Pain practice partnering with hospitals

[SEpainfree]

hi everyone, I’m starting a new pain practice splitting time between rural hospitals in Indiana. They’re providing some staff and access to their “surgical specialties clinic” for me to see patients in. They will also provide a few staff (I’ve requested 3, a receptionist and two MAs). I will pay a daily fee for these services. Overhead will be a lot less than if I try to open up part time clinics in both towns. I’ll be doing most procedures in the hospital collecting a facility physician fee and then seeing clinic patients in a private setting collecting non-facility billings. I’m having some anxiety figuring out how to set up the front office. Right now there will just be a receptionist who isn’t my employee ( but does sit at the clinic front desk 5 days a week)answering phones when I’m not there and I’m not sure they will be able to handle the volume of the clinic calls when/if we get busy. It’s important to me that patients and doctors offices are able to get ahold of use to help establish our legitimacy in an area with some history of sketchy docs. Any solutions you all have used or discussed that might avoid some of the issues I face? If I have to I can hire someone immediately but the hope was to keep overhead very low and expand as practice expands. Thanks in advance! PM me if you feel like you don’t want to discuss publicly.

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[ateria radicularis magna]

If you are doing procedures in their hospital their staff in the office while your there should be paid 100% by the hospital without any fee charges to you. You are bringing services and revenue to their hospital.

 

[SEpainfree]

We discussed this but they felt that it was less likely a stark law violation if I am paying and it’s not billed as a facility visit. You’ve seen other situations? One nice thing about the system I’m entering is that I do have some autonomy to hire my own if I feel like it.

 

[BobBarker]

Just do RVU’s and full employment track.
This does not sound like a good setup. The hospital is making too much money off of you and making you pay for the pleasure of doing so. They are going to make $750 or so off of every injection you do and you will make $85-200 and then have some costs out of that. Terrible!

 

[painfree23]

Just do RVU’s and full employment track.
This does not sound like a good setup. The hospital is making too much money off of you and making you pay for the pleasure of doing so. They are going to make $750 or so off of every injection you do and you will make $85-200 and then have some costs out of that. Terrible!

How many rvus for “full employment”

 

[BobBarker]

Around 6600/year is median if I recall correctly.

 

[SEpainfree]

As a physician who is currently employed, I’m currently placing a lot of importance on not being employed anymore. I agree they are going to do well off of me. I appreciate the advice. The goal is to start up a two location practice with minimal overhead initially. But employment is a scary proposition for me at this point in my career.

 

[Agast]

From the way you're describing your practice, you are going to be working hard/hustling to make $250,000 a year. I can't imagine you bringing in more than that from professional fees for office visits and procedures alone. If you are investing in other things (ASC, imaging, pharmacy etc) to supplement your income that is another story.

 

[SEpainfree]

Well I’m currently employed in a very busy set up, doing around 20 inj and seeing 6-7 new pts and 2-3 follow ups five days a week. Going partner next year would likely up that to mid 500s. Going on my own doesn’t guarantee me anywhere close to that production, but it does give me to flexibility to expand and hire mid levels as the practice grows. Being 2/3 that busy would put me slightly above where I am now. Being just as busy as I am now busy would put me well north of what I could make as partner. Dicey for sure, but better to make that jump early rather than later I guess. I’m just wondering if anyone else has gone down this path and encountered some tips or pitfalls they noticed.
I should mention, I am placing a high value on the referrals the relationship with the hospital will drive towards the practice. With good growth I will likely shift into a private setting with in-office procedures close to the hospitals when the practice builds out.

 

[jsaul]

Well I’m currently employed in a very busy set up, doing around 20 inj and seeing 6-7 new pts and 2-3 follow ups five days a week. Going partner next year would likely up that to mid 500s. Going on my own doesn’t guarantee me anywhere close to that production, but it does give me to flexibility to expand and hire mid levels as the practice grows. Being 2/3 that busy would put me slightly above where I am now. Being just as busy as I am now busy would put me well north of what I could make as partner. Dicey for sure, but better to make that jump early rather than later I guess. I’m just wondering if anyone else has gone down this path and encountered some tips or pitfalls they noticed.
I should mention, I am placing a high value on the referrals the relationship with the hospital will drive towards the practice. With good growth I will likely shift into a private setting with in-office procedures close to the hospitals when the practice builds out.

how do you do 20 procedures every day but only see 2-3 followups . Do you have a PA doing most of your followups?
You basically do procedures and see new patients

 

[SEpainfree]

We have a couple mid levels seeing follow ups, who also schedule patients for injections. Probably average 2 mid levels per physician.

