Questions about setting up a rural practice

[rachmoninov3]

I would love to have a practice in a small town (aprox 10K people) and then be able to drive and do a clinic day a few times a week at all the other surrounding smaller towns. How many doctors do you need to sustain such a practice? Two of my attendings were involved in a small rural practice that fell to pieces when a few of the doctors in town left, leaving only 3 or 4 physicians with hospital privileges which meant q 3-4 day call. Also, one of my other attendings used to be in private practice in such a town, and 'back in the day' took call for the OB, the peds, and the surgeon, but was working so much that his wife almost disowned him. After all, FM can cover all that, but those specialties can't reciprocate.
I know it's too early to be thinking about such a perfect practice as an intern, but I have to have something to dream about while I'm busy being docterized. So any insight into how to set up such a practice, or what to look for when joining a rural practice would be much apreciated.

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[cabinbuilder]

When I was in residency 3 years ago, they told us about companies who help you set up your own practice. It takes approx 100,000K+ or more to set up your own. I personally don't see how you would do it unless you are independently wealthy as I have been working rural medicine for the past 3 years. All of those jobs were either employed or through locums.

From what I have seen just as an employee, some things to think about:

1. You need office space
2. You need a coder/biller unless you know how to do it yourself
3. You need equipment and supplies
4. An assistant or go without
5. A receptionist for scheduling
6. Do you know how to get an EIN/UPIN/Medicare/Medicaid numbers for that state?
7. Do you know how to get signed up with the various insurance companies so you can get paid?
8. Are you willing to be on call everyday?
9. Do you plan to do clinic and inpatient? OB?
10. Do you have a way for your clinic to be covered when you go on vacation?
11. You could just go cash pay and not worry about insurance or billing


If you plan on joining a practice you need to be aware that once you sign the papers you are owned by the company and usually its the office manager who runs your life. Beware of these people. I found that on salary I don't go home until the charting is done (6-8pm) while the mgr goes home at 5pm and has no problem bitching at you about your production and needing to see more patients.

If you have student loans in excess of 200K, be sure your base pay is at least 180K so you will be ahead of your bills each month. Beware of states that have state income tax as your paycheck dwindles quickly. For example: 180K in Oregon is 15K/month but after
federal/state taxes you barely clear 9K. That sounds like a lot but all said and done when you have a house, car, insurance, food, student loans, etc. that doesn't leave much left at the end of the month.

I personally will never work a salary job again as I will never be someone's slave again. I work locums and get paid by the hour so if I have to sit there for 12 hours to get everything done at least I get paid for my time.

I don't mean to be discouraging but just know that "the good ole days" are no longer. Obamacare is upon us. There is a huge shortage of family medicine docs especially in rural areas where back up is minimal and hours are very long.

 

[rachmoninov3]

When I was in residency 3 years ago, they told us about companies who help you set up your own practice. It takes approx 100,000K+ or more to set up your own. I personally don't see how you would do it unless you are independently wealthy as I have been working rural medicine for the past 3 years. All of those jobs were either employed or through locums.

From what I have seen just as an employee, some things to think about:

1. You need office space
2. You need a coder/biller unless you know how to do it yourself
3. You need equipment and supplies
4. An assistant or go without
5. A receptionist for scheduling
6. Do you know how to get an EIN/UPIN/Medicare/Medicaid numbers for that state?
7. Do you know how to get signed up with the various insurance companies so you can get paid?
8. Are you willing to be on call everyday?
9. Do you plan to do clinic and inpatient? OB?
10. Do you have a way for your clinic to be covered when you go on vacation?
11. You could just go cash pay and not worry about insurance or billing


If you plan on joining a practice you need to be aware that once you sign the papers you are owned by the company and usually its the office manager who runs your life. Beware of these people. I found that on salary I don't go home until the charting is done (6-8pm) while the mgr goes home at 5pm and has no problem bitching at you about your production and needing to see more patients.

If you have student loans in excess of 200K, be sure your base pay is at least 180K so you will be ahead of your bills each month. Beware of states that have state income tax as your paycheck dwindles quickly. For example: 180K in Oregon is 15K/month but after
federal/state taxes you barely clear 9K. That sounds like a lot but all said and done when you have a house, car, insurance, food, student loans, etc. that doesn't leave much left at the end of the month.

I personally will never work a salary job again as I will never be someone's slave again. I work locums and get paid by the hour so if I have to sit there for 12 hours to get everything done at least I get paid for my time.

I don't mean to be discouraging but just know that "the good ole days" are no longer. Obamacare is upon us. There is a huge shortage of family medicine docs especially in rural areas where back up is minimal and hours are very long.

