Ethical Dilemma: Who to sell your practice to?

[drusso]

Mid-career MD has sunk heart and soul into a creating an opioid-free MSK/Spine practice in New England. Spouse (only child) parents develop severe, chronic health issues on opposite coast necessitating virtual 24/7 care. MD-owner has been living "bi-coastal" lifestyle for 2 years while spouse and elementary-school aged kids stabilize family's health issues. A decision is made for MD-owner to relocate and reunite the family. MD lists practice with various brokers, B2B agencies, etc...no takers. New grads not interested in practice purchase. Local health system not interested in taking over...

Finally, MD-owner gets a "hit" from an "investment group" in South Florida. Several discussions ensue, NDA's executed, purchase agreement drafted. MD-owner's attorney, while doing due diligence and checking references, discovers that "investment group" is a front for a large PI/Chiro outfit with a reputation for developing MVA-OON, ambulance-chasing, Suboxone/U-tox, WC churn machines. Stated business model involves bringing in company doctors (DC's), hiring NP's for S-2 RX's, in-house PT, compounding pharmacy, back-braces, "laser therapy," etc.

Purchase agreement offer is 3.5X EBITDA...

What's your next move?

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[BobBarker]

Put them in the nursing home and move my family back home.

 

[NJPAIN]

Reluctantly sell practice to investment group and move to be with family. Family first . Not my job to save the rest of the world.


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[hyperalgesia]

I would want to protect my pts from harm. If I could notify them that I'm leaving, fine. Or maybe if the other group is using a different practice name, OK. Otherwise, if this group of swindlers is paying for the trust that I established with my patients so they could screw them over, forget it. Keep your dirty money.

 

[SSdoc33]

no good outcome.

either you lose a boatload of money, or you screw over your patients.

personally, i'd sell, but i may be a slimeball.

is this the risk you run when you open up shop?

 

[SSdoc33]

also, is this an actual scenario? or a hypothetical one to further some sort of agenda?

 

[244913]

Mid-career MD has sunk heart and soul into a creating an opioid-free MSK/Spine practice in New England. Spouse (only child) parents develop severe, chronic health issues on opposite coast necessitating virtual 24/7 care. MD-owner has been living "bi-coastal" lifestyle for 2 years while spouse and elementary-school aged kids stabilize family's health issues. A decision is made for MD-owner to relocate and reunite the family. MD lists practice with various brokers, B2B agencies, etc...no takers. New grads not interested in practice purchase. Local health system not interested in taking over...

Finally, MD-owner gets a "hit" from an "investment group" in South Florida. Several discussions ensue, NDA's executed, purchase agreement drafted. MD-owner's attorney, while doing due diligence and checking references, discovers that "investment group" is a front for a large PI/Chiro outfit with a reputation for developing MVA-OON, ambulance-chasing, Suboxone/U-tox, WC churn machines. Stated business model involves bringing in company doctors (DC's), hiring NP's for S-2 RX's, in-house PT, compounding pharmacy, back-braces, "laser therapy," etc.

Purchase agreement offer is 3.5X EBITDA...

What's your next move?

Warn the patients and sell the practice..sounds like the new model would be completely incompatible with what has been previously built before and most of the patients would leave anyways of their own accord.

Or, work harder and hire home care RN to care for spouse's parents and tell my wife and kids to move back to where I live. Or, better yet, move parents to New England.

 

[Mad Jack]

I couldn't do the sale. There's a lot of things I could do, but not that.

 

[SSdoc33]

Warn the patients and sell the practice..sounds like the new model would be completely incompatible with what has been previously built before and most of the patients would leave anyways of their own accord.

Or, work harder and hire home care RN to care for spouse's parents and tell my wife and kids to move back to where I live. Or, better yet, move parents to New England.

im pretty sure the buyer would prevent you from doing this. you would have sign something saying you wouldnt disparage the practice. you may be able to get away by saying nothing or not promoting the new practice. but if you attempt to take it down, its not worth as much to them. i bet a decent chunk of the old patients would buy in to the trash they are selling. desperate patients will do almost anything

 

[emd123]

Mid-career MD has sunk heart and soul into a creating an opioid-free MSK/Spine practice in New England. Spouse (only child) parents develop severe, chronic health issues on opposite coast necessitating virtual 24/7 care. MD-owner has been living "bi-coastal" lifestyle for 2 years while spouse and elementary-school aged kids stabilize family's health issues. A decision is made for MD-owner to relocate and reunite the family. MD lists practice with various brokers, B2B agencies, etc...no takers. New grads not interested in practice purchase. Local health system not interested in taking over...

