treating old people = you're broke?

Dr McSteamy said:

does treating old people earn you little money?

i think i saw somewhere that treating old people will make you lose money in fact, because medicare or whatever doesn't pay you squat for your services

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Yes basically. Every rotation that I have been on, including Neurology, mentions this.
If you treat the elderly, that does equal significantly less money -- such as Preventive Medicine.
If you sit around for 45 minutes and talk about Medicine to patients, you will more than likely be dismissed from that practice.
I have seen this happen more than once, doctors asked to leave because they take too much time with patients.
Think about the Nursing Homes. You get paid less than $20,000 for directorship of a Nursing Home PER YEAR.
That shows you how much the elderly is valued.

emedpa said:

part of this is you have to know how to bill medicare properly.
things like doing an ekg on your own machine and interpreting it, billing properly for labs and draw fees, immunizations and minor procedures, etc can actually make medicare pay off.
I have several friends whose entire primary care practice is cash or medicare(as the only thing they bill) and they do very well.

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wow, see this is what nobody teaches you. Wish that I could understand this business aspect of things.

I like the fact that this thread was started. Family practitioners training now are going to have a significant bulk of their practice (whether they like it or not) comprised of the 65yo and older demographic (those are just the statistics). There will be professional expectations to cover nursing home/rehab/hospice patients. Is this feasible given the direction medicare payments are headed and the future wave of patients?

I'm a fellow in geriatrics (FP trained) and I'm trying to get a handle on how practices vary/sustain themselves in the community (ie outside of academia).

Oh, are there any fellow geriatricians out there? There doesn't seem to be a place carved out for us on SDN, or did I miss something???...

Geriatrics is definitely a rewarding field. My background was FM but I was trained as a fellow in an IM program and I enjoyed it very much because it gave me sort of a different perspective looking at patients and diseases. And my training was very rigorous and I actually worked like a FM intern.

In academia, you can spend 1 hour on each new patient and 30 min. on each f/u or 45 min each encouter if say a procedure (i.e pap, vaginal estrogen ring placement) is needed. You can still make a nice living with 6 figure salary plus university perks. It is not hard to find a geriatric academic position at this time because many FM programs/IM programs would like to use your expertise to teach med students or expose residents to geriatrics. In addition, you can assist in curriculum development as well.

Outside of academia, depending on where you want to practice, there are many subsidized geriatric clinics affiliated with a private hospital. Again, you can make your 6 figure salary and see on the avg 13-15 patients per day.

You can also do LTC 100%. If you're a medical director at a LTC facility, doing only administrative things w/o patient care, you can earn up to $30K/yr. This requires approx 1 day/week to sign papers. Non-geriatric attendings would ask you for advise on geriatric issues if needed. So a lot of geriatrics in an outpt clinic can do this on the side to make extra money. In addition, being a medical director plus being an attending at the facility, then you can make much much more money.

To make $150K, you need to take care of 13-15 subacute patients at one time and 100 NH patients. Medicare dictates that you see your subacute patients once per week and your long term care NH patients every 60 days. So it is not bad. You can also work out a deal with a PA or NP to help you so you can take care of even more patients.

Furthermore, if you go see your patients, in addition to your mandatory visits, for any acute reasons i.e. elevated BP, cough, SOB, constipation, fever, or whatever, you get to bill Medicare under Part A and treat it as a visit to the PCP.

I was told previously by my attendings that an addmission H/P/Orders to a subacute facility or transitional unit is paid more than an acute admission H/P/Orders in a hospital. I don't know why.

Having said all that, you would more likely have to be fellowship trained, board eligible, in order to do what I mentioned above.

Billing is also very important. In 60 min or even 30 min visits, you can easily bill a level 4 if you cover enough systems and document them. Also, when you document in the chart, don't write routine 3 mo. f/u or f/u for DM. You should always write f/u for DM mgt. This will get you more money...again..I don't know why but this is the way it's done during my training.

I owned 3 chiropractic clinics. Each very different. One was medicare based in Sun City Arizona. Medicare has only 3 codes it pays on for chiropractors depending on how many levels of the spine your adjust. Basically they reimburse between about $20 to $30. Thats it. no reimbursement for x-rays, therapies, exams etc - even though up until a few years ago they required x-rays for reimbursement.

Anyway it was so-so profitable. I was in the office a total of about 15 hours per week and the positive cash flow was about $60-70,000 (after fixed business expenses). The 15 hours per week included down time spent doing paperwork. I really saw patients from about 8:30 to 11:30 three days per week, then did a little paperwork. It was the least profitable of my offices, but it suited what I was doing at the time. I was making income from it while I did clinical rotations for med school.

