. Billers can very very unethical and you have to ride them all the time if they prove they are not doing a good job. With that payment base and # of patients you should easily be able to make a go of full time private practice.
This is the kind of story that makes me quit complaining about my job. I work for Kaiser Permanente...the workload is higher than I'd like, but I don't have any of the other kinds of headaches that the original poster mentions. For the most part, I can just practice medicine. I wish I had more time off, but the way things are going (both within medicine and in the current general economic environment), I have to say that I'd rather be here than out there, anywhere.
Your situation sounds awful...I agree with Sermo Doc 4, please keep your sanity intact. The options are no fun to contemplate, but are infinitely preferable to you Losing It In A Big Way.
The most aggressive personal advisers say the same thing: you *can* restart and rebuild, whether it's in clinical practice or no. As physicians most of us aren't trained to think that way, but it's true -- and always has been. Don't let yourself be fooled into thinking there's nothing else but The Box.
$100K seems like a menial debt to determine the decision making in your case. If you have a home equity line it would probably be $500/month. Your health and quality of life are worth more than that.
With the signing of Socialized Medicine Stimulis today as Daschle wrote in his book "doctors will have to give up on solo practice" Get a Gov't job ASAP!
I agree with the Opthalmologist and others who feel that nobody takes as much care and does as good a job with the business part of practice than the doc. I started with my mom and my wife and myself doing the books and learned all the ins and outs of coding and billing. Dump the management company, get a few smart, loyal and hardworking kids (not too tough in this economy) and screw the management company.
It the insurers!!! Drop them all, including Medicare and Medicaid. You can the get rid of all your staff except someone to answer the phone. Send a letter to all your patients explaining that 1) you no longer deal with insurers 2) they can still get reimbursed, but at out of network rates and they have to do the paperwork and 3) that they will be responsible for the bill at the time of the visit, and then they can collect from the insurers later. You'll lose about half you patients... but you'll increase your revenue per patient, be able to spend more time with them, have lower expenses, and be able to do a better job for yourself and your patients. Good Luck. And, oh yeah...dump the management company.
Doctorfurl, if you need another income option, you could certainly consider writing! You have a most enjoyable style, despite a rather dreadful topic, and I, for one, look forward to reading more of your prose. (Just wish it could be about something less personally demoralizing for you!)
After 23 years of solo practice in Internal Medicine, the constant harrassment of Insurance Companies, lower and lower Reimbursements and increasing overhead have given me thoughts ranging from suicide to claiming disabilty, ( I have five stents )
Three years ago I was offered the "Golden Parachute" from the company that runs a conglomerate of Hospitals and I spent 2 sleepless weeks thinking about turning over my practice. I did'nt and the group that had been formed dissolved almost as quickly as it was put together.
I have never trusted corporations and do not expect that my opinion will change esp after reading the comments so far.
I hope to last long enough to see that primary care begins to get reimbursed for the work they do as I suspect that within 5 years there will be a serious shortage of providers like us.
I realize that my situation is far different then yours but solo practice with or without a binding contract is difficult to say the least.
I have no legal expertise to lend, only my ear. It seems that there are quite a few individuals here with sound advice, listen and learn..
You are of no use to anyone if you drop dead from an MI and your children need to remember their father fondly as does your wife. (trust me divorce will be the last straw)
Remember why you became a doctor and find a place where you can ( as best as possible given the current circumstances) find peace and a measure of happiness.
The initial cost may seem outrageous but you have quite a few years to recover and you will!!!
You're at a turning point, hang in there. It takes a good five years to build a practice's foundation and you have done it. Before, it was about building your practice, now it's about maintenance and efficiency. Review the terms of your management agreement. There should be an expiration, and if it automatically renews, review the termination section. You typically need to give some type of notice to not renew the agreement or terminate without cause. There should also be a clause for termination for cause. Obviously, the former would be ideal and not require your attorney. A letter from you giving 90 day (or whatever it states) notice terminating the agreement should be suffice. Hire a billing company for no more than 8% (no more than 2% of capitation). There are billing companies that also offer EMR portion as part of their percent (AthenaHealth and SysInformation are two good ones). Employ a good front office and back office with one of them responsible enough to "manage" office duties such as ordering supplies etc. Another option, add a partner to split the overhead. Don't hire a doctor, have someone join your practice that will commit to paying half the expenses. If you don't have the space for two doctors seeing patients at the same time, be creative with your schedules. Extend your hours a few days week and shorten the others. The days you work only half day (am) the other doctor can work the afternoon and early evening. You are still accessible on a daily (mon-fri) basis for patients and offering evening appointments on a day or two. The goal is to maximize your office space and reduce your share of the overhead. Opening your office evenings and weekends can also help. You and your partner can share those shifts or hire a mid-level to work them. Your overhead will only increase slightly, but you can increase income from the additional patient visits. Additionally, add ancillary services such as waived lab tests and dispensing medications. Many of these have little overhead and are easily reimbursed by either the patient paying cash (rx dispensing) or insurance (labs). I joined a family practice over ten years ago and I am happy I stuck it out. It was difficult the first couple of years, similar to your experience, but now I have a healthy practice, income and life. You took the risk and sacrifice, you will reap the rewards. You can always sell your practice (if only for the amount of outstanding debt), but why start over and go through the same agony of building a patient base when you already have one? Even as an employee, you will still be accountable for your volume and productivity. You've described an ideal location and patient demographic, if you really don't believe you will succeed, then contact me, I might want to buy your practice ;).
i am repeatedly disgusted with both the high cost of medical school and the (esp NY expensive regulatory environment .. .. Why are so many students applying to medical school ..to become debt slaves??
first... try to decrease your hours in office and increase er... to get cash in... part time employees , 20 hrs only .... you MUST get sleep... .. and get positive emotional balence, positve intellectual balence and phsycial balance to go forwardl... you are still best working for self..but NOT as a slave... eliminate junk insurnances and move to cash care... then you can succeed.. AND patient listen to what you are trying to teach them and appreciate it too.. great parteners and not just passive demanding patinets... and yes .. your common sense probably was better than any management co which puts a fixed expense on your plate.. so strategize.. and ASK them specific questions to put them to work... and yes they may be total incompentents but if you can;t get out of contract then make them work ..if not only just to answer calls from your wife!!!!!! lol
I left a 6 provider FP (4 MD,1 PA, 1NP) in 2000 to get remarrried and move out of state. Not wanting to start all over again (was in early 50's) I took a FT position in a Minor Med Clinic (i.e. Urgent Care). Work 3 12 hour days, paid for 40 hrs/wk. No call or hospital. Great benefits, but salary is slightly below national average income for FP's (according to published stats). The clinic is run by a hospital system.
Downsides: I'm an employee with little or no say in policies. Urgent care is not FP; no chronic disease management, only episodic care. May have to see over 50-60 patients per day, with volume-related stress. Lastly, although FP's have no problem with handling the medical complaints, Urgent Care is not something I would want to do for a career, particularly after the residency training you and I went through.
I walked out of a lucrative contract when the management company that bought my practice went from inept to beyond. What helped propel me through this major rite of passage was a closing ritual that my staff and I conducted (written up in Medical Economics) Even more important than your financial needs is a time out for self care and becoming quite clear about your wants and needs; no less a support system of people who have your interests at heart. I wish you well
Close your practice and come to Leominster, Massachusetts. We have a shortage of primary care physicians which will only get worse in the next few years as the older doctors retire.
Leominster Hospital (affiliated with U Mass Medical Center) would be a good source of information and might be willing to help you set up practice here.
Leominster is a one hour drive from Boston. Good luck.
All I do is bitch about my joke of a compensation as a Neurologist. Doing pain in the ass procedures just to make some Christmas money. I have to say, my heart goes out for you guys. Working for hospitals is hit or miss. Don't ever work for UPMC or Conemaugh (PA).! I say the answer is change. No doubt in my mind it will come. Has to!! Why? The public is pissed!
Take the good advice offered. if you do not what is the chance of being alive in a year or two. What would you tell a patient of yours to do if they were in your situation?
Have you considered changing your practice to a cash-only bariatric practice? Patients will pay, you get to deposit full income on the day you earned it, and people will kiss your feet for helping them feel better. Very rewarding. And God knows we need more bariatricians. Let me know if you want more info.
Very soon, Universal Health insurance will become a reality and then then all of us will be at a reasonable salary ( Which will be more than what the military offers, and what some Dr's currently make). With single payer insurance at least we will not have to worry about insurance agents and exorbitant CEO and middle-men taking a big piece of the pie. Universal Health Insurance is what the People in USA need. I bet we could have a system which is better than the Canadian or the European or the English system. Currently we are spending over 2 Trillion dollars and over 14% of our GDP. We can do better than the current system with what we are currently spending. Hang in there.
Given the problems you had with the management company, I'd be cautious of working with locums. I've done it now for 3 years, and you need to have a business mind in order to work around them. Their loyalty is for the hospitals/clinics who hire them. I've worked with many of the companies, and consistently have had the same experience. They know little about medicine, have a high turn over rate, misrepresent the jobs, sometimes lie to you about what the hospital/clinic is willing to reimburse, and it just goes on. I've had companies forget to book a hotel, not deposit a paycheck, submit incomplete licensing apps, etc. And for all the hassle they make $25-$50 dollars AN HOUR for the entire length of your assignment. And they don't pay for anything. All your housing/car/etc expenses are charged to the hospital/clinic hiring them.
You really have to be ahead of them to make this work, but if you don't mind this aspect, it's really great to be able to walk away from a bad situation instead of feeling trapped, and you are in charge of whatever time off you want.
I am so sad to read these. Here we are: a bunch of IQ above average MDs/Dos are being mistreated by less educated business people to the point that we started abusing our own bodies to relieve the stress that we often advised our patients not to do.Why did we allow these from happening when it will stop? The very reason is that they united and form a system to deal with us,individually. The united,systemic approach can beat anyone who think that they are so smart that they can beat the system. It has proved over and over that we are wrong. it will keep coming up until we finally say, it is enough, we have to unite and form a system to win this war. Organized medicine is the only way out. Before it was HMO, now they're management companies and insurance companies.
I had a friend in a similar position who said "come after me". Never happened, it is now five years later. If your stomach can handle it, you may want to take your chances. I am not a lawyer, but have seen this more than once.
Geez, you need to get out. If they violated your contract, then walk away. How can they sue you? Remember, your medical license is yours. You are still a doctor and can start elsewhere.
All of you who are waiting for the dream of Universal coverage to come true might as well wish for Santa Claus to bring you a large sack of money. If we do get government control of healthcare, it will be run by the same friendly people who run Medicare and Medicaid. If Ted Kennedy gets his way under this grand new system, it will be illegal for you to not participate in this new medical-police state. The agency that created ICD-9 will be in charge of determining "best practices" that will be mandatory for you to follow. Eventually your EMR will be stored in giant central servers accessable to the government at all times and without your knowledge (already legal under the act that created HIPPA). You will lose your money and your autonomy. The only thing you will still have is your personal liability if the outcome is poor. Remember that if they fire you, you will have no where else to go. Your medical education does not qualify you for much else. Good luck flipping burgers.
My partner and I finally broke reliance on hospital employment in June of 2008, and went independent. It was tough the first few months, even though we took most of the former employees and all our records. (You may reach your own conclusions as to why our former hospital employer allowed us to do so.) My wife is an Attorney, but that's is only part of our solution.
We trimmed , fat, became more efficient, and our employees, have more incentive to be efficient as well. We gave good bonuses our first 6 months, better than our CPA said we should have, and really generous per my wife and atty.
Maybe we are stupid, but even in a recession, in a chronically economic depressed region, and with much competition, we are doing well, and when the economy recovers , I hope all the PCPs, like me, can survive and prosper.
I have read through almost all the postings. Many a thought was parallel to the reality that exists in this country regarding how we are perceived as doctors in general by society. The perception that doctors live the high life by manipulating the system for copious financial gains is highly prevalent.
The reality is that we our lambs being led to slaughter so any one of the "pious' entities whether they be politicians, insurance bureaucies, regulatory agencies, or the blogsite dujour claiming to provide quality info on the provider's name you type in can claim victory over the medical field which is raping the system. There is already a steady drum beat to get us all to be equated to the U.S. Postal Service.
So be it. Let the AMA become the union and we as doctors the employees. I love their dress code at the Postal Service. The Armageddon that approaches will not be because the banking system will fail. Rather the delivery of healthcare which is responsible for 14% of the GDP, if I read correctly on one of the postings, has to collapse before we as physicians are valued once again for devoting our lives and sacrificing for the sake of society's well being.
Does Dr. Nielsen our AMA president spend anytime on this posting list? Even a cursory perusal of the sentiments being voiced might be valuable in how she may approach policies for the sake of all our benefit.
I am still in solo intenal medicine practice after 40 years. I only net half of what I used to, but that is because I have made my life easier by using hospitalists for all admissions. Now I can visit my hospital patients leisurely, and listen, talk, and give good advice. Of course, my 3 children are all educated and married, so my civilian overhead is low. I would never start out as a non-proceduralist today. I should also add that no one wants to join me without a guaranteed salary, malpractice coverage, etc., and I can't afford it. I think they should give a two week course to ALL fourth year medical students on how to (a) inject Botox, (b) inject Restalen, (c) do skin biopsies. This way we can do procedures one day a week, and afford to do internal medicine the other 4 days.
I just found this thread and feel your pain also. Started a solo pedi practice 5 years ago because I couldn't stand the assembly line feel of the big practice I was in. Spent ages going over the pros and cons and finally felt it was the right decision. Had all the right reasons, but didn't foresee the law of unintended consequences.
I am currently doing OK, but stress especially over managing others. Brought in a part time doc 3 years ago which brings a whole new set of issues.
