YEAR TWO, Q1
SUBJECTIVE:
Put up on website and extra words to a sign outside my office door, no walk-ins and you need an appointment. Have had same lab rep enter twice, and prospective patients. Traditional office/clinics this isn’t an issue, but as I have a receptionist who is part time and not in the office for all open hours, walk-ins aren’t permitted. Baffles me how people read it, vocalize how they have read it ‘but I just need 5 minutes of your time’ believing they are an exception. Locums have now discovered my office number, took them a year!
Since college I have been diligent in keeping an updated CV. College, early med school, late med school, early residency, late residency, early attending, etc. Every stage, and tweaking as things need tweaking. In order to be prepared for the next step. Or ready for the next job change. Now, I’m scratching my head and wondering if there will ever be a next, another thing I will actually need to provide an updated CV for? Kind of a weird sensation to think, I don’t even need to add this practice, I don’t even need a CV anymore… I’m CV Free.
Growing tired with some of the current practice building stage with new consults, and recognizing this is likely to be a two-to-three year long process. End of 2019 data reflected having 173 total consults and ~93 active patients, that’s ~ 50% conversion from consult to follow up patient. This 2-3 year timeline is mostly impacted by future goals of dropping lower paying insurance panels which extends out this process. Lots of time and effort spent in these encounters. I’ve historically done this twice. Once for general psychiatry over 2 years, and again for an OUD clinic (1 year) which was >90% Medicaid. This is my third and hopefully final time of doing the practice building phase of an outpatient practice. Looking forward to the day when either closed or only doing 1-2 consults per week.
Got one EOB back from an insurance company, saying $0.00 payment. I just grumbled and passed to receptionist to process. She was perplexed by the rejection comment. Took initiative to call insurance to understand why denied. Learned it was listed as several dates of service and not just one! Well, done by her to take the initiative on this error from our billing company. Billing company resubmitted correctly and we actually got paid. Another billing positive, submitted a 99354 with one insurance company and they actually paid.
The new year effect, with insurance updates, seems to have been favorable with 4-6 transitions to better-than-Medicare. Some patients are getting caught unawares with the new year and deductibles re-setting. So, this has slowed collections way, way down. Really need to emphasize the impact of Q1 “deductible season” which really dampens Q1 collections (see objective data below), but I’m optimistic its mostly a delay that resolves by Q2. Hoping to keep my 99.2% collection rate. However, receptionist has observed also that much of bad debt now is stemming from consults, the patients that are a one-time consult, or simply don’t follow up. These observations might be valuable for others, away from more consultative heavy practices – unless some sort of prepay arrangement is made – which some insurance contracts don’t permit…
Local group of ARNPs dropped a lower-than-Medicare insurance, which may increase inquiries here for that insurance.
Started the practice a bit more than a year ago and thought area to be low in Psychiatrist and ARNP saturation. With slow growth rate, acknowledging my own hand in that, started to still wonder if area was saturated with ARNP. Local area does have an ARNP school minting new grads. Made a list of all the psychiatric folks in the area ranging from C/L to CMH agencies to IP to private groups, etc. Probably still missing a few, but was surprised how many people there actually are in total. Did some quick google and noted a range of Psychiatrists per 100,000 people. Going with some couple year-old WHO data, looks like US is about 10.5/100,000. My half hazard calculations reflect my area to be 6.5/100,000 but if counting a nearby area, possibly 7.2/100,000. Not sure what to think of this, but it’s a number?
Looked online at a possible office within bicycle distance of home. ~16K per year for that lease. Currently have 2 more years to go on this lease, but playing the ‘what if game’ is always painful, probably should stop doing that. MISTAKE: apparently, the local fire marshal wants to do an inspection. My presumption was wrong, and discussion with another tenant reflects I am responsible for the cost, $150. I would like to think this is covered by the land lord, but nope, I pay for my suite to be inspected. Should have got this in the contract to not have to foot the bill. So glad the pain is just a 3-year lease. I’m trying to focus on the positive of this as a 3-year learning experience.
Forgot to note this in prior posts, for all of 2019 the overhead percentage was 87.45%. Rough calculations for future projections, I should be able to get that down to 20-25% once full at 30hrs/week clinical time. Earlier monthly posts I was reflective on the weekly ebbs and flows of patients, now it’s less of a stress. Knowing that I’m clearly meeting my practice overhead and covering payroll there’s breathing room. Conceptually I’m able to switch over to looking at things from a quarterly perspective. This feels good.
