Input needed on PP startup

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ml2001

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Good morning fellow SDNer's:

I have been researching and planning on starting a pain practice and need your opinions into the following issues:

  1. Location:
    • I'm currently in a non-compete clause with the employer I'm working for. It basically restricts me from working in the area I want to open my primary office in.
    • However, I can drive 15 more minutes out of this area and start the practice over there. The market seems to be good there also.
    • I do eventually want to move into my preferred area though. I'm concerned about having two separate locations though this seems to be the common trend for any solo practice provider regardless of the subspecialty in my area.
    • Question for you guys: If I invest good money to start in this outside area, would it cost me more or less the same amount when I'm ready to open in the area I want to open in eventually. What is typically the expense to add a satellite location?
  2. Start PP now vs in 2 years:
    • One option is to work some odd job for 2 years and come back to start a single location PP
    • This sounds financially less risky, but obviously the later you start it the more time I have to wait till the practice is financially rewarding down the road.
    • With all the changes happening in healthcare, it looks like it is getting harder and harder for single guys to succeed. So, I'm concerned that I may loose out if I wait for 2 years in starting a PP
    • Question for you guys: What is your opinion on this? What would you do if this were you right now.
  3. Should I even start a PP:
    • With the way healthcare field is currently, I'm a bit nervous about starting a PP
    • Most of the pain clinics in my area were purchased by a single corporate entity. They purchased three clinics in a matter of two years. I'm confused as to why this happened because I feel like this area is a very successful one for individual pain docs.
    • My current job makes me decent money in the low 350-450K range (likely around 400K depending on quarterly bonuses), but the overhead can reach 65-70%. Unless, I buy into ASC shares, there is no chance of making more. They did offer me buy-in for the ASC, but I'm undecided at this point. My reason for branching is not just overhead, but the surgeon who started the practice could be a d**k and I feel like I'm constantly under his radar due to his crazy micromanagement. This may be a good thing for the practice, but it bothers me to no end. I feel like I'm in control of my clinic, but he reminds me he is the boss every instance he gets by doing verbal punches.
    • Questions for you guys:
      • Is there a hidden issue that is making these providers to sell their PP to a corporate entity?
      • Is it even worth it to start your own or drink from a common fountain as someone on this forum put it. Should I suck it up and stay in my current job for the rest of my life and just deal with issues at my current practice?
  4. Capital needed to start a PP:
    • What kind of capital is needed to start a bare minimum PP with a Fluoro suite. My calculation is around 100k-150K and this also includes salary for a front desk/office manager person and a MA to help with patients as well as help with C-arm during procedures.
    • The large expenses I included are:
      • Office space large enough for fluoro suite: 25K/year
      • Fluoro suite build expenses (?????). Any input as to the cost of this?
      • A comprehensive EMR with EPM and RCM. Four percent of total collections. I'm looking into EclinicalWorks vs CureMD vs Athena in the same order of preference: No upfront cost if I go with CureMD. ECW is $500/month per provi
      • Furniture(Front office, exam rooms, fixed fluoro table, computers, and phones): 15K
      • Two employees: 50K/year between them
      • Initial medical supply orders: 10K
      • My tail coverage and one year malpractice premium: 20K
      • Consultant to get the practice started: 10K
      • Rent Fluoro machine: 5K/year
      • Buy used or new RFA machine: 15K
      • Any big ticket items I'm missing here, please add to this list
  5. Doing all of this to build a practice only to make it a satellite office 2 years later and start allover again is concerning even though both locations could be successful. What you guys think?

Lot more to ask, but I'm just taking it slow and steady. I'm sure more questions will popup as time goes on.

Thnx for all your input.....

-ML

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I too am looking into going starting a solo practice in near future. However, there are many known unknowns and unknown unknowns. Considering the large upfront capital needs and already accumulated debts (student loans, etc.) it is a decision that is not very easy to make... What are some good resources available for starting a pain practice (other than paying consultants $$$ for every single aspect of practice mgmt)?

As always, very grateful to SDN members and their valuable insights.
 
