how do you start your own pain practice

[daphilster78]

Current fellow from a PM&R background. I've decided I want to do private practice and being single without family, I want to go ahead and try to start my own practice. Does anyone know how to go about this, esp for a physiatry perspective?

My current attendings have been mostly in an academic setting, so I was hoping for some input/ideas.

My thoughts were to ask a spine group if I could rent office space/fluoro suite and pay rent & give facilities fees. Or another approach would be to join a general physiatry group for clinic and see pain and general physiatry (which I like both) and then somehow find a hospital or ASC to do my procedures in. Anyone have thoughts/experience on this?

Btw, I live in Orange County, CA, quite possibly one of the most over penetrated area of all doctors (pain included).

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[deleted185747]

I also want to start a private practice. I think the area we are in will be an uphill battle. I'm looking at other states/areas with more unmet need. Any ideas as to where that may be?

 

[PMR 4 MSK]

You will need either a lot of capital, a way to get big loans for the capital, or someone to support you - i.e. pay for everything - office, equipment, staff, etc.

If someone else is supplying you, they expect a return - be it patients or money or both.

If you can swing it, find your own small office, big enough for a fluoro suite and some exam rooms, get your own office, lease a c-arm, and get a bankroll. The less you are attached financially or by obligation to others, the better.

 

[Doctodd]

there is a steep learning curve and it takes awhile to get on contracts. I joined a busy practice for a year to get experience and then started my own practice so i could learn as i go to try to soften the gradient. It's really hard to learn algebra when u dont know how to add or subtract.

 

[drpainfree]

let's say u did pain management fellowship with enough ambulatory exposure, can you start the practice on your own?

the problem with joining someone else first then going on your own is "non-compete", put aside being abused by someone for a year.

 

[Doctodd]

dont assume you will be abused cuz every practice is different.....and define abused?.....i was eager to work so it wasnt abuse to me. Im older now so i dont think i could do it again, but at the time it was ok by me to do every case i could at that age.

Yes there was a non-compete, so i moved one county down which was closer to my family anyway. I went into it thinking it was a possibility i would move if my contract wasnt renegotiated to my liking, or anything else happened. Turns out the partners started suing each other right when i left.

 

[powermd]

I'm in the process of setting up my own private practice right now. I agree the learning curve is huge, and there's no way I could have done this right out of fellowship. Working for a year provided invaluable experience learning the business aspect of pain medicine. A good intermediate option would be stating a practice with a hospital that an offer you a salary guarantee and benefits.

 

[axm397]

let's say u did pain management fellowship with enough ambulatory exposure, can you start the practice on your own?

the problem with joining someone else first then going on your own is "non-compete", put aside being abused by someone for a year.

There are some states with no restrictive covenants (California for example)

Ambulatory exposure doesn't prepare u for the practice management/business side of things. I have seen a few new grads start practicing on their own after fellowship and unfortunately, most of them have not succeeded - even ones that joined a friend or co-fellow.

The few who were successful planned the practice for several years - with consultants, friends with business experience, and had built up a lot of contacts in the area and positioned themselves in the community to get some nice referral stream. This is difficult to do right out of training.

I would agree with the above - that if u can find a job where they will actually allow u exposure/access to the business side of things (numbers, business meetings, etc.) - that will help a lot.

To the OP - orange county is ROUGH. There are a few pain docs in that area that hire once in a while and they really do abuse and use new grads. Overhead is $$$ in terms of rent, personnel, etc and the politics in the area is difficult to grasp and most new grads will be eaten alive. I have friends who have lucked out with some good positions in the area (mostly by joining established ortho groups in the area) but I have yet to see the long term results - i.e. most of them are a couple years in. u really have to compromise a lot to be in a desirable area like southern CA. It's also hard to practice in an area with a lot of charismatic, used-car salesman, drug/device ***** academicians like LA, Chicago, NY, etc. Most ppl do go by the "name" of the institution.

 

[drpainfree]

what do u propose to "compromise" in a competitive area?

in a competitive area, anyone (new grad or not) will bound to be abused if you join someone, simply because there are more supplies than demand and private pain guys in a competitive area see that and will simply hire you for a year or two, and move on to next new fish in the pond.

sure, you will gain some business experience if u are given exposure (therefore, less abused) if you join someone else first.

why not to start slow, one step at a time, gradually gain your experience, referral base, and slowly income, too.

the key is to survive the first year or two with minimum overhead expense.

any comments are welcome.

 

[Tenesma]

some states don't allow non-competes... or practice for a year far enough from where you really want to practice without interference from non-compete

what you will learn in ONE year of practice will be well worth it when you set up your own practice ---- consider the year of private practice as a "super fellowship"

i would think that most of us on this board who are in solo private practice couldn't have done it without some real-world experience re: billing, coding, referral management, patient management...

 

[sweetalkr]

so how do you approach jobs when you only want to work for a year and start your own? Do you let them know up front? or wait until contract negotiations? all is fair in love, war, and medicine but I don't want to screw a practice over you know?

 

[powermd]

so how do you approach jobs when you only want to work for a year and start your own? Do you let them know up front? or wait until contract negotiations? all is fair in love, war, and medicine but I don't want to screw a practice over you know?

