Costs and figures... startup Solo podiatry office
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deleted1235332
Does anyone have any suggestions on where to purchase equipment such as those that are reusable (nail nippers, etc) vs more one time costs such as podiatry chairs?
what about DME, bandage material, etc?
Does anyone have a specific x ray machine they reccomend? If so are there financing options available? Feel like I don’t want to go used on the x ray.
what about DME, bandage material, etc?
Does anyone have a specific x ray machine they reccomend? If so are there financing options available? Feel like I don’t want to go used on the x ray.
I'm working on a starting a practice post, but I'll throw a few things.
1. You can sometimes buy Miltex equipment on Ebay. I'm looking right now and there's not a lot there because ...I bought it all a few months ago. Miltex equipment is pretty nice. There are cheaper brands out there like Bianco brothers that advertise in PM News.
2. Some of the people who post on here saved money by not buying expensive podiatry chairs ie. they bought the more classic FM device. Fairly substantial savings on doing this - like I think $600 for the sort of table/chair you see in FM offices.
3. I've purchased podiatry chairs and I think you are doing pretty good if you get them in the $2500-4000 range. I'm open to being wrong here. Classic chairs include Midmark and MTI. Watch out for variations between them ie. Midmark 646 which are more bariatric can lower the back or raise the feet, but the chair itself doesn't go up. Watch out for chairs without foot controls because otherwise you'll be controlling them by hand. Upholstery can be changed. A new foot pedal is likely at least $600-700.
4. Some podiatry chairs are insanely heavy. Not kidding. I almost died starting my new office by being crushed to death by a podiatry chair. Definitely meme-worthy. Was behind one and it almost came back on me while loading it on a trailer.
5. Podiatry chairs show up on pallets. You can't get a pallet through the door of most offices. Which means you need a way to move it. I used a furniture dolley, but the dolley I used technically indicates the chair weight exceeds it. You will need minimum 2 people to move a podiatry chair even with a furniture dolley. You will be paying likely a fairly substantial amount of shipping to move the chairs - ie. say like $500-600 in shipping
6. Do not buy ANYTHING from Henry Schein until you've spoken to a rep. My rep cut my prices substantially but I'm still salty about what I paid on the first go. I thought they were overpriced crap. Once they switched the prices there were things that were more competitive.
7. I've bought quite a bit of stuff on Amazon.
8. Rocket orthopedic was who I used in the past for boots, braces, post-op shoes etc. Prices were good. I'm not claiming the quality was amazing...
9. My x-ray was about $25K. My suspicion is you'll go new on the computer / batteries / system etc but you can efficiently save money on the XCEL unit by getting it used/refurbished. Its likely going to all be sold to you as a parcel. Evaluate your real estate to see how large an x-ray you can fit ie. single rail vs multiple.
10. My old office used Tigerview. I'm open to someone saying something nice about them, but they had some sort of yearly subscription fee and they limited your ability to put their program on multiple computers ie. I had them on a laptop. I bought a ipad or something to put x-rays on and they wanted a huge licensing fee to add more screens or to use in room computers to show x-rays. I would personally try to find a service without a subscription. My opinion - find an x-ray system without a yearly fee if possible.
1. You can sometimes buy Miltex equipment on Ebay. I'm looking right now and there's not a lot there because ...I bought it all a few months ago. Miltex equipment is pretty nice. There are cheaper brands out there like Bianco brothers that advertise in PM News.
2. Some of the people who post on here saved money by not buying expensive podiatry chairs ie. they bought the more classic FM device. Fairly substantial savings on doing this - like I think $600 for the sort of table/chair you see in FM offices.
3. I've purchased podiatry chairs and I think you are doing pretty good if you get them in the $2500-4000 range. I'm open to being wrong here. Classic chairs include Midmark and MTI. Watch out for variations between them ie. Midmark 646 which are more bariatric can lower the back or raise the feet, but the chair itself doesn't go up. Watch out for chairs without foot controls because otherwise you'll be controlling them by hand. Upholstery can be changed. A new foot pedal is likely at least $600-700.
4. Some podiatry chairs are insanely heavy. Not kidding. I almost died starting my new office by being crushed to death by a podiatry chair. Definitely meme-worthy. Was behind one and it almost came back on me while loading it on a trailer.
5. Podiatry chairs show up on pallets. You can't get a pallet through the door of most offices. Which means you need a way to move it. I used a furniture dolley, but the dolley I used technically indicates the chair weight exceeds it. You will need minimum 2 people to move a podiatry chair even with a furniture dolley. You will be paying likely a fairly substantial amount of shipping to move the chairs - ie. say like $500-600 in shipping
6. Do not buy ANYTHING from Henry Schein until you've spoken to a rep. My rep cut my prices substantially but I'm still salty about what I paid on the first go. I thought they were overpriced crap. Once they switched the prices there were things that were more competitive.