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If you are a block shop you can do well. If not your income will suffer. Whatever you do, don't prescribe opioids at all for anyone. The DEA told docs they are going after the top 5 prescribers in each state and will shut them down as an example of what can happen to any doctor prescribing. Their tactics have become chilling...phone taps, drones, confiscation of personal property including guns and coins, accusing docs of being potential murderers for having an old vial of succinyl choline in their house (carried home after call 8 years earlier), accusing docs of insurance fraud because they dont know the cpt billing codes for UDS off the top of their heads, etc. These were related first hand and via newspaper reports. So open your practice with all this in mind.
 
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Good morning fellow SDNer's:

I have been researching and planning on starting a pain practice and need your opinions into the following issues:

  1. Location: assume you will be at one clinic. Windshield time costs $$
  2. Start PP now vs in 2 years: start now. Opportunity cost for waiting is big.
  3. Should I even start a PP: yes start your practice. Autonomy over $$. kissing surgeon a** will lead to an early grave
  4. Capital needed to start a PP: depends on geography. If buying a building can get an SBA loan for building and build out. Get a practice loan from your bank. I would think more like 250k for start up plus down payment on building. Autoclave, table, phones, copy/fax machine, crash cart, defib, Ultrasound, EMG, don't skimp on your C-arm. It is always worth it to have good tools.
You will do great. Asking all the right questions.
 
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Thank you all for your input. To add to the list mentioned above: Is there much difference in the negotiated rates with insurance companies between a solo practitioner vs a large group? Is this large enough that it effects your bottom line at the end of the day? One of the consultants I talked to mentioned about joining hands with a different solo practice in a different part of the state to get better negotiated rates. I'm not too excited about this as I would have no clue who this other person might be and meeting them once or twice before deciding is not a good idea in my opinion.
 
Hi Nvrsumr:
In response to your first response, are you saying that going in with the mindset of opening a satellite branch in my desirable area after two years of non-compete is not a good idea? If so, does this mean you recommend that I move the whole practice into my preferred location and close the other office location?
 
Most established sole proprietors are selling their practices to corporate entities because new medical graduates have neither the will nor the fortitude to run a business for themselves.
The practices I'm talking about are very mature practices of at least 10-15 years. This is why it is surprising to me that they would sell out to a corporate entity.
 
The practices I'm talking about are very mature practices of at least 10-15 years. This is why it is surprising to me that they would sell out to a corporate entity.

Pain practices look enticing to "corporate entities" when they see the profits. What they fail to recognize is those profits will most likely vanish when the docs move to an employee mindset. As an owner-operator, you will have an edge over these guys.

Just make sure to do what Algos said.
 
If you are a block shop you can do well. If not your income will suffer. Whatever you do, don't prescribe opioids at all for anyone. The DEA told docs they are going after the top 5 prescribers in each state and will shut them down as an example of what can happen to any doctor prescribing. Their tactics have become chilling...phone taps, drones, confiscation of personal property including guns and coins, accusing docs of being potential murderers for having an old vial of succinyl choline in their house (carried home after call 8 years earlier), accusing docs of insurance fraud because they dont know the cpt billing codes for UDS off the top of their heads, etc. These were related first hand and via newspaper reports. So open your practice with all this in mind.
Algos
You are basically saying it is truly open season on pain docs. Are you serious about the suggestion to stop prescribing opioids entirely?



