Forming an anesthesia group

[anesthesiadumpsterfire]

Let's take a break from Trump, Bernie, and politics for a moment here. I am an occasional poster here using a throwaway account for anonymity purposes. I have a question about forming an anesthesia group.

Here is the scenario: I am in a region dominated by AMCs of all different flavors...hospital employment AMC, big national AMC, and pseudo-regional AMC masquerading as a private practice. There are a few true private practices in the region, but they either no longer hire partners or the partnership track is like 10 years long. I currently work for the pseudo-regional AMC masquerading as a private practice. I am an employee of that practice. When I first started, the job was fine. Pay was average, but lifestyle was pretty good when I started. Without going into specifics, lifestyle has taken a hit as the practice has expanded. As expected, employees have taken on the brunt of the new workload without any increase in pay. There are some mechanisms in my contract for some minor increases in pay, but not enough to account for the increased work burden.

So there are a few recourses up my sleeve right now...some with varying likelihood of success. However, what I would really like to do is take over a contract at a hospital and form a true, democratic, private practice. There is an opening, but the chance of it happening is very small. There is a hospital that is currently staffed by one of the few remaining true private practices in the region. However, rumor has gotten out that the administration is not happy with them. This PP is run by a bunch of older anesthesiologists who are near retirement and have closed off partnership possibility for any new hires. They pay criminally low rates for the employees that they hire. As a result, the practice has become a bit of a revolving door and there have been staffing issues. The word on the street is that the contract is going to be served up to the pseudo-PP that I currently work for.

I would love to grab that contract myself, but I have no idea how to go about doing that. I can probably gather enough people to staff the place almost immediately. The question is, how do I make that known to the administration at the hospital? If the hospital then expresses even mild interest, how do I reassure them that a new, unproven practice is worth taking a risk on when there is an easy solution with the pseudo-AMC-PP that already exists and has proven itself by staffing other hospitals in the region?

One of my other thoughts was to approach the group that is currently there and under threat to lose the contract and propose that I can bring people over immediately to solve the issues that they are having with staffing and any disputes with administration in exchange for immediate partnership and an agreement to transition group management over to me and my team over 6-12 months. Is this a plausible scenario?

I have lots of questions? I've gotten great advice here before, so I figure I would pose this question and open discussion that might be of use to other people as well.

If we think this is better in the Private Forum, I am ok with that as well because I have access there with my other account.

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[dchz]

What region of this country is this? sounds like LINY.

 

[Planktonmd]

So... your current employer does not have a non compete clause in your contract?
The second question is: are the other anesthesiologists/ CRNAs you are planning to recruit currently employed by your current employer? Are you confident they will not bail out on you if it gets down to you competing with their current employer? otherwise this is a guarantee that you will end up fired.
If you are truly free from legal obligation to your current employer and you actually have loyal guys willing to jump in it with you, then you need to put together a proposal that can be competitive with what the current anesthesia group is offering and more appealing than what the AMCs are offering. The hospital administration usually wants guaranteed service at the cheapest price possible, preferably without them giving you a penny in stipend.
Your proposal should be attractive and supported with financial and staffing projections and it has to be in a language that administrators understand with power point presentations and graphs. Focus also on productivity and patient satisfaction metrics.
Look very professional, and project confidence.
Once you feel you have all that covered call the CEO and ask for an appointment.

 

[nimbus]

Read through this...

"Doctors’ spat with Atrium Health spills into rare public view"

Doctors’ spat with Atrium Health spills into rare public view Doctors’ spat with Atrium Health spills into rare public view BY DEON ROBERTS [email protected] March 13, 2018 04:40 PM Updated 1 hour 22 minutes ago Atrium Health and a group of about 100 anesthesiologists who work...

forums.studentdoctor.net

 

[anesthesiadumpsterfire]