Biggest things that have helped
(1) I have an office manager, but she has clinical skills and business skills, so she can help in all areas of the practice. (2) Farmed out billing so that it didn't rely on people in my office getting it done - they only charge me 5% which seems pretty reasonable. (3) Have joined with others for help with call. Also utilize a local nurse triage service, which takes the stress off of phone calls at night and on weekends. Costs me some money, but I recoup much of it by charging patients directly, and they appreciate speaking to someone who has not been working for 72 hours straight. (4) After a lot of soul searching, I decided to give up weekend hours. We are fortunate to have many pediatric only urgent cares who are staffed by board certified pediatricians and who communicate well with us. This frees my weekends except for rounding and allows me to spend a lot more time with my family.
I don't like the way my bottom line looks right now, as little things such as "fuel taxes" keep making my supply costs go up and up and up, but I figure I can always protest them and switch companies if I have to.
I am glad to read about all the difficulties with management companies and the like - I have been approached many times by groups to do this - it seems they no longer exist soon after.
I don't foresee being able to do this for a very long time and would love to hear from others about non-clinical careers they may have found happiness in. I rack my brain all the time trying to think of what else I might do and just can't seem to come up with a good alternative.
Interesting thread. Lot's of encouragement towards joining a hospital based system. In my experience, the overall health care costs to payors/employers/consumers in higher on a line per line item for large multispecialty groups, and hospital system based groups. All you need to do is look at COLLECTED fees per CPT codes and see the difference in negotiated contracts due to market share and leverage. In my opinion, this is non-sustainable, and the eventual need for diversity and more cost effective alternatives will a necessity, and likely demanded. Large systems eventually reach a point where there efficiencies of scale cannot keep up with revenue requirements, unless they find a way to continue to grow. Almost all eventually implode. But be sure, we it comes time to cut costs, the easiest and surest way to do so will be to look at payroll and benefits, including those of the employed physician. I advocate collaboration and partnering with local businesses/employers, to look for win-win situations. I have several direct contracts that eliminate 3rd party payors, and even though the reimbursement is not a good as my best commercial contracts, the "cost" of collection, and cash flow easily makes up for it. A win for me, and a win for the employers I provide services for.
Stay tuned. Think outside the box. Look for for places to partner and collaborate with other physicians, business, and even hospitals. Don't feel the need to roll over to hospital pressures, you will find there are many competing forces, and the political climate is right to provide alternatives to the status quo.
Where were you 5 years ago when I opened my private family practice clinic? If only I had known...now I am in a very similar situation. I haven't taken a pay check home since December but can't afford to get out. It sucks. This is not what I went into medicine to do.
Can't offer any advice as I am in trouble too. Just know you are not alone.
Closed my practice 12/08. Like you had good pt base with insurance. Insurance companies took their time to pay and I wasn't collecting much of a salary. Did not declare bankrupty due to "owning the building". Now trying to lease. am now a happily employed FP/OB making more than I could have ever done on my one. Good Luck!
I'm sorry about what's happening to you. I was in a situation in Texas where our practice management group basically ran the practice into the ground. I was fortunate enough to see the light about 2 years before the end and managed to get out of my share of the partnership and moved to California. I'm currently in a group of 15 docs that is being managed by a local PM group, and we're doing fantastically well. We've got about 70,000 charts, and we're all making a very good salary. We have a very good personal relationship with the 2 managing partners of the PM firm - I regularly play golf Saturday morning with one of them. The older guys who were here before the PM group are making about 60% more per year than they were before we turned over the business end.
I'm letting you know this just to show that not every PM group is bad, though I've been on the wrong end of one of those. I just turned 40, and have 2 young children. I'm on call one day a week and one weekend in 6. I take no hospital call, thanks to the hospitalists, so I can spend my call days anywhere where my cell phone has coverage. If I have to answer more than 5 pages during an entire weekend, It's a busy one. We're looking to expand the practice, with a goal of reaching 20-25 docs by 2015, so if you want to come to California, send me a message.
OK, brother...I can see that you are at your wit's end, and understandably so. Be of good cheer, this is one problem that we can solve for you. Fortunately, you are in a much more advantageous position than you appreciate. Of the two medical specialties in highest current demand, you have the good fortune of being in one.
Firstly, we need to find job interviews. There are, I dare say, generous available sites and practice types that need to invest in a competent, thoughtful, young physician who's best friend is named, "Hard Work". It will be best to limit your interviews to large groups and/or institutions, as they will need to shoulder the $100K debt that you have left on your practice. In short, have your attorney find an appropriate contract that will be fair to the both of you, see if you and your family can live for the next 5 years in that location and sign it.
It is, of course, commonplace for institutions to offer "income guarantees" to physicians starting a practice. The economics work a bit like this: M.D. needs 3 years to build mature practice, likely they will need somewhere between 45-100K over the first year to accomplish this, and the agreement expects that the loan will be forgiven (but still reportable by you as income, later) over the remainder of the contract. The institution makes money, in that, for every $1 the practice earns, $7 is generally generated for the institution at various levels. Further, if the physician is of good moral and ethical quality, the institution has the opportunity to keep them in the community long-term as they've now established roots.
In this scenario, everyone wins...physician, patient, and institution. With the newer model of health care rapidly coming into focus, primary care physicians may likely double their incomes, and $100K is just not a large figure of investment in the right physician. The key point to remember is that you'll need to find the correct health system that already has an established large patient base and needs only a hard-working, excellent physician to provide a long term commitment to the community.
Trust me on this one.....these opportunities are out there today and ready for you to find. Make a few telephone calls, get a service to three looking on your behalf and fly you and your wife out to interview at a few places. I can see this problem being solved within three months if you and your family desire it. If you don't find what's right for you, send me a note and I'll see if the local system that we have in place can't provide an interview.
Keep practicing high quality medicine and there will always be a place for you.
I can empathize with your problem and am going through something similar, and have considered closing my own practice. The main difference is, and mostly because of my own ignorance and independent streak, not because I knew what I was doing, is I have no contractual obligations and am beholden to no one. When things were at their lowest a year or so ago, it was only a teary-eyed moment of me standing in front of all my patients' charts when I realized I could not (yet) do it because of them. Now, as I face the prospect of a 3 month deployment to Afghanistan with no coverage, I am considering closure again. Fortunately, I really love Army medicine and have a potentially good career there full time (I am Guard right now), so I do have options, however, that would probably mean leaving my kids. Anyway, I do not imagine you have the time to read all of these (I read yours, but no one else's), but if you do, and whether you want an ear to bitch to, or to consider taking over a pediatric practice in Hawaii , I am available. Just send me a message through Sermo & I will get my contact info to you. Just do not do anything self-destructive or desperate... I still believe one can never be too old to run away (although I am not quite sure of to where I would run away from Hawaii!) J'
It is a really sad story. I am reminded of some outrageous, non-negotiable fees I recently paid to an electrician and an attorney, for very small jobs. By contrast, why must only doctors' fees have to be (de)capitated by the insurance companies? We all agree that there is a deepening crisis in our profession - we are managed by executives rather than by doctors. I also agree with an earlier poster that the only way to get out of this is for us to unite as one front, but who would lead such an effort?
Hi, doctorfurl Sorry to hear about your situation. Do you want to move to TN? I know a hospital there near Dunlap that will guarantee your income for 3-5 years- with $250,000.00/year. If you are interested, please let me know.
GOOD GRIEF! I am soooo sorry to hear about your situation, and others in the situation as well. I knew medicine was bad, but not this bad! I've read every single post on this and am appalled. I have to be happy I'm an anesthesiologist. Much as the surgeons b---h and complain, and tough as it can be sometimes, I do get off, I do get some rest, and I do get paid. Yikes. I hope you do well and good luck. My husband's IM doc has started a concierge practice and he's doing very well. Hope you come up with a good solution.
As a well trained neurologist with no training or desire to deal with buisness aspect of
medicine. Neither I wanted to deal with kick backs, ordering unncessary tests or stress about malpractice constantly. VA positions are the best kept secrets in this day and age of medicine with HMO's and poor returns. Great balance of life and work.
The number of posts here shows what a serious widespread problem this is. I've been in solo peds practice for 20 years. Overhead rises every year, we lose money on imms, and though we have a large, busy metropolitan practice with second generation families, we're struggling just to get by. Schedules are full every day and our patients have good insurance, but it pays very little for what we do. Working 12 hour days and weekends, no weekends and have consulted a bankruptcy attorney recently. For now, we'll keep on keeping on, but we've halved our salaries, doubled the work load and do nothing but work. Have large debt and banks won't lend now. I feel like there's no way out. I'm 56 years old and would retire if I had the money, but do not. Two kids in college and modest mortgage. No money left at the end of month. It's very hard.
I am about a year out of residency and I have never really entertained the thought of owning my own practice. Most of my friends are going to an employed model and they are happy. I do think that you should get a list of references that you can call and speak openly with about the company you are considering. Tell them if they can't give you at least 5 other docs, then you shouldn't work with them. I was burned by my first hospital which thought I would be happy doing adult medicine only and abrubtly closed the newborn nursery (the way I planned on building my practice). I was told lie after lie and eventually realized I had made a huge error by signing with them. I have now learned A LOT about dealing with CEO's and administrators. Be honest with them and ask that they be honest with you and you should find a happy medium that allows you to continue your practice. Ask your local hospital system if they can help you.
You are making a lot of bad choices, and are risking not only your license but being charged with crimminal offences, jail time etc: "PROVIGIL is a federally controlled substance (C-IV) because it can be abused or lead to dependence. Keep PROVIGIL in a safe place to prevent misuse and abuse. Selling or giving away PROVIGIL may harm others, and is against the law. Tell your doctor if you have ever abused or been dependent on alcohol, prescription medicines or street drugs." (from the package insert)
I have to say I totally agree with Sermo Doc 92. From many of your comments, sounds like many of you don't see a light at the end of the tunnel. I personally don't buy the BS I hear about the horrors of a nationalized system. Doesn't work in Canada because they don't have enough Doctors. Their mistake is simply that they cap salaries. Take a gander at Germany. I happen to know Physicians from Germany, and all I can tell you is that they are a lot happier than we are!!!
Have to say that I had your same attitude years ago, but learned my lesson with this whole managed care ordeal. Have to be proactive and aware of what regulations the government wants to bestow upon you. It was this, "what can you do" attitude that got us in trouble in the first place.
Sermo Doc 21, I can't agree. If doctorfurl loses his license and/or his health, there is no way he can use his talents and skills to dig out of his financial mess. He needs to stop self-medicating and get healthy, then figure out what to do about the rest.
I was solo for 9 years, and had a partner for the last 12. We've avoided joining a hospital system like the plague; too many of our colleagues have succumbed, then left in disgust after being mistreated. By working 10-hour days and trimming overhead to the bone, even in a city with high managed care penetration and relatively low reimbursements, some years we make incomes into 6 figures. Many of our colleagues are going the concierge route, with pretty good success so far. We have serious reservations about the ethics of that, as we feel that we need to remain available to our lower-income patients as well. I'm also a licensed attorney, but discovered in law school that taking care of patients is much more meaningful to me, if less lucrative.
There are 2 kinds of doctors. The geat employees and the entrepreneurs. If you "just want to practice medicine, then you should absolutely become an employee with as much salary guarantee AND OTHER COMPENSATION BENEFITS as you (or someone on your behalf) can negotiate. If you are entrepreneurial-minded and have any business know-how, and the desire to add management to your duties, then consider owning your own business, but....be prepared to work it, hire expertise in marketing, customer service and accounting and most of all billing.
The most common situation I see with good docs failing practice, is that they don't have the knowledge and don't commit the time to practice management. They commonly try and work harder and cut the wrong costs, rather than make good investments (like expert personnel) and dropping bad payors. Most of them should have been employee docs from the beginning. The best thing I learned in business school was how much there is to learn about business.
Sermo Doc 1 - why are you so against salaried positions? I'm in one and love my job. I don't have to worry about all the business stuff that I got no training in.
I am currently in the middle of trying to set up my own concierge practice after leaving a large multispecialty group practice a year and a half ago. I really don't believe there are any SAFE havens for 1' care docs right now. As prior writers have noted, 1' care, Medicare paid for (and all those insurances who base their rates of Medicare) do not pay a "living wage" to 1'care docs. We do not make enough to survive on our own without the financial support of a hospital or other entity. The large group practice I was in was supporting the 1'Care docs for years through MRI,CT and other ancillary reimbursement - when Medicare cut the rates for that, the clinic went into the red. I left before they got bought out by a Large Hosp organization which this year cut rates to 1'care docs 15% (AFTER they bought the local hosp system so the local docs had nowhere to go to). As far as I am concerned, unless you want to live off someone else's support, the only option is fee for service or concierge care OR seeing 40+ pts a day which I don't believe is good medicine. Fee for service and concierge care by no means have to mean service to only the wealthy - the middle class can be fully included esp with high deductible health plans - people need only be educated on what type of health plan they need to enter to get the type of care they want most affordably. working with local labs and radiology services to get reduced rates for fee for service care can help reduce these rates for patients as well. Most concierge practices see about 10% of patients for free - so the poor do not get excluded and probably get more care than in usually busy practices. The only detriment to the "Health care System" as a whole would then be the # of patients treated by each physician - as this would worsen the health care shortage of PCPS. But you worsen it more by NO ONE being able to make a decent living unsupported. I do not advise ANYONE in medical school or residency to go into primary care unless they are willing to look at this option.
Wow. I'm feeling better now about quitting my recent job (with a national physician services company) and having found some local options to help fill the gap until I get a new position. A few thoughts:
The military: not a bad option, if you're temperamentally inclined. Your wife will have to accept the possibility of deployments and separations, but it sounds like you're already not home that much. Also might consider the Reserve forces -- they have bonus options, training opportunities, loan repayment programs, and the like. I speak from experience -- I'm at 17 years of AF time myself, and am an active member of the Air Nat Guard.