Luminello finally got around to converting my Rx service from DoseSpot to DrFirst. Slightly better interface, bit complex at first impression, but with use, its quicker than DoseSpot. Also, now prescription refills automatically integrate with pharmacy requests and present in Luminello for 90% of refill requests, the remaining 10% are still thru faxes. However, the conversion to it is slowing things down lately as I need to input allergies and pharmacies in for each patient all over again and that’s a pain.
Now that I’m refining my quarterly data for what I keep track of, I’m a bit antsy. Low level excitement feeling like a kid on birthday “what’s it going to be?” So, throughout the quarter I have to remind myself, just wait, it’s not time to crunch the numbers. I know at some time in the future it’ll be like ‘meh’ and won’t even bother….
COVID-19 now enters the scene: I add to this post throughout the quarter, and everything prior was first ~9 weeks, and early March everything has changed with Covid. Now I have drastically reduced my expectations of growth, and simply hope to keep the lights on, and meet payroll with no real reductions. For Q2 and Q3, I have no expectations to even pay myself. *sigh* As result of Coronavirus I urgently added doxy.me to facilitate telepsych service line. I wanted to delay this for a few years, but need to dive in now. The UDS requirement for Stimulants and Suboxone have been suspended until further notice. Positively my electronic emphasis from the start with intakes, has contributed to an easy conversion for majority of my patient panel. Sending more 90 day prescriptions in for patients to limit pharmacy trips, and encouraging at risk cohorts to switch to drive thru pharmacies. The handful of hypnosis patients, I have suspended that part of their treatment due to lagging audio/video at times. I have given the receptionist the ability to work from home, which means no active answering of the phone, only voicemail returns, and could hurt our ability to get people in. Getting some waves of payments from patients on their deductible sized bills, in March, so ‘Deductible season’ might just be Jan/Feb phenomenon. March and a bit of late Feb was a low consultation period and definitely reduced my calculated weekly clinical hours compared to 2019 Q4. However, there is quite the ebb/flow to consults, and even if this is all Covid related, there may be a counter Covid upswing in the coming weeks? Optimism? Receptionist and I have talked about if a down swing persists possible cost cutting with need to close 1 day of the week. She’s motivated to keep this place afloat, as she too has no desire to go back to a Big Box Shop level employment. Luminello supposedly will roll out some sort of integration with Doxy.me, which is nice as that was the tele service I elected anyways! A good friend keenly noted that had Covid-19 started this time in 2019, this practice would have sank hard – this is a positive, and in celebrating the positives where they come, I’m glad Covid wasn’t a year ago. However, I do believe if someone were to plan to open a practice on the downswing, improvement side of Covid, it could be excellent timing. I mean, many employed physician jobs are slashing pay right now or even cutting hours for their docs, so if you were to already get hit, may as well be productive with a practice start up.
Last day of the quarter a random employee from a neighboring medical office, enters into the office, and I’m kicking myself for not remembering to lock the door. In comes a box being dragged, and she asks, if I use these toner cartridges, and imagine the odds, I do! She was instructed to throw away 7 perfectly good cartridges but instead opted to try and find them a home first. I just got for free $525 worth of office supplies! About a month ago I had just bought two replacements at $75 each. I think I’m good for a few years now. Made my day.
Positively pay for this quarter was more than the total of all of 2019, that’s progress!
