2 years later

[bronchospasm]

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It has been a little over 2 years since I started my practice. I have learned so much from this board that I feel should to share my experience.

I feel that my practice style has change a little bit. Initially I used to think that my procedures can cure cancer as well as world hunger. But now have settled for a more balanced approach. I now utilize and emphasize on HEP, PT as well as taking care of the psych end of things. Unless the patient is in moderate to severe pain, I use interventions only when above conservative therapy has failed. This has led to a slight decrease in procedures but overall results and patient satisfaction has improved leading to more patient referrals. Weeds out myofascial pain and can the directly jump to facets if appropriate.

Patient volume has dropped a bit partly due to maturation of the practice and also due to getting more appropriate consults. I have adjusted to that by taking Friday's off. Continue to see 5-6 new patients, 10-12 procedures including 1-RFA and 14-16 follow ups a day. 30-32 total patients per day. Work through lunch. Finish at 5-5:30 pm.

Opioids: Still have a handful of patients who are on greater that 30 MEQ a day. Mostly inherited from others. About 40-50% are on tramadol and Tylenol #3. Other patients are on 1-2 norco 7.5 mg a day. No Roxicodone or OxyContin ever prescribed. Few cancer patients on FTL patches.

Use a lot more cymbalta in addition to Gabapentin and Lyrica

Did about 30 and 34 stim trials last 2 years. Also 20 kyphoplasty / year.

Still accept patients via physician referral only. No self pay. No Medicaid. 60% Medicare and 40% commercial insurance.

HR issues: Had to let go of one MA due to personality issues and another one because I found out that she was on Suboxone. This was probably the most stressful part over the past 2 years as we had just 3 MA's. Went from 3 MA's to 5 MA's in part to hedge against similar situations in the future if I have to let go of someone. Also cross trained everyone.

Bought another used 2008 Philips pulsera 12 inch C-arm for 35K and cancelled the $6.5k annual Phillips MAINTAINANCE contract. Planning to setup a satellite office in the next 6 months. Still in the infancy stage.

EMR : changed from Dragon to Dictation of plan and HPI in the patient room. Physical exam is template based. This has saved a lot of after hours and weekend time. Transcriptionist enters it in EMR.

Overall income has stayed the same since expenses have increased due to increased supplies/ equipment and employee expenses.

Future plans to be completed by the end of June 2016: satellite office, in office UDS. DME, nurse practioner, psychologist.

QOL has improved dramatically since closing the office on Friday's.

Have learnt a lot from others on this board.

Practice is Small and Clean rather than Big and Dirty.

 

[Aether2000]

Nice! Way to go!

 

[NJPAIN]

Good for you! Just curious, what kind of area are you in? Rural, urban, etc? What kind of competition do you have? Did you leave a group in the area?

 

[drusso]

I hope that your experience inspires others on this Board to get out from under the thumb of the "the system," start their own shop, and own their success.

 

[NOSfan]

Kudos on your success!

While clinically optimal, would take a close look at adding the in-house psychologist as this tends to be a financial sink.

 

[drusso]

Kudos on your success!

While clinically optimal, would take a close look at adding the in-house psychologist as this tends to be a financial sink.

Licensed clinical social workers are cheaper.

 

[yancantcook]

thank you for sharing the experience, interested in learning how you go to your practice, were you with a group and went off on your own or did you start on your own immediately after fellowship?

 

[bronchospasm]

Good for you! Just curious, what kind of area are you in? Rural, urban, etc? What kind of competition do you have? Did you leave a group in the area?

I am in a suburban area with quad city metro area population of about 100k.?

There are 2 other PMR physicians who do ESI's for everyone with headaches to hemorrhoids. They are in a group with 10 other ortho guys.

I am the only BC and fellowship trained pain physician. So really no competition although I do not get any referrals from the ortho docs. Basically only doc doing cervical ESI, RFA, Kyphoplasty and Stim trials.

 

[bronchospasm]

Licensed clinical social workers are cheaper.

Working on getting a part time psychologist who will split time with another pain doc who is about 50 miles away. Psychologist will be eat what you kill model and independent contractor. When I open another office he can use the space when it is empty. Basically a free service.

 

[bronchospasm]

thank you for sharing the experience, interested in learning how you go to your practice, were you with a group and went off on your own or did you start on your own immediately after fellowship?