So... your current employer does not have a non compete clause in your contract?
The second question is: are the other anesthesiologists/ CRNAs you are planning to recruit currently employed by your current employer? Are you confident they will not bail out on you if it gets down to you competing with their current employer? otherwise this is a guarantee that you will end up fired.
If you are truly free from legal obligation to your current employer and you actually have loyal guys willing to jump in it with you, then you need to put together a proposal that can be competitive with what the current anesthesia group is offering and more appealing than what the AMCs are offering. The hospital administration usually wants guaranteed service at the cheapest price possible, preferably without them giving you a penny in stipend.
Your proposal should be attractive and supported with financial and staffing projections and it has to be in a language that administrators understand with power point presentations and graphs. Focus also on productivity and patient satisfaction metrics.
Look very professional, and project confidence.
Once you feel you have all that covered call the CEO and ask for an appointment.

I have a non-compete clause, but it would not encompass the new hospital. With that said, as you rightly point out, it would invite numerous legal challenges and would probably result in my immediate termination. I would not seriously move forward with it unless I had a really great plan in place. That’s why one of my ideas was to offer a life line to the current group and allow them to keep the contract. That would give me the immediate access to the hospital leadership and would require less people that are loyal to me moving forward.

Essentially the region is polluted by a few anesthesiologists making ALOT of money and the rest of the anesthesiologists stuck choosing between bad job A and slightly less bad job B.

 

[IMGASMD]

I haven’t been in this long enough to know what to do..... there was a small group around here who end up just hiring lots of locum crna to cover. I wouldn’t call it a disaster, but it wasn’t pretty. Their surgeon didn’t trust them, even their ob try to transfer pts out.

Do your homework. High risk high reward if you’re in a good payer mix area.

I am looking for a job. Wink wink.

 

[aneftp]

You need PR people to get into ears of hospital coo, cmo, and eventually ceo. That’s how these deals are usually done. Get your rpf ready to present. Professional people should develop charts and graphs how efficient you can be. How much value your competing contract will garner.

I wouldn’t even go to the current practice and threaten them. Leave them out.

you will need to get a ball park figure what the payor mix is. if it’s over 60% Medicare plus 10-15% Medicaid. It’s very tall order to be successful with subsidy if you are covering 24/7 plus ob.

 

[Pharmado]

OP, this is a difficult thing to do, but this IS the type of thing doctors should be doing. We need to take back territory we lost when money was good and no one fought to keep the AMCs out. Good luck, let us know how it goes.

 

[aneftp]

Unless you go all out all MD equal partners from day 1 who are willing to wait 3 plus months to get paid. You will have to get a loan or something to pay for staff before the collections comes in. Do you have that type of money? Or access to that type of money.
That’s why the doc who took over Carolinas hospitals. Someone was fronting him the money.

 

[deleted162650]

Unless you go all out all MD equal partners from day 1 who are willing to wait 3 plus months to get paid.

That’s how the majority of groups out west operate. Might be a tough sell if that’s not the norm in your neck of the woods though.

 

[Sushirolls]

Psychiatrist here...
1) leave out the other group, they have no real incentive to work or talk with you, and if already showing trends of not playing well with their new hires, the most certainly won't want to play ball with you.
2) You need to already have the other docs lined up who would join you truly showing commitment, and not 3 months, but 6 months of viability to go without pay.
3) Think of a corporation name. Small and less is best, especially if patients will be writing you checks. No one wants to write it out: Most Amazing Intubating Gasing Masters of America, LLC
4) You'll need to open up a corporation and ideally do this when you meet with a lawyer to outline best structure for this. Also get your state business license too.
5) Pick a CPA
6) once you get your Tax ID number from lawyer incorporation, and state business ID then go open up a bank account. Deposit some seed money.
7) Start keeping track of things as CPA and you agree
8) You'll need to get a Type II NPI number for this newly formed corporation
9) You'll want to reach out to a billing company that also does CREDENTIALING i.e. they will panel you with all the insurance companies under your new Type II NPI number, this can potentially cost $800-2000 per PERSON for all the insurance companies in your area, likely 14+
* The tricking thing with this, is they can't credential you and update all your details with CMS thru PECOS, CAQH, NPPES, etc until you have a practice address, phone numbers, and fax numbers, and hospital privileges. This gets tricky... do you move forward with privileges etc and first or later, if you do this later, you LOSE TIME in insurance paneling/credentialing and that delays income... Doing it too soon, your current job or the group you are trying to usurp might catch wind.
10) You'll also need to have liability insurance.... this likely needs to be done before step 9. But if you do it before you have privileges with hospital, they'll need to be updated after you get privileges, and then the hospital will also be named party on your Certificate of Liability sheet.
11) You may need a nice pretty neat presentation to get a contract as others above pointed out. This may cost money to get the presentations created. Will you do the sales pitch, will you hire someone? If hiring someone this means more time spent with the CPA early on to get payroll issues and quarterly payroll taxes established with CPA. This means CPA is getting PAID which means more seed money to get this up and running.
12) As you and every anesthesiologist on here knows, you guys get grumpy with small details in the contracts and how people are paid for them and how work shifts delt with. You need to already have the details of pay, shift differentials, on call, etc all established and written down in your corporate operating agreement in advance. As you know unhappy docs will leave. This means more time and money spent with the Lawyer back at step 4.

