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How do you start your own rehab ctr?

Discussion in 'PM&R' started by SpineBound, 02.21.08.

  1. SpineBound

    SpineBound Large Member

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    I would like to open my own rehab hospital / center and was wondering if anyone knows how to go about this. I have no money, only medical school debt. :thumbup:
  2. JiminyCricket

    JiminyCricket Junior Member

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    Correct me if I am wrong, but I think there are many legal pitfalls to creating your own rehab centers. I dont even think we are allowed to "own" a rehab center because we would be referring our patients to our own center's PT's and there would be a conflict of interest. I think some docs get around this, but it is in less than legal ways and they take on a HUGE risk by potentially losing their license.

    But then again, if we cant own rehab facilities, how do other docs hire PA's to work for them and Psychiatrists hire Psychologists to work for them? Arent they functioning in a conflict of interest environment as well?

    Dont Orthos own most of the private rehab centers? How do they do that?
  3. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    There's always ads for hospitals looking for rehab floor directors - I used to do one, I was the only PM&R in town.
  4. doctobe2

    doctobe2

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    Please correct me if I am wrong- being a inpatient rehab director is not exactly the same as owning your own rehab hospital? However, I am sure there might be some positive similarities, can you please compare these two roles?
  5. SpineBound

    SpineBound Large Member

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    The appeal behind owning a rehab center is that you employ lots of people and make $ off each employee; basically getting paid for doing business and administrative stuff. Being a rehab director I think you are getting paid for your work setting medical protocol, hiring staff, etc.

    How does the whole "self-referral" thing work? Are there seperate companies that are all under the same roof, owned by different people?
  6. tchoupdoc

    tchoupdoc attending

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    Rehab medical director is an administrative position funded by the hospital, mostly from medicare reimbursement dollars. It is a stipend for quality control and oversight. By definition, it does not involve patient care. You can negotiate it as high as you want.

    "Owning a rehab hospital" means exactly that, and I don't know of any physiatrist who "owns" a hospital, or would want to. Ownership is the same as owning a house, boat, bar, etc. It involves borrowing money, insurance, zoning, et al. There may be rehab doctors who are investors in a facility, but I doubt they outright own a facility that provides 24 hour care.
  7. tchoupdoc

    tchoupdoc attending

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    See above post. In answer to yours, I don't know what you mean by "rehab center." If you mean outpatient PT, a single doc could own it. Same as you could own a restaurant. Instead of collecting money from patrons and paying your waitstaff and cooks, you would collect from insurance and pay your PT's and office staff. It is running a business, and I don't think you would need an MD to do it.

    This gets us to the self-referral thing. The advantage the MD would have is that patients would come to see him/her for medical treatment, and then can refer to the therapists that work for him/her IN THE SAME BUILDING. As long as you refer to services provided in your own office, you are not in violation of Stark provisions.

    Before you plunk down a bunch of change as an investor, keep in mind that these provisions can change whenever Congress decides to look at them.
  8. SpineBound

    SpineBound Large Member

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    Thanks, this is helping me formulate what is feasable. An outpatient rehab center is more what I was interested in. I think a bigger building, bigger sign, more staff, and more patients would make it easier to get referrals from the community. I suppose I will start small and then expand once I show a profit for several years (in order to qualify for a large loan)
  9. tchoupdoc

    tchoupdoc attending

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    Why do you want to do this? Just curious. I am five years out, so a relatively new PMR doc, and I don't recall anyone else thinking of this when I was a resident. What you envision may be a very rewarding line of work, but it sounds like an awfully big undertaking.

    PM me if you want.
  10. Disciple

    Disciple Senior Member

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    Sure you can do this if you can compete. Tough to do in a major metropolitan area.

    Who will you be competing against?

    -Corporations like Health South (anybody know if they're still around?)

    -Outpt PT centers, both university and private

    -Occ Med clinics that have PT in-office e.g. Concentra and privately owned practices
  11. SpineBound

    SpineBound Large Member

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    I am very goal oriented and need a new goal! I reached all my previous goals and want bigger and better.