7. I've bought quite a bit of stuff on Amazon.
8. Rocket orthopedic was who I used in the past for boots, braces, post-op shoes etc. Prices were good. I'm not claiming the quality was amazing...
9. My x-ray was about $25K. My suspicion is you'll go new on the computer / batteries / system etc but you can efficiently save money on the XCEL unit by getting it used/refurbished. Its likely going to all be sold to you as a parcel. Evaluate your real estate to see how large an x-ray you can fit ie. single rail vs multiple.
10. My old office used Tigerview. I'm open to someone saying something nice about them, but they had some sort of yearly subscription fee and they limited your ability to put their program on multiple computers ie. I had them on a laptop. I bought a ipad or something to put x-rays on and they wanted a huge licensing fee to add more screens or to use in room computers to show x-rays. I would personally try to find a service without a subscription. My opinion - find an x-ray system without a yearly fee if possible.
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deleted1235332
Great info. Thank you. Look forward to your thread.
Many clinics these days are going with more of a Medspa-style chair that usually runs in the $2k range rather than your Midmark $4-6k range. Not sure the durability of those chairs, but they actually look a little nicer and less TFP-esque.
Yes. McKesson makes a lot of things (DME, bandages, etc) that are exact same as major brands... they just can't use the brand name. The reps will basically tell you this.
... for my office, I buy a lot of supplies from McKess, some from Chicago Medial Supply, some Henry Schein, a good bit ShopMedVet... obviously some AliExpress and eBay and amazon too.
I can comment more on this later (chairs, instruments, etc), going to a movie now. Basically, it's worth saving on the big items and the stuff you use a LOT. The oddball stuff that you use few of and that aren't too expensive are usually not really worth price comparing.
Good info on brands - I think the big thing to me is there is not a lot of immediate clarity on pricing for these items when you first look. A lot of things behind "membership walls" and the need for getting a rep to tell you the actual price. I look around going - who is the main supplier and what does a discount look like. The other day I wanted a 4mm verruca style curette. Some website was listing $160 - ridiculous- while another had it for $40 which is still absurd. Its a metal stick with a tiny spoon. Everything I've bought for equipment has been used or Ebay. I initially wondered if some of the Amazon things I bought would be problematic or broken, but none are expired and yeah - the McKesson stuff I've bought has been plenty nice.
I do think pricing and exploring is paying off for me - I'm finding individual items where I could easily spend $10 a purchase more or even a $1 an item more. That sort of thing day by day adds up.
One of the things that killed me was that for 7 years my partner insisted on purchasing the worst ace bandage in the world. Found 1 I like for cheap immediately on Amazon and the quality was great.
I do think pricing and exploring is paying off for me - I'm finding individual items where I could easily spend $10 a purchase more or even a $1 an item more. That sort of thing day by day adds up.
One of the things that killed me was that for 7 years my partner insisted on purchasing the worst ace bandage in the world. Found 1 I like for cheap immediately on Amazon and the quality was great.
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deleted1235332
This is all good info. Agree that it’s very difficult to know the true price of things. These midmark chairs are $7000+ brand new. Not sure I can afford that in my office. And getting used could be a pain with the shipping/quality. Might look into the med spa chair route
Medspa chair and if you need the pull out tray, just get a short mayo to slide under the foot to catch blood/debris/whatever. Even if the chair breaks within 10 years, you can buy 2 or 3 of them for the price of one midmark which may break or need expensive maintenance as well.
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deleted1235332
Is there one in particular you recommend?
Yes is there a particular medspa chair that has been working for anyone here? Im starting my practice in a few months as well and am in the market for chairs. It seems almost everyone I know is getting the midmark chairs....they say it's because it can handle some of our heavier patients, whereas the medspa chairs are for more normal sized people..
Betty Mills
I practiced for a few years using ortho tables... They're like what 300 400 bucks. You can do everything you need to like that except for cut toenails.... Now you're in private practice so you're probably going to be cutting a lot of toenails but you could certainly skimp on one or two rooms and just do these tables instead of your fancy midmark nail care chairs
I cannot vouch for these, but I have seen other pods in FB groups refer to these types of chairs on Amazon. They seem to have decent ratings, but who knows how legit Amazon ratings are. If it were me, I'd probably get a couple of these and then one Midmark/MTI for a procedure/fatty chair. The Amazon chairs are rated to 400 lb so they are partially but not fully-Texan proof.
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deleted1235332
Nice that can save so much money if these work well. But yeah maybe one midmark chair for the heavies….
Podiatry chairs are def marked up just because they’re medical.
They are marked up and people act like they're unbreakable which they are not. I see people asking/complaining about getting them fixed on the reg and you have to hire one of their technicians to fix it which is more $$$.
How much would you say you spent starting your practice? Do you own the real estate?