Now you also got to ask yourself, if you are championing this endeavor, and expanding all this energy are you sure you want to give away your time and energy for this dream free? For the sake of democratic structure that others will swoop in and not really life a finger but yet still demand good pay and hours? As you chin stroke on this and the reality of how much TIME and MONEY you will spend on getting this dream up and running, you might find yourself drifting towards less democratic, and more like, well, the group you are trying to replace....

 

[vector2]

: Most Amazing Intubating Gasing Masters of America, LLC

dibs

 

[Sushirolls]

All yours

 

[Sushirolls]

Oh and if you are lucky the contracts with insurance companies will be heavily based on the NPI type II identifier, and they will allow the ability to call them up and simply say, "Hey, please add Dr. Lighting Needle with NPI ...." and they just it it to the list of whose in or out for the organization. But other companies, don't do such a list. They will require a new contract process for each, and every doc, and that takes more than a month list update but the whole 3-6 months....

 

[deleted162650]

dibs

Too late.

MAIGMA is my group’s name founded back in the late ‘90’s.

And contrary to what @Sushirolls says, we have no problems collecting from patients.

 

[anesthesiadumpsterfire]

Unless you go all out all MD equal partners from day 1 who are willing to wait 3 plus months to get paid. You will have to get a loan or something to pay for staff before the collections comes in. Do you have that type of money? Or access to that type of money.
That’s why the doc who took over Carolinas hospitals. Someone was fronting him the money.

I think this is by far the biggest hurdle. It would be a near impossibility to convince the number of docs I would need to form a group of the size I would need to cover the hospital. Obviously anyone who joined me from day 1 on this crusade would be equal partners. I'm just not sure I could convince that may people to take the risk of job loss and income loss while we get off the ground. There is also the possibility that we put in a whole lot of effort, lose our jobs, and don't get the contract in the process. A lot of risks.

 

[anesthesiadumpsterfire]

You need PR people to get into ears of hospital coo, cmo, and eventually ceo. That’s how these deals are usually done. Get your rpf ready to present. Professional people should develop charts and graphs how efficient you can be. How much value your competing contract will garner.

I wouldn’t even go to the current practice and threaten them. Leave them out.

you will need to get a ball park figure what the payor mix is. if it’s over 60% Medicare plus 10-15% Medicaid. It’s very tall order to be successful with subsidy if you are covering 24/7 plus ob.

A lot of good information here. The question is one of timing. Do I form the group first before I try to get into meet with hospital administration? Can I get a core group to initiate the discussion before I continue to recruit? Are there people that I can hire that will help me put together the presentations that I need that the hospital admin will want to hear? Where do I get numbers from for hospital surgical volume, payer mix, etc. if I've never worked there?

 

[Sushirolls]

Where do I get numbers from for hospital surgical volume, payer mix, etc. if I've never worked there?