    What I want out of life:

    1) Time with family
    2) Able to take a week off every couple of months for a surf trip
    3) Plenty of money
    4) Feel like I'm doing something good for people
  12. The JockDoc

    The JockDoc lighting up the court

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    Maybe I'm naive and learned enough about the field yet, but I was thinking that physiatrists would be really well suited to open up their own rehab facility. The business could hire physical therapist's, which you (as a physiatrist) could refer to, and collect from further rehab. It could also have orthopod partners, which would mean even more in-house referrals both to and from the surgeons. If you're trained to do injections, you can offer those as well.

    From some of the posts here, it sounds like this is an unusual situation. I don't understand why it would be because it fits with the physiatrists scope of practice in directing patient care from the onset of injury until the completion of surgery, rehab, or whatever procedure if necessary.
  13. DOctorJay

    DOctorJay

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  14. Disciple

    Disciple Senior Member

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    The above link is more of a medical practice with in-house PT.

    It's not so much the services you offer, but your ability to market yourself. PCPs know traditional classifications such as Ortho/neurosurgery, Pain-Management and Occ Med. Insurers usually contract with corporate clinics like Concentra or private Occ med practices for the initial care of injured workers. If you want their referrals you're going to have to convince them in addition to telling them. It's much easier to convince your friends in other specialties during training or the IM/FP residents in your hospital than it is to go out in your community talking to docs who have been in practice for a while and are set in their referral patterns, which is why I think it's important for PM&R residencies to reach out to other departments with educational lectures for their residents.

    As it stands, we Physiatrists still get most of our outpt referrals through the reps of other specialties, i.e. we work for the surgeons or enlist under pain-managment. So, clearly, we can do a better job of this in the future.

    A final point, when marketing your services, it should never be about "My treatment philosophy is better, or I do a better job than this or that specialty", which I've heard alot of Physiatrists make claims to, but more of "I do the same thing as these specialties, plus x,y and z". Remember, business is about "What I can do for you".
  15. tchoupdoc

    tchoupdoc attending

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    Background on me, before I answer: I am PMR grad 02, boarded 03, now employed and very happy, almost too busy, working for an academic ortho practice. 1/4 injections, 1/4 electrodiagnostics, 1/4 clinic, 1/4 academics/life in a 5 day workweek (let's not quibble about math, if that doesn't make sense.)

    Ownership of outpatient PT centers by physiatry is rare, IMO, because a person motivated enough to make that work can use that motivation to make as much money with a lot less headache just being a doctor.

    Example: your exemplary, organized MOA/receptionist realizes that she can do a nurse's job as well or better than the ones that you have introduced her to. She resigns to go to nursing school. Now you have to find a replacement, with the knowledge that the brightest will likely do exactly the same.

    Example: your late for work, disorganized MOA/receptionist is falsifying her time card, and you fire her. Then you discover that she has been stealing copays. You are a couple of grand in the red. You confront her. She says that she had to leave (not that you fired her, no mention of the theft) because she felt sexually harassed by the PT. Your attorney asks you to produce the HR handbook to prove that she did not file a complaint per protocol. You reluctantly admit that you had none, because you didn't know why you would need one (you are a doctor, after all). The bills start to add up.

    Example: your spinal/thoracic manipulation, pelvic floor trained PT gets another job offer. you have realized (and this is very difficult for any doctor to admit) that she can make headway with idiopathic inguinal crease pain in 30-45 young professional women like no one else. You can't take over, because you don't have time (because of the sex harassment stuff and patient care) and let's be honest-- do you know how to teach a dermatologist/former swimmer high frequency/low amplitude oscillations of the femur for symptoms? And this dermatologist has referred a lot of her friends your way. Can you make this PT an offer she can't refuse?