Australia/NZ: Don't know about DO's -- but it is free to ask. I went to AUS with Global Medical Services (I think they've changed their name, but you could google them) and really enjoyed the experience. Took the wife and kids with me. The pay is lousy, but they did give us a car and a housing allowance. Unfortunately, the allowance isn't close to what it costs to rent for a family. Still, it was a good professional experience, a good personal experience, and a way to recharge the batteries and get interested again.
Balance billing: sorry to hear about your being charged this for the anesthesia bill for the BMT -- when I had my own practice, I never balance billed colleagues. I always felt perfectly comfortable billing the insurance co, but not fellow professionals.
It's not too late to join the military. If I had it do do over, I'd be a full time flight surgeon, as I was in the Air Guard. I joined at age 43, put in 21 years, traveled, was paid to do things I couldn't pay to do (Antarctica, flying in F 16s, served in Desert Storm, Enduring Freedom, much more, happy to discuss) excellent pay, great co-workers, pride.
WOW - looks like you're not alone.
The commentary as a whole is discouraging -
Life seems too short to slave away under those stressors.
I have a close friend who recently had a near-death experience, and as a result has had a moment of clarity regarding what is important to them. Their employer doesn't know it yet, but when their disablity benefit runs out, they're gone!
New mottos include "have little, want less;" "live in the moment;" "just say no."
As physicians we are not good at any of that.
Hopefully you have a moment of clarity right now - take a deep breath, get a night's sleep, and use it. Good luck, and God save us all.
I am happy for those of you who have had good experiences as employed physicians. You are the lucky ones. That may change at any moment. You, yourself, are the only boss you can trust. It is naive to believe otherwise.
Until physicians have to right to form a union and bargain collectively, employed physicians have no power and no security.
Are so many of us really OK with being told when, where, and how to work by a business manager with half our intelligence and none of our commitment to patient care. Please think back to college when you were studying so hard. What was your business manager doing? Male or female, I have yet to meet one who doesn't boast of their drunken debauchery during the time you were sweating it out in college, medical school, internship, residency, and fellowship. When you work harder to produce an extra dollar, does it really go in your pocket or theirs? More importantly, when you give control of your practice to a businessman, your patients cease to be patients and become a mere revenue source - as do you. If you insist on caring for the patients as patients, you will be eliminated. After all, you gave them the power to do it.
Have you seen the ongoing "Medical Economics Case Conference"? drjbf1 writes on his outstanding success in founding and growing an cash-only urgent care clinic! Should be interesting reading. And if you switch from family practice to "urgent care", then you might not be in violation of the contract anymore! Consider this and ask you attorney. But read the post, it has some very good thoughts on how to make money in medicine while providing good care!!
Well, for what it's worth, I was working towards burnout about 5 years ago. I'm a solo, rural FP. My wife's a Psych MD. I had at the time a 13 year old daughter. I knew I needed to get enough distance from my practice to think things through. My wife (also a solo MD) and I CLOSED our practices and went Locum Tenens to New Zealand for a year. We each worked full time for 6 months and part time for 6 months, so that there would be one of us available to run the household and be available for our daughter.
It was the best move we ever made as a family. Incredible country, incredible experience, not to mention it was great to work in a medical system. Despite the fact that our tenant at home trashed our house and left us holding the bag for about $3500, that I had to manage a remaining employee to copy records and still pay the rent on my office building as well as our mortgage, my dad died while we were in NZ, and I had my employee implode when her dad died and I had to find a replacement for her...I still had an incredible relaxing, rejuvenating year. The pace of life there is so laid back and the kiwi's (New Zealanders) embraced all of us.
I'm also sold on Socialized medicine...the patients were happier there, but more importantly, the DOCTORS were happier there!
We returned and re-opened our practices a year later. Financially it wasn't easy at first, but we survived, and so did my sanity.
Good luck wherever you end up.
i have been in solo practice for 15 years... a lot of ups and downs, but for the most part, i love it.... i manage my own practice... i do not have a manager.... i see patients from 8:30 to 2:30 ... no lunch.. go straight thru.... then, i spend 1-2 hours going over the day's insurance checks, post them, and then assign problem claims to my employees... they make the insurance calls in between patients.... i make my hospital rounds around 4:30 and am home by 6 or 6:30....
for a good office manager, you have to pay 40-60k per year, or 4-5 k per month.... with taxes and other employee expenses, you are looking at 6-7 k per month... AND, there is NO guarantee the manager is doing a good job... instead, i have opted to see a few less patients each day, and optimize my collections / billing.... the revenue i lose by not seeing more patients is made up with the savings of not having a manager and higher collections rate and efficiency ...
AND, most importantly, i get home at a decent hour, see my family, and get a good night's rest....
if you spent a fraction of the time you are spending in the ER, you could manage your own office very efficiently, as well as save your health and marriage....
I just don't understand... I finished training last summer, but yet I still filed taxes for 2008 for $320,000 just on moonlighting ER work and now I am thriving in a multispecialty group almost earning over my guarantee salary of $250,000 with the hope of clearing double that by the time I'm a shareholder. And I don't have an ounce of business experience, all I do is see patients and manage my one medical assistant and nurse. Something just isn't right here.
This is just pitiful. Of all professionals to suffer such finanical defeat. I struggled for more than ten years in a solo family practice. Everything that I scrapped in and I do mean scrap went to pay employees and bills to have the privilege to work as a doctor. I have been suffering from gloom and despair just having to retake the certificaiton boards. It cost a fortune to become a doctor and it never ends. The high standard expected is rewarded with the burden of finanical devastation. Where I practice it is the NP, PA that have their own practice that are thriving. How is it fair that they can even have a practice and be addressed as "Dr.' ? If this is all that is really needed to provide health care to pateints then I wasted ten years of my life studying and training. The NP that work locally are LPN that received their RN by correspondence courses and then did one year extra study. Really no formal training or BS degrees.
I have over $100,000.00 on my books and the patients won't pay. That's a lot of work for free. Two years ago I became a paid employee with a salary and I love it. The money is MINE and not my practice. If this ends then I will find another salary job. I will NOT go back into that dark world and bottomless pit of finanical ruin. Before I became a doctor I had a good life and standard of living. I felt like welfare for ten years. My patients made more money than I did and most of them were poor.
Next time I will become an engineer and work for GMC, FORD or Chrysler and make millions, go broke and then make millions when the government conviences the entire world that the economy and work force will fold if someone doesn't bail me out with billions. I can do this without one HEAL or Sally Mae loan.
Good luck to you guy. You are young and a new career might be an option. Hospital CEO around here make half million dollars and play golf and eat out and vacation.
author, why is it that I know several FP's who are making more than I do and I am a relatively busy ophthalmologist. If you're busy, then you must not know how to play the game.
Consider getting a medical student, PA student, nursing student/other to help out, relieve some stress while you actually have to be there. I'm salaried, but I get almost giddy on Thursday night when I know the weekend is coming and I won't see any patients back-to-back in a rushed fashion. We docs need a better way to do what we love.
thanks Silva, culbO3 and others .... take are of yourself and family as a priority!!!
one of the best SERMO threads!!!
... my prayers too.... remembering that ALL of us wage thruthe medical profession thick and thin, yet going home at the end of the day... welldone good and faithful servants unsung but quietly respected in the healing profession we are called forth!
I am sorry that your dream of having your own ofice became a night mare. I do not know about managment company as I do not know them but I was also in Solo practice in Gastro. I did well and made money but it is not worthed. We are doctors we are not buisness orineted and the ones wo are will choke us up. Life is too short. I took leave from my practice and am looking for a job.
Leave it what ever way you can. Declare burn out and see a psychologist or what ever but do not continue. You are providing jobs for others and probably making the management company rich. I am sure your employee and the CEO of management company sleep better than you.
I thought opening a practice means you are your own boss. NOOOP not true. You have to provide for every one else then if what is left is yours. Go and become an emplyoee.
That si what i will do even though I do procedures and make more money than FP.
My advice would be to join the Navy Reserves ( less likely to go to war) then find a voluntary recall to active duty assignment. Once you have orders there are laws protecting you from many contractual arrangements so I think you can be free of that burden. Your wife and young kids will find most of the assigment possibilities exciting and you will be sharing the work load and get a needed break. If by chance you are activated to a war zone the income is tax free. I pays a lot better than New Zealand and they do take DO's and they will pay moving and housing and offer a signing bonus if you go active duty right off the bat. Best of luck.
I really blame the academic people (medical school faculty, residency directors, etc.) for a lot of this. They keep pushing primary care specialties trying to keep their programs filled knowing damn well that their graduates are facing an impossible future. Primary care is a commodity, and commodities can no longer be sold profitably in little mom and pop stores. People want primary care but don't want to pay much for it. Insurance companies merely reflect the public's willing to pay. Only WalMart and Dollar General know how to make a profit selling cheap commodities. Therefore, if primary care is your passion, accept the fact that if you want to be in it for the long haul, you will need to be happy working for a WalMart-type healthcare organization and go with the flow.
Sermo Doc 34, have no idea about playing the game. I am into patient care. If a FP is making more than you then maybe it is you that doesn't know how to play the game.
Once again, I thank all of you for contributing. It helps to know others sympathize with my situation.
I think I have found a good new practice. It is completely different from what I am doing now, allows for flexibility in scheduling and I will actually get 4 weeks of vacation per year! I'll see my family more, won't have to moonlight in the ER anymore (I'll probably pull 2 shifts per month to keep skills up) and I'll be able to get some exercise and sleep again! I'll update in the future as this progresses (still haven't signed the contract yet).
Commodities are characterized by price competition, and health care is not. FP may be treated like a commodity, but the difference is it's integrated into a program into which people are already paying something like $7,000/yr on the average in premiums. That's what makes it different from Walmart. What FP needs is either a better share or independence from the system, with a different insurance plan entirely or, at the very least, repeal of all proscriptions on balance billing.
Hmmm, there's an idea. Entirely different primary care coverage. That's not unlike some of the plans that the state of Florida is offering the uninsured, BTW.
doctorfurl,.... I hurt for you. Solo practice is tough. I am solo, and have been for 9 years. I have practiced where I am now for 18 years, but my first and only past partner broke off 9 years ago. It would surely take a great deal of time to understand your current situation, but whatever you do, don't give up.
I am rural...and lease my building, pay for CPA help from a local firm, and purchase some 'select management' through a very large firm 90 miles away (they do my billing).
I have five employees ( two clinic nurses, one phone LPN, one coding person, and one general secretarial,...plus my wife ( who transcribes for me)) ...and my kids ( who clean the clinic every night - for hire). I lease my building and have for 18 years (wish I could have owned, but it wasn't possible),....own all of my own equipment,....and work 4 1/2 days per week...plus hospital / nursing home / and minimal ER bakcup.
We admittedly live well within our means (family of seven), ...which I believe I learned to do as I grew up,....and which I am certain has helped us along the way. Immediately after residency (which I finished in 1990) we worked at paying off our home (~7 years later it was owned), ....we never have purchased a new vehicle, and never any vehicle unless we could pay cash for it, .....and we do not take expensive vacations (we camp, and have a blast!), ....etc...etc...
I accept "every kind of insurance that will accept me", bar none,....I see any and all patients, bar none....I do not limit medicare or medical assistance numbers,....I do house calls when necessary, .....and have continued OB.
I believe that there is a rural practice for you, should you care to live in rural America. No, it may not be solo,...but the rural community will appreciate you if you offer yourself to care for them. You will KNOW your patients. You would be able to "do things" out there as well. I have done colonoscopies, EGDs, OB/Gyn Ultrasounds....all for 18 years. My residency was a county hospital setting where we had to learn to do many things.
I share these things ONLY, I trust, to point out some of the practice differences that I believe exist between Metro and Rural. I have the sense that metro medicine is dog eat dog. Oh, there's some of that out here as well, but not as bad,.....I don't think. Not yet anyway. It's Obama that's going to hurt me.
I NEVER follow my bottom line financially. I do not let myself "do things" to "make more money". I care for people...and let the dollars to what they do. Sure, I do my best to be good to my 5 staff, ...be careful with resources, ...and run things well,....but I never fret over the income. It is not worth doing. If it gets too low someday, I'll have to decide, like you, what's next.
I will admit that I have never gone through what you are. I feel for you. Do not give up. Seek wise counsel...and listen to them. So what they tell you to do. Reduce your debt where at all possible. Proverbs 3:5&6 jdt
I am more convinced than ever that we should advise our kids to choose a different career than medicine. We have been robbed of a lot of the satisfaction and prestige that used to come with being a doctor. I predict most of our medical problems will be handled by PA's and NP's in the future, leading to a greater number of medical errors.
ellivina.....that day is here and now. PA and NP are already taking over. the nursing profession really stick together and lobby their cause all the way to the legislators. they are vocal about how much their services are needed. just think about it. all you hear on tv is the nursing shortage. not much in the real world news about doctors. we read and hear about each other at sites like this or medical magazines.
Have you considered going micro---where you have a two rooms, and you take care of everything with your PDA and laptop? Patients make their appointments online, or come in and wait, as in the good old days.
I'd send a lawyer letter outlining the breach of contract on their part to your management company and terminate. You aren't worth their time or money to pursue. Send a copy to your state's Attorney General as well.
Then start accepting payment at time of service from your patients, and let them file with the insurance companies. Or if they don't want to file, have a cash rate.
I have a solo practice, and have always been my own office manager. I've been doing this for 8 years. In the last year I've seen my income drop by at least 1/3 due to "neurohospitalists" take away my once successful inpatient practice.
But I would still rather be doing this. I am my own boss. I am setting up my practice to expand to other things, and the loss of the hospital has meant more family time.