Walk into the hospital one day. Ask the help desk or volunteer folks where the medical staff office is. They'll get you there. Ask the medical staff clerk who the surgical services admin is, likely an RN who climbed the manager positions. Ask them if you can get her email. Let them know who you are and a simple line that 'I'm wanting to discuss anesthesiology coverage here at the hospital.' Email her with a brief introduction of who you are, and if she would be willing to schedule a meeting one day in her office, or if she would be willing to meet you for dinner, your treat, and you'd be bringing your spouse along too, and she'd be welcome to bring hers too. Make note that the meeting is preferred to not be advertised within in the department, ideally, discretion. See what happens.

You also might be able to find medicare numbers publicly buried somewhere on your local medicare MAC website. Or you might be able to look up each of the Anesthesiology doctors at that hospital on the medicare MAC to see how much they have billed Medicare, then look yourself up, that might give you a starting point to extrapolate from. Bare minimum what you need to know, and if you are already in the local area, is %medicare, %medicaid, %better-than-medicare private, %lower-than-medicare private.

 

[vector2]

A lot of good information here. The question is one of timing. Do I form the group first before I try to get into meet with hospital administration? Can I get a core group to initiate the discussion before I continue to recruit? Are there people that I can hire that will help me put together the presentations that I need that the hospital admin will want to hear? Where do I get numbers from for hospital surgical volume, payer mix, etc. if I've never worked there?

How many months of living expenses do you have in your F-you fund? Seems like things could go south for you quickly if your current group got wind of your play before you were actually ready to strike.

 

[anesthesiadumpsterfire]

How many months of living expenses do you have in your F-you fund? Seems like things could go south for you quickly if your current group got wind of your play before you were actually ready to strike.

I can easily live off my F-you fund for a few years. However, there is so much locums work around me, that would never be an issue. I could step into a desperate AMC’s job tomorrow if needed.

I’m nowhere near the stage where I would consider making a serious play at this. I just want to get a better understanding of the process at this stage because I do find that these opportunities are presenting themselves more and more as hospitals tire of the AMC revolving door. I guess I’ve just never been content being an employee even though those are the only options in my neck of the woods.

 

[Sushirolls]

Need to ask, what's AMC? Academic medical center?

 

[vector2]

Need to ask, what's AMC? Academic medical center?

Anesthesia management companies, aka mednax, envision, teamhealth, napa, etc

 

[Mman]

(I may have missed earlier in this thread if already brought up)

Aside from forming a company, you probably need to negotiate contracts with most/all the major insurers in the area or you won't be collecting anything when you start. And considering the moves United has been pulling recently, might not be that easy to get anything resembling a decent rate right now.

Starting on day 1 if you can't collect from insured patients is a good way to go broke quickly.

 

[anesthesiadumpsterfire]

(I may have missed earlier in this thread if already brought up)

Aside from forming a company, you probably need to negotiate contracts with most/all the major insurers in the area or you won't be collecting anything when you start. And considering the moves United has been pulling recently, might not be that easy to get anything resembling a decent rate right now.

Starting on day 1 if you can't collect from insured patients is a good way to go broke quickly.

So how do you form a company and negotiate contracts with insurers if you don’t have a place to administer anesthesia yet? It seems like a chicken or the egg conundrum. Do you form a company and try to nab a small contract at some plastic surgery office first before you go after a hospital?

 

[Mman]

So how do you form a company and negotiate contracts with insurers if you don’t have a place to administer anesthesia yet? It seems like a chicken or the egg conundrum. Do you form a company and try to nab a small contract at some plastic surgery office first before you go after a hospital?

forming a company is paperwork and negotiating a contract I think is just contacting them and telling them generically what you will be doing and negotiating rates. I assume they will just tell you they will pay you a nice low amount. It's only if you have a big enough case volume that you have any sort of leverage over them to get better rates than whatever they are going to offer. But you gotta start somewhere and having a contracted rate is infinitely preferable to being out of network with everyone on day 1. Besides the hospital(s) you are attempting to take over may require you to be in network with all providers as a condition of the contract. The easiest thing to do (if you can) is merge with some entity that already has contracts you can bill under.