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if I were opening a practice for the first time at this point, there is no way in hell I would prescribe opioids for anyone no matter how bad they claim they hurt and no matter what the consequences. In some states it absolutely is open season on pain doctors who are prescribing opiates, even those prescribing legitimately. The state and federal laws are not firm on what constitutes prescribing for a legitimate medical purpose. The latitude afforded prosecutors and the DEA in interpreting this phrase is what is being used to destroy doctors. Any patient death, no matter how unrelated to opioids, is considered due to opioids by prosecutors if opioids were being prescribed. The pain doctor has to prove that the patient did not die of opioid overdose and the doctor is presumed automatically to be guilty until he proves his innocence by having a slew of expert witnesses and pathologists testifying on his behalf to the tune of 50 grand. One doctor recently spent 2 years and $400,000 of his own money to be exonerated and yet the DEA and state have no culpibility for false charges. Doctors not ensnared by false charges of medical misconduct on the state level then face charges by the DEA and then after that trial the state tries them again for medicaid fraud (prescribing opioids when not indicated therefore defrauding the government.) It is waves of prosecution one after another. and that doesn't even begin to cover the issues of what happens in other states where a doctor is licensed. There is one prosecution after another after another in each of those States as a reflex for what is alleged in the first state. My suggestion is to cut all pain patients to low or no opioids and stop prescribing any opioids to medicaid and medicare due to potential fraud charges. Also stop prescribing for headaches or fibromyalgia or chronic abdominal pain.
 
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This is very worrisome. Are physician groups, pain medicine societies, etc. doing anything to advocate on behalf of the patients?
 
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No. The pendulum does need to swing in the direction it is going but the guillotine of revolution beheads both the innocent and the guilty equally without deference to standards of care or in this case, rule of law.
 
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What guidelines does the law use when persecuting physicians? They are not trained physicians, so they must utilize some form of guidelines in evaluating each cases (or expert witness that in turn utilizes guidelines) for any deviation from standard practice?
 
if I were opening a practice for the first time at this point, there is no way in hell I would prescribe opioids for anyone no matter how bad they claim they hurt and no matter what the consequences. In some states it absolutely is open season on pain doctors who are prescribing opiates, even those prescribing legitimately. The state and federal laws are not firm on what constitutes prescribing for a legitimate medical purpose. The latitude afforded prosecutors and the DEA in interpreting this phrase is what is being used to destroy doctors. Any patient death, no matter how unrelated to opioids, is considered due to opioids by prosecutors if opioids were being prescribed. The pain doctor has to prove that the patient did not die of opioid overdose and the doctor is presumed automatically to be guilty until he proves his innocence by having a slew of expert witnesses and pathologists testifying on his behalf to the tune of 50 grand. One doctor recently spent 2 years and $400,000 of his own money to be exonerated and yet the DEA and state have no culpibility for false charges. Doctors not ensnared by false charges of medical misconduct on the state level then face charges by the DEA and then after that trial the state tries them again for medicaid fraud (prescribing opioids when not indicated therefore defrauding the government.) It is waves of prosecution one after another. and that doesn't even begin to cover the issues of what happens in other states where a doctor is licensed. There is one prosecution after another after another in each of those States as a reflex for what is alleged in the first state. My suggestion is to cut all pain patients to low or no opioids and stop prescribing any opioids to medicaid and medicare due to potential fraud charges. Also stop prescribing for headaches or fibromyalgia or chronic abdominal pain.

Algos, have you discontinued opioid prescription for all your current patients?

I am aware of two large scale pill-mills here in Washington state being investigated by the DOJ and FBI at this time. But these two practices are very bad actors.
 
Algos, have you discontinued opioid prescription for all your current patients?

I am aware of two large scale pill-mills here in Washington state being investigated by the DOJ and FBI at this time. But these two practices are very bad actors.

They are in all states. Are big problems are those trading narcs for procedures. One megagroup in Georgia keeps growing and growing....
 
I am closing one practice in 6 weeks...the other is a group practice and we are rapidly lowerung opioids
 