    The above are a half made up/half real examples that I have observed from the time I have to spend in the private world to be able to pay for that 1/4 academic/life time.
  16. tchoupdoc

    tchoupdoc attending

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    A final point, when marketing your services, it should never be about "My treatment philosophy is better, or I do a better job than this or that specialty", which I've heard alot of Physiatrists make claims to, but more of "I do the same thing as these specialties, plus x,y and z". Remember, business is about "What I can do for you".[/quote]

    As usual, I agree with bruce lee.:laugh:

    And also think that PMR could get a lot of business by marketing symptoms to patients: eg

    "Your hand fall asleep?" on a billboard

    There. you got your myofascial pain, NCS, cervical ESI if you choose to do them.
  17. MSKalltheway

    MSKalltheway I got the magic stick

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    Do you find that working for a group of ortho's/neurosurg's works fine for you? I wouldn't mind if the benefits of this outweigh those of owning my own practice someday, but my biggest fear would be to work for a group of docs, be underpaid, overworked and find that leaving and starting anew would be even more of a headache than just doing it outright.

    I ask this only because my father is in this situation, and if someone is gonna work me 70-80hrs a week until retirement, I'd rather do it owning my own practice and (hopefully!) getting paid better. Any insight would be greatly appreciated!
  18. The JockDoc

    The JockDoc lighting up the court

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    This is one of the major benefits that I see in opening your own practice. At least if you're working hard, you're calling the shots and aren't a cog in someone else's wheel. I know there will be pros and cons, but I wonder if anyone on this board has personal experience with hanging their own shingle and can elaborate some more.
  19. tchoupdoc

    tchoupdoc attending

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    It has worked fine for me. It didn't work for 2 other docs who came before me, and left. It wasn't a question of working for the surgeons, it was that they didn't want to work very hard, and I do.

    The advantage of starting your first job under anyone else's practice, whether pain, surgery, or pmr is that you can watch all those examples I mentioned above play out, and the infinite other ones, and then decide if you want to go out on your own. Just practicing medicine for the first year is nerve-wracking enough.
  20. ampaphb

    ampaphb

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    Meaning no disrespect, Dr. Tchoup, but don't you think your situation is somewhat unique, given the pre-existing relationship you had with the department prior to your joining them?
  21. tchoupdoc

    tchoupdoc attending

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    ampaphb is referring to the following: I had a family member in my dept, now no longer true. My "somewhat unique" situation got me a job interview.
    being overworked and underpaid, working for someone else? Been there. I was appraised of the fact that in my first year I was paid 120k and had earned 92. The surgeons who knew my family member don't pay my salary, the practice plan does. It was made quite clear to me that I would have to earn my pay, and that is how I learned the pitfalls alluded to above.

    He is correct in this sense: I don't work for the surgeons. The surgeons and I all have our checks signed by the practice plan. This is different from a PMR grad who signs on with an established NS/ortho private spine practice, where you might be paid out of their earnings...though that sounds insane. That would be like a radiologist agreeing to be paid by the ordering doc for the reading instead of by billing the insurance company him/herself.

    In that setting, I would expect that your discograms had better be positive.
  22. Disciple

    Disciple Senior Member

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    I would either start my own, or sign up with a group where you think you can become a partner.

    If you want a long-term employee type position, I would sign up with a VA or someplace like Kaiser where you'll have good hours, steady pay, and be well taken care of after retirement.
  23. tchoupdoc

    tchoupdoc attending

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    Re-read this post.

    Yes, my situation was unique--I knew its history in very stark terms. I knew that they had let brilliant, but non-productive doctors go for not earning their keep. This was a surgery dept. If they would let a surgeon go, they would definitely let a pmr go. That's what made my work hard.
  24. drusso

    drusso Moderator Emeritus Lifetime Donor

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    I think it would be great to see more physiatrists start owning equity in their facilities. Radiologists can become partners in imaging centers; surgeons in surgery centers and various specialty hospitals. Why shouldn't physiatrists own rehab hospitals, SNF's or LTACs? There are anti-kickback and Stark self-referral issues to deal with, but physicians can ethically and legally own facilities and use the services of those facilities under specified conditions.

