Family Med private practice AMA

[cobalyfam]

Currently netting at about $350k but overhead varies. Got a lot of advice from this place a while back so thought I'd give back. Background, after I graduated from Fam Med residency I got a job with a private practice in a pretty big city on the east coast about $200k. I paid off my loans and invested in opening my own clinic. My clinic has developed its own little niche in the community I'm in. I have 3 nurses that work under me and see about 40 patients per day. Mon-Fri 730am-530pm and one month off a year give or take what I feel

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[Cath Up]

Currently netting at about $350k but overhead varies. Got a lot of advice from this place a while back so thought I'd give back. Background, after I graduated from Fam Med residency I got a job with a private practice in a pretty big city on the east coast about $200k. I paid off my loans and invested in opening my own clinic. My clinic has developed its own little niche in the community I'm in. I have 3 nurses that work under me and see about 40 patients per day. Mon-Fri 730am-530pm and one month off a year give or take what I feel

How much did it cost to open the clinic?

 

[popopopop]

Hello, thanks for doing this. How did you decide on FM vs IM or anything else?

 

[Dr jones]

Is there many situations where you don't know what your patients diagnose is or how to treat it?

 

[BorntobeDO?]

How do you integrate the midlevels into your practice and at the same time keep an eye on them with them seeing 40 pts? Are you just letting them do their own thing or do you make patients see you every X amount of visits, etc?

 

[W19]

How do you integrate the midlevels into your practice and at the same time keep an eye on them with them seeing 40 pts? Are you just letting them do their own thing or do you make patients see you every X amount of visits, etc?

I don't see where the OP talks about midlevels. Nurses are NOT midlevels...

I am just wondering why would OP needs nurses (RN or LPN/LVN) as opposed to medical assistants...

 

[QueenJames]

What's ur take on procedures? Did you learn any to increase billing? Do you incorporate OMM at all? How much time are you spending after work charting and all that? Are there opportunities for weekend call anywhere to get paid more or would you have to do locums for that?

Appreciate it.

 

[68PGunner]

Currently netting at about $350k but overhead varies. Got a lot of advice from this place a while back so thought I'd give back. Background, after I graduated from Fam Med residency I got a job with a private practice in a pretty big city on the east coast about $200k. I paid off my loans and invested in opening my own clinic. My clinic has developed its own little niche in the community I'm in. I have 3 nurses that work under me and see about 40 patients per day. Mon-Fri 730am-530pm and one month off a year give or take what I feel

$350K net before tax and retirement distributions or after? Thank you.

 

[DrGainzzz]

I'm assuming you have a large patient list seeing 40 a day so I'm just curious how long it took to build the practice to where it currently is?

 

[group_theory]

I don't see where the OP talks about midlevels. Nurses are NOT midlevels...

I am just wondering why would OP needs nurses (RN or LPN/LVN) as opposed to medical assistants...

Immunizations (adults, kids), rapid strep, urine dip stick, wet prep, in office neb treatment

Phone triage (very important)

Filling out prior authorization paperwork. Filling out insurance appeals letter. (they require someone with clinical knowledge to be able to read the progress notes and know how to fill those things out)


A ratio of 3:1 (office staff to provider) seems about right ... there is a lot of back-end stuff that patients never sees - nurse/MA, scheduler, billers/coders, receptionist, etc

Curious what your overhead office expense is - close to 50%? Do you take new Medicare and Medicaid patients? Workman's Comp?

How long, after starting a new practice, did you finally get positive cash flow from your account receivables? Did you end up leasing office equipment or buying them? Same for building - lease/rent or buy?

Are you part of an ACA? How do you keep up with the MOC requirement from ABFM, and MACRA from Medicare?