Even though you didn't ask me specifically I'll answer the question for myself...I'm planning on going live in September. Will be subleasing a spot for 3 days a week at first. total start up cost for me to start a bare bones podiatry practice from scratch will be about 30-40K (and that includes used xray machine and podiatry chairs)
So I am familiar with Texas sized people. I am now in a state or at least an area which significantly less obesity it was immediately noticeable to me. There was a woman orthopedic surgeon here who used to practice and her phrase for obese people in this state was "a Minnesota medium"
I spent roughly same, probably a bit more ~$50k. I did not get XR (rent suite in hospital, so I cannot).
Then, you need saving (or line of credit) for about the same ~50k to be a safety net in case schedule doesn't fill and/or collections don't come in as quick as hoped for. You can't be sweating payroll day or buying some marketing push in the early going. It obviuosly depends on area rents and wages.
...Your MAIN expenses are not physical supplies. Furniture and computers and biz machines cost money, but they are then good for years. Those aren't insignificant, but the staff and the utilities and EMR and rent are the main costs. Those costs don't stop if you take a week off or there is power outage or blizzard day. If you want good staff, you need to pay them over the area average. That payroll has been my #1 expense every year, and it's not close (add team lunches, team outings, bonuses, gifts, all that).
Some of the EMR and internet/phone/etc untilities give teaser intro rates, but don't be fooled. Expect a max increase allowed or expire of promo rates fairly soon afterwards (most of mine have had multiple increases each year lately with inflation.... roughly since Ukraine war). Be pleasantly surprised if your major monthly bills stay stable on price for more than about a year or two at a time.
- Marketing is also not insignificant early on. You need to get full, make relationships with PCPs. So, a few ads, build website, probably a photographer, all that.
- Attorney/accountant/credential fees are also sizeable up front... well worth it, but a good chunk spent there. You can draft stuff, but let them review and finalize.
- Expect both physical supplies and marketing to get a bit lower as you get further into it (less marketing once busy, and only have to "fill up" on supplies once... then just top off stocks).
- Expect staffing to go up and up. It's worth it. People have options. If you want good people and dependability, reward them, give raises, bonuses. If not, have fun interviewing, training, dealing with sick days, re-training often, repeat endlessly. 🙂
...You will find that PP startup is basically a race between staff/utilities/rent costs and getting payments coming in (credentialed, filling up schedule, billing/collections, PCP relationships). It's good to keep your personal expenses like travel/cars/clothes/dining/lux real low during that time, assuming you didn't have big savings researes going in.
You want to get well insured patients, fill the schedule. Less drama, more income, fewer patients per day. For me, that means:
- from PCPs (you know they have insurance, are dependable pts typically, built in goodwill as they were told you are good)
- some work comp (need a high quality biller, but it can be good rates)
- from patients referring other friend/neighbor/co-workers (goodwill built in, feels good, likely same/similar insurance)
- some ER and UCare refers and inpt pts early on that f/u office, but that's more mixed results (many of those pts are lazy, mixed insurances).
- some carefully placed ads can do ok, but it is high cost for what you get (newspaper, direct mail, store fronts, local movie theatre, etc).
- I avoid social media and blanket ads/marketing as it is too wide a net and brings out the crazies. Leave that to supergroups. It's that simple.
PS, those heifers and wide wheelchairs folk also will break your waiting room chairs, doorways, other stuff in your office too. No thanks.
Wrong. The power chairs are NOT for the DiaBetties and TwoTon Tommies. Don't use the pneumatic lift on them.. you will face expensive repairs very fast. Don't put them up at all. You can use the power chairs for the normal weight folks, but don't use the lift on the bigguns (tilt, or nothing for them). Instruct your MAs of same.
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I see no mention of the cost of flour, butter, chocolate chips etc. Do you have an oven on the office for baking cookies for other docs? Does autoclave work if you use self rising flour? Can you write off part of your mortgage or kitchen remodel if you use the oven at home. Thank you .
1. I had an excel sheet where I was keeping track of everything, but I've been less diligent about it since I started reconciling my accounting software and having stuff go in directly. Its also somewhat interesting reporting some of my expenses because yes - I am both the practice and the landlord.
2. I'm not going for bare bones - I'm trying for fully functional, cut above the rest. I'm in the same town, essentially down the street from my old office where I already had an adequately busy practice. My old office was a dark dingy, strangely painted craphole. It had a leak in the roof of my procedure room that just couldn't be fixed.
3. I'll call practice expenses $60K, but it may be a bit more than that now. I'm still picking up stuff and I still have some DME to buy. That doesn't include a downpayment on the building or some of the plumbing/electrician expenses I picked up. And it doesn't include the paint job either. I'm tired of spending, but I don't regret what I've done.
4. I'm trying for a correction of all the mistakes of my last office. As ridiculous as this sounds - the number one word that patients have used to describe my new office is beautiful. We're clean as hell. We're freshly, brightly painted. My wife picked out all the art and its themed to the area. The building is powerwashed. All of the plants and flowerbeds were manicured and cleaned out. Are we actually beautiful? Are we dermatology? Hell no. But we aren't the usual filthy podiatry pathetic that every other podiatry office in town that I've been to is. Mixed in amongst my competitors reviews are "this guys office is filthy". There's no crap on my counters. There's no metricide buckets. We're going for sterile. Instruments in bags.