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if I were opening a practice for the first time at this point, there is no way in hell I would prescribe opioids for anyone no matter how bad they claim they hurt and no matter what the consequences. In some states it absolutely is open season on pain doctors who are prescribing opiates, even those prescribing legitimately. The state and federal laws are not firm on what constitutes prescribing for a legitimate medical purpose. The latitude afforded prosecutors and the DEA in interpreting this phrase is what is being used to destroy doctors. Any patient death, no matter how unrelated to opioids, is considered due to opioids by prosecutors if opioids were being prescribed. The pain doctor has to prove that the patient did not die of opioid overdose and the doctor is presumed automatically to be guilty until he proves his innocence by having a slew of expert witnesses and pathologists testifying on his behalf to the tune of 50 grand. One doctor recently spent 2 years and $400,000 of his own money to be exonerated and yet the DEA and state have no culpibility for false charges. Doctors not ensnared by false charges of medical misconduct on the state level then face charges by the DEA and then after that trial the state tries them again for medicaid fraud (prescribing opioids when not indicated therefore defrauding the government.) It is waves of prosecution one after another. and that doesn't even begin to cover the issues of what happens in other states where a doctor is licensed. There is one prosecution after another after another in each of those States as a reflex for what is alleged in the first state. My suggestion is to cut all pain patients to low or no opioids and stop prescribing any opioids to medicaid and medicare due to potential fraud charges. Also stop prescribing for headaches or fibromyalgia or chronic abdominal pain.

Overdose deaths are indeed a sad outcome. However, our opioid agreements and informed consent for treatments with opioids always include potential overdose/deaths. When I discuss this with my patients, they understand the consequences and decide to engage in treatment. Even in patients prescribed low doses of opioids there is still possibility of overdose (may be not as much as higher doses)... Are the informed consents or opioid agreements not enough to protect physicians in case of unfortunate overdose when otherwise the physicians are not bad actors?
 
No, informed consent does not protect the physician against prosecution for illegitimate prescribing, manslaughter or murder charges
 
I have heard from several people that DEA doesn't go after doctors under the umbrella of hospitals/universities (either employed physicians or private) no matter how bad the prescription habits are e.g. very high MEDs, bad combinations (BZD, methadone, soma, ambien, etc.), narcs for procedures, etc. Compared to so many examples of DEA going after private practices. Why is there a bias against private practices?
 
Low hanging fruit? The incorrect assumption that hospital based places restrictions on prescribing? The DEA having to fight a hospital legal team with enormous resources?
 
Most established sole proprietors are selling their practices to corporate entities because new medical graduates have neither the will nor the fortitude to run a business for themselves.
There's a lot of us in the younger crowd that are hungry for a private practice job and all that entails. Trouble is we've got so much debt nowadays that buying into a practice usually requires us to build capital in an employed position first- hard to put 250-500k down on starting something or buying in when you've got 400k in debt already.

Of course, there's also a lot of lazy millennials out there, so I'm not saying it's all debt...
 
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The opioid prescription fiasco is troubling, but your focus should be on neuropathic and tca meds anyway. If one had focused on this route from the beginning, their pp would be fine, just like most of us on this forum.

I would focus on what your referral base and payer mix will be. It's hard to get pcp referrals in a region with monopoly ACO's. Next realize theses scumbag ACO's are commanding 200% of Medicare rates. That at least gives you an arguement when you negotiate your commercial contracts, which is also very critical(try for 120-180% of Medicare)... Good luck, go for it, hopefully patients will wise up and protest the ongoing governmental infringement on healthcare.
 