40 patients a day? Although typical for a PCP, I still think that's insane (that's like 4 patients/hr). Are most of your visits 99213? What percentage do you think are well child visits, or level 4/5 visits? I only see half of that (as a specialist I have that luxury, and usually the appointments are level 4/5 visits, whether new/established)

 

[Postictal Raiden]

Immunizations (adults, kids), rapid strep, urine dip stick, wet prep, in office neb treatment

Phone triage (very important)

Filling out prior authorization paperwork. Filling out insurance appeals letter. (they require someone with clinical knowledge to be able to read the progress notes and know how to fill those things out)


A ratio of 3:1 (office staff to provider) seems about right ... there is a lot of back-end stuff that patients never sees - nurse/MA, scheduler, billers/coders, receptionist, etc

Curious what your overhead office expense is - close to 50%? Do you take new Medicare and Medicaid patients? Workman's Comp?

How long, after starting a new practice, did you finally get positive cash flow from your account receivables? Did you end up leasing office equipment or buying them? Same for building - lease/rent or buy?

Are you part of an ACA? How do you keep up with the MOC requirement from ABFM, and MACRA from Medicare?

40 patients a day? Although typical for a PCP, I still think that's insane (that's like 4 patients/hr). Are most of your visits 99213? What percentage do you think are well child visits, or level 4/5 visits? I only see half of that (as a specialist I have that luxury, and usually the appointments are level 4/5 visits, whether new/established)

You touched upon few things that id like to ask about:

Isn’t 3:1 ratio too low? I was under the impression that you’d need a receptionist, a biller, an MA for charting and an office manager. That’s 4:1, and I have seen many offices where they have 2 MAs for charting.


Aside from staff salaries, rent, and bills what are other notable costs one should be aware of? Does one need to purchase an EMR or can you subscribe to one?

I feel that at 40 pts a day, one should generate an income higher than 350k. Doing back of an envelope calculations, at 40 pts a day, assuming half are billed at 99213 and the other half at 99214, and assuming 50% overhead, one should make 450k+. What do you think?

 

[cobalyfam]

This is my personal take home, after taxes. And they aren't all nurses--I just call them that. One is nurse practitioner others medical assistant types. There are free EMRs as well. And you don't really make tons of money first 6 months

 

[cobalyfam]

Hello, thanks for doing this. How did you decide on FM vs IM or anything else?

You will get better training in IM residency, in my opinion. And you can set up pretty much same thing

 

[DO2015CA]

You will get better training in IM residency, in my opinion. And you can set up pretty much same thing

If you think you’ll get better training then why did you do FM. I understand IM gets more inpatient training, but how does this translate to being better at outpatient medicine?

 

[kubyx]

AMAs typically work the best when you answer questions.

 

[avhopeful]

AMAs typically work the best when you answer questions.

I lol'd at this roast.

 

[studentdoct4281]

bump

 

[avhopeful]

bump

Why? lol OP went AWOL

 

[BorntobeDO?]

How do you integrate the midlevels into your practice and at the same time keep an eye on them with them seeing 40 pts? Are you just letting them do their own thing or do you make patients see you every X amount of visits, etc?

Following up my own question because I got to see a doctor (tho in endocrine) who is doing the midlevel integration par excellance IMO. She has it so that the midlevel will 'see' patients on her own but basically consults/huddles with her each case. The attending says if she agrees with the plan and then flys in the room for a couple minutes to confirm the plan with the patient, but basically does no charting for the 'NP's' patient.

I think this presents several advantages. Namely it allows every patient to see 'the doctor' which they all want to anyway, but reduces the paperwork and administrative burden. It also allows an increase in face time and billing at the same time. This particular physician also employs an dietician and an RN for educators on things like the pumps, and lifestyle/diet modifications. Anyway, I really enjoyed it. She gets to see about 40-50 people a day, but without the nightmare of EMR box checking that would normally be part of it.

 

[QueenJames]

Why? lol OP went AWOL

OP is also an actual physician seeing 40-50 patients a day rather than a pre-med who just got into med school spending most of his day jerking off and on SDN being a big man.

Calmeth the eff down little homie.

 

[avhopeful]

OP is also an actual physician seeing 40-50 patients a day rather than a pre-med who just got into med school spending most of his day jerking off and on SDN being a big man.

Calmeth the eff down little homie.

Hahaha very true... Sounds good, my queen broski.

Added: Totally forgot how creepy online forums can get.

 

[HueySmith]

This is cool and all, but when in about 5-10 years down the line, primary care will get congested and saturated.

