Truth vs. conjecture

[FrenchyM.D/D.O]

Hello everyone! Once again this is FrenchM.D/D.O coming back to you live!
Not too long ago, I shadowed a D.O (IM) in Boston. He claims that as a D.O, he gets paid more than the avg. M.D because he gets to charge for osteopathic manipulative techniques (~$70) on top of what an M.D would get per visit (~$120).So that would mean: M.D= ~$120/visit vs. DO= ~$190/visit
So... conjecture or truth ? If you know more about this, please share it with us. I would love to expand my knowledge.
PS: Not trying to start anything here, as I know many are sensitive about this.

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[Pacna]

Hello everyone! Once again this is FrenchM.D/D.O coming back to you live!
Not too long ago, I shadowed a D.O (IM) in Boston. He claims that as a D.O, he gets paid more than the avg. M.D because he gets to charge for osteopathic manipulative techniques (~$70) on top of what an M.D would get per visit (~$120).So that would mean: M.D= ~$120/visit vs. DO= ~$190/visit
So... conjecture or truth ? If you know more about this, please share it with us. I would love to expand my knowledge.
PS: Not trying to start anything here, as I know many are sensitive about this.

In my experience, DOs don't use OMM. I work with many and have never seen one use it.

It is true that DOs can bill for OMM while MDs cannot.

[flame] However, MDs can bill for surgeries while DOs can only work in the country on horses and farmers. [/flame]

 

[Mad Jack]

Hello everyone! Once again this is FrenchM.D/D.O coming back to you live!
Not too long ago, I shadowed a D.O (IM) in Boston. He claims that as a D.O, he gets paid more than the avg. M.D because he gets to charge for osteopathic manipulative techniques (~$70) on top of what an M.D would get per visit (~$120).So that would mean: M.D= ~$120/visit vs. DO= ~$190/visit
So... conjecture or truth ? If you know more about this, please share it with us. I would love to expand my knowledge.
PS: Not trying to start anything here, as I know many are sensitive about this.

OMM takes time. Getting the patient prepped, positioned, and treated with OMM will take longer than just seeing another patient. So in a revenue per hour sense, a DO can charge more for such a visit, but will lose out due to the time the treatment takes.

Unless he's just billing for OMM while not really doing it or doing some BS treatment that takes a few seconds. Then it's just fraud.

 

[FrenchyM.D/D.O]

Well then... I did not know that D.O's could only work in the country on horses and farmers. Don't vets do that kinda job. just kidding you guys. I knew someone was going to go there. lol
Mad Jack: What kind of prep are you talking about? The D.O that I shadowed, (it was actually a whole building full of D.O's so I have met/seen quite a few) never had to prep any patients. Yes, they position the patient but thats's quick. The last OMM I saw was a spencer treatment/technique.(Youtube it, if you'd like to learn something). It really does not take that long. I personally never went to D.O school, (I am just a lowly premed) so I can't judge on the efficacy.
Again, I am just here to learn as much as I can before making one of the biggest decisions of my life; deciding whether to attend allo or osteo.

 

[FrenchyM.D/D.O]

The ones I have shadowed do use OMM on about 60 to 75% of their patients. Maybe, it depends on the location.idk

 

[Mad Jack]

Well then... I did not know that D.O's could only work in the country on horses and farmers. Don't vets do that kinda job. just kidding you guys. I knew someone was going to go there. lol
Mad Jack: What kind of prep are you talking about? The D.O that I shadowed, (it was actually a whole building full of D.O's so I have met/seen quite a few) never had to prep any patients. Yes, they position the patient but thats's quick. The last OMM I saw was a spencer treatment/technique.(Youtube it, if you'd like to learn something). It really does not take that long. I personally never went to D.O school, (I am just a lowly premed) so I can't judge on the efficacy.
Again, I am just here to learn as much as I can before making one of the biggest decisions of my life; deciding whether to attend allo or osteo.