5. Airbud makes fun of me all the time and tells me I should have left my last job years ago. In fact him and dtrack both said I was an imbecile for not leaving during covid. Its true, but I really feel like picking up this real estate when I did is my path to future success. I was looking at stuff in strip malls previously. At one point I was looking at a former podiatrists office with the smallest, crappiest layout that was crawling with homeless people sleeping at its entrance.
6. With the exception of the autoclave/printers/computers - basically everything is used. And I really feel like I got some good finds. Went to a used furniture store and they were showing me the sort of stuff you see in doctors offices / hospitals. I thought - damn, I can't afford these. And then randomly they showed me a set of large really nice comfortable front office chairs that were perfectly priced for me that I'm already getting good feedback on.
7. Big thing though - Feli is right about payroll. I've mostly stopped spending on new things. The problem though is I have to have staff to answer the phones. I'm the landlord so giving myself free rent is just moving money from one hand to the other.
8. I was only going to bring 1 staff with me when I started the office. I ended up bringing 2 and that obviously dramatically increases the price. If you read 619s prior post about starting they recommended having 1 and doing a lot of tasks yourself. My receptionist from my last office told me she was either quitting or coming with me. She's x-ray certified, can be a receptionist or an MA, really enjoys billing, is great on the phone/learns and speaks well, and isn't a flake. Everytime I check on her she's watching Trizetto videos and working on billing. Hilariously the MA I brought with me who was going to be my only employee learned the EHR we're using during a stint at another office when my partner ran her off. Showed up on day 1 and was like "hey I already know this EHR". But I'm paying them and I'm still not collecting yet.
9. I'm really trying to go hard on not committing to big expenses my last office couldn't avoid. ECW is driving me crazy, but paying Athena $6K a month drove me crazier. My partner was paying an IT company almost $2K a month. Yeah - really. Screw that. I'd find a way to cut the bill and he'd just let them add some new charges on. Not sure what life is going to be like without health insurance (plan is Crowdhealth) but I can't deal with premium prices going up 16% a year like they were at my last office. Neither of my 2 employees were on the last offices health insurance so no one lost anything when they came with me.
10. I did match my 2 employees pay to each otherwhich meant 1 got a large raise. I don't want to say what I'm paying them because its really high. No real benefits other than time off at present, but I am going to 401k everybody. Cash benefits like pay and 401k just seem way easier to control and understand than benefits like health insurance. I'll like add future incentive bonuses based on things like shockwave or orthotic sales.
One hack for getting phones answered and missing very few calls is answering service.
It's usually X calls for Y dollars monthly (then small fee per minute aka per call over the plan setting). You just set the your phones to forward to the answer service after two rings, then they pick up (human with "your business name, how can we help you"), and the service sends you an email message (to office general email staff check) with caller's name, DOB, callback number. You can tell them to call your own cell phone for urgent calls (I instruct as being calls from another doctor, ER, etc... or if patient calling says it's an emergency). It's great... A+ service.
ex:
"Channing Tatum
DOB 05/05/85
CID: 555-999-2222
Call back: 555-111-0000
Needs new patient appointment for heel pain, referral was sent from his family doctor."
or
"Becky Wilson
DOB 01/01/61
CID: 555-555-1111
Call back: 555-555-1111
Needs refill of pain medication before the weekend, please call her work phone."
They make the messages concise and generally good. Sure, you get the occasional nonsense call from a new patient or something that makes a minor thing sound 'emergency' and the operator calls your cell (operators are obviously not medical). You'll also get the occasional spam/marketing message, but they filter most of those out (and tell them "do not call"). All in all, it's generally worth its weight in gold. It will take your rate of people leaving a message from probably sub 10% voicemail to maybe 50/50 with answer service. People hate AI and phone trees... especially old people. Everyone also hates voicemail and/or most will leave crummy voicemails with missing info or babbling or bad phone connection. We've realized this as we may hear some phone calls during our meeting, and then we get 2 or 3 clean and good emailed messages when we check. Basically, you come back from lunch to a couple emails of callers needing appointment, cancel, refill Rx, whatever... and your front desk just takes care of it. Established patients who need to change appointment, pay a bill, etc feel taken care of (they talk to real person, not AI or just voicemail). The occasional person will not deal with answer service and the rare person will call the answer service every hour for the same thing and run up your bill a tiny bit leaving three messages for same issue, but it's still a drastically higher success rate than plain voicemail (and WAY faster for you to get and return messages typed up in an email versus listening to audio voicemail or trying to decipher crap digital transcribed messages from Google Voice or other automated/AI message taking).***
***= yes, I know heybrother will still try AI answering, which may be there someday, but is not right now
...I use this one, and it is very good. They've raised prices a bit (like any utility/service has past couple years), but I would definitely pay double what they charge, honestly... we send them Xmas gifts. You basically get 100 calls answered and emailed to you (nearly a month's worth for us... basically just the calls we miss at lunch, while on the other line, or evening/weekend messages), and that month costs only about what you'd pay a good employee for one single day. This service is priceless on days staff are on vacation, days office is closed... and days it's open. HIGHLY recommended. 👍👍
It's usually X calls for Y dollars monthly (then small fee per minute aka per call over the plan setting). You just set the your phones to forward to the answer service after two rings, then they pick up (human with "your business name, how can we help you"), and the service sends you an email message (to office general email staff check) with caller's name, DOB, callback number. You can tell them to call your own cell phone for urgent calls (I instruct as being calls from another doctor, ER, etc... or if patient calling says it's an emergency). It's great... A+ service.