 

[QueenJames]

This is cool and all, but when in about 5-10 years down the line, primary care will get congested and saturated.

Well since you can obviously tell the future with your crystal ball..

How about you give me the winning lottery numbers? Or better yet... when's that apple stock dropping back down?

Nah... U know what...

You should drop out of medicine and go into investment banking or hit Wall Street...

Since you seem to be so evidently great at predictions and baseless claims.

LOL

GTFOH.

 

[HueySmith]

Well since you can obviously tell the future with your crystal ball..

How about you give me the winning lottery numbers? Or better yet... when's that apple stock dropping back down?

Nah... U know what...

You should drop out of medicine and go into investment banking or hit Wall Street...

Since you seem to be so evidently great at predictions and baseless claims.

LOL

GTFOH.

Nice, classy, and, as always, insightful comment by the man himself, who seems to like to double space every single sentence he writes or write "U" for you". Good luck, internet warrior!

 

[QueenJames]

Nice, classy, and, as always, insightful comment by the man himself, who seems to like to double space every single sentence he writes or write "U" for you". Good luck, internet warrior!

Why do they continue to let people like you into medical school?

 

[HueySmith]

Why do they continue to let people like you into medical school?

Same with you.

 

[QueenJames]

Same with you.

U know what...

You just got a one-way ticket to...

BLOCKTOWNNNN!

 

[HueySmith]

U know what...

You just got a one-way ticket to...

BLOCKTOWNNNN!

That makes me laugh, lol

 

[814965]

This is cool and all, but when in about 5-10 years down the line, primary care will get congested and saturated.

It won't get congested unless you want to live in NYC/DC/LA/SF/LV/Austin/Seattle. Labor market troubles in Des Moines, Detroit, Cleveland, Kansas City, or plain old Small Town, USA don't seem likely in the near future.

 

[HueySmith]

It won't get congested unless you want to live in NYC/DC/LA/SF/LV/Austin/Seattle. Labor market troubles in Des Moines, Detroit, Cleveland, Kansas City, or plain old Small Town, USA don't seem likely in the near future.

Finally, a thoughtful response!

 

[deleted600623]

This is cool and all, but when in about 5-10 years down the line, primary care will get congested and saturated.

Sure. If you want to practice FM in a huge city with 6 million people...But I’d question other things if one chose to do this anyway.

 

[VA Hopeful Dr]

This is cool and all, but when in about 5-10 years down the line, primary care will get congested and saturated.

People have been saying that since I started med school. That was 13 years ago and the primary care job market is still spectacular.

Plus, all the baby boomer doctors are about to retire and that's going to be a significant portion of the workforce gone in about a five to 10-year period, so our job market is going to get even better.

 

[deleted600623]

People have been saying that since I started med school. That was 13 years ago and the primary care job market is still spectacular.

Plus, all the baby boomer doctors are about to retire and that's going to be a significant portion of the workforce gone in about a five to 10-year period, so our job market is going to get even better.

Not to mention all of those baby boomers needing medical care too. Lots of patients to see..

 

[HueySmith]

People have been saying that since I started med school. That was 13 years ago and the primary care job market is still spectacular.

Plus, all the baby boomer doctors are about to retire and that's going to be a significant portion of the workforce gone in about a five to 10-year period, so our job market is going to get even better.

Really? You don't think all the medical students (primarily DOs) each year who are going the primary care field in addition to NPs and PAs filling for in as primary care roles are going to saturate the market?

 

[Fission Chips]

I realize the OP isn't around to answer questions, but maybe someone else can. Isn't 350k after taxes pretty insane for most fields, let alone FM? I mean, when I look at different surgical subspecialty median total compensation on MGMA and then factor in taxes, they're probably taking home 350k with the exception of NS/ortho... and they seem to be working ~10 hours/week more. That's assuming paying a little under 30% in taxes... and I thought Total compensation included the value of benefits?

There is a really, really good chance I have no idea what I'm talking about. If that's the case, my bad. Could someone lay down some education for me?

 

[VA Hopeful Dr]

Really? You don't think all the medical students (primarily DOs) each year who are going the primary care field in addition to NPs and PAs filling for in as primary care roles are going to saturate the market?