Started own practice after fellowship. I started reading this board about a year before fellowship.... Took notes . Had saved up about $125 k... I realized that there were a lot of scumbags out there who are looking to make a buck by promising partnership, equity etc.
I moonlighted every weekend for 6 months to avoid dipping into savings.

Luckily, everything started falling in place.

 

[EtherBunny]

Started own practice after fellowship. I started reading this board about a year before fellowship.... Took notes . Had saved up about $125 k... I realized that there were a lot of scumbags out there who are looking to make a buck by promising partnership, equity etc.
I moonlighted every weekend for 6 months to avoid dipping into savings.

Luckily, everything started falling in place.

Thanks for sharing your experience! That's awesome. Kudos to you for having the courage to start a practice right out of fellowship.

A couple of questions for you:
1) Did you use one of the practice startup consultant services or did you manage everything on your own? I'm just curious because it seems like it would be fairly challenging to navigate the process of getting hospital privileges and getting on various third party payors in your target area.
2) Did you buy a C-arm or rent initially?

 

[Papa Lou]

What's the UDS for if so few pts on 30 MED or more?

 

[IN2B8R]

Care to comment on your referral patterns and how you got those started so quickly as the new guy in town?

 

[bronchospasm]

What's the UDS for if so few pts on 30 MED or more?

That's why I do not have it so far.. I send between 5-7 UDS per day. May not be worth the additional hassle. Still thinking about it.

 

[bronchospasm]

Care to comment on your referral patterns and how you got those started so quickly as the new guy in town?

Spoke to every family doc in town. That was 2 years ago. Rest is word of mouth. Patients asking for their family member or friend to be referred for evaluation if they saw good results. I made it very clear to the family doc that I do not prescribe high dose narcotics.

 

[bronchospasm]

Thanks for sharing your experience! That's awesome. Kudos to you for having the courage to start a practice right out of fellowship.

A couple of questions for you:
1) Did you use one of the practice startup consultant services or did you manage everything on your own? I'm just curious because it seems like it would be fairly challenging to navigate the process of getting hospital privileges and getting on various third party payors in your target area.

I did everything myself. Read through each and every post here going back a few years. Every aspect of starting a practice is described in detail here. I had hospital privileges due to anesthesia so that was not an issue. Initially just had BSBS, Medicare and Tricarr. Then later added CIGNA AND UNITED. That covers 99% of payers.

I did use an outside company for credentialing. They got everything done in 3 months. Health buisness navigators.

2) Did you buy a C-arm or rent initially?

Bought used 2008 pulsera and Stryker multigen.

 

[drpainfree]

congrats on a successful build-up of your practice. I'm in your similar situation about 2 years ago.

How do you get around quickly input your notes? Right now I'm typing my HPI/A/P, which takes quite a lot of time. The rest can be delegated if I really want to. I'm getting busier and would like to find an easier way to finish notes every day.

Do you dictate or HPI/A/P?

 

[NJPAIN]

Were you happy with Health Business Navigators?? Did you use for anything other than credentialling

 

[SSdoc33]

congrats on a successful build-up of your practice. I'm in your similar situation about 2 years ago.

How do you get around quickly input your notes? Right now I'm typing my HPI/A/P, which takes quite a lot of time. The rest can be delegated if I really want to. I'm getting busier and would like to find an easier way to finish notes every day.

Do you dictate or HPI/A/P?

typing? unless you are like Scotty in Star Trek 4, that is a colossal waste of time. bite the bullet and get a transcriptionist. also, avoid dragon like the plague....

 

[bronchospasm]

congrats on a successful build-up of your practice. I'm in your similar situation about 2 years ago.

How do you get around quickly input your notes? Right now I'm typing my HPI/A/P, which takes quite a lot of time. The rest can be delegated if I really want to. I'm getting busier and would like to find an easier way to finish notes every day.

Do you dictate or HPI/A/P?

Dictate HPI and plan while in the room. Physical exam is usually click.

8 cents / line transcription cost.

 

[bronchospasm]

Were you happy with Health Business Navigators?? Did you use for anything other than credentialling

Only credentialing. They delivered what they had promised.

 

[pastafan]

Dictate HPI and plan while in the room. Physical exam is usually click.

8 cents / line transcription cost.