In FM that usually means shooting Botox, offering anti-aging "medicine", and buying a laser, none of which actually is practicing FM. It's a shame one has to accept a lower than average income for one's own specialty for actually honestly practicing that specialty.
drfurl, Join your AOA brethren and myself in DC on March 5 for DO Day on Capitol Hill, so that the guys making decisions have any idea the real impact of these ridiculous ideas. I am in my 3rd yr. of solo practice and almost embarassed to say that I feel like I am doing pretty well. I keep my salary low, but I love the Autonomy. I play on a tennis league and sometimes play on friday mornings. We have evening clinic on Wednesdays, and are going to start one week on, one week off, early morning clinic starting at 0700, skipping lunch but finishing at 1400. I do procedures every tuesday, and we are very proactive about true preventative care. A lung age on a spirometry report is a much stronger motivator for smoking cessation than 30 minutes of you droning on about lung cancer. I beseech you, truly look at why you went solo in the first place. I couldn't stand signing a time sheet or begging for an up to date cryogun any longer. If my nanny needs to bring my 4 y/o to my office for a little while, well it is MY office. I have 2 very compassionate and thorough part-time ARNPs who do not think that they are Physicians and welcome the opportunity to learn more through chart review and case discussion. I happen to have an exceptional practice management group that I only pay 12%, but I hold their feet to the fire. We meet once a month with the entire team, billing manager, accountant, and HR. I demand to review EOB's and I look for places that we can improve practice efficiency. One month we only did 6 EKGs and we were able to quickly correct the behavior of the MAs and get that back on track.
Don't throw out the baby with the bath water, if you are a caring, compassionate, high quality doctor, the patients will stick around for the most part. Diversify your payer mix, don't ever become too dependent on any one group. One last thought, the grass is always greener, but...I served 11 yrs in the military, got out and went to a mega group ownwed by a hospital, lasted 88 of my initial 90 days in my opt out clause. Went to a smaller very well run group as an employee but hated to ask for time off or having to have 11 owners input for every question, like could we have Bicillin in the office. My personality and practice style is very well suited for solo work, and it sounds as if yours is too.
OBTW, the AOA can definitely help you in a big way with these legal battles, contact me and I will help steer you in the right direction. See you in DC?
I got tired of the threats of reduced reimbursement from Medicare and the fact that my salary was the only expense left to reduce. While I enjoyed running my own practice, I calculated that I was unwilling to work for what I could expect to earn and closed the office, having a silent auction for the equipment I couldn't sell. I am now working as a locum tenens in New Zealand and the US and loving it. The lack of responsibility and regular pay checks, as well as the freedom to work when I want to is marvelous. I am in Buenos Aires today, flying back from a trip to Antarctica. I have fewer expenses and no debt, (and was spared from bankruptcy). It is sometimes sad that I no longer provide best practice Geriatrics in a rural community that needs it, but the flexibility of working as a generalist makes up for it most of the time. And the quality of life in general is so superior that I wish I had understood how easy it was to take control a long time ago!
The practice of Medicine has been ruined for primary care physicians. I have been in it 25 years, have been a public health doc , an ER doc, an inpt and outpt physician, spent 2 years in a group practice. I went from inner city Chicago/Philadelphia training to rural America. The paper work has become intolerable. More patients want to do telephone care, E-mail care, there is so much time spent with activities that make no income. Some work is the result of specialists dumping undesirable work on the primary doc. Patients want free things a lot. I could go on and on. I can see the whole thing as a challenge, an opportunity for personal growth and other BS. If you have not done so, walk in the shoes of a solo doc for a few years and see how you feel. There are very fulfilling moments and some wonderful people along the way , enjoy that as you age more quickly and time rushes by. Get out if you can. If you are new , don't get in. Become a super specialist , but that has its own prices to pay. Get into something that you really believe in that does not have a KNOWN track record for burnout. Me, I burned out and just kept working. I have an interesting brain wave pattern -- low frequency alpha that can rise about 10 Hz during mental tasks. Burnout but capable of intense focus and creative problem solving. I work, take mid day power naps using audio-visual equipment like NovaPro 100 , I come home and crash, i spend time absolutely out of the office , I have taken up artistic photography, I try to live in the moment more and realize that life could be a LOT worse.
Just want to say best of luck, do GET OUT before this kills you one way or the other! It is so not worth it!
I am salaried with 401(k), benefits, and a good lifestyle. I am also able to focus on taking care of my patients (all very psychiatrically ill children as I do all inpatient), and never worry about financial stuff. It is great.
I know that we need more docs of all sorts in Montana, so if you think you would like the lifestyle out here, check it out!
In the mean time, Hang In There - :-)
I had a family practice for years but now am much happier working for a state health department. Look at your state health departments. They have insurance benefits and also retirement which you will not get if you are in private practice unless you fund it yourself. My hours are less and I do not have to worry about the payroll, the bills, the billing, ect. I wish I had started working for the department of health for the past 20 years.
I really sympathize for what you are going through. I wish I had some words of wisdom, but alas, I can not offer any. You are only a few years older than I. It's a tragedy that doing good medicine is not sufficient to make it in the world of private practice.
You say you have 5000 charts. I would guess not all of them are active. But if even 20% of them are active you might stand a chance at a retainer practice. Sermo Doc 25 replied above - check him out further at Sermo Doc 25.blogsplot.com. Particularly if the insurance in your region is transitioning to high deductible, a reasonable retainer fee is a great deal, especially for people with families.
You need to ditch the management company, this will be difficult and costly but ultimately possible. If you had a separate revenue stream of cash patients, does this have to flow through the management company? In other words, could you just quietly suffocate their revenue stream from your practice, while staying within the rules?
Osteochick, I left academics a few years ago. I was a surgical specialist like yourself. If you join a good group you will do better and have more control, if you join a bad group you will do less well and feel more screwed than you are currently.
I would suggest (to osteochick, sorry for the thread hijack) that you carefully define your minimum tolerable income for the next 5 years. Get that as a guaranteed base in your contract. They will scream and wail that 5 years is "too long". If they have told you of the financial glories available to you, then they shouldn't be stressed, right? because you will bring in 2x base with no problem, right? [Note their risk: you prove to be lazy, get pregnant, etc.] Also, expect to get a disproportionate share of poorly funded patients and ask about RVU tracking. You have an ok (secure) position right now, dont' move too fast.
With a broken heart and debt up to my eye balls I closed my private practice. The VA pays the bills now. Medicare and Medicaid put me in financial ruin. After paying overhead you can take home about $10 per visit or less from these two insurance companies. You'll pay the waitress a bigger tip than that at dinner. Cash is king. You might try that with that big a patient base. Walking away has been great for my family, hard for me. I'll never go back to solo practice, I'll never have that kind of money again. It didn't kill me the first time, but I nearly ended up divorced, bankrupt, hated by my kids and physically ill. It was still a great job in many many ways.
It is interesting to go back to this in light of discussions in the news about health "reform"
If I understand it correctly, Obama is going to open up Medicare to anyone who wants to buy in. If this is the case, cash practice will probably disappear. Can you imagine anyone buying insurance at $1000/month family or an employer doing the same when subsidized insurance is right there? I laugh when the discussion says that they will make sure that it doesn't undercut private insurance fees. But what it means is that the Medicare fee caps will be in place with no point of service fees or out of network reimbursement, and private insurance will largely disappear.
SOOOOO
It is even more important now to work on getting overhead reduced starting now, not waiting till you wake up with all your fees reduced.
They wii, of course, force EMR on you, so it might be a good time to look into open code software that you can do yourself. If you wrote your note at the time of service and coded it, then the software can generate your bill and you might skip the need for some staff.
<cash practice will probably disappear> I beg to disagree, no offense Sermo Doc 24.
While I too see a crisis, I see an opportunity as well.
Just because, everyone has 'marqui baby medicare' insurance, it does not mean everyone will have access to quality healthcare. (eg Massachusetts). There is a strong possibility that traditional way of practicing solo/small practice will disappear. That means no access to "my good old doctor" who was always willing to listen to my needs and who had 5 staff in his office. Going to a grand central station in New York (University clinics, large groups, Kaisers) for health care is no fun. I work for an HMO owned large group practice. In 3 years, I have not got after-hours patient call on >3 occasions. Reason? We simply dont have a phone system in place that they can use. It is probably intentional, as the same HMO owns our only local hospital and DOES want these pt to end up in ER for high blood sugars etc.
Even currently, many practices do not take medicare and are doing quite well. (eg Barbados) When crisis worsens, there will be more and more people "being forced" to buy their own care with out of pocket dollars. I think much of primary care (basically any service that is not subsidized by alternate sources of income) will be delivered in this model. There will be some (just like now) who would value their pack of cigarette more than their doctor.
Only exception will be IF govt mandates participating in medicare as a condition to medical practice. That day, I will start packing.
Other major theme that could flourish is low overhead, micro-practice. This model may get seriously damaged if EHR is forced upon us.
For now, this is my plan: A) Have an alternate source - moonlighting, attachment to rural clinic, part time hospitalist, etc B) Keep overheads low - take only those insurance which pay at least ok and hassle at least less than ok (lot of variable here). If you lose 10$ a visit, seeing more pt of that insurance will only make you lose more. Insurances that pay ok now, may cut their rates dramatically once pubic plan comes, as they will be in do-or-die situation and they will have nothing additional to lose if they cut rates dramatically as the only hope of survival. All pt of such insurance today could be my cash pt tomorrow. C) Focus on cash patients - This might be my future. D) Do not buy house, do not buy any big stuff (furniture etc) that I can not just discard and catch a flight out of US, if need be.
doctorfurl Family Medicine Posted Feb 03, 2009 at 12:34 AM
Sermo Doc 14: I've considered the military. I am the only male member of my family to have never been in the Army. My grandfathers were Col.s, uncle a general, and dad a captain when they retired. I've even looked into options of converting to ER. Would have to complete an ER residency. Not a viable option for me. I have 3 kids 4 and under. My wife, a PA-C, has in no uncertain words said "that will not happen. You will not go through a residency with this family." OUch.
>> Your wife thinks residency would suck? The Army would make you long to re-do your internship over and over. I don't care how many hours you worked in internship... hot, dusty, barren undisclosed locations with a good chance of a mortar round coming through the roof of your plywood "officer's quarters", thus ensuring that your 3 kids under 4 would never see you again... THAT'S what she should be making ultimatums about. Just my opinion, I could be wrong.
Also went bankrupt due to Medicare and Blue Cross not paying me for months, plus high overhead. I switched to a cash practice but too late; it would have succeeded if the practice hadn't accrued so much debt. I had over 3,000 patients, worked all the time, and saw hospital patients too. That same year, my state's BCBS posted over $100 million in profit.
I've been getting back on my feet first with Locums, and now in the Indian Health Service. You should consider these options. I've been very happy, and made decent money.
If I ever go into private practice again, it would be a cash practice. No insurance companies, No Medicare, No Medicaid. Just OPT-OUT, baby!
UPDATE: I have pulled the trigger to sell the practice. Staff doesn't know, but does know that I might "sell to a larger group" or take on a new staff member.
PLANS: Join a large multispecialty hospitalist group and get out of outpatient medicine altogether. Salaried position with bonus structure, clearly defined work periods, and freedom to rearrange schedule for "kid stuff" (I've got small children). I've got a good situation and contract waiting for me once I get out.
I'll keep you posted. Once the sale goes through, will start a new post about that.
sad, that it happened this way glad, that you were able to get out
just a word of caution.... when you are employed, all you have to do to get your life upside down is to piss off one person (CEO, or usually a senior clipboard nursie) ......... some hospitalist keep a list of pt that they think they will be able to keep in their practice if hospitalist does not work out for them and they end up starting on their own again ........... some hospitalist run hybrid system .......... depending on their contract
...thanks for reminding me why I still work for myself.
I just had a conversation with my daughter, who is an attorney. She told me about a case in which a physician was dumped by her university hospital employer and then couldn't find work because all potential employers presumed there must have been a lot more to her termination than someone simply not liking her or failing to maximize revenue for them. Simply put, the presumption, which her employer had no interest in rebutting, was that there were quality of care issues or serious personal misbehavior that was not being disclosed as part of a de facto plea bargain.
Now I"m sure that's not news to any number of physicians who post here or have read some of the sorry stories, but it's worth reminding you that being employed is a totally different world and you'll need to watch your back in a way you didn't need to while working for yourself. Don't confuse your own idea of doing your job really well with your potential employer's evaluative matrix, which might be 90% a simple "I don't like your attitude".
I looked at a job a year ago and pretty quickly realized, "If these people decide in 2 months they want to terminate me for their own reasons, that I think I'm doing a great job no longer matters and they can walk in one Friday at 4 and have security show me the door, after which I'm professionally screwed. No thanks."
I was "employed" by a hospital group for outpatient family practice fresh out of residency 13 years ago. I thought it would be sweet to work 9-5 and collect a fat paycheck. Then they start controlling everything you do. "See more patients", "too many referrals", "a patient complained that you didn't spend enough time with them". It was a living hell. I had to get permission from the $12/hr receptionist when I wanted to take vacation time. And, I signed up for a 9-5 M-F job, but soon after "they" made saturday hours mandatory. And once one of the medical directors flunky's called during mandatory saturday hours about her sick kid who wasn't even my patient, I offered to call in something, but she informed me "if you don't see him today I'm going to tell Dr. (insert name of medical director)". You will have no respect and will be treated like the "provider" employee that you are.
Sermo Doc 20 is right, if you have nice management then bless you, but if you piss off the wrong person even once they can make your job hell. That's why I have sort of a hybrid career. I have my own practice part time that is bordering on qualifying as a non-profit organization, but I get to make the rules and practice medicine as I see fit. And I supplement that by working part time for various other part time physician jobs just to pay the bills. But I always know that I can tell them to suck-this if they piss me off!
when you work for someone else, a person, place or thing, you lose control of your future. While the future may look bleak for our profession, it is more because we have let it happen.