 

[drusso]

As a physician who is currently employed, I’m currently placing a lot of importance on not being employed anymore. I agree they are going to do well off of me. I appreciate the advice. The goal is to start up a two location practice with minimal overhead initially. But employment is a scary proposition for me at this point in my career.

You can't put a price on freedom.

 

[lonelobo]

We have a couple mid levels seeing follow ups, who also schedule patients for injections. Probably average 2 mid levels per physician.

Oh...Injection factory

 

[jsaul]

We have a couple mid levels seeing follow ups, who also schedule patients for injections. Probably average 2 mid levels per physician.

I don't know how you do things, but you mentioned that

"It’s important to me that patients and doctors offices are able to get ahold of use to help establish our legitimacy in an area with some history of sketchy docs."

Well I know a lot of people will think what you are doing currently is "sketchy" Just sayin. No offense. Just the perception. Now if you are not going to it this way in your new hospital partnership then that's different

 

[thecentral09]

Well I’m currently employed in a very busy set up, doing around 20 inj and seeing 6-7 new pts and 2-3 follow ups five days a week. Going partner next year would likely up that to mid 500s. Going on my own doesn’t guarantee me anywhere close to that production, but it does give me to flexibility to expand and hire mid levels as the practice grows. Being 2/3 that busy would put me slightly above where I am now. Being just as busy as I am now busy would put me well north of what I could make as partner. Dicey for sure, but better to make that jump early rather than later I guess. I’m just wondering if anyone else has gone down this path and encountered some tips or pitfalls they noticed.
I should mention, I am placing a high value on the referrals the relationship with the hospital will drive towards the practice. With good growth I will likely shift into a private setting with in-office procedures close to the hospitals when the practice builds out.

With this set up and production you should be making 600-700k+/year. Correct?

 

[SEpainfree]

yikes.
The hope is to make more than I would as a partner or at least the same amount but either working less or at least enjoying have more control.
We are definitely a busy clinic. I think “injection factory” and “sketchy” is a mischaracterization although I’d like to hear your viewpoints in a PM so as not to derail the purpose of the thread. I was hoping to get some advice on the front office setup those before me have found some success with. I appreciate any insights you have.

 

[ateria radicularis magna]

Why would the hospital staffing the clinic constitute a stark law violation ?

 

[SommeRiver]

100 injections per week!?!?

Hahahaha...

When you do an injxn that a PA/NP scheduled you're making sure it is appropriate and reasonable before you do it, or just see them on the procedure table?

Coming to this forum has made me nervous to recommend Tylenol for God's sake.

 

[SommeRiver]

With this set up and production you should be making 600-700k+/year. Correct?

More than that! What are the collections on 100 per week for 52 weeks? That is 5200 procedures per year, so take a few weeks of vacation and let's just say 4750 per year...

 

[lonelobo]

INJECTION CLINIC

 

[SommeRiver]

If this forum finds out he puts bupi, lido, or ropi into all these pts the board will crash...

 

[jsaul]

I want to know what the OP considers a "sketchy" doc given how he works now in his current job

 

[myrandom2003]

Zero stark law. Guy in my neck of the woods has that exact setup only hospital doesn’t charge him. He gets his pro fee and they (hospital) get all the other fees and absorb the costs.

 

[SEpainfree]

I think the hospitals I’ve talked to have definetly wanted to avoid any gray area with the stark laws, to their benefit, obviously. But in speaking with three hospitals, none felt that providing staffing support couldn’t be done without it possibly being construed as a financial benefit to the physician in exchange for referring procedures to their facility. I’m aware that some hospitals have felt ok with it, but apparently in my region, they’ve sided against it. While less overhead would be nice especially at the beginning, my colleagues who work in hospitals without their own employees seem to lament not having very much administrative control, and that would not be something I’d like to experience if I can help it.