Not even a little.

As of 2016, 20% of the physician workforce is 60 or older. Its fair to extrapolate that to mean 20% of primary care doctors are in that age group as well. That's a full 1/5th of primary care that's going to retire in the next 10-ish years.

Beyond that, midlevels aren't going into primary care any more than most medical students. Plus, most patients want to see a doctor. Now that people aren't just paying a $10 co-pay, they want a physician.

Beyond even that, while we are increasing residency slots for primary care its not happening at a crazy rate. We're more or less producing the same numbers of PCPs per population that we always have.

Beyond even THAT, more and more IM grads are choosing hospitalist work over outpatient primary care (assuming they don't go on to fellowship). So you're seeing fewer and fewer IM trained PCPs.

Plus, I just looked. In the 4 counties here (where I live and the 3 surrounding) we have roughly 885,000 people - so not huge. There are currently 18 job listings in this area, and that's just with local hospitals. There are I think 4-5 urgent care jobs, 3 employer-based places, 6 locums, and 3 faculty jobs.

So yeah, I'm not worried in the slightest.

 

[VA Hopeful Dr]

I realize the OP isn't around to answer questions, but maybe someone else can. Isn't 350k after taxes pretty insane for most fields, let alone FM? I mean, when I look at different surgical subspecialty median total compensation on MGMA and then factor in taxes, they're probably taking home 350k with the exception of NS/ortho... and they seem to be working ~10 hours/week more. That's assuming paying a little under 30% in taxes... and I thought Total compensation included the value of benefits?

There is a really, really good chance I have no idea what I'm talking about. If that's the case, my bad. Could someone lay down some education for me?

So let's do some math.

OP is seeing 40 patients/day, 5 days/week. That's 200 patients/week. He/she said they took 1 month off/year. Round that up to 6 weeks total to include holidays, so we're at 9,600 patient encounters/year. I know they said they owned the practice, but just to simplify let's assume they are paid via wRVUs like many of us. Each patient, nationally speaking, averages out to 1.3 wRVUs these days. So for the year, this person is earning 11,960 wRVUs per year. The average rate is $40/wRVU, so OP is grossing $478,400. Using a paycheck calculator in my state for a married person with no kids, net pay from this is $314, 930.

That's working from RVUs. Most practice owners do better than that, assuming a decent payer mix.

Its why I'm always amused when people talk about how little money family docs make. Our starting salaries aren't ortho level, but we can do very well once we get a busy practice going.

 

[Mad Jack]

Really? You don't think all the medical students (primarily DOs) each year who are going the primary care field in addition to NPs and PAs filling for in as primary care roles are going to saturate the market?

New DOs don't magically create new residency positions. The same number of residents graduate each year, give or take, DOs just make them American graduates instead of IMGs.

 

[neoexile]

Currently netting at about $350k but overhead varies. Got a lot of advice from this place a while back so thought I'd give back. Background, after I graduated from Fam Med residency I got a job with a private practice in a pretty big city on the east coast about $200k. I paid off my loans and invested in opening my own clinic. My clinic has developed its own little niche in the community I'm in. I have 3 nurses that work under me and see about 40 patients per day. Mon-Fri 730am-530pm and one month off a year give or take what I feel

If you wanted to see psychiatric patients, despite being a family doctor, how easy would it be to tailor your practice to that population? Even if you aren't a psychiatrist?

 

[VA Hopeful Dr]

If you wanted to see psychiatric patients, despite being a family doctor, how easy would it be to tailor your practice to that population? Even if you aren't a psychiatrist?

FM sees quite a bit of psych. I'd say around 15-20% of my patients have some psych disorder I'm treating.

Now its mostly mild-moderate depression anxiety. I don't want to treat anything like bipolar or schizophrenia, and I'm not trained to treat anything Axis 2.

 

[neoexile]

FM sees quite a bit of psych. I'd say around 15-20% of my patients have some psych disorder I'm treating.

Now its mostly mild-moderate depression anxiety. I don't want to treat anything like bipolar or schizophrenia, and I'm not trained to treat anything Axis 2.