if I were opening a practice for the first time at this point, there is no way in hell I would prescribe opioids for anyone no matter how bad they claim they hurt and no matter what the consequences. In some states it absolutely is open season on pain doctors who are prescribing opiates, even those prescribing legitimately. The state and federal laws are not firm on what constitutes prescribing for a legitimate medical purpose. The latitude afforded prosecutors and the DEA in interpreting this phrase is what is being used to destroy doctors. Any patient death, no matter how unrelated to opioids, is considered due to opioids by prosecutors if opioids were being prescribed. The pain doctor has to prove that the patient did not die of opioid overdose and the doctor is presumed automatically to be guilty until he proves his innocence by having a slew of expert witnesses and pathologists testifying on his behalf to the tune of 50 grand. One doctor recently spent 2 years and $400,000 of his own money to be exonerated and yet the DEA and state have no culpibility for false charges. Doctors not ensnared by false charges of medical misconduct on the state level then face charges by the DEA and then after that trial the state tries them again for medicaid fraud (prescribing opioids when not indicated therefore defrauding the government.) It is waves of prosecution one after another. and that doesn't even begin to cover the issues of what happens in other states where a doctor is licensed. There is one prosecution after another after another in each of those States as a reflex for what is alleged in the first state. My suggestion is to cut all pain patients to low or no opioids and stop prescribing any opioids to medicaid and medicare due to potential fraud charges. Also stop prescribing for headaches or fibromyalgia or chronic abdominal pain.
The posts from Algos in this thread are the most disturbing that I have seen on SDN. The question is what can we do about this. I am not a COT fan and agree that the focus needs to be on other aspects of the practice. I would not be saddened by an end to COT. However, it would need to be an end to COT for everyone. From what Algos is describing you don't have the luxury of giving it to Grandma and Grandpa or to the 52 year old with whatever condition who remains active and employed. That does make it easy. Acute injury or surgery, maximum six weeks of opioids and done. Perhaps the government won't make the end of COT official because the agencies, prosecutors and those in law enforcement find doctors to be easy targets and a great way to earn points and move up the ranks. If the government won't officially prohibit COT then either we declare the end as a consensus or we demand that the government make the medical decision. As crazy as it may seem to allow the government to make medical decisions for COT; why not? After all, COT is not curing cancer. Submit a brief summary to a government oversight committee and they give the thumbs up or down. If you have a patient who you really think would benefit from COT, obtain government prior approval. Would like to hear other participant's thoughts on what to do. I think it is a mistake to ignore this and think that your "expertise" will protect you.
 
I am closing one practice in 6 weeks...the other is a group practice and we are rapidly lowerung opioids

Wow I'm so sorry. Sounds like you have enough stress on your head. I know you have a very well established practice with many long term patients. How are you getting the message to your patients effectively and efficiently? I can't imagine having the "I'm tapering you off" conversation multiple times per day. Is your front staff warning patients ahead of time to prime them for the news when you see them? Knowing you, I'm sure you have worked this out. I am confident your practice manages these patients well and appropriately, it is sad to hear this is happening due to our beloved bureaucrats.
 
I have heard from several people that DEA doesn't go after doctors under the umbrella of hospitals/universities (either employed physicians or private) no matter how bad the prescription habits are e.g. very high MEDs, bad combinations (BZD, methadone, soma, ambien, etc.), narcs for procedures, etc. Compared to so many examples of DEA going after private practices. Why is there a bias against private practices?

It is the entire paradigm for our federal government; destroy private practice by eliminating or reducing payment, increase overhead expenses thus depleting profits, persecute and prosecute private practice docs for opioid prescription, persecute and prosecute private practice docs for coding errors (and be sure to make coding impossible), pay nothing to private practice docs but pay 5x the amount for same services to hospital employed docs, require pre auth for everything and deny all claims as often as possible depleting revenue stream and requiring more staff to get our money. They are attacking us from every possible angle. And our own "societies" and supposed representatives are further burying us with MOC requirements, opportunity costs do to MOC, and direct costs due to MOC. Same with 10 year recertification.

The entire system is rigged to kill us off in private practice, put us in the employ of hospitals, and then CONTROL us with press-ganey BS, administrators, and noctors.

Then add in our own physician colleagues that vote for socialists and love big government.

F them.
 
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I read a few of the "society" positions during the comment period for "Meaningful Use Reform/MIPS". Not pain per se but all of medicine. It was unbelievable. Most societies said things like (paraphrased of course), "We love meaningful use and everything about it but we think instead of 25 measures, there should only be 24 measures." Bureaucracies really do enjoy each other's company...
 
I'm sorry ligament, your tirade would be reasonable..,

But what gives you the presumption that most if not all your complaints are not appropriate for hospital based docs? HOPD docs have to get auth. HOPD docs get paid a lot less in our professional fees (admin gets the facility fees) and are getting fees cut every time. HOPD docs are always being accused of being lazy - I guess if 60 hours a week is lazy - for 2/3 max the pay PP docs average (based on last MGMA data I had access to) with no respect at all from members of this board...