Finally, MD-owner gets a "hit" from an "investment group" in South Florida. Several discussions ensue, NDA's executed, purchase agreement drafted. MD-owner's attorney, while doing due diligence and checking references, discovers that "investment group" is a front for a large PI/Chiro outfit with a reputation for developing MVA-OON, ambulance-chasing, Suboxone/U-tox, WC churn machines. Stated business model involves bringing in company doctors (DC's), hiring NP's for S-2 RX's, in-house PT, compounding pharmacy, back-braces, "laser therapy," etc.

Purchase agreement offer is 3.5X EBITDA...

What's your next move?

If this was a house sale, you'd know nothing about the buyer and they'd know nothing about you and the sale would be done. And if you hadn't been given this info, the deal would likely already be done. But since you have this information, it makes it a tough decision. On one had you want to sell to the highest bidder. On the other hand you don't want to feel you sold out your patients to a group that isn't going to be treating them the way you'd like them treated. Ideal situation: A second buyer comes along soon, that you feel more comfortable with, and you sell to them.

 

[deleted185747]

Physicians should own more businesses because otherwise there is no ethical consideration. Physicians control what they do with patients and are used to considering ethics for their patients. Businessmen are used on manipulating variables to increase revenue and are unaccustomed to considering ethics. I don't have the answer but applaud that there is a consideration, because if this question was on a business forum the recommendations would only be about $$$$

 

[Ducttape]

I’m not sure your statement is true. The fact that a physician is a businessman may be an inherent conflict of interest.

You are making an unfounded assumption that a physician- businessman will act ethically. My non-EBM- based clinical impression is that, most commonly, ethical considerations are subjugated to the necessity of financial solvency and profit.

 

[SSdoc33]

I’m not sure your statement is true. The fact that a physician is a businessman may be an inherent conflict of interest.

You are making an unfounded assumption that a physician- businessman will act ethically. My non-EBM- based clinical impression is that, most commonly, ethical considerations are subjugated to the necessity of financial solvency and profit.

agreed. there is an inherent, unavoidable conflict of interest in the fee-for-service model.

and this is not only for private practitioners.....

 

[emd123]

Hospital administrators and CEOs care about profits as much as physician practice-owners, if not more. The same goes for employed physicians working on an RVU basis and government run hospitals.

Everybody works for "profit." There are no hospital or physicians that work for "losses." You can pretend, but it's literally not a thing. Even in socialized medicine, there are "profits." The only difference is, the politicians and the government cash the check. No system, private or government, socialized or free market, can run on "losses" very long.

You can talk about "eliminating fee for service" all you want, but there's no way to pay people for their work, accept for paying them for their work. Dress it up, give it a new name, put a wig on it, but to compensate workers providing a service, you have to compensate them for providing a service. They perform a service. They're paid a "fee" in return. If you don't pay the worker (physician or otherwise) for performing the service, the service will stop happening, the worker will stop working. There is no scheme to get around this.

 

[hyperalgesia]

If this was a house sale, you'd know nothing about the buyer and they'd know nothing about you and the sale would be done. And if you hadn't been given this info, the deal would likely already be done. But since you have this information, it makes it a tough decision. On one had you want to sell to the highest bidder. On the other hand you don't want to feel you sold out your patients to a group that isn't going to be treating them the way you'd like them treated. Ideal situation: A second buyer comes along soon, that you feel more comfortable with, and you sell to them.

You can liquidate the assets of your practice like a house. But selling the whole practice includes selling your obligations that you agreed to with your pts. You agreed to follow up with them, etc.

If I'm gonna sell my practice, I'll be looking for a good match for my pts and then I'll notify them all. I wouldn't pretend that I care about them and that I'll see them next month and then sell their medical records and their appointments to the highest bidder as I slink away with the cash.

We have opportunities our whole careers to sell out in one way or another. I'd rather have less money and more integrity.

 

[emd123]

You can liquidate the assets of your practice like a house. But selling the whole practice includes selling your obligations that you agreed to with your pts. You agreed to follow up with them, etc.

If I'm gonna sell my practice, I'll be looking for a good match for my pts and then I'll notify them all. I wouldn't pretend that I care about them and that I'll see them next month and then sell their medical records and their appointments to the highest bidder as I slink away with the cash.