I just meant positioning, explaining the procedure, getting comfortable, etc. Maybe if they're patients that regularly undergo OMM it is different, but I would imagine if it is their first time you have to explain what it is you are doing, ask if they would like to undergo treatment, position them, perform the treatment, do a post treatment assessment... a signle patient can be seen in six minutes or so, I feel like all of the above would take longer than that.

 

[FrenchyM.D/D.O]

While a single patient can in fact be seen in 6 minutes or so, Is that really the best we can do as future health care providers? I have a friend who switched from regular practice to concierge practice because he could not stand the fact that he had to jump from one patient to the next. I think, it is sad that as a pre-med, you already have that mentality but I do not blame it on you but on the system.( I DO NOT JUDGE YOU FOR THIS) It looks like it is what it takes in order to repay loans and have an ok lifestyle. BUT what happened to the good ol' "Aegar primo"?

 

[FrenchyM.D/D.O]

I just meant positioning, explaining the procedure, getting comfortable, etc. Maybe if they're patients that regularly undergo OMM it is different, but I would imagine if it is their first time you have to explain what it is you are doing, ask if they would like to undergo treatment, position them, perform the treatment, do a post treatment assessment... a signle patient can be seen in six minutes or so, I feel like all of the above would take longer than that.

 

[Mad Jack]

While a single patient can in fact be seen in 6 minutes or so, Is that really the best we can do as future health care providers? I have a friend who switched from regular practice to concierge practice because he could not stand the fact that he had to jump from one patient to the next. I think, it is sad that as a pre-med, you already have that mentality but I do not blame it on you but on the system.( I DO NOT JUDGE YOU FOR THIS) It looks like it is what it takes in order to repay loans and have an ok lifestyle. BUT what happened to the good ol' "Aegar primo"?

I was just analyzing his particular situation. If he is billing the amounts he does, he accepts insurance and isn't a concierge provider. And if he is talking about money per patient, he probably had money as a high priority. So I was just saying that perhaps if he wanted to make more money, he wasn't going about it in the most efficient manner.

Personally I'm a huge proponent of concierge medicine. I would likely never practice primary care myself, but if I somehow ended up in it, concierge is the way to go. You end up with happier, healthier patients and a better work-life balance, it's a win-win.

 

[Law2Doc]

As mentioned if he is doing additional procedures on patients, it means he is seeing fewer patients per hour. On top if that, he may be paying slightly higher insurance premiums if he is offering additional services beyond the typical office visit for an internist. My bet is we aren't talking about much of a difference in net revenue. Plus the elephant in the room is that the odds of getting into the most lucrative specialties are even now still a bit worse coming from DO, and were more so when this guy was in med school, so he already ate a big opportunity cost years ago in terms of specialty choices.

 

[Law2Doc]

...
Personally I'm a huge proponent of concierge medicine. I would likely never practice primary care myself, but if I somehow ended up in it, concierge is the way to go. You end up with happier, healthier patients and a better work-life balance, it's a win-win.

Meh, concierge practices sound good in theory but really don't work in the long run. Each locale can support very few such providers because you have to have decent disposable income to forego using the health insurance your employer is willing to provide. So every wealthy region can support a few, but in a region such as Boston (where the OP is talking about), they rapidly drive each other into bankruptcy. Having worked with several failing concierge practices in my prior career, i can Assure you this isn't a great business model. Additionally it suffers the same fatal flaw as HMOs. This kind of practice sounds great when you are talking about young healthy people, like the twenty something Californians Clinton used as national examples when he rolled out the HMO plan. But once you add older sicker people into the mix, the demand outstrips the value. Now all hmos are in financial distress, and this system is really no difference. Concierge banks on providing services to people who will rarely bother you between annual checkups. But if you have the geriatric person with co-morbidities, suddenly you are providing services at a loss. And guess which group is growing faster in our country.

So unless you can be the only guy doing it in you community and unless you can carefully screen patients to only those that are young and healthy, your concierge business is on borrowed time. Not a good business model for more than the 1-2 first movers. For most it's lose-lose.