There are many cash style practices that will survive and even flourish. You just need to do alot of research and manage the transition. Otherwise, welcome to the world of waiting for the pink slip.
I left my partnership for a salaried position in a hospital 2 years ago and have not regretted it . Chalk it up as another victim of damaged care ( and my ex-partner..........).
Dear Doctorfurl, I am so glad to see so many kind and helpful comments. I went the "SimpleCare", cash practice route. Dr. David MacDonald, who co-founded simplecare (www.simplecare.com) came down from Renton WA to my office in Salem, OR to cheer me up and help me see a way out of the crazy worked to death and still broke state that came from having HMO contracts. I started with opening my practice to cash paying patients and then dropped the most onerous HMO. After a while, as a birthday present to myself, I just dropped Medicare and all the rest. I have been embezzled from and if you need help in cash tracking, essential in a cash based practice, please email or call: Manya Helman MD 503-779-3945, Sermo Doc 157@aol.com. I have a second job as the medical director at the local methadone clinic, which has also helped. I plan to get the addiction medicine certificate. I think that solo practice can be done, but we need to help/mentor eachother so that we don't get hurt any more than unavoidable. Best regards, Manya
I have been in practice since 1998, private office since 2006. Employment was abusive because the expectation is that you can and will be in more than 1 place at the same time...hospital, clinic and test lab. In my case, my "supervisor" was a surgeon who did not like that I ordered imaging tests on patients I saw after he had operated on them. My senior colleague was not expected to do as much it seems. I contributed to my enslavement by offering to take call 2/3 of the month to ensure 24/7 coverage until we got a third person in the team...the problem is my colleague rarely did her 1/3. Docs prefered consulting me and often bypassed her on the call roster, but I could not take it anymore. Barely short of a nervous breakdown and bilateral AKAs, I decided to quit.
Private solo practice is heaven compared to employed positions, but it keeps me on call 24/7/365 and involves a lot of paperwork and battling with insurance companies. But.......my feet are not swollen now so that I'm back to my original shoe size. I spend as much time as I want with each patient and I don't see more than 12-15 patients a day. I sleep nearly every night. I order the tests I want and I am only on call when I tell the hospital when I am on call. I make as much as when I was employed also, and I have 1 weekday off every week. And I get home to see my family when they're awake.
But in spite of all the conveniences of private practice, my overall satisfaction is low, particularly since this healthcare reform was announced. I pray the healthcare reform bill does not pass because I know my life can be better and I can soon enjoy my job more (when I drop insurance companies and get someone to share call with)...
...but if it passes...I'll just quit in a few months. ...And then, I will be free.
PS. I was never close to getting AKAs...it was just a hyperbolic illustration of my swollen feet from walking 12-16 hours a day and not sleeping.
I swore I would never, never give up.
You truly need to walk away, before you leave what is left of your sanity behind.
md.sermo.com
I have a solo practice, I'm doing great but I need another doc.
You should be able to make significantly more than the average FP here.
The other option is locums work overseas. I have been looking into a company that places physicians in Australia and New Zealand. The contracts are anywhere from 6 months to 2 years. The weather is great, you get paid, and they furnish a car and a house. It's a good way to get away and forget your troubles for a few years.
Thank you, ladies and gents, for your response. It encourages me on this endeavor, especially to know others have done it. It's not exactly something everyone is talking about in the doctors' lounge. Being in solo practice, I haven't been in a doctors lounge since residency (9 years ago). Even then we avoided it so as not to have too much assigned scut work...
Seriously, thanks. I will be replying to all who offered to PM with me. I will keep this updated daily.
The AOA should be able to tell you where in the world DOs are accepted - most of the developed nations recognize us as equals.
I'm so sorry for your troubles. I would like to hear more from you as you go through this process...just for my learning/knowledge.
I wouldn't worry about the 100k debt too much...if you get a good employed position you can pay that off within 4-5 years easily. It sucks but I think it is better than bankruptcy.
login.yahoo.com
Hearing the hoofbeats of burnout.... time for an adult time out (and having enough time to be with family)
Look into a hospital relationship, not just a small community hospital that will dump you when times are tough though. A practice as big as yours can bring them lots of surgical referrals which is what they like.
The delay and occasionally long periods of time waiting for insurance payments to come in seems to be what gives my practice the biggest problem. (Right now have nearly $200,000 in medicare billing I'm fighting for) When the companies are all paying promptly, I am just barely able to keep things covered. As soon as payments are delayed, then I'm behind in my payments to everyone else again.
I own the building my practice is in, because it is a rural area and there were no buildings that would work for a medical practice available. The bank tried to foreclose once a few years ago during a similar time, but payments came in and we were able to avoid that. So far they are holding off on filing anything this time. If they decide to file before I get the payments in from Medicare, I will be in your position.
Glad to see someone talking about their situation openly. Don't feel like you are alone. Would be happy to commiserate, or offer any help I can.
To the rest of you, whom I'm sure will jump in with questions about the medicare amount...I have gotten both a lawyer involved and the local congressman. Congressman was able to get them to finally process a few claims and send a small check. Senator's help is next on the list. Anyone have other ideas? Anyone know of a physical location to visit to accost Palmetto GBA (Midwest region's medicare provider)?
Who is telling you guys to use these management companies and get lots of staff?
No one knows how to run a practice like the doc who writes all the checks.
If you need a management company, you should not be in a solo private practice.
I suggest you talk to Sermo Doc 9. The guy has some management experience and is good with the numbers.
I have done practice consulting also but it has been a while.
Cbland: had similar problems with Medicare when I wasn't with a practice management company. It was one of the driving forces for me to join with them. I feel your pain, too. I would rather not commiserate (thanks for the offer, though), but instead focus on solutions for you, me, and everyone else. That's why I am responding on the post and not by PM. One idea I have - do you have a billing company? They often have a much better relationship with a warm-body-behind-a-desk-at-the-Medicare-office. Sometimes that's all that is needed, a contact to expedite (or at least minimize delays). I had a nurse a few years ago who worked for CMS, and said that kind of arrangement definitely helps. Sucks you of 8% (at least), but it might be worth it for you. I can tell you it wouldn't be for me. I have stopped all new Medicare patients in my office. They suck too much time for the reimbursement and in fact take me away from higher paying patient plans.
Ellie1: Agree with you entirely. Provigil is from the sample closet. I've taken a long hard look at myself and situation, and limit Provigil to use only after shift work. Still sneaking a Red Bull or two per day...
Lawdoc: Other docs have sworn by use of management companies. In retrospect, they were all in large groups...
DoctorSH: Agree with you, too. I shouldn't be in solo practice. I am actively looking for a group practice. The hospital system I'm talking too is interested in making my solo practice a group.
Drmomof3: Thanks. I appreciate your kind words...
Stargirl65: I'm right with you on taxes. One thing that has worked for me: instead of escrow, I set up an online ING savings account that gets about 3% interest versus the 0.25% I get from a local bank. Not much still, but when you subtract escrow fees and add in the additional interest earned, it's way better. I've set it to auto-withdraw bimonthly, so at the end of the year there is enough for our home taxes. I'm sure you could set that up for other taxes as well. I get the message, though. Income is not enough to offset the taxes incurred.
Sermo Doc 29: Please PM me with the name of the management group you dealt with. Sounds familiar to me... Agree with you, and my lawyer is working on that exact "bailout package" for me in addition to the other strategies and their legal ramifications. I wonder if I could apply for a "bailout" like all these other large companies?
You have to deal wit a little bit of beurocracy but lot less heartaches and headaches that you describe. You see pt's from 8-4 and go home, relaxed. What more, you have
weekends to yourself. VA has all electronic medical records which is the jewel. Once
you get used to EMR's, you will not go back to paper records for any amount of money.
You practice best medicine for pt's without worrying about whether they can pay for certain test or meds or not. And NO billing headaches. It is win-win situation.
Nowadays it seems that the only way to keep your head above water as a physician is to let somebody else do the BS so that i can do patient care.
I gave away my practice for nothing to a local hospital. The only thing I got in return was their committment to handle all the charts and copying in the hopes that the pts would stay at their hosp owned practices.
My wife and I sold our office building and made some money there but that has since evaporated in the stock market.
The coup de grace was when the management company told me I owed them $10,000 bucks after everything was settled. I sent them a five page letter, through my attorney, detailing how they violated the letter and spirit of the contract and threatened to sue them for a large sum. They dropped it ASAP and I haven't heard from them since. That was in 2004.
I have the utmost respect for primary care docs no matter what the specialty. My doc is FP and she is fantastic in so many respects. When I have patients ask me "why didn't my doctor explain that?" I tell them that is why they are seeing me. I take a few minutes out to explain that we are the only professionals in the country who have no control over our fees, etc. And I make sure they understand noone hates it more than their doc, who went into primary care to get to know the whole patient and care for them that way. It is a travesty. Yet another example of our third party payer system being penny wise and pound foolish. Invest in good primary care and preventative medicine and people will have better health....
I wish you the best of luck and hope that this dark time is just before the dawn of a wonderful new beginning for you and those you love.
This is exactly the attitude that will make you go broke. You are running a business and you better learn all of the ins and outs or it will bite you in the ass.
just my 2 cents, but if there is any true wrongdoing, don't be shy about seeing a lawyer to sue as there is enough money involved for it to be done on consignment.
Although I will never be rich, and my salary is laughable for a specialist, I hang on, albeit barely.
Green Lantern, it is possible to do so without committing fraud. But not if you sign insurance contracts. I bill insurance, but I am no one's preferred provider. That way, I can balance bill. It's the only way to survive--legally and ethically.
stargirl, not sure about Maryland, but I know that Oregon and Washington are 50th and 49th in the Union for Medicare reimbursement rates. Our private payors are not much better. Hope you can figure out a plan. It's sad when it comes down to this for so many of us.
Now, after reading your posts I'm suddenly even more anxious than I already was.
From the way you describe your work it sounds like doing another residency would actually be a pay raise and fewer hours for you.
Just stick to the basics- yes, you got screwed by a management co. It's really an irony in itself if you look back when you started solo and then took on a management co. When you decided to be solo, you basically "announced" (in a way) that you want control over your affairs. the co. took you on knowing it can push you against the wall, which it did.
But, hey- that's water under the bridge. You can still make a go of this. You just have to kick the co. out. There has to be a loophole somewhere.
Then, get a trustworthy office manager, one that won't screw you (no Freudian implications, pls.), AND an honest-to goodness billing company (yes there are still some). If you can't, then I agree with locums- the way to go, and it may even be therapeutic for you.
At any rate, good luck. Remember that they can never take what you truly are- hardworking, professional, competent...unless you let them.
(How can I say all of the above? Had been with a big group before, and had high overhead- 25 employees for 4 docs, we rented a big space at 6K a month back in 1998. We each had to see a minimum of 40 pts/day, 5 days a week, aside from inpatients averaging 4-8 per doc per week, PLUS nursing home.
then I went solo in 2001. am still solo, am "in the red" 10 out of 30 days in a month, so I guess that's okay. Can I take on a new partner? I wished.)
send you my p.f. later ;-)
How about 300,000?
that is equivalent to 1000 patient panel, 1$ a day per patient COP, with overheads of 65,000 or lower
Also, you really need to TAKE A BREAK. I know it will cost you the coverage, but you need to STOP and take a rest, to allow yourself the energy to find a creative solution to this stressful situation. Easier said than done, I realize, but just do it!
Slowly reduce the energy drinks, take a daily 30 minute walk, and get a locum for a week.
Ask yourself what you really value most....your family? your health? your sanity? and do whatever it takes to preserve these precious commodities.
You will get through this difficult period, but you need to take care of yourself first.
If there is a minimum to be paid, even if he does not make a dime, he will have to pay that fee
do you have a non-compete clause?? if not, could you set up a cash-only practice and the need for many office staff would plummet.
I saw many good comments above. I also would not be afraid of bankruptcy if it gets you out of the claws of the management company.
The fact that you have a panel of 5000 patients is great! Can't you switch to cash only as Doctor SH did? I would at least consider it. having experience, being in private practice for 5-10 years and having a large following is THE precondition for success in cash only. And, the "management company" would be superfluous, since there is minimal billing required. Cash in advance. No collectons required.
"Amazing Charts" offers an EMR for only 1200 and they do you billing for 8%, using the data you enter into the EMR. Sounds like a good offer.
It obviously depends on your personal circumstances, on your running expenses, mortage, family etc, but an adventure into Business as Cash only might be worth it. What do you have to lose?
First I would like to say so sorry for your predicament! After reading your story, I was immediately concerned for your mental and physical well-being as it seems that you are spiraling down into a deep abyss. The anxiety level that I sensed seems on the verge of mania and your wife, it seems, is attempting to corral your urges to enter ER residency. Just that comment alone was a red flag that you are truely reaching anxiously and aimlessly about. Quit the modafinil and whatever else you may be indulging in as you need to climb out of this hole with a sane and clear mind.
Too many physicians lead lives of self torture and quiet desperation. Most high earning specialists make money because they have high fixed costs, but times are changing. Low overhead and fixed cost are the keys to success. If you are a PCP, you can run on low fixed cost. Patients will always pay for quality, caring, and genuine physicians.
I suggest reading Rich Dad, Poor Dad and rereading the House of God.
In any case, please remember that you owe it to yourself and your family to stay healthy, sane, and available to them. Nothing else is more important than this.
Good luck and God Bless
1.Marketing Your Clinical ... Third Edition by Neil Baum, Hardcover - April 2004. $77 This book contains the sum of all other advice that I had ever heard before. It is an absolut must for private practice.