ex:
"Channing Tatum
DOB 05/05/85
CID: 555-999-2222
Call back: 555-111-0000
Needs new patient appointment for heel pain, referral was sent from his family doctor."
or
"Becky Wilson
DOB 01/01/61
CID: 555-555-1111
Call back: 555-555-1111
Needs refill of pain medication before the weekend, please call her work phone."
They make the messages concise and generally good. Sure, you get the occasional nonsense call from a new patient or something that makes a minor thing sound 'emergency' and the operator calls your cell (operators are obviously not medical). You'll also get the occasional spam/marketing message, but they filter most of those out (and tell them "do not call"). All in all, it's generally worth its weight in gold. It will take your rate of people leaving a message from probably sub 10% voicemail to maybe 50/50 with answer service. People hate AI and phone trees... especially old people. Everyone also hates voicemail and/or most will leave crummy voicemails with missing info or babbling or bad phone connection. We've realized this as we may hear some phone calls during our meeting, and then we get 2 or 3 clean and good emailed messages when we check. Basically, you come back from lunch to a couple emails of callers needing appointment, cancel, refill Rx, whatever... and your front desk just takes care of it. Established patients who need to change appointment, pay a bill, etc feel taken care of (they talk to real person, not AI or just voicemail). The occasional person will not deal with answer service and the rare person will call the answer service every hour for the same thing and run up your bill a tiny bit leaving three messages for same issue, but it's still a drastically higher success rate than plain voicemail (and WAY faster for you to get and return messages typed up in an email versus listening to audio voicemail or trying to decipher crap digital transcribed messages from Google Voice or other automated/AI message taking).***
***= yes, I know heybrother will still try AI answering, which may be there someday, but is not right now
...I use this one, and it is very good. They've raised prices a bit (like any utility/service has past couple years), but I would definitely pay double what they charge, honestly... we send them Xmas gifts. You basically get 100 calls answered and emailed to you (nearly a month's worth for us... basically just the calls we miss at lunch, while on the other line, or evening/weekend messages), and that month costs only about what you'd pay a good employee for one single day. This service is priceless on days staff are on vacation, days office is closed... and days it's open. HIGHLY recommended. 👍👍
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Haven't tried AI yet for phones. Am currently using Ringrx for VOIP phones for $15. Voicemails go directly to my personal email.
Correct.
And website (if you are talking practice website) is one of those things you might eventually want to go professional on. It's usually worth it. I had a real basic one for awhile at maybe $100/yr domain and $100/yr software, but you can do pretty well with professional ones $200/mo or so (also takes a pro photo session or two to get pics). It's usually better overall (vids/motion, phone version, etc) and it's real easy to change/add pics or content after that by just emailing them.
The refers from PCPs are always the main thing, but most people will still tend to glance at your Google biz listing/reviews and your website to verify before appointing.
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deleted1235332
man this forum has so much useful information. Thanks for all these posts @Feli @heybrother
Im getting my used xray from a local pod for about 18K with computer and everything. I'm still looking into chairs but will only have 1-2 chairs to begin with. Definitely looking into getting a MedSpa chair instead of Midmark. not completely sure about that one though. Wish I knew someone who had any positive experiences with the medspa chairs..
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Ask in some of the Facebook podiatry groups. I know there's a few practitioners in there who use them.
I recently bought a MedSpa chair, but I wouldn't get it again. The thing that I don't like about it is the leg rest. The very end of the leg rest can extend if you have a taller patient in it and to extend it there is a knob that you twist underneath the foot rest. I don't like the positioning of it, because to get the torque to twist it, you have to bend over and get your face really close to their feet. When you lower the leg rest down to 90 degrees, you need to make sure that the leg extender is all the way in, otherwise it will start lifting the whole chair. I do prefer to have a debris tray, which these don't have.
Things I like about the chair. They look nice. They cost a fraction of what MTI or Midmark chairs cost.
If you have other specific questions, please feel free to ask.