 

[Mad Jack]

Traditional high fee concierge practices can only be supported in small numbers in any given area. I am more interested in cash only DPC model practices that have low monthly fees and still charge a fee for visits and consultations, but in exchange charge markedly reduced prices for testing and procedures by bypassing insurance and dealing directly with imaging and testing providers. Not saying it's a sure shot or that you'll be rich, but if you were to open such a practice in a non-urban environment, I believe you could do well for yourself. I was reading about such a practice in Texas that has actually started brokering deals with large employers under such a model, wherein the employers are paying for the employee monthly fees and a wraparound insurance plan, which legally qualifies as full insurance per an ACA exemption. This lowers employer costs, provides their employees with high quality primary care and low diagnostic prices, and spares the employees from dealing with insurance unless they end up in the hospital or requiring specialty services. I'm curious to see how it turns out in a few years- not saying it's the holy grail, but it might be a viable model to reduce the number of patients you have to see and still maintain a modest lifestyle.

Not that it really matters to me. Primary care just isn't my thing. I just really hope they find a way out of their current mess, and the only possibly viable path I can see for that is some innovative non-insurance based model.

 

[FrenchyM.D/D.O]

Thank you guys!! Very informative discussions.That's why I joined SDN.

 

[Law2Doc]

... I am more interested in cash only DPC model practices that have low monthly fees and still charge a fee for visits and consultations, but in exchange charge markedly reduced prices for testing and procedures by bypassing insurance and dealing directly with imaging and testing providers. Not saying it's a sure shot or that you'll be rich, but if you were to open such a practice in a non-urban environment, I believe you could do well for yourself. I was reading about such a practice in Texas that has actually started brokering deals with large employers under such a model, wherein the employers are paying for the employee monthly fees and a wraparound insurance plan, which legally qualifies as full insurance per an ACA exemption. This lowers employer costs, provides their employees with high quality primary care and low diagnostic prices, and spares the employees from dealing with insurance unless they end up in the hospital or requiring specialty services. I'm curious to see how it turns out in a few years- not saying it's the holy grail, but it might be a viable model to reduce the number of patients you have to see and still maintain a modest lifestyle.

Not that it really matters to me. Primary care just isn't my thing. I just really hope they find a way out of their current mess, and the only possibly viable path I can see for that is some innovative non-insurance based model.

This format of how you want to run a concierge model doesn't really change things. I stand by my above post even for the form you are describing here and have actully worked with multiple bankrupt individuals who were trying to run businesses exactly as you have described, even in more favorable economic times. It's one of those things that sounds good in theory, but if too many people try it, the market share simply isn't big enough. It will forever be something premeds talk about as viable, but clinicians will fail at in droves. If it really worked, tons would do it, and the opportunity would almost certainly be gone before you got there (you are acting like none of this has been thought of) - the concept of concierge businesses is not at all new. The truth is, except in rare pockets of the country where the climate is exactly right and the competition is nonexistent, it simply doesn't work, which is why people still only talk about it, but aren't doing it in any number. And why former business lawyers like me made a lot if money doing workouts with these practices that pretty much all went belly up.

 

[Mad Jack]

This format of how you want to run a concierge model doesn't really change things. I stand by my above post even for the form you are describing here and have actully worked with multiple bankrupt individuals who were trying to run businesses exactly as you have described, even in more favorable economic times. It's one of those things that sounds good in theory, but if too many people try it, the market share simply isn't big enough. It will forever be something premeds talk about as viable, but clinicians will fail at in droves. If it really worked, tons would do it, and the opportunity would almost certainly be gone before you got there (you are acting like none of this has been thought of) - the concept of concierge businesses is not at all new. The truth is, except in rare pockets of the country where the climate is exactly right and the competition is nonexistent, it simply doesn't work, which is why people still only talk about it, but aren't doing it in any number. And why former business lawyers like me made a lot if money doing workouts with these practices that pretty much all went belly up.