Sommeriver, while I’m sure someone is making a lot of money off of the busy doctors in my practice, I am not one of them. I’m well below average. Anyway, just looking for advice on practice start, and I appreciate the feedback from you all.

 

[BobBarker]

You don’t understand the gravity of the situation. You are not going to make any money!

 

[SEpainfree]

You don’t understand the gravity of the situation. You are not going to make any money!

Well yes that would be bad...
While the projections I’ve seen are not as dire, there’s if definetly more risk than an employment model. The overhead in this situation still appears to be much less than private practice and the profit/loss calculations between this situation and a private clinic appear much closer than I would’ve thought they would be.

 

[Ducttape]

This set up us so completely out of your element... no offense but your work in a block shop has you unawares of how it works otherwise.

Right now, at 20 procedures per day alone, you are probably bringing in the current practice over $1.5 million.

With getting only professional fees, same practice, you’d bring in 1/3rd of that AT BEST.

You are essentially talking about the salary of a family practice doc, after you pay a secretary with federal poverty level salary...

 

[SEpainfree]

I definetly understand what you’re saying Ducttape. In a very simplified spreadsheet, using just Medicare numbers, ( and just for the sake of the calculations) assume 13 injections, with a assortment of esi, joint, MBB, maybe an RFA, if done on a daily basis ( not super likely but again, just for examples sake), with private clinic medicate numbers you will collect a bit over 1mil. At around 65% overhead you’re looking at 350k after overhead. In a hospital employed setting, I imagine this could be north of 500k salary, in the example I proposed, Billings would be Just over 500k, and the overhead in this scenario Is around 100k netting around 400k revenue. When you factor in patient visits these actually skew revenue higher in the hospital model since that will be billed as an private scenario since I’m covering all the overhead in that setting.
I thought the numbers would be much farther off but they don’t seem to be. And I’ve checked over these numbers with a consultant as well.
Employment looks better for sure, but as I mentioned before, I’m looking to avoid that.

 

[SEpainfree]

If you were to focus only on clinic visits, again using Medicare numbers for simplicity, consider a scenario where you see 3 NP and 8 follow ups a day averaged over 240 days a year. ( half 99203 and 99204 and the follow ups just being 99213), both private clinic and the clinic in the hospital where I pay the hourly overhead yield the same reimbursement: about $240k
In a clinic practice, maybe you can assume overhead on the clinic side will be substantially less...say 45%. Your revenue will be about $130k. In the situation I’m looking into overhead is still just 100k/ year. Revenue is essentially the same at ~140k.

 

[SommeRiver]

Sommeriver, while I’m sure someone is making a lot of money off of the busy doctors in my practice, I am not one of them. I’m well below average. Anyway, just looking for advice on practice start, and I appreciate the feedback from you all.

My point is that you're in a situation where it is guaranteed that you're doing things that a lot of ppl wouldn't. I feel comfortable saying you're not ensuring the injxn referrals you're getting are appropriate, and it is common for you to just inject the pt without a chart review bc it was sent to you by a mid level. Our mid levels are very experienced and I STILL get pts sent to me for epidurals that have 100% axial neck pain with a golf ball C3-4 facet. It happens all the time.

You may not be getting paid what you've produced, but it is still a block shop. This is the stuff that hurts our specialty, so I would encourage you to figure out a way to work in a different set up. I can't comment on your actual question about hospital-based stuff.

 

[Ducttape]

I definetly understand what you’re saying Ducttape. In a very simplified spreadsheet, using just Medicare numbers, ( and just for the sake of the calculations) assume 13 injections, with a assortment of esi, joint, MBB, maybe an RFA, if done on a daily basis ( not super likely but again, just for examples sake), with private clinic medicate numbers you will collect a bit over 1mil. At around 65% overhead you’re looking at 350k after overhead. In a hospital employed setting, I imagine this could be north of 500k salary, in the example I proposed, Billings would be Just over 500k, and the overhead in this scenario Is around 100k netting around 400k revenue. When you factor in patient visits these actually skew revenue higher in the hospital model since that will be billed as an private scenario since I’m covering all the overhead in that setting.
I thought the numbers would be much farther off but they don’t seem to be. And I’ve checked over these numbers with a consultant as well.
Employment looks better for sure, but as I mentioned before, I’m looking to avoid that.