This is unrelated to the costs but aren't you guys ever nervous starting your own practice? Maybe because I will be straight out of residency if I start on my own but the thought of it is super scary to me and I think that is what's preventing me to take the plunge. I know nothing about billing, handling business transactions, laws/regulations, etc. I am also afraid that if I start, what if my practice goes down the drain a year from now and I lose everything?
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deleted1235332
I'd highly recommend working for someone else first. When I was out of residency it was hard enough to focus just on patient care. It's totally different being the only one responsible for patients for the first time. If you work in a group you have second opinions available instantly. If you are worried about a case you can have someone else scrub with you. You have to learn how referrals work in your area too. Who is the vascular guy? Who is the infectious disease guy? Who do I send to when XYZ happens?
Do this for 1-2 years and you will have so much more experience that it will be way easier when you start one on your own. Just make sure you don't have a non-compete or make sure it's illegal to enforce a noncompete (depends on state).
People have done it straight out of residency though... but in that case I highly highly recommend a consultant who has helped open solo private practices.
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deleted1235332
which specific medspa chair did you buy? The DIR one mentioned in this thread seems pretty legit and good reviews (from non podiatrists). The issue I can see is that the chair is a little long and for any plantar heel pathology it could be difficult to evaluate as the foot won't hang off the chair. but the cost difference is too much to pass up in my opinion... so i'm leaning towards getting it even with any potential podiatry negatives.
If you don't know what you are doing you'll go out of business way before then 🙂 Most new grads don't have the experience to start out immediately as an owner.
I'm firing my practice up currently and have already had a day where cash collections exceeded payroll for the day which was nice. That said, I also have to kick $10,000 of capital in within the next month and I'm really hoping this is the last infusion.
I got this one
Swivel Medical Spa Treatment Table, Electric Esthetician Chair
DIR Pavo: Electric swivel medical spa treatment table & esthetician chair. Ideal exam table for medical & spa professionals, offering comfort and precision.
www.dirsalonfurniture.com
Did you get your capital via savings or a business loan?
Savings. I only borrowed for real estate. I don't know what the loan terms would look like on a loan of that nature. The real estate loan is backed by property if I default but a business loan might not have anything backing it which would possibly result in higher rates. Years ago I read a story about a business loan that some eye doc took and they didn't allow early payoff.
Just my n=1, and it wasn’t for a solo practice.
My rate was about double the going mortgage one. That put it around federal student loans. I’m not an actuary, but I suspect it would fall somewhere in that vicinity.
Since it was technically unsecured, I had to get a life insurance policy, but they let me get away with only that because the practice has been with them forever and they weren’t worried I’d default. They’ll almost certainly want some collateral, and I’d expect them to be on the higher end of the ledger.
Definitely look at a regional bank or credit union, especially if you have some kind of relationship with them. Chase and BOA don’t do HYSA for a reason, so the big ones are likely going to gouge you (but still worth checking in if you’ve got the time).
Walk if they won’t let you pay early. No joke, I saved a quarter mil in interest with this. Remember that the interest is tax deductible at least.
How long have you used this chair for??? I'm planning on buying podiatry chairs soon and cant decide between medspa chairs or the traditional midmarkI got this one
Swivel Medical Spa Treatment Table, Electric Esthetician Chair
DIR Pavo: Electric swivel medical spa treatment table & esthetician chair. Ideal exam table for medical & spa professionals, offering comfort and precision.
Are you happy with what you bought? Would you recommend this to the rest of us?
I've had the Medspa chair for about 2 months. I personally wouldn't get one again for my practice. It's got a good price point and that can be really helpful for someone just starting out and trying to keep prices down.
But my practice is running well, so I'm not having the cash flow issues that starting practices have. I'm already looking to replace it with a traditional chair.
What was the licensing/regulatory process like to get the x-ray set up
State specific. In Texas you have the x-ray installed. You contact the department of health and safety - some sort of acronym - and submit 3 forms and like $450. The forms essentially declare you are registering a podiatric x-ray machine and indicate you are the radiation safety officer. I was approved on the first go without issue. In Texas you have 30 days from installation to have an environmental site assessment performed. Essentially, someone comes out and makes sure your beam doesn't scatter. My x-ray vendor put me in touch with a company but they wanted $1600. I found a local company who did it for $425. Your x-ray vendor will hopefully provide you with a pre-written guide that you keep in the office explaining your x-ray policies that has to be shown to employees etc.
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I don't have any exp with biz loans (or biz credit cards, or anything). Loans were barely happening at all when I came out of residency (banks and economy were still crippled from GFC), and I just prefer to save up, use debit cards, etc. By the time I started my own office, I just had cash savings and cashed out a small 401k from IHS job. You don't need as much as you think. I would've needed loans for some of the big buyouts I considered (but decided were flawed/overpriced).
I agree it's crazy to not let you pay off early, though. Most of us have student loans a bit higher interest rate, and the market has also been hot. But a lot can change in 10yrs or whatever loan term... in most markets, that 5% guaranteed payoff is a very good option to have. That said, practice loans are worth it if you need it to get going - almost regardless of terms (obviously compare a few banks/CU) or if you have to take some high taxes to cash out IRA/401/etc.
