Practice management

[painfree]

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How many patients are you guys seeing in a day, new and established pts, with what type of support staff, PA's, MA's etc.

how long did it take to get to that level in your practice.

 

[mille125]

How many patients are you guys seeing in a day, new and established pts, with what type of support staff, PA's, MA's etc.

how long did it take to get to that level in your practice.

I started my practice from scratch. First week of practice I saw two patients and first two months of collections were 450 and 650 dollars respectively (ouch). At three months I was at 5 patients per day every day. At six months 10-12 per day. Five years later, I see 12-14 on a very slow day and 25-30 on a very busy day. Average is 15-20. Works out to about 60 new and 225 established per month. I have one MA, one receptionist, and one office manager. Procedures are all done in the ASC (except for triggers, occipital nerve blocks, ilioinguinal blocks, etc) and total about 115/month.

 

[Tenesma]

re: practice management

i think we all have potential for slow days --- i have trained my office manager to scour our schedule about two weeks ahead... any day, that for some odd reason looks very light, gets cancelled... this happens about once every 3-4 months - the patients rarely if ever mind, and those that get a bit cranky get some VIP service (a coupon to a local coffeeshop).

this allows me then to use that day to catch up w/ paperwork or a free day to spend with family...

i find that slow days are particularly brutal, because you really can't get much done while waiting between patients.

anybody have other ideas, tips?

 

[brori]

Started my own practice seven months ago (previously in ortho group). These are averages 16 office visits per day (3 new consults) Somedays its 20, somedays 14.
10 fluoro procedures on Mondays
3 fluoro procedures on Tuesdays
2 fluoro procedures either on Wednesday or Thursday
5 EMGs per week
2-3 hospital consults per week.

Ideally I would like to schedule only half days every Wednesday (mornings only), On that afternoon, I would do marketing/paperwork/networking/golf.

 

[Tenesma]

it is CRUCIAL that you have at least one half-day to one full day off per week... for your sanity and business stuff...

if you spend every day leveraging yourself to create income, you will miss opportunities to develope strategies that leverage others to create passive income.

 

[lobelsteve]

it is CRUCIAL that you have at least one half-day to one full day off per week... for your sanity and business stuff...

if you spend every day leveraging yourself to create income, you will miss opportunities to develope strategies that leverage others to create passive income.

You could charge for that.👍

 

[Doctodd]

ahhhhh......the passive income ghost appears again. I thought it was a myth?....lol. It is the leprechaun at the end of the rainbow. But like Steve said, if you find it, many will pay for the knowledge.

 

[mille125]

it is CRUCIAL that you have at least one half-day to one full day off per week... for your sanity and business stuff...

if you spend every day leveraging yourself to create income, you will miss opportunities to develope strategies that leverage others to create passive income.

i agree... i make nearly double my practice income in "passive income"..."passive income" does not require nearly as much work

 

[painfree]

considering the patient volume you guys are doing, how long do you spend with a new patient, a established patient.
how long is the patient in the clinic for...from check in to check out.

whats up with this passive income, can't possibly stocks.

 

[mille125]

considering the patient volume you guys are doing, how long do you spend with a new patient, a established patient.
how long is the patient in the clinic for...from check in to check out.

whats up with this passive income, can't possibly stocks.

New patient 30 minutes
Established patient 15 minutes
Check-in to check-out 20 minutes added to office visit

Passive income: Own physical therapy clinic (25%), multiple surgical center shares, own an in-clinic pharmacy (100%), own MRI center (5%)

 

[Jeff05]

an in clinic pharmacy - is that only for pain meds?
how may PT therapists do you employ?

New patient 30 minutes
Established patient 15 minutes
Check-in to check-out 20 minutes added to office visit

Passive income: Own physical therapy clinic (25%), multiple surgical center shares, own an in-clinic pharmacy (100%), own MRI center (5%)

 

[brori]

New patient 45 minutes
follow ups 15min

Average patient wait time to see me is 0-5minutes (I set my clock 10 min ahead, arrive 5min early, and hate waiting;; so I don't like to make others wait).

Own an in office pharmacy 100%.
Didn't know you could do that

I have posted a DME questions thread in private forum. I actually just wrote something about physician owned pharmacies on the private forum DME thread. Consider the DME thread as a "passive income thread" and feel free to hijack it with other "passive income" practices/ideas.

 

[knoxdoc]

New patient 45 minutes
follow ups 15min

Average patient wait time to see me is 0-5minutes (I set my clock 10 min ahead, arrive 5min early, and hate waiting;; so I don't like to make others wait).


I hate to let patients wait too. My problem is not my scheduling, its the jackholes who show up at the time of a new appointment, not 30 min early as instructed, to fill out paperwork. They then take 45 min to fill out basic crap. They don't bring films, so we call around town to get the info. Then, they expect work restrictions, FMLA papers, and they want to argue for 15min about the hydros. THAT is the crap that gets me behind.

 

[mille125]

New patient 45 minutes
follow ups 15min

Average patient wait time to see me is 0-5minutes (I set my clock 10 min ahead, arrive 5min early, and hate waiting;; so I don't like to make others wait).