Why? Odds are that's what they have planned for you. I would look for a salaried non-partner track job. The base salary should be higher, and you can leave with no expectation you were going to stay on. Just make sure you negotiate occurrence malpractice, or that they pay tail on your exit. Otherwise, save up enough to pay it.

 

[daphilster78]

It sounds like a HUGE uphill battle no matter which approach you take. I was thinking of working for someone for a year or two, but it just seem disingenuous if I ended up setting up shop nearby in the overcrowded OC and competing with them later. I've thought of working in nearby Arizona where things are less crowded, but I spoek to a friend who discouraged me from doing this because although I would be gaining billing/insurance/accounting experience, it would not be specific to the location I want to work eventually. Also, in that time, I would not be forming contacts with referring PCP's and surgeons.

That's why I had the idea of starting off doing general physiatry and a little bit of pain on the side and building up slowly. I guess my question is does anyone have experience with this? I'd imagine if I approached a few ASCs or orthopedists they'd be interested in someone renting out a procedural suite for 1 day a week because I would help them lower their overhead?? (I have no idea if this would work)

 

[daphilster78]

oh btw, does anyone know the ballpark of how much is needed to start a practice for the first year in a major metropolitan area. Renting the clinic, c-arm, hiring staff, billing, RNs, EMR, etc. I definitely need a business consultant if I go through with this in the future.

 

[Doctodd]

oh btw, does anyone know the ballpark of how much is needed to start a practice for the first year in a major metropolitan area. Renting the clinic, c-arm, hiring staff, billing, RNs, EMR, etc. I definitely need a business consultant if I go through with this in the future.

algos wrote up a nice summary awhile back....it was on the painrounds.com front page but it fell and is now a little dated, especially the part about dragon software. Here it is linked....

http://painrounds.com/index.php?option=com_content&task=view&id=35&Itemid=28

 

[Tenesma]

you have to figure about a 100-150k line of credit to manage cash-flow (primarily leases, payroll) for the first 4-6 months...

and you have to figure about 100-200k capital to set it up right (if there is a fluoro suite involved)...

i have to argue with my bank for my current line of credit and I at least have a track record, multiple years of profit/nice tax forms, and have to use my AR as my collateral for that line of credit... i don't know how somebody fresh out without anything would get a line of credit...

 

[onewithpain]

If you like rural then here is a different approach. Small rural hospitals are designated as Critical Access Hospitals and in my area are able to collect 14% more from medicare, and often have generous contracts with private insurers (100%). So I knock on the door and tell them about the facility fees that I can generate and they are willing to do all my PAs, billing, collecting and they provide the facility, staff, MA, and lunch. I have one MA to catch the stuff that others drop. My malpractice is subsidized because I'm rural. GE has sold 3 9900s to sites where I work. I have my RFA generator in the trunk and charge for it by the case. I don't write narcs but push lidoderm and handouts on exercise and nutrition. I drive too much but the scenery is great and everywhere I go people howdy me. You leave the facility fee in each community hospital and support specialties are rare, but you reduce your overhead and you pick up a couple of generous private insurance reimbursements each day. Fish and golf on weekends. I'm only scratching the surface of the market.

 

[tchoupdoc]

That's why I had the idea of starting off doing general physiatry and a little bit of pain on the side and building up slowly. I guess my question is does anyone have experience with this? I'd imagine if I approached a few ASCs or orthopedists they'd be interested in someone renting out a procedural suite for 1 day a week because I would help them lower their overhead?? (I have no idea if this would work)[/QUOTE]

This is basically what I did.

I've been out 8 years now, and the best thing that happened for my practice was when the one physiatrist doing EMG/NCS left. My dept bought a used xltech for 8k. Was it worth it?

I am now EMG boarded and 1/3 of my workweek, at least, is electrodiagnostics. The hospital has hired a tech so I can have NCS done while I see clinic patients or do emg's. Two orthopedic practices welcome me to use their clinic on their surgery days to test their patients.

 

[PMR 4 MSK]

I make most of my EDx money from doing the NCS myself. I don't let anyone hire a tech to do it. Plus I don't trust a tech to do much more than basic distal median and ulnar studies, and even then I question it. Too many rely way too much on the machine for their numbers.

 

[lobelsteve]

I make most of my EDx money from doing the NCS myself. I don't let anyone hire a tech to do it. Plus I don't trust a tech to do much more than basic distal median and ulnar studies, and even then I question it. Too many rely way too much on the machine for their numbers.

Something about EMG/NCS is an extension of the physical exam. I'm sure a lot of the dipshnitzels out there let their tech do their exam anyways.

Let's put together a study looking at correlations of EMG/NCV with normal physical examination. I bet we could get CMS to not pay for the testing if it were upto symptoms, but would pay if it were based on examination.

 

[tchoupdoc]

I make most of my EDx money from doing the NCS myself. I don't let anyone hire a tech to do it. Plus I don't trust a tech to do much more than basic distal median and ulnar studies, and even then I question it. Too many rely way too much on the machine for their numbers.

Agreed. When I'm not in the hospital, I do my own.

Work at an HCA facility. System is set up so that it is impossible for a doc to collect technical component, even on my equipment. HCA policy.

Techs are AANEM certified. Do they miss or overcall? yes. I review printed waveforms and encourage questions. But if I don't use them in this set up, I am losing money doing NCS and being paid for interpretation only when I am both interpreter and technologist.