On top of that, JCAHO and annual visits, nursing admin flexing muscles all the time, hospital admin telling docs what to do, inpatient consults every week that pay zilch, can't hire or fire staff, huge Medicaid population, and on top of that, have to have a frogging written response to every stupid patient compliant that they didn't get their drug fix from me, that PP docs can flush down the toilet...


And if you really think that everyone is out to only get you and PP docs, then sell out and join a hospital system. In many ways, YOU have it good...


My point: We are in this together. Please stop it with the oh- woah-is-me-the-PP-doc. These changes affect ALL pain docs.

Sent from my iPhone using SDN mobile
 
I'm sorry ligament, your tirade would be reasonable..,

But what gives you the presumption that most if not all your complaints are not appropriate for hospital based docs? HOPD docs have to get auth. HOPD docs get paid a lot less in our professional fees (admin gets the facility fees) and are getting fees cut every time. HOPD docs are always being accused of being lazy - I guess if 60 hours a week is lazy - for 2/3 max the pay PP docs average (based on last MGMA data I had access to) with no respect at all from members of this board...

On top of that, JCAHO and annual visits, nursing admin flexing muscles all the time, hospital admin telling docs what to do, inpatient consults every week that pay zilch, can't hire or fire staff, huge Medicaid population, and on top of that, have to have a frogging written response to every stupid patient compliant that they didn't get their drug fix from me, that PP docs can flush down the toilet...


And if you really think that everyone is out to only get you and PP docs, then sell out and join a hospital system. In many ways, YOU have it good...


My point: We are in this together. Please stop it with the oh- woah-is-me-the-PP-doc. These changes affect ALL pain docs.

Sent from my iPhone using SDN mobile

Im owned by a hospital. I have a salary cap. I gave up sedation in the office and now send out half my kypho cases to IR guys. But if admin treated me poorly or wanted to cut my pay or add duties, i would walk. Hanging a shingle isnt something i would want, but im sure id learn quick.
 
I'm sorry ligament, your tirade would be reasonable..,

But what gives you the presumption that most if not all your complaints are not appropriate for hospital based docs? HOPD docs have to get auth. HOPD docs get paid a lot less in our professional fees (admin gets the facility fees) and are getting fees cut every time. HOPD docs are always being accused of being lazy - I guess if 60 hours a week is lazy - for 2/3 max the pay PP docs average (based on last MGMA data I had access to) with no respect at all from members of this board...

On top of that, JCAHO and annual visits, nursing admin flexing muscles all the time, hospital admin telling docs what to do, inpatient consults every week that pay zilch, can't hire or fire staff, huge Medicaid population, and on top of that, have to have a frogging written response to every stupid patient compliant that they didn't get their drug fix from me, that PP docs can flush down the toilet...


And if you really think that everyone is out to only get you and PP docs, then sell out and join a hospital system. In many ways, YOU have it good...


My point: We are in this together. Please stop it with the oh- woah-is-me-the-PP-doc. These changes affect ALL pain docs.

Sent from my iPhone using SDN mobile
United we stand. Divided we fall.


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Guess there's no point to go into pain medicine anymore.
 
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I'm sorry ligament, your tirade would be reasonable..,

But what gives you the presumption that most if not all your complaints are not appropriate for hospital based docs? HOPD docs have to get auth. HOPD docs get paid a lot less in our professional fees (admin gets the facility fees) and are getting fees cut every time. HOPD docs are always being accused of being lazy - I guess if 60 hours a week is lazy - for 2/3 max the pay PP docs average (based on last MGMA data I had access to) with no respect at all from members of this board...

On top of that, JCAHO and annual visits, nursing admin flexing muscles all the time, hospital admin telling docs what to do, inpatient consults every week that pay zilch, can't hire or fire staff, huge Medicaid population, and on top of that, have to have a frogging written response to every stupid patient compliant that they didn't get their drug fix from me, that PP docs can flush down the toilet...


And if you really think that everyone is out to only get you and PP docs, then sell out and join a hospital system. In many ways, YOU have it good...


My point: We are in this together. Please stop it with the oh- woah-is-me-the-PP-doc. These changes affect ALL pain docs.