2 Practice Management: A P... by Christian Rainer. Paperback - April 2004, $28.00. Very practical, basic, down to earth, easy to read, written by a physician. Since it is short, you may have time to read THIS. If you only have time for one book, this should be it.
3. Think Business! Medical Practice Quality, Efficiency, Profits, Paperback, 2007
by Owen Dahl, 225 pages, by Greenbranch Publishing. $64 and worth it. Looking at the topic more from a much more economical and business perspective. Written by an office manager with a talent for teaching. More complicated, kind of an MBA for the office.
4. The Successful Physician: A Productivity Handbook for Practitioners. Paperback, $40
by Marshall Zaslove. More of a great guide to personal productivity and happiness, which of course will have an impact in your practice. Very good.
5. Also consider Steven Knoop "Concierge Medicine". - a great intro into cash only medicine. Might just be the solution for you!
The "Guerilla Marketing" Series. I would start with the basic or or two books. Most of them are very good, and inexpensive. It inspires and motivates you, makes you creative, gives you ideas.
Please be very very very very careful with physician recruiters!!!!!!
They represent only a very small segment of the available positions, and the recruiter positions usually are the less desirable ones! Please check the blog "A Physician on Job Search and Practice" for tips on how to find a job. Also look on WikiHow "Hot to find a physician job"
Physician recruiters are salespeople that DO NOT have your best interests in mind. They routinely fudge over the drawbacks of job just to sell them.
And , since they are not physicians, and since they have not walked in our shoes, they do not know as well as we do what matters and what doesn't.
And a recruiter that speaks for 10-15 minutes with a potential employer will not be able to tell you much about a job anyway
Huberetal: I'm glad you are in a good situation now. Looks like I'm headed down that path...
clinped: Good advice. Thanks for words of encouragement. I hadn't thought about teaching, but I'll look into it...
Sermo Doc 38: Thanks. You've lifted my spirits with your comments.
haystack: Already in the planning. When I started realizing that this was going to happen (about 2 months ago) I contacted an attorney who wanted to have my involvement in a law suit involving about 10 other doctors against the management company. My personal attorney advised against it, as it may affect our ability to sell this practice, or have it taken over by a larger entity. "No one will buy into this if there is a lawsuit pending." I'm waiting for the dust to clear to go back to the attorney and have him work his magic. He estimated that the case would last about 1-2 years, and said I can join it if I decide later.
migrainemaven: Agree, balance billing is a must. How did it ever happen that all contracts don't allow primary care physicians to balance bill? It chapped my ass royally recently, when I had to pay balance billing for anesthesia services on my kid's myringotomy tube placement. I said to my PA-C wife, "Why in the hell can't we do that?"
klong72: I'm laughing, genuinely. I probably would be making more money in residency, especially if I could moonlight.
daverey60: good ideas, thanks for the comments and I'll keep at it..
wplummer: I knew there would be other people on Sermo with my or similar situation. I never thought I would find so many willing to tell me about their experience. This whole post has been therapeutic for me. I agree with your comment. Also, there is a pre-med student that is the daughter of one of our medical assistants. I have told her not to go into primary care, or even medicine for that matter. She wants to be a surgeon. "Go into anything but family, as you can't subspecialize much in family practice."
BeReal: Agree with the need for rest. I'm likely to get a locums soon, but will have to work elsewhere in the meantime (I'm a month behind on my mortgage...)
martina: noted your comments, thanks. Greatly appreciated.
Sermo Doc 50: see my first response above on this comment...
abc1530: Amazingly, there is no noncompete or restrictive covenant in the contract. They just make it so hard to leave, and sue your ass if you do before hand, that most people can't afford to fight it. An insider told me once, that whenever they are in a lawsuit, they ask "how is this guy fighting this?" Not, "does he have any case, " or "what did we do wrong?", hell no. They use the court to strong-arm their docs. I hadn't thought of the cash only thing. I worry about using that model in this area, as most of these folks are young, middle class, live paycheck to paycheck (hell, that's me). I'll definitely look into it.
To ALL: Thank you for your responses. I'm a little behind in responding, so if I missed you, It is still greatly appreciated. It's now 3:30 am, and I need to get my usual 3-4 hours of beauty rest so I can move the meat tomorrow. Thanks for the great advice and helping me find hope in this horrible predicament.
It is difficult to manage your scenerio on the meds both Rx and OTC that you consume. You are constantly pushing, pushing, pushing. Stop. Patiently finish your ER obligations. Save as much as you can. Decrease your expenses both personal and business temporarily. Just because your management company wants controversy, doesn't mean you have to hire legal advice and pay pay pay for probably nothing. Let them pay pay pay for legal advice and when they are finished then you can stand up and address their issues and requests. In the meantime, take two weeks off from your private practice. Private practice includes management whether we like it or not.. Several good books have been mentioned above. Your 5,000 charts might need to be checked to see who didn't follow up. Man, I know many can work as employee for people or companies who want to make money from them but it takes a lot of visits per day to pay for that many salaries. It seems we can't make as much in private solo practice but working for others means no or little autonomy in how you want to practice. Think about it. Take time to stop and ascertain your situation and where you think you should be in this endeavor.
I have been there and done that more than once. Currently struggling to keep doors open in solo private practice. Recent economy has hurt hard and heavy locally. But, lo and behold starting to pick back up. Good luck to you.
I have pursued non-clinical work with varying success - many have left practice like I had to.
Today, I got two more contacts on potentially joining a group. My hopes are to potentially set up a bidding war, have the principals bid up on a salary or bonus and/or benefits, etc, until my debts are paid off or I get a really good salary. I can still hope.
Another factor that is weighing on my head is my wife has MS. She does well, is working, and doing fine on Copaxone. I've got to have a job with good (as it gets) health insurance. Hence the need to look for large groups. The stress of all of this is not good for her condition or for my hypertension. My dad died of a heart attack at the age of 57. I do control my bp and LDL with meds quite well, and he was a smoker (I'm not), but suffice it to say my FamHx worries me at times. I'm keeping my fingers crossed and saying prayers every day.
Stop the provigil and the energy drinks, STAT.
Tell you wife what is going on so she fully understands (if she doesn't already). She needs to know how bad things have really gotten. And as much as everyone likes to blame MS flares on stress, there are no studies that demonstrate it, so stop "protecting" her and start working as a team with her. Yes, the meds are expensive and she'll need continuous insurance coverage unless you want to pay ~$1500/month for meds out of pocket.
The kids are young, and aren't in school. Move to a state with tort reform and a low cost of living and a reasonable public school district.
Then let your lawyer handle it so you can get a fresh start. Hopefully, others in here will see the mess a "management company" put you in. Work for yourself or join a successful practice elsewhere where you can become a partner. Don't trust any middleman with respect to your career. Good luck.
Goal is to minimize office overhead.
I use ringcentral for phones- web based system 50.00 per month.
My EHR- Office Ally 30.00 per month.
Billing is through office ally No fee service they are a clearing house paid by insurance Co.
Don't get ripped off by other EHR. They should all be low cost or free.
Office staff of 2 - 1 front office and 1 MA.
Only contract with efficient good paying PPO. Emphasize Cash up front payment. Provide discount to cash patient.s. I charge 80.00 per OV for cash at time of service.
Dispense generics to cash patients. It is profitable and appreciated by patients. I use PDRx.
Accommodate Cash patients with Appointments within 48 hours. May want to consider following your patient in hospital and SNF. Don't need to moonlight you will be busy with your own patients. Its hard, it can be done. Please seek help from an FP/Internist regarding Provigil and other issues.
We are trying to survive. There is little support from other physicians in local community. I think we are just too proud to express our situations and emotions. Realize that your health and your family is the top priority in your life.
Be EXTREMELY careful with selling your practice to a hospital or PMG especially if you are going to stay as a physician!!!!!!!
You have to rely on their accounting and WILL end up in the hole which will make you more dependent on them and perhaps unable to leave due to money owed them!!
I have had some experience with this. One doc in our sold his practice to a hospital and now owes them $200,000 which they say they fronted him tokeep him afloat in his own practice!!
He is still having to moonlight in Urgent Care.
Please just get out (with some money if u can) and go where docs are needed and you will be happy. You can get group insurance for your wife.
Keep O/H down!!!!!!! That is the name of the game today.
My take: If you're really intent on leaving the practice, transition your patients to other docs, while still cashing the "aging collectibles". You have to give your patients, by contract with insurance companies, about 2-3 months' notice (depending on the ins. co.) your closing the practice. You should also "advertise" the closure per your state law (in most states, check w/ your lawyer). This should be during the "phasing-in" of your new assignment- hopefully, with a bigger practice, not a hospital entity.
"But wait", you say, "there are all sorts of FP jobs available that they can't find anyone to fill". True enough, but those are primarily "capitalize as you go" jobs. That is, a hospital may create one, but you'd damn well better be ready to pay them back by means of ordering tests people don't need and making lots of referrals (that will lead to more tests patients don't need). Hospitals aren't looking to create real FP, they're looking to create their own version of primary care, sort of an urgent care/clinic "fill in the gaps and round out our services" dumping ground for patients that they really don't know what to do with after they've done little more than suck them dry of insurance revenue and still not "fixed" them with their expensive diagnostic test driven hospital and specialist centered care.
And, if you don't believe that, then you need to look no further than their replacement of FPs with NP/PAs for a whole lot less money. It's not primary care they want, but the appearance of it, and "mids" can give them that and be more compliant in ordering the testing they want. FPs fail because they offer better outcomes to a provider that wants more process.
The future of FP, if it has one, is in jobs created by the current payers - employers. It's employers who are going to have to capitalize the practices, creating jobs for the FPs whom they need to take care of their employees in a way that focuses on greater efficiency and convenience and better outcome rather than more process. Until then, I'm saving a heck of a lot of money for a whole lot of payers who can't see what I'm doing and don't have to pay for it, while being of less and less value to a hospital centered system that hates me for being good at what I do because they care less and less about the patients and more and more about revenue.
It's a difficult time.
I've reviewed all the input, what a wonderful group of caring docs. What invaluable input. I've learned a lot, and I'm a busy, practicing solo psychiatrist with a very large practice. So many of us care enough to contribute. I've learned a lot from all these very able docs.
i'm young, single, looking to become "un-single" one day, and want to leave my current academic salaried position....but perhaps this is not the way to go????
What can you do? Nothing, they have the money and lawyers on their side. Maybe consider academics....not perfect but at least you can survive.
The most aggressive personal advisers say the same thing: you *can* restart and rebuild, whether it's in clinical practice or no. As physicians most of us aren't trained to think that way, but it's true -- and always has been. Don't let yourself be fooled into thinking there's nothing else but The Box.
I feel your pain!!!
After 23 years of solo practice in Internal Medicine, the constant harrassment of Insurance Companies, lower and lower Reimbursements and increasing overhead have given me thoughts ranging from suicide to claiming disabilty, ( I have five stents )
Three years ago I was offered the "Golden Parachute" from the company that runs a conglomerate of Hospitals and I spent 2 sleepless weeks thinking about turning over my practice. I did'nt and the group that had been formed dissolved almost as quickly as it was put together.
I have never trusted corporations and do not expect that my opinion will change esp after reading the comments so far.
I hope to last long enough to see that primary care begins to get reimbursed for the work they do as I suspect that within 5 years there will be a serious shortage of providers like us.
I realize that my situation is far different then yours but solo practice with or without a binding contract is difficult to say the least.
I have no legal expertise to lend, only my ear. It seems that there are quite a few individuals here with sound advice, listen and learn..
You are of no use to anyone if you drop dead from an MI and your children need to remember their father fondly as does your wife. (trust me divorce will be the last straw)
Remember why you became a doctor and find a place where you can ( as best as possible given the current circumstances) find peace and a measure of happiness.
The initial cost may seem outrageous but you have quite a few years to recover and you will!!!
God Bless and good luck
Review the terms of your management agreement. There should be an expiration, and if it automatically renews, review the termination section. You typically need to give some type of notice to not renew the agreement or terminate without cause. There should also be a clause for termination for cause. Obviously, the former would be ideal and not require your attorney. A letter from you giving 90 day (or whatever it states) notice terminating the agreement should be suffice. Hire a billing company for no more than 8% (no more than 2% of capitation). There are billing companies that also offer EMR portion as part of their percent (AthenaHealth and SysInformation are two good ones). Employ a good front office and back office with one of them responsible enough to "manage" office duties such as ordering supplies etc.
Another option, add a partner to split the overhead. Don't hire a doctor, have someone join your practice that will commit to paying half the expenses. If you don't have the space for two doctors seeing patients at the same time, be creative with your schedules. Extend your hours a few days week and shorten the others. The days you work only half day (am) the other doctor can work the afternoon and early evening. You are still accessible on a daily (mon-fri) basis for patients and offering evening appointments on a day or two. The goal is to maximize your office space and reduce your share of the overhead. Opening your office evenings and weekends can also help. You and your partner can share those shifts or hire a mid-level to work them. Your overhead will only increase slightly, but you can increase income from the additional patient visits.
Additionally, add ancillary services such as waived lab tests and dispensing medications. Many of these have little overhead and are easily reimbursed by either the patient paying cash (rx dispensing) or insurance (labs).