We have opportunities our whole careers to sell out in one way or another. I'd rather have less money and more integrity.

I agree, and that's why I said, "Ideal situation: A second buyer comes along soon, that you feel more comfortable with, and you sell to them."

 

[drusso]

agreed. there is an inherent, unavoidable conflict of interest in the fee-for-service model.

and this is not only for private practitioners.....

There is no data to support that. In fact, the "conflict of interest" might be more salient for non-financial renumeration...fame, power, career advancement, advancement of an ideological agenda...

 

[DOctorJay]

this has been going on long enough...



it's reMuNeration

 

[drusso]

this has been going on long enough...



it's reMuNeration

Wow...I never noticed that...

 

[geauxg8rs]

I’ll buy your practice for this lower amount and take good care of them. I just need the name of the slime all offer as well,
Just for due diligence.

 

[lobelsteve]

Meh. Im good either way.

Renumeration vs Remuneration (reimbursed financially), which is correct?

 

[DOctorJay]

This is part of my OCD and as a previous Latin scholar this bugs the crap out of me. So does intralaminar and translaminar. Those mean within and through the lamina respectively. Interlaminar is accurate.

Back to selling this dudes practice.


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[Agast]

I’m sorry, I don’t see an explanation why the in-laws can’t move to you? That seems like the least disruptive move and either way you and your wife are doing your duty to them by taking care of them. Surely they’re not unstable for transport?

 

[Doctodd]

are the patients being forced into staying with the practice?(rhetorical question)

 

[hyperalgesia]

I’ll buy your practice for this lower amount and take good care of them. I just need the name of the slime all offer as well,
Just for due diligence.

As long as there's no gag clause, I have no problem selling it to whoever.

I just would not be okay with Grandma bringing cookies in and getting told she needs a series of 3 by a Chiro. If I were okay with that, I might as well just do the series of 3 myself. This could be followed by a few SCS trials and multilevel B/L TFESIs. All right before I skip town because WTH, that's why I became a doc, to get as much cheese as possible before I die...

 

[Ducttape]

I assume you are being facetious. don't forget magenta there, hyperalgesia....


emd, I disagree with you to the extent that profit drives our treatment. it clearly is driving your treatment now. bu I don't think about profit at all in this hospital employed practice, because I am salaried. as long as im busy... maybe it is a matter of layers/degrees, but those are important.

(maybe that's why the current admin doesn't like me that much....)


did $$$ drive your treatment in the ER?

 

[emd123]

emd, I disagree with you to the extent that profit drives our treatment. it clearly is driving your treatment now. bu I don't think about profit at all in this hospital employed practice, because I am salaried.

If you don't think 'profit' has anything to do with your payment for treatment, cut the amount of patients you see in half, and see what happens. Then after a month or so, cut your productivity in half again. Let me know what the people who sign you paycheck have to say about it.

 

[Ducttape]

That has little to do with the individual decisions I make regarding what treatment I will give a patient.

You are equating volume to profit. My volume of patients does not influence what I do for each individual patient.


And I am stating that the decision to provide costly treatment is influenced more when the money goes directly into my pockets as opposed to some broad system.

 

[drusso]

And I am stating that the decision to provide costly treatment is influenced more when the money goes directly into my pockets as opposed to some broad system.

Prove it. You are the system.

 

[Ligament]

Meh. Im good either way.

Renumeration vs Remuneration (reimbursed financially), which is correct?

Jesus. My University of Michigan degree never taught me this.

 

[cowboydoc]

Jesus. My University of Michigan degree never taught me this.

My B1G degree (in Journalism, no less) failed me, too. I guess SSdoc is right, I should have coughed up $250k for a private university on a coast.

 

[Ducttape]

Prove it. You are the system.

You can look at my entire practice for the answer to this question. I see about 40% Caid, 25% care, rest WC and private insurance.


I average 4 follow up appointments for each injection. I spend probably 5x the amount of time talking about CBT, exercise and functionality than doing injections.

it’s not about narcotics. Using 2015 Medicare data, I prescribe the slightly less opioids than you and 1/4th of what 101N had prescribed in the day.

I would get a lot more wRVUs and make a bit more from bonus if I gave every patient an ESI or MBB + RFA, but that’s only going to help the system make $$$. Esp with ASC SOS differential.

Not me. And won’t help these patients.