Sent from my iPhone using SDN mobile

I agree YOU are getting screwed too, however I was talking about private practice. The business model.

Yes you are getting screwed too, but your employer/business - the hospital - is making a killing..from YOUR WORK.

In private practice the physician and the business are both being killed
 
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There's a lot of us in the younger crowd that are hungry for a private practice job and all that entails. Trouble is we've got so much debt nowadays that buying into a practice usually requires us to build capital in an employed position first- hard to put 250-500k down on starting something or buying in when you've got 400k in debt already.

Of course, there's also a lot of lazy millennials out there, so I'm not saying it's all debt...

Work for someone else and buy-in...
 
Work for someone else and buy-in...
That's what I'm planning on- pay down my debt then either put in my time or money to partner up at a place. We'll see though. With all the changes going on, the government might make PP unfeasible in the near future...
 
It is the entire paradigm for our federal government; destroy private practice by eliminating or reducing payment, increase overhead expenses thus depleting profits, persecute and prosecute private practice docs for opioid prescription, persecute and prosecute private practice docs for coding errors (and be sure to make coding impossible), pay nothing to private practice docs but pay 5x the amount for same services to hospital employed docs, require pre auth for everything and deny all claims as often as possible depleting revenue stream and requiring more staff to get our money. They are attacking us from every possible angle. And our own "societies" and supposed representatives are further burying us with MOC requirements, opportunity costs do to MOC, and direct costs due to MOC. Same with 10 year recertification.

The entire system is rigged to kill us off in private practice, put us in the employ of hospitals, and then CONTROL us with press-ganey BS, administrators, and noctors.

Then add in our own physician colleagues that vote for socialists and love big government.

F them.

Doctors brought this onto themselves by trading their autonomy for "magic beans" of hospital employment. This story goes wag back to the Nixon, The HMO act of 1973, Henry Kaiser, the AMA.

In short, MD's were ball-less and didn't want to risk giving up government cheese of Medicare, Nixon needed votes (especially working class African American votes), and Henry Kaiser was the biggest con-man and ponzi scheme creator ever--it would make Bernie Madoff blush...

John D. Ehrlichman: “On the … on the health business …”

President Nixon: “Yeah.”

Ehrlichman: “… we have now narrowed down the vice president’s problems on this thing to one issue and that is whether we should include these health maintenance organizations like Edgar Kaiser’s Permanente thing. The vice president just cannot see it. We tried 15 ways from Friday to explain it to him and then help him to understand it. He finally says, ‘Well, I don’t think they’ll work, but if the President thinks it’s a good idea, I’ll support him a hundred percent.’”

President Nixon: “Well, what’s … what’s the judgment?”

Ehrlichman: “Well, everybody else’s judgment very strongly is that we go with it.”

President Nixon: “All right.”

Ehrlichman: “And, uh, uh, he’s the one holdout that we have in the whole office.”

President Nixon: “Say that I … I … I’d tell him I have doubts about it, but I think that it’s, uh, now let me ask you, now you give me your judgment. You know I’m not to keen on any of these damn medical programs.”

Ehrlichman: “This, uh, let me, let me tell you how I am …”

President Nixon: [Unclear.]

Ehrlichman: “This … this is a …”

President Nixon: “I don’t [unclear] …”

Ehrlichman: “… private enterprise one.”

President Nixon: “Well, that appeals to me.”

Ehrlichman: “Edgar Kaiser is running his Permanente deal for profit. And the reason that he can … the reason he can do it … I had Edgar Kaiser come in … talk to me about this and I went into it in some depth. All the incentives are toward less medical care, because …”

President Nixon: [Unclear.]

Ehrlichman: “… the less care they give them, the more money they make.”

President Nixon: “Fine.” [Unclear.]

Ehrlichman: [Unclear] “… and the incentives run the right way.”

President Nixon: “Not bad.”
 
The bottom line is that "health care is a right" is not compatible with "fee for service". The "health care is a right" theme is winning so we are moving toward the only feasible solution, which is population-based HMO type capitated care.
 