Who do you use for transcription? Do they paste dictation into EMR for you to sign later?

 

[bronchospasm]

Who do you use for transcription? Do they paste dictation into EMR for you to sign later?

Its a local retired office manager who does this for me. Former patient. She does paste it directly into the EMR. I used dragon for about 1 year. It is cheaper but very inefficient.

transcription costs more but saves time. Weekends are a LOT better now

 

[DOctorJay]

What kind of microphone were you using with dragon? I have a power mic II and it works great. The newer versions of the Phillips microphones are even better.

I will concede however that dictating into a digital recorder is faster. However, all of my notes are signed and done by the time the patient leaves the office.

 

[Ducttape]

How much does it cost though?

Scribes are another option, and i believe the cost is not that different from a full dictation service.

 

[bronchospasm]

What kind of microphone were you using with dragon? I have a power mic II and it works great. The newer versions of the Phillips microphones are even better.

I will concede however that dictating into a digital recorder is faster. However, all of my notes are signed and done by the time the patient leaves the office.

I used Tablemike 6 in 1 .. works well.

Used to use the Philip DPM 8000 but last month switched to a $10 iPhone app called express dictate where it transfers the notes to transcriptionist in real lime. Love it.

 

[bronchospasm]

How much does it cost though?

Scribes are another option, and i believe the cost is not that different from a full dictation service.

$400-$500 per month

 

[knoxdoc]

Why is Dragon bad? I was actually thinking about trying it with our new EMR but I'm having second thoughts after reading these posts.

 

[drpainfree]

how do you get dictation done in the room while you are with patients? is it kind of rude to ignore your patients while dictating?

 

[DOctorJay]

Why is Dragon bad? I was actually thinking about trying it with our new EMR but I'm having second thoughts after reading these posts.

Make sure you get the medical version if planning on using with EMR. It's a racket but no other dragon versions will work in an EMR. Not sure if you can "transfer text" from the dictation box into the EMR or not. I'm sure they've figured that out though.

Also make sure to get a high end handheld mic and dictate as you normally would. Don't watch the screen or the performance will not be as good.

 

[DOctorJay]

how do you get dictation done in the room while you are with patients? is it kind of rude to ignore your patients while dictating?

I rotated with a doc who did this and it was very smooth. Most pts seemed to like the fact he did it as they knew exactly what was going into the note. Most pts knew to be quiet and only interrupt for corrections.

 

[pastafan]

Make sure you get the medical version if planning on using with EMR. It's a racket but no other dragon versions will work in an EMR. Not sure if you can "transfer text" from the dictation box into the EMR or not. I'm sure they've figured that out though.

Also make sure to get a high end handheld mic and dictate as you normally would. Don't watch the screen or the performance will not be as good.

Dragon non-medical will work with some EMRs but not the big boys.

I tried with a high end mic and it was killing me spending hours correcting. I went with a dictation service. Best money that I have spent to date although I think that I am paying on the high end for my dictation.

 

[bronchospasm]

Why is Dragon bad? I was actually thinking about trying it with our new EMR but I'm having second thoughts after reading these posts.

DMPE2 costs about $1800. It was great but I was taking notes in the patient rooms and coming back to the dictation area and was still only able to complete half the dictations. Had a lot of left over dictations that were done after hours. It is definitely better than typing or templates.

I still use it if we need a PA or if a note needs to be completed urgently for a referral.

 

[bronchospasm]

I rotated with a doc who did this and it was very smooth. Most pts seemed to like the fact he did it as they knew exactly what was going into the note. Most pts knew to be quiet and only interrupt for corrections.

At the end of the encounter, just before the patient is ready to leave, I say " let me just enter everything in your chart" and start dictating. Patients are comfortable knowing what is going into their chart and in some ways also reinforces the same plan.

 

[bronchospasm]

Make sure you get the medical version if planning on using with EMR. It's a racket but no other dragon versions will work in an EMR. Not sure if you can "transfer text" from the dictation box into the EMR or not. I'm sure they've figured that out though.

Also make sure to get a high end handheld mic and dictate as you normally would. Don't watch the screen or the performance will not be as good.

I think the there is a new medical practice version coming out soon. Please check before you buy.

 

[bronchospasm]

How much does it cost though?

Scribes are another option, and i believe the cost is not that different from a full dictation service.