Do you feel it might be a more viable model in lower-competition areas with few providers? Is it possible most doctors are just bad at running a business in general and couldn't really sell themselves properly? Or is it just not viable at all? You've obviously got a lot of experience in this area, so I'm really curious if there is any way you feel it could work or if you're pretty much doomed from the start if you try it.

 

[Law2Doc]

Do you feel it might be a more viable model in lower-competition areas with few providers? Is it possible most doctors are just bad at running a business in general and couldn't really sell themselves properly? Or is it just not viable at all? You've obviously got a lot of experience in this area, so I'm really curious if there is any way you feel it could work or if you're pretty much doomed from the start if you try it.

It perhaps works for a while in lower competition areas, but those areas themselves are not going to exist forever, and others trying the same thing cut into your margins, so the word "viable" isn't a good one. Is swimming in shark infested waters viable when you are just talking about the window before the sharks see you? Doctors are bad at running businesses for sure, but there is a bigger reason these practices fail independent of that -- it's just a flawed model because it depends on young healthy people using disposable income and foregoing using employer covered insurance or ever getting sick/old. It's doomed from the start, which is why even though the idea has been bandied around for decades, the market has more or less corrected away most who try to go this route.

 

[Mad Jack]

It perhaps works for a while in lower competition areas, but those areas themselves are not going to exist forever, and others trying the same thing cut into your margins, so the word "viable" isn't a good one. Is swimming in shark infested waters viable when you are just talking about the window before the sharks see you? Doctors are bad at running businesses for sure, but there is a bigger reason these practices fail independent of that -- it's just a flawed model because it depends on young healthy people using disposable income and foregoing using employer covered insurance or ever getting sick/old. It's doomed from the start, which is why even though the idea has been bandied around for decades, the market has more or less corrected away most who try to go this route.

If you're collecting a fee per visit, sick patients would actually net you more money though. If you've got a $600/year fee, you could survive off of a base of 500 patients, with a medical assistant and office expenses excluded, still netting you 180k/year after the 85k for facilities and utilities and 35k for a medical assistant. With 500 patients, if you charge 20 dollars for a phone conversation and 35 for a visit, the sicker they are, the more money you would potentially make. Even if every single patient had to visit you once a month, that is still 30 minutes (far more than the average visit allows) per patient if you keep 8-6 hours, and would also bring in an extra 210k in revenue. This would be a horrible lifestyle, but would pay fairly well in theory. I'll trust that you're right though- this is all just ideas.

Children and marriage aren't in the cards for me, ever, so if by some awful chance I end up not matching and scramble into primary care, I'm just trying to feel out if there is any way to make money on it if I don't give a damn about lifestyle or location.

 

[1012526fs]

Frenchy... when you're talking a physician vs a physician in who gets paid more per patient, you know what it really comes down to?... two things. 1. What did they do for the patient. And 2. Coding. The way a provider (or whoever documents for them and codes) describes what they do and puts down the specific ICD9 (or 10 now) codes, is the way it will be billed. But bottom line, if the exact patient and exact presentation and exact treatment and exact coding are done by an MD and DO, but the DO throws in a manipulation, then yes, the DO will make more for that single patient encounter. However, a savvy MD will know how to document well and will likely make more in the long run than any of their peers, MD or DO.

 

[FrenchyM.D/D.O]

That actually makes a lot of sense, "Louisville" (I like the name). In fact, I went to the dentist the other day and was worried that I might have to pay a lot of money for the work that he performed but he said: " Kiddo (hmm..I 'm 27 BTW), don't worry I know exactly what to pt this under so the insurance company sees nothing" I was quite confused but didn't ask since I was not going to pay (well... directly that is) but it makes a lot more sense now.
He must have all those codes memorized by now and knows what to use, under what circumstances, but it looks like it is working for him. Very savvy like you say.
So you're saying that M.D's and D.O's do that too?