the best I am getting in calculating your numbers is below 500K. professional fees are significantly less than you imagine.

that does not factor in that a significant portion of your practice will be Medicaid, from the hospital referrals. Medicaid pays procedures mostly the same but requires significantly more secretarial work (for prior auths) and your no show rate may be as high as 30%. Medicaid patients do not respond well to interventional spine set ups, so you will be doing significantly more med management and getting 13 injections per day will not be tenable.

if I were you, I would set up an independent private practice and agree to do some procedures at an ASC in exchange for shares and agree to do consults for the hospitals. or decide to do more multidisiciplinary work and go full bore with hospital employment with guaranteed base salary and generous bonus. the hard labor...

 

[Tapspatellas]

I hope it works out great for you. At worst, you can bail on the set up and start over somewhere.

To your question about the receptionist for the phones; this will be an issue after a short time if you build any volume. She is obviously answering for other clinics and I am assuming has some other functions as well, so I’m typical hospital admin fashion they are going to just plop something else on her plate. I hope she is a great receptionist and treats patients with respect. If she is trainable, you can work with her to help triage if there are any items she can handle: scheduling appointments, sending records to a docs office calling, etc. If not, then your MAs are going to have to handle this it sounds like. You all need to sit down and come up with a plan ahead of patient 1 setting foot in the door, and you need to give some constructive feedback at short intervals during the start up process, then intermittently when practice is more mature. Your MAs should make sure she has a contact phone to get in touch with them every day, and they should email/talk to her daily ensuring she has this until the schedule is ingrained. Any clinical items need to be forward through to them, and if she is able to send EMR messages, any non-urgent items should be messaged through to them.

 

[MiddleOfNowherrr]

I ditto what Tapspatellas said. Be prepared to have to hand walk the receptionist through a lot of work while training him/her. And also you will have to give a lot of constructive criticism at regular intervals to keep everything on track. Staff tend to get off track when they get comfortable. Get ready for a lot of turnover in the beginning, as you often have to go through several bad apples to finally land a token staff/employee. I couldnt quite grasp from reading above—is the hospital hiring the receptionist and MAs for you? Quite often they just hire warm bodies and dont take the time to seek out the most qualified and competent staff. And when u want to discipline or fire them it will require you nothing less than selling your left kidney to get anything done about it. Try to maintain some power with the hiring/firing. Hospital systems will try and sing a beautiful song to you at this stage, but after u sign the contract you will see how the tides will turn. I doubt you will enjoy a lot of freedom working as such with a hospital.
The Receptionist should handle the clerical phone calls and send the more clinical stuff to the MAs who should be trained on how to field what messages get forwarded to you. What happens when the receptionist calls in sick on your clinic days—does the hospital supply a temp? We had to cross train our MAs to do the checkin/out process because of this.
Is the hospital going to supply a practice manager? Or someone of the sort? IF he/she is good they should be able to help you orchestrate a lot of the workflow...

 

[Ducttape]

odds are, that that receptionist will change not infrequently. also, she will get vacation time, PTO, etc. expect to see someone who has no idea at all about what is going on.

 

[SEpainfree]

Thanks for the heads up. The hospital at one location is considering these issues while the other location has a speciality clinic where ma and receptionist handle the workflow for a few different specialties, including mine. I will make sure I have the option to bring in my own staff instead, should I need to. I think that’s something I will likely face soon after starting but we wanted to establish and generate a patient visit pattern before expanding the employment side of things.

 

[SEpainfree]

I intend to use the hospitals EMR for now but I wondering what systems you all have used that worked ok? If you can ball park costs that would be good too. I know there are some very bare bones systems out there for cheap, but my assumption is you get what you pay for. I’ve used athena, eclinicalworks and epic and didn’t find either heads or tales above another, but a lot of hospitals and imaging companies locally use epic so that’s a leg up...