I joined a family practice over ten years ago and I am happy I stuck it out. It was difficult the first couple of years, similar to your experience, but now I have a healthy practice, income and life. You took the risk and sacrifice, you will reap the rewards. You can always sell your practice (if only for the amount of outstanding debt), but why start over and go through the same agony of building a patient base when you already have one? Even as an employee, you will still be accountable for your volume and productivity. You've described an ideal location and patient demographic, if you really don't believe you will succeed, then contact me, I might want to buy your practice ;).
first... try to decrease your hours in office and increase er... to get cash in... part time employees , 20 hrs only .... you MUST get sleep... .. and get positive emotional balence, positve intellectual balence and phsycial balance to go forwardl... you are still best working for self..but NOT as a slave... eliminate junk insurnances and move to cash care... then you can succeed.. AND patient listen to what you are trying to teach them and appreciate it too.. great parteners and not just passive demanding patinets... and yes .. your common sense probably was better than any management co which puts a fixed expense on your plate.. so strategize.. and ASK them specific questions to put them to work... and yes they may be total incompentents but if you can;t get out of contract then make them work ..if not only just to answer calls from your wife!!!!!! lol
Downsides: I'm an employee with little or no say in policies. Urgent care is not FP; no chronic disease management, only episodic care. May have to see over 50-60 patients per day, with volume-related stress. Lastly, although FP's have no problem with handling the medical complaints, Urgent Care is not something I would want to do for a career, particularly after the residency training you and I went through.
Leominster Hospital (affiliated with U Mass Medical Center) would be a good source of information and might be willing to help you set up practice here.
Leominster is a one hour drive from Boston. Good luck.
You really have to be ahead of them to make this work, but if you don't mind this aspect, it's really great to be able to walk away from a bad situation instead of feeling trapped, and you are in charge of whatever time off you want.
Good luck!
We trimmed , fat, became more efficient, and our employees, have more incentive to be efficient as well. We gave good bonuses our first 6 months, better than our CPA said we should have, and really generous per my wife and atty.
Maybe we are stupid, but even in a recession, in a chronically economic depressed region, and with much competition, we are doing well, and when the economy recovers , I hope all the PCPs, like me, can survive and prosper.
The reality is that we our lambs being led to slaughter so any one of the "pious' entities whether they be politicians, insurance bureaucies, regulatory agencies, or the blogsite dujour claiming to provide quality info on the provider's name you type in can claim victory over the medical field which is raping the system. There is already a steady drum beat to get us all to be equated to the U.S. Postal Service.
So be it. Let the AMA become the union and we as doctors the employees. I love their dress code at the Postal Service. The Armageddon that approaches will not be because the banking system will fail. Rather the delivery of healthcare which is responsible for 14% of the GDP, if I read correctly on one of the postings, has to collapse before we as physicians are valued once again for devoting our lives and sacrificing for the sake of society's well being.
I am currently doing OK, but stress especially over managing others. Brought in a part time doc 3 years ago which brings a whole new set of issues.
Biggest things that have helped
(1) I have an office manager, but she has clinical skills and business skills, so she can help in all areas of the practice.
(2) Farmed out billing so that it didn't rely on people in my office getting it done - they only charge me 5% which seems pretty reasonable.
(3) Have joined with others for help with call. Also utilize a local nurse triage service, which takes the stress off of phone calls at night and on weekends. Costs me some money, but I recoup much of it by charging patients directly, and they appreciate speaking to someone who has not been working for 72 hours straight.
(4) After a lot of soul searching, I decided to give up weekend hours. We are fortunate to have many pediatric only urgent cares who are staffed by board certified pediatricians and who communicate well with us. This frees my weekends except for rounding and allows me to spend a lot more time with my family.
I don't like the way my bottom line looks right now, as little things such as "fuel taxes" keep making my supply costs go up and up and up, but I figure I can always protest them and switch companies if I have to.
I am glad to read about all the difficulties with management companies and the like - I have been approached many times by groups to do this - it seems they no longer exist soon after.
I don't foresee being able to do this for a very long time and would love to hear from others about non-clinical careers they may have found happiness in. I rack my brain all the time trying to think of what else I might do and just can't seem to come up with a good alternative.
Good luck.
Olinder MD
Stay tuned. Think outside the box. Look for for places to partner and collaborate with other physicians, business, and even hospitals. Don't feel the need to roll over to hospital pressures, you will find there are many competing forces, and the political climate is right to provide alternatives to the status quo.
Can't offer any advice as I am in trouble too. Just know you are not alone.
I'm letting you know this just to show that not every PM group is bad, though I've been on the wrong end of one of those. I just turned 40, and have 2 young children. I'm on call one day a week and one weekend in 6. I take no hospital call, thanks to the hospitalists, so I can spend my call days anywhere where my cell phone has coverage. If I have to answer more than 5 pages during an entire weekend, It's a busy one. We're looking to expand the practice, with a goal of reaching 20-25 docs by 2015, so if you want to come to California, send me a message.
Firstly, we need to find job interviews. There are, I dare say, generous available sites and practice types that need to invest in a competent, thoughtful, young physician who's best friend is named, "Hard Work". It will be best to limit your interviews to large groups and/or institutions, as they will need to shoulder the $100K debt that you have left on your practice. In short, have your attorney find an appropriate contract that will be fair to the both of you, see if you and your family can live for the next 5 years in that location and sign it.
It is, of course, commonplace for institutions to offer "income guarantees" to physicians starting a practice. The economics work a bit like this: M.D. needs 3 years to build mature practice, likely they will need somewhere between 45-100K over the first year to accomplish this, and the agreement expects that the loan will be forgiven (but still reportable by you as income, later) over the remainder of the contract. The institution makes money, in that, for every $1 the practice earns, $7 is generally generated for the institution at various levels. Further, if the physician is of good moral and ethical quality, the institution has the opportunity to keep them in the community long-term as they've now established roots.
In this scenario, everyone wins...physician, patient, and institution. With the newer model of health care rapidly coming into focus, primary care physicians may likely double their incomes, and $100K is just not a large figure of investment in the right physician. The key point to remember is that you'll need to find the correct health system that already has an established large patient base and needs only a hard-working, excellent physician to provide a long term commitment to the community.
Trust me on this one.....these opportunities are out there today and ready for you to find. Make a few telephone calls, get a service to three looking on your behalf and fly you and your wife out to interview at a few places. I can see this problem being solved within three months if you and your family desire it. If you don't find what's right for you, send me a note and I'll see if the local system that we have in place can't provide an interview.
Keep practicing high quality medicine and there will always be a place for you.
J'
Sorry to hear about your situation.
Do you want to move to TN?
I know a hospital there near Dunlap that will guarantee your income for 3-5 years- with $250,000.00/year. If you are interested, please let me know.
medicine. Neither I wanted to deal with kick backs, ordering unncessary tests or stress about malpractice constantly. VA positions are the best kept secrets in this day and age of medicine with HMO's and poor returns. Great balance of life and work.
Have to say that I had your same attitude years ago, but learned my lesson with this whole managed care ordeal. Have to be proactive and aware of what regulations the government wants to bestow upon you. It was this, "what can you do" attitude that got us in trouble in the first place.
I was solo for 9 years, and had a partner for the last 12. We've avoided joining a hospital system like the plague; too many of our colleagues have succumbed, then left in disgust after being mistreated. By working 10-hour days and trimming overhead to the bone, even in a city with high managed care penetration and relatively low reimbursements, some years we make incomes into 6 figures. Many of our colleagues are going the concierge route, with pretty good success so far. We have serious reservations about the ethics of that, as we feel that we need to remain available to our lower-income patients as well. I'm also a licensed attorney, but discovered in law school that taking care of patients is much more meaningful to me, if less lucrative.
The most common situation I see with good docs failing practice, is that they don't have the knowledge and don't commit the time to practice management. They commonly try and work harder and cut the wrong costs, rather than make good investments (like expert personnel) and dropping bad payors. Most of them should have been employee docs from the beginning. The best thing I learned in business school was how much there is to learn about business.
The military: not a bad option, if you're temperamentally inclined. Your wife will have to accept the possibility of deployments and separations, but it sounds like you're already not home that much. Also might consider the Reserve forces -- they have bonus options, training opportunities, loan repayment programs, and the like. I speak from experience -- I'm at 17 years of AF time myself, and am an active member of the Air Nat Guard.
Australia/NZ: Don't know about DO's -- but it is free to ask. I went to AUS with Global Medical Services (I think they've changed their name, but you could google them) and really enjoyed the experience. Took the wife and kids with me. The pay is lousy, but they did give us a car and a housing allowance. Unfortunately, the allowance isn't close to what it costs to rent for a family. Still, it was a good professional experience, a good personal experience, and a way to recharge the batteries and get interested again.
Balance billing: sorry to hear about your being charged this for the anesthesia bill for the BMT -- when I had my own practice, I never balance billed colleagues. I always felt perfectly comfortable billing the insurance co, but not fellow professionals.
Best of luck with your transitions
UNCLE SAM NEEDS YOU!
The commentary as a whole is discouraging -
Life seems too short to slave away under those stressors.
I have a close friend who recently had a near-death experience, and as a result has had a moment of clarity regarding what is important to them. Their employer doesn't know it yet, but when their disablity benefit runs out, they're gone!
New mottos include "have little, want less;" "live in the moment;" "just say no."
As physicians we are not good at any of that.
Hopefully you have a moment of clarity right now - take a deep breath, get a night's sleep, and use it. Good luck, and God save us all.
Until physicians have to right to form a union and bargain collectively, employed physicians have no power and no security.
Are so many of us really OK with being told when, where, and how to work by a business manager with half our intelligence and none of our commitment to patient care. Please think back to college when you were studying so hard. What was your business manager doing? Male or female, I have yet to meet one who doesn't boast of their drunken debauchery during the time you were sweating it out in college, medical school, internship, residency, and fellowship. When you work harder to produce an extra dollar, does it really go in your pocket or theirs? More importantly, when you give control of your practice to a businessman, your patients cease to be patients and become a mere revenue source - as do you. If you insist on caring for the patients as patients, you will be eliminated. After all, you gave them the power to do it.
It was the best move we ever made as a family. Incredible country, incredible experience, not to mention it was great to work in a medical system. Despite the fact that our tenant at home trashed our house and left us holding the bag for about $3500, that I had to manage a remaining employee to copy records and still pay the rent on my office building as well as our mortgage, my dad died while we were in NZ, and I had my employee implode when her dad died and I had to find a replacement for her...I still had an incredible relaxing, rejuvenating year. The pace of life there is so laid back and the kiwi's (New Zealanders) embraced all of us.
I'm also sold on Socialized medicine...the patients were happier there, but more importantly, the DOCTORS were happier there!
We returned and re-opened our practices a year later. Financially it wasn't easy at first, but we survived, and so did my sanity.
Good luck wherever you end up.
for a good office manager, you have to pay 40-60k per year, or 4-5 k per month.... with taxes and other employee expenses, you are looking at 6-7 k per month... AND, there is NO guarantee the manager is doing a good job... instead, i have opted to see a few less patients each day, and optimize my collections / billing.... the revenue i lose by not seeing more patients is made up with the savings of not having a manager and higher collections rate and efficiency ...
AND, most importantly, i get home at a decent hour, see my family, and get a good night's rest....
if you spent a fraction of the time you are spending in the ER, you could manage your own office very efficiently, as well as save your health and marriage....
good luck...
I have over $100,000.00 on my books and the patients won't pay. That's a lot of work for free. Two years ago I became a paid employee with a salary and I love it. The money is MINE and not my practice. If this ends then I will find another salary job. I will NOT go back into that dark world and bottomless pit of finanical ruin. Before I became a doctor I had a good life and standard of living. I felt like welfare for ten years. My patients made more money than I did and most of them were poor.
Next time I will become an engineer and work for GMC, FORD or Chrysler and make millions, go broke and then make millions when the government conviences the entire world that the economy and work force will fold if someone doesn't bail me out with billions. I can do this without one HEAL or Sally Mae loan.
Good luck to you guy. You are young and a new career might be an option. Hospital CEO around here make half million dollars and play golf and eat out and vacation.
one of the best SERMO threads!!!
... my prayers too.... remembering that ALL of us wage thruthe medical profession thick and thin, yet going home at the end of the day... welldone good and faithful servants unsung but quietly respected in the healing profession we are called forth!
Leave it what ever way you can. Declare burn out and see a psychologist or what ever but do not continue. You are providing jobs for others and probably making the management company rich. I am sure your employee and the CEO of management company sleep better than you.
I thought opening a practice means you are your own boss. NOOOP not true. You have to provide for every one else then if what is left is yours. Go and become an emplyoee.
That si what i will do even though I do procedures and make more money than FP.
I think I have found a good new practice. It is completely different from what I am doing now, allows for flexibility in scheduling and I will actually get 4 weeks of vacation per year! I'll see my family more, won't have to moonlight in the ER anymore (I'll probably pull 2 shifts per month to keep skills up) and I'll be able to get some exercise and sleep again! I'll update in the future as this progresses (still haven't signed the contract yet).
Thanks, Sermo community. You've given me hope.
Hmmm, there's an idea. Entirely different primary care coverage. That's not unlike some of the plans that the state of Florida is offering the uninsured, BTW.
I am rural...and lease my building, pay for CPA help from a local firm, and purchase some 'select management' through a very large firm 90 miles away (they do my billing).
I have five employees ( two clinic nurses, one phone LPN, one coding person, and one general secretarial,...plus my wife ( who transcribes for me)) ...and my kids ( who clean the clinic every night - for hire). I lease my building and have for 18 years (wish I could have owned, but it wasn't possible),....own all of my own equipment,....and work 4 1/2 days per week...plus hospital / nursing home / and minimal ER bakcup.
We admittedly live well within our means (family of seven), ...which I believe I learned to do as I grew up,....and which I am certain has helped us along the way. Immediately after residency (which I finished in 1990) we worked at paying off our home (~7 years later it was owned), ....we never have purchased a new vehicle, and never any vehicle unless we could pay cash for it, .....and we do not take expensive vacations (we camp, and have a blast!), ....etc...etc...
I accept "every kind of insurance that will accept me", bar none,....I see any and all patients, bar none....I do not limit medicare or medical assistance numbers,....I do house calls when necessary, .....and have continued OB.