Your initial office/equip invest will have more ROI in the years to come than almost anything else you'll ever buy... stocks, house, bonds, Cooper Flagg rookie cards, etc etc. You will recoup any interest paid or early withdrawl fees easily over time. It is never bad to consider a moderate loan or cash-out and then a LOC (instead of a bigger loan or cash-out), though. It's hard to say when you'll be full and highly profitable, but it'll come. The LOC (from a bank or parents or bf/gf/spouse or whatever) handles that but sidesteps the interest of additional loan or the fees of more cash-out. Had it taken my office awhile to get full, I had LOC basically with my Roth and/or my partner as a way to cover payroll and utilities awhile (never used it, though).
...With how few and far between good employed jobs for DPMs are, it's just worth it to start your own office.
It happens in all med/dent specialties that PE or hospitals or PP owners exploit them, but podiatry is the most saturated (besides maybe chiropractors?).
We all know a ton of podiatrists who are sick of applying for jobs, sick of moving for jobs, sick of on-call, sick of being way outside civilization for a fair pay job, sick of their boss, sick of being broke, sick of their mediocre staffing or marketing or hours (I was most/all of those for awhile while employed). It's sad that even our VA/IHS jobs get such high interest and numbers of applications. Break the cycle. 🤠
I agree it's crazy to not let you pay off early, though. Most of us have student loans a bit higher interest rate, and the market has also been hot. But a lot can change in 10yrs or whatever loan term... in most markets, that 5% guaranteed payoff is a very good option to have. That said, practice loans are worth it if you need it to get going - almost regardless of terms (obviously compare a few banks/CU) or if you have to take some high taxes to cash out IRA/401/etc.
Your initial office/equip invest will have more ROI in the years to come than almost anything else you'll ever buy... stocks, house, bonds, Cooper Flagg rookie cards, etc etc. You will recoup any interest paid or early withdrawl fees easily over time. It is never bad to consider a moderate loan or cash-out and then a LOC (instead of a bigger loan or cash-out), though. It's hard to say when you'll be full and highly profitable, but it'll come. The LOC (from a bank or parents or bf/gf/spouse or whatever) handles that but sidesteps the interest of additional loan or the fees of more cash-out. Had it taken my office awhile to get full, I had LOC basically with my Roth and/or my partner as a way to cover payroll and utilities awhile (never used it, though).
...With how few and far between good employed jobs for DPMs are, it's just worth it to start your own office.
It happens in all med/dent specialties that PE or hospitals or PP owners exploit them, but podiatry is the most saturated (besides maybe chiropractors?).
We all know a ton of podiatrists who are sick of applying for jobs, sick of moving for jobs, sick of on-call, sick of being way outside civilization for a fair pay job, sick of their boss, sick of being broke, sick of their mediocre staffing or marketing or hours (I was most/all of those for awhile while employed). It's sad that even our VA/IHS jobs get such high interest and numbers of applications. Break the cycle. 🤠
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Hardest part of starting a new private practice right now.
1. Getting insurance companies to offer contracts in line with contracts I just negotiated for my old practice a year ago.
"This rate is still higher than what we normally approve for other providers of your same specialty." Negative translation - we pay podiatry less. Positive translation - they're offering to pay me more than other podiatrists who they don't normally approve good rates for.
2. Medicare Advantage plans. Yeah, as usual f*** them. Medicare allows retroactive billing - you see the patient and you ultimately submit the billing once you are enrolled. MA plans do not and we have heavy United penetration in my area. Some of the the United plans in my area are Wellmed with a $95 OON copay. For the purposes of cash flow/trying to stay alive for a minute - that's not a hard decision for a follow-up when you weren't in network at your last job and the patients were used to paying. Bill the $95 through Square and move on - you picked up about the value of a 99213 in hopefully 10 minutes. No, I don't want to commit to 2 11750s and x-rays, but I'll take it for a follow-up plantar fasciitis visit. But a lot of the patients have United retirement plans with $0 copays. They are not used to paying. These plans classically are "good" plans on the spectrum of UHC OON (they pay Medicare even if you are out of network so they are mostly functionally equivalent to Medicare), but since you can't charge the plan and the patients aren't using to paying its a hassle because no one seems to know they have Medicare Advantage until they get to your office. The patients schedule as Medicare and then when they get there they have the MA. Ideally they'd submit their cards ahead of time but they are all demented and can't figure it out. When you have 20 patients and 1-2 show up with an insurance you don't accept its annoying. When you have 10-12 and 2 people show up with an insurance you can't bill its more painful.
3. Last sad thing. BCBS revised their Texas rates a month ago while I was transitioning out / not following and the rates went down. Still better than most, but womp womp.