OBJECTIVE: (compare to post #155 for 2019 Q4)
| Total Active Patients: | 95 | | |
| Insurance Payor Mix: | 37 < Medicare | 7 Medicare | 51 > Medicare (54.8%) |
| Follow Ups: | 170 | 13.1 (weekly mean) | range of 6-22 per week |
| Consults: | 36 | 2.8 (weekly mean) | range of 0-7 per week |
| Weekly Clinical Hours:* | 9.3 (quarterly mean) | | |
| Blended Payer Mix: ** | $135.45 per follow up | | |
| Overhead Percentage: | 63.58% | | |
| Days Off: | 2.5 | | |
*simply dividing the follow ups by two, and adding to consults (goal is 30 per week)
**Using the custom made Sushirolls’ formula
| Jan 2020 | Feb 2020 | Mar 2020 | Total |
| Total Income | $9,353.57 | $8,760.90 | $14,149.06 | $32,263.53 |
| Expenses | | | | |
| Accountant | 0.00 | 0.00 | 515.00 | 515.00 |
| Advertising & Marketing | 107.57 | 137.72 | 131.32 | 376.61 |
| Board Certification Fees | 350.00 | 0.00 | 0.00 | 350.00 |
| Credit Card Processing Fees | 75.93 | 103.64 | 115.69 | 295.26 |
| Medical Billing Services | 605.74 | 495.00 | 495.00 | 1,595.74 |
| Office Supplies & Software | 82.29 | 50.64 | 193.41 | 326.34 |
| Other Business Expenses | 0.00 | 0.00 | 126.00 | 126.00 |
| Payroll Expenses | 1,351.62 | 1,346.81 | 1,515.16 | 4,213.59 |
| Payroll Taxes | 0.00 | 0.00 | 845.72 | 845.72 |
| Rent & Lease | 3,301.42 | 3,301.42 | 3,482.75 | 10,085.59 |
| Repairs & Maintenance | 27.10 | 0.00 | 0.00 | 27.10 |
| Taxes & Licenses | 0.00 | 150.00 | 731.00 | 881.00 |
| Utilities | 130.84 | 129.83 | 129.83 | 390.50 |
| State Tax | 0.00 | 0.00 | 483.95 | 483.95 |
| Total Expenses | $6,032.51 | $5,715.06 | $8,764.83 | $20,512.40 |
| Net Income | $3,321.06 | $3,045.84 | $5,384.23 | $11,751.13 |
ASSESSMENT:
1) Professional Dissatisfaction
2) Slow practice growth rate
3) Optimization Deficiency
4) Infrastructure Deficits
5) Retirement Exposure
PLAN:
1) In Remission, continue this private practice and never return to Big Box shop employed practice. Continue to cruise over other forums on SDN where dissatisfaction reigns more intensely, and use that as a reminder – never again.
2) Growth rate had continued to steadily increase at pace of comfort, limited stress, until Covid-19 struck. It is acknowledged that the SDN diaspora is quite displeased by this rate of growth, but no drastic change in marketing nor intake process at this time to accelerate it. Did drop Google ads due to limited yield and considering doing a local online newspaper.
3) Not yet time to drop Medicare, nor lower payer insurance until about 20 clinical hours per week achieved. Currently paying $60/month for website maintenance and back up and upgrades, might consider dropping this safety net of ensured web presence. Would be nice to get locums to stop contacting me as I’m highly unlikely to need them. Starting to reply/end their inquiries on email by clicking ‘unsubscribe’ now. Debating what to do with texts/calls. Another poster on SDN noted haggling down the fee rates for credit card processing with Luminello 3rd party processor, might need to do this. An issue that as time passes, will become more pressing when do I switch from 3rd party biller and shift to in house? Currently thinking of using Luminello built in feature with ApexEDIs. Humans make mistakes, more humans in the process the more mistakes, so when billing company makes a mistake that adds 30-45 minutes of extra work for my assistant to square it away. Shifting the billing to internal may be an optimization. I’ve crunched some numbers for when the inflection point will happen, but don’t want to even consider it until after Medicare is dropped due to its complexities. This really is one of those chin stroking conundrums. How you do the math, and how much faith can you put in the projections. I have a relatively good rate company at about 5%, and as billings increase their percentage drops. Will put a pause on this for now.
4) Still debating on buying a blood pressure cuff, defer until after Covid. Delaying securing loans for owner occupied construction loan to facilitate transitioning away from this lease until after Q2. But with Covid juggernaut thrusting the economy into the Tele sphere, there may be a long term down trend in office real estate that pursuing building ownership might be a poor choice?
5) Although exposed to retirees and showing high risk behaviors of reading on retirement account management, very low risk of conversion to retirement at this time. Will continue to treat with high dose of bills for suppression, and monitor with these quarterly assessments. And of course, Covid market crash is further ensuring against this conversion. Pay for this quarter will be ~$11.7K, and 20% of that will be put aside for SEP-IRA contribution, and then 25% of that 0.8 put aside for taxes, leaving ~$7.0K to pay personal bills.