Many of the patients had secondary insurances (not to be confused with supplemental insurances, which does very little to add to income).

I was able to get 40+ hours a week in med school rotations at local teaching hospitals, while working part time, and clearing $60-70K after paying for office rent, staff payroll, advertisting, supplies, power, malpractice etc.

I would do it again if I could afford to start a new business. But after losing big money in real estate here my choices are very limited. Damn.

If I could have billed for exams, x-rays, freezing actinic keratoses with liquid nitrogen, etc like you can with an MD - dayum. 15 hours per week would have been VERY lucrative.

You can make money from medicare - I doubt $300,000 positive cash flow (over and above fixed office expenses) - but you never know

Medicare patients are very good in many ways. They have few conflicts to make them miss appointments -whereas younger patients might have a sick child, work conflicts etc - old people often find going to the doctor the highlight of their week.

You get done early - most like to come in first thing and once its 2 in the afternoon like to take naps. You can run a medicare practice by just working 7 to 2 - its ideal for a working mother who wants to be home with kids after school. Old folks get up early to pee, can't get back too sleep, but then want to take a nap.

Medicare patients are ideal for working mothers who want to be home in the afternoon or for someone who has 2 practices - they can do Medicare in the morning and then cater to the younger people when they get off work in the afternoon.

Medicare deductible is just over $100. If you are in an affluent retired area like Sun City they have money - their home in Sun City is just a second home for "wintering", and both homes are fully paid for. They have no more kids to put through college or any other big expenses like younger married people.

If they have a secondary insurance it covers everything not allowed by medicare. A supplemental insurance covers the co-pay and deductible of what medicare allows. So if medicare allows 1 prostate exam a year and you want to do daily prostate exams - the secondary covers it. This is the difference between a secondary and a supplemental.

It takes little to make Medicare patients happy - a little real doctoring and a little friendliness.

Doowai said:

It takes little to make Medicare patients happy - a little real doctoring and a little friendliness.

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It takes a lot of time to make Medicare patients happy- some of this is due to having more med problems than a younger person, some is because many older pts view going to the doctor as a social occasion, the highlight of their day. In my sleep practice, I am able to see medicare pts because the income from reading sleep studies subsidizes my outpt practice. A doc can doing ok seeing older pts if he is receiving some type of hospital/univ subsidy or capturing ancillary/procedural revenue; a doctor who relies on the income from outpt Medicare office visits will go broke.

I don't know much about seeing NH pts, so I can't comment on the economics of that.

Thanks for the input. I especially appreciated Dr. Grim's input and attention to the response. I also trained in FM and am currently in an internal medicine geriatric fellowship. Next year i will be doing another fellowship in palliative care. It's reassuring to hear the details of how to make geriatrics work in a fiscal sense. I'm not sure at this point what my future job prospects look like. I'm shying away from academics mainly because of my 300k of debt. It seems that the private practice alternatives may be more lucrative? Not sure.

bunnymd said:

Thanks for the input. I especially appreciated Dr. Grim's input and attention to the response. I also trained in FM and am currently in an internal medicine geriatric fellowship. Next year i will be doing another fellowship in palliative care. It's reassuring to hear the details of how to make geriatrics work in a fiscal sense. I'm not sure at this point what my future job prospects look like. I'm shying away from academics mainly because of my 300k of debt. It seems that the private practice alternatives may be more lucrative? Not sure.

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You can also take on several medical directorships as well for financial incentives in addition to your patient care responsibilities. It has been done by quite a few of our adjunct clinical professors and it is definitely do-able. If you're also interested in medical directorship as a geriatrician, I wuold encourage you to attend the AMDA annual symposium. You can also apply to their FUTURES program for scholarship for this event. Later on, obtaining a CMD would be worthwhile. G.

I just spoke with one of the faculty regarding the Futures program. I'm definitely applying for that. It sounds like a great opportunity for education and networking. Is a CMD a medical director certificate? How does one go about getting it?

bunnymd said:

I just spoke with one of the faculty regarding the Futures program. I'm definitely applying for that. It sounds like a great opportunity for education and networking. Is a CMD a medical director certificate? How does one go about getting it?

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You'd have to take some courses with AMDA/CME and have I believe 2 years of LTC experience.

I have seen that the AMDA has advocated for higher nursing home physician billing/compensation and has made progress. Does this bode well for outpatient as well?