Rant aside - what's funny to me is I'm mostly no longer spending money and the revenue is finally starting. Lot of Medicare billing piling up. And there really shouldn't be any heavy uncontrollable bills coming - I hope? No Athena 8.07% on everything. The first 3 BCBS ACH payments arrived. $95, $10 (ha), and $205. Athena would have taken 8% of all of these. Yeah, Healow took their cut of the copay, but I think they don't get any of the ACH. I haven't signed up for health insurance and I'm not paying for it for the staff? Good idea? Guess we'll see, but my total family cost previously was like $1700 a month and was supposed to go up to like $2K. Feels like we can buy a lot of care for that out of pocket. Probably will sign up for crowdhealth. And no expensive IT bill. No office manager who once told me in the span of 2 days "what's a Q modifier" and "what's a 25 modifier" after having the job more than a year. My staff told me they've stopped having migraines and hypertension because they no longer work with my former partner.
1. Getting insurance companies to offer contracts in line with contracts I just negotiated for my old practice a year ago.
"This rate is still higher than what we normally approve for other providers of your same specialty." Negative translation - we pay podiatry less. Positive translation - they're offering to pay me more than other podiatrists who they don't normally approve good rates for.
2. Medicare Advantage plans. Yeah, as usual f*** them. Medicare allows retroactive billing - you see the patient and you ultimately submit the billing once you are enrolled. MA plans do not and we have heavy United penetration in my area. Some of the the United plans in my area are Wellmed with a $95 OON copay. For the purposes of cash flow/trying to stay alive for a minute - that's not a hard decision for a follow-up when you weren't in network at your last job and the patients were used to paying. Bill the $95 through Square and move on - you picked up about the value of a 99213 in hopefully 10 minutes. No, I don't want to commit to 2 11750s and x-rays, but I'll take it for a follow-up plantar fasciitis visit. But a lot of the patients have United retirement plans with $0 copays. They are not used to paying. These plans classically are "good" plans on the spectrum of UHC OON (they pay Medicare even if you are out of network so they are mostly functionally equivalent to Medicare), but since you can't charge the plan and the patients aren't using to paying its a hassle because no one seems to know they have Medicare Advantage until they get to your office. The patients schedule as Medicare and then when they get there they have the MA. Ideally they'd submit their cards ahead of time but they are all demented and can't figure it out. When you have 20 patients and 1-2 show up with an insurance you don't accept its annoying. When you have 10-12 and 2 people show up with an insurance you can't bill its more painful.
3. Last sad thing. BCBS revised their Texas rates a month ago while I was transitioning out / not following and the rates went down. Still better than most, but womp womp.
Rant aside - what's funny to me is I'm mostly no longer spending money and the revenue is finally starting. Lot of Medicare billing piling up. And there really shouldn't be any heavy uncontrollable bills coming - I hope? No Athena 8.07% on everything. The first 3 BCBS ACH payments arrived. $95, $10 (ha), and $205. Athena would have taken 8% of all of these. Yeah, Healow took their cut of the copay, but I think they don't get any of the ACH. I haven't signed up for health insurance and I'm not paying for it for the staff? Good idea? Guess we'll see, but my total family cost previously was like $1700 a month and was supposed to go up to like $2K. Feels like we can buy a lot of care for that out of pocket. Probably will sign up for crowdhealth. And no expensive IT bill. No office manager who once told me in the span of 2 days "what's a Q modifier" and "what's a 25 modifier" after having the job more than a year. My staff told me they've stopped having migraines and hypertension because they no longer work with my former partner.
D
deleted1235332
So you don’t have a billing company at all charging a %?
I may eat these words in the future, but at present its unclear to me what they do.
1. I already eat a 3.5% + 30 cent charge from ECWs Healow when the credit card is ran for copays or bills that are paid.
2. Healow will also send out text messages asking the patient to pay their bill and I believe they send paper statements once the patient doesn't respond.
3. So someone is already charging me to run credit cards.
4. I enter my own fee schedules. I enter the billing while I close out the encounter. My receptionist submits the batches and checks them against Trizetto.
5. I'm trying to keep some of these services in house, but I'm likely to need to expand my team to do so.
6. I guess its unclear to me what a biller brings - they want 5%+ of my ACH Medicare that takes no work to collect so that they can claim they are going to pursue my unpaid BCBS charges that aren't going to be paid because once a patient leaves the office with an uncollected balance they won't be back...?
We'll see if I regret this. The best biller argument is "you spend 5% to get 95%" but what the biller really wants is the low hanging fruit. And the funny thing is - I'm OON with Humana, Aetna, and United so I've already dropped the plans that deny claims that need resubmission work. I'm also willing to see fewer people on a Friday to spend an hour going through old claims each week. I don't believe that seeing more patients every single day is actually the best path to more revenue.
The system has gotten us cornered. at least its time for me to break out of the matrix. my last day being a PP slave is at the end of the month. really appreciate the advice im getting on sdn and from you sir specifically on starting a new practice.....it's very generous of you, most people are quite stingy about sharing their knowledge and experiences