    The first place to start is determing whether your state is "certificate of need state." Then, line up the investors, by dirt, build something, jump through all the accreditation hoops. One interesting thing to keep your eye on is the HFAP program through the American Osteopathic Association. Only the Joint Comission and the AOA's HFAP have "deeming authority" for medicare accreditation of facilities. It's hold-over from the days when MD's wouldn't let DO's practice in their hospitals; so the DO's went off and created their own federally-approved hospital accreditation program giving the MD's the proverbial "Nanny-nanny-boo-boo!" Several smaller hospitals (regardless of whether DO's are on staff) still use the HFAP process because it tends to be less administratively burdensome and it's kind of finding a "second life" among "entrepreneurially-minded" physicians...

    http://www.hfap.org/

    I'm always amazed how thing change in the health care market when *physicians* start poning up their pennies and put skin in the game. Suddenly, "new efficiencies" are possible when before the standard answer was "no."
  25. Louisville04

    Louisville04 Junior Member

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    I don't see how you can work that many hours. Most ortho/neurosurg groups have regular office hours (40-50 hours/wk) with the office closed on weekends. There would be no inpatient work.
  26. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    With the financial future of rehab facilities (inpt at least, possibly oupt), I wouldn't invest in one the way one would invest in an ASC.

    Having your own practice, and a seperate outpt PT/OT clinic is feasable if you want to get referals from other docs for PT. If the two are not seperate, you have to see every patient before they have PT.

    However, from talking with the PT's in our office, most PT's and OT's are being trained to stay away from doctor-owned PT clinics. They are being pushed towards D.PT and D.OT (doctorate) and recommended to only join PT's or start their own clinic. We're having a hard time recruiting partly for this reason.
  27. dc2md

    dc2md

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    why would PTs be averse to joining physician-owned clinics??
  28. tchoupdoc

    tchoupdoc attending

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    Maybe I have only seen the worst of the worst, or am not as good with people as I have previously thought. But I am surprised that so many posters, who have put so much time into schooling, think that joint ownership is an easy undertaking. This is not school.

    I have learned a lot from drusso's postings, but I still think that this is not just a question of jumping through a few hoops. I've seen a local practice lose 100k + to a billing manager of 8 years who got a new boyfriend with a gambling problem. Far more common is the practice whose front office people either go to nursing or law school, or get pregnant and go home to be mothers. You have two weeks notice before no one is answering your phone. While I think that any of us could handle the oversight/firing/hiring, do you really want to do this before, and during, and after a full day of seeing patients?

    BTW, the difference between a surgeon investing in an asc and a pmr doc in rehab center are enormous.

    How many vascular surgeons do you see invested in asc's? or transplant? Very few. Because you get a vasculopath with potential limb loss, or organ transplant patients waiting for definitive care, and their length of stay wipes out any profit for the investors. I would venture to say the same for inpatient rehab. Can you predict LOS for one Rancho IV vs another, with all the variable in discharge?
  29. drusso

    drusso Moderator Emeritus Lifetime Donor

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    I agree 100% with what you're saying. I don't think that it would be *easy* but the fact that the overwhelming # of physiatrists don't even think about these kinds of arrangements is revealing...

    We all know that the 75% rule and Medicare squeeze on inpatient rehab is largely the result of direct pressure from the SNF industry and their lobbyists. Just one look at the demographics of this country will reveal that there is GOLD in the post-acute care arena! Is it any wonder that SNF's skyrocked while inpt rehab shrunk? There is a HUGE unmet need for inpt rehab services out there and many patients are left withering in nursing homes who could have a much higher degree of independence in the community after intense rehab.

    You couldn't go after complex TBI from the get go. You would have to develop a "catch and release" program for the non-neuro orthopedic polytraumas who leave your community and go to some tertiary care center for acute care and come home for rehab. You'd have to form liasons with community hospitals and get the "simple" sub-cort strokes and medically complex deconditioned patients with hip fractures, etc thus off-loading acute care beds and keeping acute care DRG margins optimized.