 

[FrenchyM.D/D.O]

I don't mean to insult your knowledge or anything like that, but concierge practice CAN be very lucrative and it can work.( man... I sound like all I care about $$$. Not true though)
But I like I said, I have a friend who makes over 700k/year net as an IM doc. (an M.D for all it is worth). I must admit that most of his patients are very very wealthy people in the Boston area ( I would name some of his patients for I am sure you guys would all know them but I am scared to violate some kind of Hippa law or some other law), Brookline to be more specific. His practice is so upscale, it's ridiculous! If you're curious, he is the co-founder of MDVIP. That's all I can give you.
You are right about the fact that one must have plenty of cash to start something like that.

 

[Law2Doc]

I don't mean to insult your knowledge or anything like that, but concierge practice CAN be very lucrative and it can work.( man... I sound like all I care about $$$. Not true though)
But I like I said, I have a friend who makes over 700k/year net as an IM doc. (an M.D for all it is worth). I must admit that most of his patients are very very wealthy people in the Boston area ( I would name some of his patients for I am sure you guys would all know them but I am scared to violate some kind of Hippa law or some other law), Brookline to be more specific. His practice is so upscale, it's ridiculous! If you're curious, he is the co-founder of MDVIP. That's all I can give you.
You are right about the fact that one must have plenty of cash to start something like that.

This guys practice works until someone else sets up shop across the street and starts stealing market share. Or it works because he's so established nobody else can get in there. Thats kind of my point. If it can work for one person but fails for the next ten who try to do the same thing, that means it's not a good business model for you to embrace as a premed. You are so far behind the curve at this point, you are trying to lay a sports bet on a game that was played yesterday. There's a good Reason the idea of concierge practices has been around for at least thirty years and still isn't but a blip on the landscape. It's because MOST people who go down this road end up broke. By contrast, most people can earn a decent living as a PCP taking insurance and scrambling/hustling a bit. so unless your goal is to keep lawyers like I used to be, living the high life, you probably should avoid this model like the plague. It's a short term play at best.

 

[1012526fs]

That actually makes a lot of sense, "Louisville" (I like the name). In fact, I went to the dentist the other day and was worried that I might have to pay a lot of money for the work that he performed but he said: " Kiddo (hmm..I 'm 27 BTW), don't worry I know exactly what to pt this under so the insurance company sees nothing" I was quite confused but didn't ask since I was not going to pay (well... directly that is) but it makes a lot more sense now.
He must have all those codes memorized by now and knows what to use, under what circumstances, but it looks like it is working for him. Very savvy like you say.
So you're saying that M.D's and D.O's do that too?

MD's and DO's may not do it directly, but if they want to have any idea how they or their clinic or hospital are billed and paid for the work they do, then they will get smart on coding. However, it's the job of the certified coders to do that. I personally code a lot of what I do on my own, but a coder is always right behind me to check my work and change it to whatever they know is a more accurate code. Also, coders are very smart in that realm, but they're not providers and may not be fully aware of what a specific term or procedure entail. Feel free to find your coders in the future and stop by to chat every now and then, especially when your business starts doing a new procedure, etc.

 

[FrenchyM.D/D.O]

This guys practice works until someone else sets up shop across the street and starts stealing market share. Or it works because he's so established nobody else can get in there. Thats kind of my point. If it can work for one person but fails for the next ten who try to do the same thing, that means it's not a good business model for you to embrace as a premed. You are so far behind the curve at this point, you are trying to lay a sports bet on a game that was played yesterday. There's a good Reason the idea of concierge practices has been around for at least thirty years and still isn't but a blip on the landscape. It's because MOST people who go down this road end up broke. By contrast, most people can earn a decent living as a PCP taking insurance and scrambling/hustling a bit. so unless your goal is to keep lawyers like I used to be, living the high life, you probably should avoid this model like the plague. It's a short term play at best.

Thank you very much Law2doc!! I appreciate you sharing your knowledge and will definitely share it with my older sister. She went to Suffolk Law School.