Scribe will cost you about $ $24-28 k / yr. if you can get a qualified scribe.

 

[Ducttape]

the price quotes i had gotten have been $1 a line, from 2 different companies. in a typical note, for me, maybe averages $30 per encounter?

 

[bronchospasm]

Shop around.. There is also a post dedicated to transcription services here. You might have to search through other boards.
$1 per line is about $300 an hour. Which is more than what we make.

 

[Disciple]

At the end of the encounter, just before the patient is ready to leave, I say " let me just enter everything in your chart" and start dictating. Patients are comfortable knowing what is going into their chart and in some ways also reinforces the same plan.

I'm assuming that excludes patients whom you've just told their symptoms don't match their physical examination findings.

 

[Disciple]

I went with a dictation service. Best money that I have spent to date although I think that I am paying on the high end for my dictation.

What do you consider high-end, if you don't mind me asking?

I've paid between 8-13 cents/line in the past.

 

[pastafan]

What do you consider high-end, if you don't mind me asking?

I've paid between 8-13 cents/line in the past.

I am paying $90/hour for dictation or 11.5 cents a line. I have not taken the time to check actual charge per line as dictation is pasted into EMR by the service. Totally accurate so I don't need to edit.

 

[bronchospasm]

I'm assuming that excludes patients whom you've just told their symptoms don't match their physical examination findings.

Even for the seekers, note is dictated in front of them. I will most likely not be seeing them again so it does not matter if they are upset. It is what it is.

 

[Disciple]

I am paying $90/hour for dictation or 11.5 cents a line. I have not taken the time to check actual charge per line as dictation is pasted into EMR by the service. Totally accurate so I don't need to edit.

Just to be clear, $90/hour of dictation/voice file time?

and $90 per hour averages out to 11.5 cents per line, depending on how fast one dictates?

 

[pastafan]

Just to be clear, $90/hour of dictation/voice file time?

and $90 per hour averages out to 11.5 cents per line, depending on how fast one dictates?

Yes and I talk fast. 😉

 

[emd123]

It has been a little over 2 years since I started my practice. I have learned so much from this board that I feel should to share my experience.

I feel that my practice style has change a little bit. Initially I used to think that my procedures can cure cancer as well as world hunger. But now have settled for a more balanced approach. I now utilize and emphasize on HEP, PT as well as taking care of the psych end of things. Unless the patient is in moderate to severe pain, I use interventions only when above conservative therapy has failed. This has led to a slight decrease in procedures but overall results and patient satisfaction has improved leading to more patient referrals. Weeds out myofascial pain and can the directly jump to facets if appropriate.

Patient volume has dropped a bit partly due to maturation of the practice and also due to getting more appropriate consults. I have adjusted to that by taking Friday's off. Continue to see 5-6 new patients, 10-12 procedures including 1-RFA and 14-16 follow ups a day. 30-32 total patients per day. Work through lunch. Finish at 5-5:30 pm.

Opioids: Still have a handful of patients who are on greater that 30 MEQ a day. Mostly inherited from others. About 40-50% are on tramadol and Tylenol #3. Other patients are on 1-2 norco 7.5 mg a day. No Roxicodone or OxyContin ever prescribed. Few cancer patients on FTL patches.

Use a lot more cymbalta in addition to Gabapentin and Lyrica

Did about 30 and 34 stim trials last 2 years. Also 20 kyphoplasty / year.

Still accept patients via physician referral only. No self pay. No Medicaid. 60% Medicare and 40% commercial insurance.

HR issues: Had to let go of one MA due to personality issues and another one because I found out that she was on Suboxone. This was probably the most stressful part over the past 2 years as we had just 3 MA's. Went from 3 MA's to 5 MA's in part to hedge against similar situations in the future if I have to let go of someone. Also cross trained everyone.

Bought another used 2008 Philips pulsera 12 inch C-arm for 35K and cancelled the $6.5k annual Phillips MAINTAINANCE contract. Planning to setup a satellite office in the next 6 months. Still in the infancy stage.

EMR : changed from Dragon to Dictation of plan and HPI in the patient room. Physical exam is template based. This has saved a lot of after hours and weekend time. Transcriptionist enters it in EMR.

Overall income has stayed the same since expenses have increased due to increased supplies/ equipment and employee expenses.