    You would have to have pretty clear organizational and administrative lines between The Center and The Practice. You would have to *EMPLOY* your therapists, but they would be Center employees not Practice employees. Your physicians would have to be limited partners/share-holders with voting status like any single-specialty group practice. Thus, they could also be investors in The Center. There would have to be a separate board of directors for The Center and The Practice.

    It's complex...but I've thought about it...:D The first step is getting docs to pony up their pennies and take control of their facilities instead of being controlled by them! If you take the Spine Specialty hospital in Tyler, TX as an example (a non-certificate of need state, I believe) you'd have to have about 20 docs pony up $1-2 million each in capital to get the ball rolling. For a rehab hospital, the initial construction costs might be lower since you wouldn't OR's, ICU's, etc.

    http://dallas.bizjournals.com/dallas/stories/2002/02/25/daily4.html
  30. tchoupdoc

    tchoupdoc attending

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    once again, you know your stuff.
  31. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    It's the schools pressuring it - part of the indepence thing - wanting PT's to see pt's without MD orders - just another push in that direction, I believe.
  32. Xardas

    Xardas

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    You would need an enormous amount of capital, something you cannot secure without some track record with a potential lender.

    Can you own something some day? Sure anything is possible. But you need:

    (a) a proven track record-- you need quality people: administrators, therapists, nurses, etc. working for you. Quality people demand experienced leadership. Getting someone to change jobs mid career is a risk.. they want to know what they are getting into.

    (b) clinical experience -- residency gets you so far. You still learn a ton as an attending... quality inpatient rehab care has a lot of facets. With experience comes the ability to handle patient care on a very large scale and not just patient by patient which is how we take care of things as physicians.

    (c) vison -- people either have this or they don't. Can you predict where to put the center - somewhere where there is a lot of growth? OR in the middle of a poor area with high percentage of uninsured? People laugh may laugh... but neighborhoods change all the time. And so on.

    I think its a great idea.. many physicians are fearful of dreaming big. But yeah you really need a lot more business and clinical experience to make it happen.
  33. olafa

    olafa

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  34. PMRMD2B

    PMRMD2B

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    This is mainly to PMR 4 MSK, but anyone with solid information, please reply.

    I know POPTS or Physician Owned Physical Therapy Services has been a hot topic (at least in some states) recently. I can see where there could be a conflict for say and ortho who owns a in-house (or outside) rehab center. However, I don't understand why it would create anymore potential for increased services than an in-house x-ray, lab, massage therapist, etc would create.
    From what you know on this topic, could a PMR doc still employ a PT, as long as you technically didn't "refer" to the PT and only had the PT perform services under the MD? Is there any conflict with this?

    I hate to talk money in here, but I would like to ask practicing PMR docs a question on billing as well (sorry I am asking a million questions in one post). From whatever state you are in, what is the range (I know I can look up codes and reimbursements) of payment you recieve for injections, by area.. ie, shoulder, hip, knee, elbow, spine. In addition, what are the ranges of payment on EMG/NCV and do you bill the global (professional and technical components of the procedure)?

    Last question (at least for today), can Family/Internal medicine physicians bill AND get paid for EMG/NCV's and joint injections from most private carriers? If so, are they getting paid less, not as often, etc?

    Thank you all in advance for answers to any of these questions!

    JW
  35. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    I had my own solo clinic and hired a PT. I paid her salary, billed her services under my number. Worked out ok, but had a hard time getting chronic pain patients to show up.

    I now work in a large clinic of ortho's, podiatrists, rheums and myself. We have a large PT clinic and patients are again billed under our #'s. That means a doc has to be there at all times, so we can't do extended hours or weekends. There is no conflict with this. It's getting more common.

    I can PM you some figures. It's not a good idea in general to post what you get. I bill global for EMGs, but we have a seperate legally-approved method for dividing it, different than my regular billing.

    Most FP/IM do some joint injections and bill as normal. As for EMG, differs by carrier of course. I don't believe they can bill for EMG under Medicare due to their specialty, but some have a PM&R or Neuro who comes to the office to do them and get paid. AANEM just published some new reccomendations regarding this.

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