Thanks for your input. I'm hoping to avoid being an employee of a larger corporation (under the guise of an ACO) and would really like to join an existing practice if I can find one. If not...I guess I better start playing the lottery. You mentioned nightly call....how many docs can a town of 10K and surrounding communities really support? Weekly call would be nice but can you make $$$$ if there are 7 docs for 10K patients?

 

[cabinbuilder]

Most likely you will always be an employee even if you join an existing practice. Most are not self sufficient and belong to a greater group that covers the malpractice, health insurance, pay for the staff, the building, etc. You would most likely have a salary + RVU model.

I was stating nightly call as a worst case scenario. I am currently working locums in a town of 30K where there are around 12 permanent primary care docs. The doctors are struggling to take care of everyone and there is a huge shortage of primary care in this country. I seriously doubt you will find a town of 10K that has 7 doctors there who are not locums. The call depends on the set up that is agreed upon. It also depends on if you are admitting patient to the hospital, have hospitalist service or you admit your own. Too many variables. Essentially, until you have your student loans paid, you will be working for someone.

 

[EdibleEgg]

I live in a town of about 15 thousand. There are no locums here except occasionally in the ED. We are opening a satellite clinic in the next (smaller) town with in the next year. We have a physician owned practice, there are mid level, but no physician employees. I joined the practice. I can't imagine setting up my own practice from scratch, but I don't like the idea of being employed.

 

[EdibleEgg]

Here we have a physician's association that does contract negotiation and credentialing. It was 1K upfront and 600 dollars per year. They took care of all the insurance/medicare/medicaid credentialing. The hospital gave me a start up loan that is forgiven over a four year period. As long as I don't move in the next year, there will be no real start up costs for me. Our EMR does most of the coding and directly bills.. the office manager follows up on all claims not paid. It all can be overwhelming, and again I personally wouldn't want to go it alone, but it can be done.

 

[cabinbuilder]

Thanks for the other responses. There are plenty of scenarios out there. Some are good, some are bad, location does matter and some areas of the country are better provided for than others. Since I work locums I tend to be where there just aren't enough doctors. Every practice is different, every physician is different, it means being very careful about what you sign, have your contract lawyer go over every page.

 

[goprisko]

Here we have a physician's association that does contract negotiation and credentialing. It was 1K upfront and 600 dollars per year. They took care of all the insurance/medicare/medicaid credentialing. The hospital gave me a start up loan that is forgiven over a four year period. As long as I don't move in the next year, there will be no real start up costs for me. Our EMR does most of the coding and directly bills.. the office manager follows up on all claims not paid. It all can be overwhelming, and again I personally wouldn't want to go it alone, but it can be done.

It seems to me that it is critical to remove insurance companies from the food chain. Yes, they did serve a purpose 50 years ago, when my father led the 3 year strike against Standard Oil, to get company paid hospitalization among other benefits. However, things have progressed to the point Insurance Companies run medicine. In other threads various costs of doing business with them are mentioned, coders, 90-120 days after billing for reimbursement, audits, <90% reimbursement of charges, etc. I estimate that dealing with insurance companies costs 25% of gross billings to the average practice.

If a physicians assn can provide the above benefits, why can't provide re-insurance to members who adopt the direct primary care model, in which patients become members of a practice, which is organized as a non-profit, and in which members are entitled to a complete range of medical services, with the emphasis on preventative care, that is physicians now spend effort on prevention, counseling and other activities to keep their patients well.

Given a membership of 1000 / physician @ $125/month each member can be guaranteed 60 mins / yr with his physician, quarterly checkups, prescription coverage, coverage of full diagnostics, etc. For an additional $100/month, I believe the reinsurance arm could provide full hospitalization.

Thus for $225/patient-month or $2600/patient-yr ~ 1/3 current US costs the average physician should make $600,000 / yr the average patient should have much more time with his doctor.

Before you flame me that patients won't pay this:
1. My wife's gym membership costs $80/month
2. The average sat-tv bill is $100/month.
3. The average family of 4 now pays $22,000 / yr for medical care.

I am interested in exploring this further with physicians currently offering "direct primary care".

This is not concierage medicine. In concierage medicine as I understand it, the patient pays a retainer for availability. In direct primary care as I envision it, the patient joins a group, and pays his membership to qualify for a full range of medical services, emphasizing preventative medicine.

Thus my vision for direct primary care is the HMO model, with patients paying the practice they belong to, directly, with no middle man, no codes.

WRT the elderly, I envision the Physician Assn forming a medicare advantage plan, billing medicare $ monthly per patient to cover a full range of services provided by assn members, with the plan owned by the assn members, splitting revenues across the group based upon the number of patients each has, with a reinsurance pool to cover travel and other costs.

Your comments please!

INDY