Can family practice physician seek out further training in psychotherapy if they so desired? Or would this not be possible?

 

[VA Hopeful Dr]

Can family practice physician seek out further training in psychotherapy if they so desired? Or would this not be possible?

I'm sure there's a way, I just don't know of it offhand.

My somewhat snarky answer is that if you want to do a lot of psychotherapy, then either become a psychiatrist or a psychologist.

 

[BorntobeDO?]

People have been saying that since I started med school. That was 13 years ago and the primary care job market is still spectacular.

Plus, all the baby boomer doctors are about to retire and that's going to be a significant portion of the workforce gone in about a five to 10-year period, so our job market is going to get even better.

Not going down this path too far, but in 10-15 a significant portion of the patients will be gone (i.e. the baby boomers). That is when we will have the bear market. I think that physicians will not feel it as bad as PAs or NPs (people will choose us over them for anything near the same cost). Anyway, the issue is not that the boomers retiring, but that the generation below them is much smaller, and in general, poorer.

 

[Fission Chips]

So let's do some math.

OP is seeing 40 patients/day, 5 days/week. That's 200 patients/week. He/she said they took 1 month off/year. Round that up to 6 weeks total to include holidays, so we're at 9,600 patient encounters/year. I know they said they owned the practice, but just to simplify let's assume they are paid via wRVUs like many of us. Each patient, nationally speaking, averages out to 1.3 wRVUs these days. So for the year, this person is earning 11,960 wRVUs per year. The average rate is $40/wRVU, so OP is grossing $478,400. Using a paycheck calculator in my state for a married person with no kids, net pay from this is $314, 930.

That's working from RVUs. Most practice owners do better than that, assuming a decent payer mix.

Its why I'm always amused when people talk about how little money family docs make. Our starting salaries aren't ortho level, but we can do very well once we get a busy practice going.

Thank you for your response... I find it difficult to get people to talk about finances in medicine, which is unfortunate when you are trying to learn about this stuff. Out of curiosity, what other revenue streams would the OP potentially have in FM? I guess I'm asking... if he/she is grossing 478k/year, doesn't a substantial portion of that have to go to overhead and salaries of the workers? There has to be other revenue coming in to cover those costs, no? I'm sure if they own the office and equipment then the overhead is pretty low, but don't you still have to dish out a good amount for the NP in that practice (maybe 100k) and the other house staff (maybe another 100k combined)? Or do you think it's more likely that he/she only takes private insurance?

I guess I'm just really surprised at what that gross must be in order to get a take-home that high after covering all the costs associated with running a business... regardless of specialty (for the most part).

In your opinion, is ~12k RVU/year sustainable for most, or do you think that is a recipe for burnout?

 

[VA Hopeful Dr]

Thank you for your response... I find it difficult to get people to talk about finances in medicine, which is unfortunate when you are trying to learn about this stuff. Out of curiosity, what other revenue streams would the OP potentially have in FM? I guess I'm asking... if he/she is grossing 478k/year, doesn't a substantial portion of that have to go to overhead and salaries of the workers? There has to be other revenue coming in to cover those costs, no? I'm sure if they own the office and equipment then the overhead is pretty low, but don't you still have to dish out a good amount for the NP in that practice (maybe 100k) and the other house staff (maybe another 100k combined)? Or do you think it's more likely that he/she only takes private insurance?

I guess I'm just really surprised at what that gross must be in order to get a take-home that high after covering all the costs associated with running a business... regardless of specialty (for the most part).

In your opinion, is ~12k RVU/year sustainable for most, or do you think that is a recipe for burnout?

wRVUs take overhead into account. For example, a 99213 visit (most commonly used outpatient Primary Care code) is right at 1 wRVU but my insurance pays $93 for it. Using the $40/rvu above that leaves $53 to cover expenses.

That number of RVUs in Primary Care is a very busy day. I'm sure there's people that can do that everyday for 20 years but I think most of us would not enjoy that.