Future plans to be completed by the end of June 2016: satellite office, in office UDS. DME, nurse practioner, psychologist.

QOL has improved dramatically since closing the office on Friday's.

Have learnt a lot from others on this board.

Practice is Small and Clean rather than Big and Dirty.

Just curious. Did your revenue drop when you started closing Friday's or were you able to cram enough patients in 4 days to hold things steady?

 

[Pacman27]

Dont want to steal the OP thunder, but I figure this is to help others. It will be 2 years Jan 2016 since I opened my practice. Here are my thoughts so far.

1. Medicine is a tough business if you start equating reimbursement to the work you do. Meaning you get paid what you get paid, just do the right thing for the patient. If a back brace is indicated, give the patient a back brace. On the flip if a ESI is indicated do the ESI.

2. Rule of 10 or 15. Meaning you will go to 10 to 15 offices and 1 will start referring to you. However, if you never went to the 10 or 15 you would have never found that 1. Be persistent. Don't let your emotions get the best of you. Dont get too excited or disappointed. A home run lunch may amount to no referrals.

3. Call your good patients personally. this is huge, docs do not do this anymore

4. Align with the good pain docs in the area. There are plenty of good patients. They may have skill sets or perform things that you dont and vice versa.

5. Find your work life balance, its easy to get caught up in work related dinners and meetings. Dont let it consume you. Remb, the alternative is that there is a job somewhere for you.

6. Think outside of the box and look for more then commercial insurance payors. Create a great rep in the area as a great doc and patients will find you for good treatment.

Finally, this is not for everyone. It is actually pretty brutal and there is always some baseline of stress. Its like having a kid. Family support is huge. Location is also huge. Overall, I am very pleased and while I maybe able to make more money working for a larger group, I love the fact that I control my schedule.

Hopefully I can expand to another location soon and give another doc an opp to grow a practice

 

[drusso]

Dont want to steal the OP thunder, but I figure this is to help others. It will be 2 years Jan 2016 since I opened my practice. Here are my thoughts so far.

1. Medicine is a tough business if you start equating reimbursement to the work you do. Meaning you get paid what you get paid, just do the right thing for the patient. If a back brace is indicated, give the patient a back brace. On the flip if a ESI is indicated do the ESI.

2. Rule of 10 or 15. Meaning you will go to 10 to 15 offices and 1 will start referring to you. However, if you never went to the 10 or 15 you would have never found that 1. Be persistent. Don't let your emotions get the best of you. Dont get too excited or disappointed. A home run lunch may amount to no referrals.

3. Call your good patients personally. this is huge, docs do not do this anymore

4. Align with the good pain docs in the area. There are plenty of good patients. They may have skill sets or perform things that you dont and vice versa.

5. Find your work life balance, its easy to get caught up in work related dinners and meetings. Dont let it consume you. Remb, the alternative is that there is a job somewhere for you.

6. Think outside of the box and look for more then commercial insurance payors. Create a great rep in the area as a great doc and patients will find you for good treatment.

Finally, this is not for everyone. It is actually pretty brutal and there is always some baseline of stress. Its like having a kid. Family support is huge. Location is also huge. Overall, I am very pleased and while I maybe able to make more money working for a larger group, I love the fact that I control my schedule.

Hopefully I can expand to another location soon and give another doc an opp to grow a practice

This is pure gold. I would add the following: Medical school, residency, fellowship, etc teaches you NOTHING about what it takes to do it your own. Not everyone has the chops for it, but there is not greater satisfaction than running your own show.

 

[bronchospasm]

Just curious. Did your revenue drop when you started closing Friday's or were you able to cram enough patients in 4 days to hold things steady?

It did drop some, I think about 10%. I adjusted by increasing one new patient and a follow up a day. But a 10 percent drop is about 4% drop after taxes and expenses so not really noticeable. Also overtime for employees dropped as well. Last year I paid about 9K in overtime ..None this year.

 

[Jcm800]

Man, if you can go to 4 days a week, and keep virtually the same income, congrats man! That is great. I gotta find a way to make that happen

 

[clubdeac]

So let me ask you pp guys, what would you be happy making if you could work only 30 hrs a week, including all work i.e. paperwork, administrative work etc.? Oh and take 8 weeks off a year. What kind of annual income could you generate doing that?