Im owned by a hospital. I have a salary cap. I gave up sedation in the office and now send out half my kypho cases to IR guys. But if admin treated me poorly or wanted to cut my pay or add duties, i would walk. Hanging a shingle isnt something i would want, but im sure id learn quick.
If enough physicians remain independent and out of ACO's, there is some hope, based on the fact that there is an overall physician shortage. Our field for better or worse is specialized and small as well. there should be some long term leverage. Also I agree with Steve, there is a point where I would sit out and live of my investments. I believe a 60% fed tax rate would do it....
 
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So far the discussion on the hardships faced in private practice have been very interesting.
Do any of the guys that run their own practice have any info on the startup costs?

Some of the start up costs seem low to me; however, the on-going total overhead costs seems high.
I don't have any information on leasing equipment since the practice where I am employed purchases everything.
Our overhead is near 50% and is in no way run as efficiently as possible.
 
I have heard from several people that DEA doesn't go after doctors under the umbrella of hospitals/universities (either employed physicians or private) no matter how bad the prescription habits are e.g. very high MEDs, bad combinations (BZD, methadone, soma, ambien, etc.), narcs for procedures, etc. Compared to so many examples of DEA going after private practices. Why is there a bias against private practices?

We like to say low hanging fruit. Why is it low hanging? Its because they make it that way. Look at the majority of bad actors that each of you know. Almost all are PP. I'm PP, but I can honestly say that every shady practice I know is PP. The hospital guys have some oversight and/or don't get greedy and hire 12 NPs to see their methadone patients. Nothing against you other PP guys as I'm sure most of you aren't the problem. I highly doubt the crowd I talk about comes online to read about these issues.
 
We like to say low hanging fruit. Why is it low hanging? Its because they make it that way. Look at the majority of bad actors that each of you know. Almost all are PP. I'm PP, but I can honestly say that every shady practice I know is PP. The hospital guys have some oversight and/or don't get greedy and hire 12 NPs to see their methadone patients. Nothing against you other PP guys as I'm sure most of you aren't the problem. I highly doubt the crowd I talk about comes online to read about these issues.

Shouldn't the doctors be overseeing the hospital administrators and not the other way around?
 
We like to say low hanging fruit. Why is it low hanging? Its because they make it that way. Look at the majority of bad actors that each of you know. Almost all are PP. I'm PP, but I can honestly say that every shady practice I know is PP. The hospital guys have some oversight and/or don't get greedy and hire 12 NPs to see their methadone patients. Nothing against you other PP guys as I'm sure most of you aren't the problem. I highly doubt the crowd I talk about comes online to read about these issues.
This might be because hospitals vet doctors before hiring AND are ready to fire anyone that might be a liability.

Drusso, increasingly more hospital CEOs are physicians. And I agree, there should be much more. In most instances, this would be preferable, although I have had the luxury of being in a system with 2 excellent nonphysicians. This should be encouraged as an alternate pathway in medical school, especially those who may be underperforming in med school...

http://voxeu.org/article/should-physicians-manage-hospitals


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Shouldn't the doctors be overseeing the hospital administrators and not the other way around?
YES. It SHOULD be. Unless other areas are like mine and physicians themselves are the only ones to blame if one were to disagree with that statement. There is a huge amount of greed and disregard for the good of the patient among numerous PP in my area. It's sad but it is what it is.
 
I hate admin and government as much as anyone on this board. But the disappointing number of bad apples have ruined it for the rest of us.
 
This should be encouraged as an alternate pathway in medical school, especially those who may be underperforming in med school...

Why would you want those underperforming in med school to be "overseeing" those providing patient care?
 
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The practices I'm talking about are very mature practices of at least 10-15 years. This is why it is surprising to me that they would sell out to a corporate entity.

The practices you speak of probably peaked 10 years ago in the current model. There has been a steady decline since, accelerated greatly over the past 3 or so years. For those physicians who are not interested in significantly changing their business model/restructuring their practices at this point, and who may be approaching retirement age, selling to a corporate entity may not be such a bad option.
 
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