 

[VA Hopeful Dr]

Not going down this path too far, but in 10-15 a significant portion of the patients will be gone (i.e. the baby boomers). That is when we will have the bear market. I think that physicians will not feel it as bad as PAs or NPs (people will choose us over them for anything near the same cost). Anyway, the issue is not that the boomers retiring, but that the generation below them is much smaller, and in general, poorer.

I'm not really seeing that, but I certainly can't claim to speak for the entire country

 

[Atom612]

wRVUs take overhead into account. For example, a 99213 visit (most commonly used outpatient Primary Care code) is right at 1 wRVU but my insurance pays $93 for it. Using the $40/rvu above that leaves $53 to cover expenses.

That number of RVUs in Primary Care is a very busy day. I'm sure there's people that can do that everyday for 20 years but I think most of us would not enjoy that.

As an MS1, these numbers and conversions make my head spin. Is there a resource somewhere I could learn more about how reimbursements and RVUs work? Or is it more of a learn-on-the-job type deal?

 

[QueenJames]

As an MS1, these numbers and conversions make my head spin. Is there a resource somewhere I could learn more about how reimbursements and RVUs work? Or is it more of a learn-on-the-job type deal?

Seeing as you got more than 5-6 years before you are anywhere near signing some contract for an attending position...

I wouldn't worry about it and study for boards if you haven't started already.

 

[VA Hopeful Dr]

As an MS1, these numbers and conversions make my head spin. Is there a resource somewhere I could learn more about how reimbursements and RVUs work? Or is it more of a learn-on-the-job type deal?

I'll try and make it simple.

So everything we physicians do has a procedure code associated with it (a CPT code). Office visits, appendectomies, c-sections, autopsies, lacerations, amputations, everything. Each CPT code has a value associated with it, called a Relative Value Unit, or RVU. This determines how much Medicare (and private insurance) pays for a given code. An RVU is worth a certain amount of money to Medicare. Let's say its $100 per RVU.

So if a regular office visit is worth 1 RVU, Medicare will pay $100. Let's say an appendectomy is worth 6.5 RVUs. That means a surgeon would get paid $650 for doing one.

That said, an RVU does take overhead into account. So the RVU is broken down further into 3 sections: physician work (wRVU), practice expense, and malpractice. There are worth, in order, 52%, 44%, 2% of each total RVU.

So for that $100 office visit, Medicare expects a physician to earn $52 of that while $44 goes to office overhead and $2 goes to malpractice.

So if we go to the Medicare Fee Schedule (Overview of the Medicare Physician Fee Schedule Search) and look up a 99213 which is the most common outpatient office visit code, in my area it is worth $70. So Medicare expects me to earn as pure income 52% of that, or $36.40. Its a 15 minute-type visit so I can do 4 in an hour which brings me to $145.6 per hour income by Medicare rules.

It gets more complicated as you get deeper into it, but that's the short version.

 

[Atom612]

I'll try and make it simple.

So everything we physicians do has a procedure code associated with it (a CPT code). Office visits, appendectomies, c-sections, autopsies, lacerations, amputations, everything. Each CPT code has a value associated with it, called a Relative Value Unit, or RVU. This determines how much Medicare (and private insurance) pays for a given code. An RVU is worth a certain amount of money to Medicare. Let's say its $100 per RVU.

So if a regular office visit is worth 1 RVU, Medicare will pay $100. Let's say an appendectomy is worth 6.5 RVUs. That means a surgeon would get paid $650 for doing one.

That said, an RVU does take overhead into account. So the RVU is broken down further into 3 sections: physician work (wRVU), practice expense, and malpractice. There are worth, in order, 52%, 44%, 2% of each total RVU.

So for that $100 office visit, Medicare expects a physician to earn $52 of that while $44 goes to office overhead and $2 goes to malpractice.

So if we go to the Medicare Fee Schedule (Overview of the Medicare Physician Fee Schedule Search) and look up a 99213 which is the most common outpatient office visit code, in my area it is worth $70. So Medicare expects me to earn as pure income 52% of that, or $36.40. Its a 15 minute-type visit so I can do 4 in an hour which brings me to $145.6 per hour income by Medicare rules.

It gets more complicated as you get deeper into it, but that's the short version.

This helps a lot, thank you!