I believe that there is a rural practice for you, should you care to live in rural America. No, it may not be solo,...but the rural community will appreciate you if you offer yourself to care for them. You will KNOW your patients. You would be able to "do things" out there as well. I have done colonoscopies, EGDs, OB/Gyn Ultrasounds....all for 18 years. My residency was a county hospital setting where we had to learn to do many things.
I share these things ONLY, I trust, to point out some of the practice differences that I believe exist between Metro and Rural. I have the sense that metro medicine is dog eat dog. Oh, there's some of that out here as well, but not as bad,.....I don't think. Not yet anyway. It's Obama that's going to hurt me.
I NEVER follow my bottom line financially. I do not let myself "do things" to "make more money". I care for people...and let the dollars to what they do. Sure, I do my best to be good to my 5 staff, ...be careful with resources, ...and run things well,....but I never fret over the income. It is not worth doing. If it gets too low someday, I'll have to decide, like you, what's next.
I will admit that I have never gone through what you are. I feel for you. Do not give up. Seek wise counsel...and listen to them. So what they tell you to do. Reduce your debt where at all possible.
Proverbs 3:5&6
jdt
I'd send a lawyer letter outlining the breach of contract on their part to your management company and terminate. You aren't worth their time or money to pursue. Send a copy to your state's Attorney General as well.
Then start accepting payment at time of service from your patients, and let them file with the insurance companies. Or if they don't want to file, have a cash rate.
But I would still rather be doing this. I am my own boss. I am setting up my practice to expand to other things, and the loss of the hospital has meant more family time.
In FM that usually means shooting Botox, offering anti-aging "medicine", and buying a laser, none of which actually is practicing FM. It's a shame one has to accept a lower than average income for one's own specialty for actually honestly practicing that specialty.
Don't throw out the baby with the bath water, if you are a caring, compassionate, high quality doctor, the patients will stick around for the most part. Diversify your payer mix, don't ever become too dependent on any one group. One last thought, the grass is always greener, but...I served 11 yrs in the military, got out and went to a mega group ownwed by a hospital, lasted 88 of my initial 90 days in my opt out clause. Went to a smaller very well run group as an employee but hated to ask for time off or having to have 11 owners input for every question, like could we have Bicillin in the office. My personality and practice style is very well suited for solo work, and it sounds as if yours is too.
OBTW, the AOA can definitely help you in a big way with these legal battles, contact me and I will help steer you in the right direction. See you in DC?
I am now working as a locum tenens in New Zealand and the US and loving it. The lack of responsibility and regular pay checks, as well as the freedom to work when I want to is marvelous. I am in Buenos Aires today, flying back from a trip to Antarctica. I have fewer expenses and no debt, (and was spared from bankruptcy).
It is sometimes sad that I no longer provide best practice Geriatrics in a rural community that needs it, but the flexibility of working as a generalist makes up for it most of the time. And the quality of life in general is so superior that I wish I had understood how easy it was to take control a long time ago!
The paper work has become intolerable. More patients want to do telephone care, E-mail care, there is so much time spent with activities that make no income. Some work is the result of specialists dumping undesirable work on the primary doc.
Patients want free things a lot. I could go on and on. I can see the whole thing as a challenge, an opportunity for personal growth and other BS.
If you have not done so, walk in the shoes of a solo doc for a few years and see how you feel. There are very fulfilling moments and some wonderful people along the way , enjoy that as you age more quickly and time rushes by.
Get out if you can. If you are new , don't get in. Become a super specialist , but that has its own prices to pay. Get into something that you really believe in that does not have a KNOWN track record for burnout.
Me, I burned out and just kept working. I have an interesting brain wave pattern -- low frequency alpha that can rise about 10 Hz during mental tasks. Burnout but capable of intense focus and creative problem solving. I work, take mid day power naps using audio-visual equipment like NovaPro 100 , I come home and crash, i spend time absolutely out of the office , I have taken up artistic photography, I try to live in the moment more and realize that life could be a LOT worse.
I am salaried with 401(k), benefits, and a good lifestyle. I am also able to focus on taking care of my patients (all very psychiatrically ill children as I do all inpatient), and never worry about financial stuff. It is great.
I know that we need more docs of all sorts in Montana, so if you think you would like the lifestyle out here, check it out!
In the mean time, Hang In There - :-)
I really sympathize for what you are going through. I wish I had some words of wisdom, but alas, I can not offer any. You are only a few years older than I. It's a tragedy that doing good medicine is not sufficient to make it in the world of private practice.
You need to ditch the management company, this will be difficult and costly but ultimately possible. If you had a separate revenue stream of cash patients, does this have to flow through the management company? In other words, could you just quietly suffocate their revenue stream from your practice, while staying within the rules?
Osteochick, I left academics a few years ago. I was a surgical specialist like yourself. If you join a good group you will do better and have more control, if you join a bad group you will do less well and feel more screwed than you are currently.
I would suggest (to osteochick, sorry for the thread hijack) that you carefully define your minimum tolerable income for the next 5 years. Get that as a guaranteed base in your contract. They will scream and wail that 5 years is "too long". If they have told you of the financial glories available to you, then they shouldn't be stressed, right? because you will bring in 2x base with no problem, right? [Note their risk: you prove to be lazy, get pregnant, etc.] Also, expect to get a disproportionate share of poorly funded patients and ask about RVU tracking. You have an ok (secure) position right now, dont' move too fast.
If I understand it correctly, Obama is going to open up Medicare to anyone who wants to buy in. If this is the case, cash practice will probably disappear. Can you imagine anyone buying insurance at $1000/month family or an employer doing the same when subsidized insurance is right there? I laugh when the discussion says that they will make sure that it doesn't undercut private insurance fees. But what it means is that the Medicare fee caps will be in place with no point of service fees or out of network reimbursement, and private insurance will largely disappear.
SOOOOO
It is even more important now to work on getting overhead reduced starting now, not waiting till you wake up with all your fees reduced.
They wii, of course, force EMR on you, so it might be a good time to look into open code software that you can do yourself. If you wrote your note at the time of service and coded it, then the software can generate your bill and you might skip the need for some staff.
I beg to disagree, no offense Sermo Doc 24.
While I too see a crisis, I see an opportunity as well.
Just because, everyone has 'marqui baby medicare' insurance, it does not mean everyone will have access to quality healthcare. (eg Massachusetts). There is a strong possibility that traditional way of practicing solo/small practice will disappear. That means no access to "my good old doctor" who was always willing to listen to my needs and who had 5 staff in his office.
Going to a grand central station in New York (University clinics, large groups, Kaisers) for health care is no fun. I work for an HMO owned large group practice. In 3 years, I have not got after-hours patient call on >3 occasions. Reason? We simply dont have a phone system in place that they can use. It is probably intentional, as the same HMO owns our only local hospital and DOES want these pt to end up in ER for high blood sugars etc.
Even currently, many practices do not take medicare and are doing quite well. (eg Barbados) When crisis worsens, there will be more and more people "being forced" to buy their own care with out of pocket dollars. I think much of primary care (basically any service that is not subsidized by alternate sources of income) will be delivered in this model. There will be some (just like now) who would value their pack of cigarette more than their doctor.
Only exception will be IF govt mandates participating in medicare as a condition to medical practice. That day, I will start packing.
Other major theme that could flourish is low overhead, micro-practice. This model may get seriously damaged if EHR is forced upon us.
For now, this is my plan:
A) Have an alternate source - moonlighting, attachment to rural clinic, part time hospitalist, etc
B) Keep overheads low - take only those insurance which pay at least ok and hassle at least less than ok (lot of variable here). If you lose 10$ a visit, seeing more pt of that insurance will only make you lose more. Insurances that pay ok now, may cut their rates dramatically once pubic plan comes, as they will be in do-or-die situation and they will have nothing additional to lose if they cut rates dramatically as the only hope of survival. All pt of such insurance today could be my cash pt tomorrow.
C) Focus on cash patients - This might be my future.
D) Do not buy house, do not buy any big stuff (furniture etc) that I can not just discard and catch a flight out of US, if need be.
And we agree on the danger of EHR to keeping overhead low. That is why doctors should be working NOW to reduce overhead and explore options.
Sermo Doc 14: I've considered the military. I am the only male member of my family to have never been in the Army. My grandfathers were Col.s, uncle a general, and dad a captain when they retired. I've even looked into options of converting to ER. Would have to complete an ER residency. Not a viable option for me. I have 3 kids 4 and under. My wife, a PA-C, has in no uncertain words said "that will not happen. You will not go through a residency with this family." OUch.
>> Your wife thinks residency would suck? The Army would make you long to re-do your internship over and over. I don't care how many hours you worked in internship... hot, dusty, barren undisclosed locations with a good chance of a mortar round coming through the roof of your plywood "officer's quarters", thus ensuring that your 3 kids under 4 would never see you again... THAT'S what she should be making ultimatums about. Just my opinion, I could be wrong.
I've been getting back on my feet first with Locums, and now in the Indian Health Service. You should consider these options. I've been very happy, and made decent money.
If I ever go into private practice again, it would be a cash practice. No insurance companies, No Medicare, No Medicaid. Just OPT-OUT, baby!
PLANS: Join a large multispecialty hospitalist group and get out of outpatient medicine altogether. Salaried position with bonus structure, clearly defined work periods, and freedom to rearrange schedule for "kid stuff" (I've got small children). I've got a good situation and contract waiting for me once I get out.
I'll keep you posted. Once the sale goes through, will start a new post about that.
glad, that you were able to get out
just a word of caution.... when you are employed, all you have to do to get your life upside down is to piss off one person (CEO, or usually a senior clipboard nursie) ......... some hospitalist keep a list of pt that they think they will be able to keep in their practice if hospitalist does not work out for them and they end up starting on their own again ........... some hospitalist run hybrid system .......... depending on their contract
I just had a conversation with my daughter, who is an attorney. She told me about a case in which a physician was dumped by her university hospital employer and then couldn't find work because all potential employers presumed there must have been a lot more to her termination than someone simply not liking her or failing to maximize revenue for them. Simply put, the presumption, which her employer had no interest in rebutting, was that there were quality of care issues or serious personal misbehavior that was not being disclosed as part of a de facto plea bargain.
Now I"m sure that's not news to any number of physicians who post here or have read some of the sorry stories, but it's worth reminding you that being employed is a totally different world and you'll need to watch your back in a way you didn't need to while working for yourself. Don't confuse your own idea of doing your job really well with your potential employer's evaluative matrix, which might be 90% a simple "I don't like your attitude".
I looked at a job a year ago and pretty quickly realized, "If these people decide in 2 months they want to terminate me for their own reasons, that I think I'm doing a great job no longer matters and they can walk in one Friday at 4 and have security show me the door, after which I'm professionally screwed. No thanks."
I was "employed" by a hospital group for outpatient family practice fresh out of residency 13 years ago. I thought it would be sweet to work 9-5 and collect a fat paycheck. Then they start controlling everything you do. "See more patients", "too many referrals", "a patient complained that you didn't spend enough time with them". It was a living hell. I had to get permission from the $12/hr receptionist when I wanted to take vacation time. And, I signed up for a 9-5 M-F job, but soon after "they" made saturday hours mandatory. And once one of the medical directors flunky's called during mandatory saturday hours about her sick kid who wasn't even my patient, I offered to call in something, but she informed me "if you don't see him today I'm going to tell Dr. (insert name of medical director)". You will have no respect and will be treated like the "provider" employee that you are.
Sermo Doc 20 is right, if you have nice management then bless you, but if you piss off the wrong person even once they can make your job hell. That's why I have sort of a hybrid career. I have my own practice part time that is bordering on qualifying as a non-profit organization, but I get to make the rules and practice medicine as I see fit. And I supplement that by working part time for various other part time physician jobs just to pay the bills. But I always know that I can tell them to suck-this if they piss me off!
Good luck my friend.
There are many cash style practices that will survive and even flourish. You just need to do alot of research and manage the transition. Otherwise, welcome to the world of waiting for the pink slip.
I am so glad to see so many kind and helpful comments. I went the "SimpleCare", cash practice route. Dr. David MacDonald, who co-founded simplecare (www.simplecare.com) came down from Renton WA to my office in Salem, OR to cheer me up and help me see a way out of the crazy worked to death and still broke state that came from having HMO contracts. I started with opening my practice to cash paying patients and then dropped the most onerous HMO. After a while, as a birthday present to myself, I just dropped Medicare and all the rest. I have been embezzled from and if you need help in cash tracking, essential in a cash based practice, please email or call: Manya Helman MD 503-779-3945, Sermo Doc 157@aol.com. I have a second job as the medical director at the local methadone clinic, which has also helped. I plan to get the addiction medicine
certificate. I think that solo practice can be done, but we need to help/mentor eachother so that we don't get hurt any more than unavoidable. Best regards, Manya
Private solo practice is heaven compared to employed positions, but it keeps me on call 24/7/365 and involves a lot of paperwork and battling with insurance companies. But.......my feet are not swollen now so that I'm back to my original shoe size. I spend as much time as I want with each patient and I don't see more than 12-15 patients a day. I sleep nearly every night. I order the tests I want and I am only on call when I tell the hospital when I am on call. I make as much as when I was employed also, and I have 1 weekday off every week. And I get home to see my family when they're awake.
But in spite of all the conveniences of private practice, my overall satisfaction is low, particularly since this healthcare reform was announced. I pray the healthcare reform bill does not pass because I know my life can be better and I can soon enjoy my job more (when I drop insurance companies and get someone to share call with)...
...but if it passes...I'll just quit in a few months. ...And then, I will be free.
PS. I was never close to getting AKAs...it was just a hyperbolic illustration of my swollen feet from walking 12-16 hours a day and not sleeping.