Month Twelve:
Busy week one, new record I believe for follow ups and consults.
The entropy of time… I’m settling in to the role of a heavy med check clinic. I’m loving the beauty and simplicity of this practice. Only one brief 10 minute monthly meeting. I have a great receptionist/assistant. There’s no work place drama. No ridiculous “quality” metrics being pushed, no billing people looking over my shoulder. No scheduling or vacation barriers to deal with or pages of rules for CME reimbursement. No counting wRVUs. The heavy, wet concrete blanket of bureaucratic oppression is … gone. Whether I was on a burn out spectrum in the past or simply being a psychiatrist who spotted scat in his own life and took steps to improve them, this practice set up is amazing! However, being on staff at the local hospital where ECT might develop has now exposed me to the flood of emails rampant in large health systems once again. I was adept in the past at cruising and deleting non-essential emails pouring in from admins, but having been free of them for some time, to again get them is painful.
Another flu/cold moved thru the house. And it hit me hard, too. Reality is I’m the flex person who gets the kids to and from places, more prone to do sick care for kids. Without a quality practice partner to share in logistics of an ECT service start up, I can’t be 100% devoted to work for 1-2 years of getting this service up and running. I’m officially going to kill the ECT dream. Some sadness, similar to the closing of doors as med student to resident, and resident to attending, etc. But I’m now more accepting of not being the Psychiatrist who does ‘More’ or has extra ‘Bells and Whistles.’ Simply doing med check focus is good enough. I can still do more by precepting third year students. I used to have a sweet rotation with IP, OP, CL, ECT, Suboxone clinic, etc all packed nicely into a month-long rotation, but what I lack with these other exposures I’ll try to supplement with more designated 1:1 didactic teaching. The communications were officially sent – dead. THE BOSS is sad with this decision but understanding. I do still believe the future of Psychiatry may trend towards most offices having TMS, and offering ketamine in some fashion, but I am willing to accept not being ahead of this curve and trying to react and catch up in the future if needed. To paraphrase a non-medical good friend, "I'll choose lifestyle every time."
Updated website to show I’m no longer taking schizophrenia or schizoaffective, nor offering LAI. I simply didn’t see the vivitrol numbers I originally thought, and haven’t been able to test out the relationship I attempted to start with a local pharmacy. Secondly, my few young first break psychosis patients are not med compliant, and my hopes of having thoroughly educated on diagnosis, treatment plan early with family would yield positive outcomes, but both patients have already had some non-compliance. This office isn’t set up with case management for these purposes. So this will be a new practice limitation. Also, updated website to reflect ESA letters not written out of this office. Did other website updates like adding Assistant, sort of end of year housekeeping.
Have some forms/documents I need to create within Luminello but struggling to get the time. Whenever I think I have a window, it gets used up for catching up on charting delays from previous setbacks that got me behind. May truly just need to block a whole darn day in the future to devote to these admin/process/flow improvements.
Goals for 2020:
- Pay myself Quarterly, and however small/big that number, remember I am free and not working for some Big Box Shop entity.
- Achieve 20 clinical hours per week by end of Q2
- Start taking on some med students again
- After Achieve 2, look at patient panel and consider dropping Medicare, low payor, or low payor.
- By end of Q2 know if THE BOSS is going to open/build an office I rent from or if I will pursue it myself using my own business identity.
- Achieve 30 clinical hours per week by end of Q4
Review of patient panel shows 93 total active patients: 44 have better rates than Medicare (two are cash pay), 8 are Medicare, 41 have lower rates than Medicare. 47.3% of the panel is better than Medicare in summary. Census increased from Q3 to Q4 by 22 patients. Earlier posts had reflected my optimism to be at 20-30 clinical hours by the end of 2019. That didn’t happen. Disappointing, but the growth rate currently is manageable with how I document and I’m not feeling overly stressed. Estimate I’m 10-12 clinical hours currently per week overall. Just by the number, if I am growing 22 patients per quarter, and if 93 patients correspond to 10-12 clinical hours, I should be at 181 patients and 20-24 hours by end of 2020. So, we shall see, end of 2020 will it be 20 or 30 clinical hours and will I achieve the above 1-6 goals?
Bad debt for the year. Total of $3271.20, which also includes some intentional charity care. My understanding is that because I’m a professional and not a non-profit organization, none of this can be ‘written off’ or used as a tax deduction. Just pure monetary loss. $2771 was from the first 6 months, and some were hard learned lessons noted in earlier posts of being HMO insurance, one was a HMO/Medicaid insurance. Positively, I try to learn, and the last 6 months of 2019, only $499 was bad debt, which was mostly co-pays or co-insurance of patients that didn’t follow up. To further put in perspective the first 6 months I had ~20K in collections, and the last 6 months I had ~64K in collections, and I had a collections rate of 88.03% for the first 6 months, and 99.22% for the last 6 months.
Month 12 finished with total income $16095, minus overhead of $9489, yielding income of $6606 for the month.
| JAN - MAR, 2019 | APR - JUN, 2019 | JUL - SEP, 2019 | OCT - DEC, 2019 | TOTAL |
Income | $3,551.53 | $16,825.42 | $28,936.40 | $35,192.57 | $84,505.92 |
| | | | | |
Expenses | $11,326.06 | $17,684.72 | $17,969.97 | $23,114.46 | $70,095.21 |
| | | | | |
NET INCOME | ($7,774.53) | ($859.30) | $10,966.43 | $12,078.11 | $14,410.71 |
| | | | | |
Not yet reviewed and finalized by an accountant, but my rough draft
income I’ll actually pay myself, for the entirety of 2019, is ~$12K (this is a pre-tax number). Approximately 20% of that number is going into a SEP-IRA. Had to also subtract out employee SEP-IRA, too.
The way some expenses have fallen I have just left them where the dates materialized, I’ll sit down with accountant in coming days to see how things truly need to be. For instance, Payroll taxes to government show up not during the quarter they are for, but several days into the following quarter. Is that where they belong? Good thing I have an accountant to square this away.
My future posts will now be on a Quarterly basis.