Own an in office pharmacy 100%.
Didn't know you could do that
I have posted a DME questions thread in private forum. I actually just wrote something about physician owned pharmacies on the private forum DME thread. Consider the DME thread as a "passive income thread" and feel free to hijack it with other "passive income" practices/ideas.

you can but there are many many regulations that you must follow

 

[mille125]

an in clinic pharmacy - is that only for pain meds?
how may PT therapists do you employ?

1) It is a full service pharmacy.
2) There are now 3 PT's, one OT, and two techs

 

[PMR 4 MSK]

My problem is not my scheduling, its the jackholes who show up at the time of a new appointment, not 30 min early as instructed, to fill out paperwork. They then take 45 min to fill out basic crap. They don't bring films, so we call around town to get the info. Then, they expect work restrictions, FMLA papers, and they want to argue for 15min about the hydros. THAT is the crap that gets me behind.

That's a universal problem and my biggest source of stress most days. If it weren't for patients that do this, I'd be a very happy guy, instead of just a really happy guy...

 

[Tenesma]

new patients: 30 min
follow-ups: 15 min

i double book everybody - and pray for cancellations (medicaid patient population always come through on that one)....

the only patients who don't get double booked are ANY referrals for chronic multifocal pain, or MULTIPLE issues - the referral coordinator keeps track of that.

any patient who shows up late (without a good excuse), or can't get their paperwork done in time... they get cancelled and re-scheduled for another day... i ain't gonna let them slow my day down...

my biggest frustrations are with URGENT referrals -- i find that 90% of my URGENT referrals are never URGENT and are usually bogus patients to begin with --- they probably harass PCP doctor's secretary enough for the PCP's office to make that request with us... of course, we always comply and i get screwed squeezing in patients URGENTLY for pain that they have had for 19 years without any exacerbations.... so for now, the new rule is: any urgent referral the PCP/referring dr has to speak w/ me... so far that seems to have significantly cut down on the surprise URGENTS.

I also have instituted a policy that anybody who has to wait longer than 40minutes gets a $4-5 coupon to a coffeeshop, donuts place, whatever.... that has been a great idea, improved satisfaction and barely costs me more than $100/month.

i have looked into pharmacy --- 2 issues - volume of patients getting meds... how many patients do you have to rx for for this to break even... other issue is safety of storage - we have had a few break-ins at local pharmacies (CVS, etc) for opioids and other bogus meds (probably for re-sale - i heard PEPCID has got a great re-sale value - go figure)...

 

[painfree]

Thanks for the input, it helps know how others are doing.

Do these times include your notes?
How are you doing your notes, dictating or EMR?

Thanks

 

[brori]

I dictate-like its flexibility. 45 min new patient includes dictation, scripts, orders, etc. Follow ups 15 minutes also includes dictation (usually 30sec-1min) unless new issue.

Will probably go to EMR eventually, just don't like the look of computer generated notes. They look artificial and odd with the weird spacing and subtle font changes.

I have recently instituted a cancellation fee (if less that 24 hrs). This has significantly cut down on no shows and reschedules. The policy has also improved patient timeliness. There have been some repeat offenders, but they always pay the fee.

 

[mille125]

new patients: 30 min
follow-ups: 15 min

i double book everybody - and pray for cancellations (medicaid patient population always come through on that one)....

the only patients who don't get double booked are ANY referrals for chronic multifocal pain, or MULTIPLE issues - the referral coordinator keeps track of that.

any patient who shows up late (without a good excuse), or can't get their paperwork done in time... they get cancelled and re-scheduled for another day... i ain't gonna let them slow my day down...

my biggest frustrations are with URGENT referrals -- i find that 90% of my URGENT referrals are never URGENT and are usually bogus patients to begin with --- they probably harass PCP doctor's secretary enough for the PCP's office to make that request with us... of course, we always comply and i get screwed squeezing in patients URGENTLY for pain that they have had for 19 years without any exacerbations.... so for now, the new rule is: any urgent referral the PCP/referring dr has to speak w/ me... so far that seems to have significantly cut down on the surprise URGENTS.

I also have instituted a policy that anybody who has to wait longer than 40minutes gets a $4-5 coupon to a coffeeshop, donuts place, whatever.... that has been a great idea, improved satisfaction and barely costs me more than $100/month.

i have looked into pharmacy --- 2 issues - volume of patients getting meds... how many patients do you have to rx for for this to break even... other issue is safety of storage - we have had a few break-ins at local pharmacies (CVS, etc) for opioids and other bogus meds (probably for re-sale - i heard PEPCID has got a great re-sale value - go figure)...

Concerning urgent consults....I find that if you make the referring physician call that this will not be abused...most of my "urgent" consults are for very large herniations.....maybe I am just lucky

Concerning coupons.....I really like that idea...do you mind if I steal it?

Concerning pharmacy security.....Get a lot of cameras.....my security system costs more than my building....if someone cracks it, they can have the hydro because they are smarter than me

Concerning volume of scripts.....you need 35-40 per day to break even..marketing is key here (like with everything)...i have a very good marketing approach which involves supplies meds to patients in multiple ASC's at discharge...this way they dont have to wait in line at the pharmacy after recovering from general anesthesia....this generates about 60 scripts per day......(boy am I smart..ha ha ha)

 

[powermd]

For those of you in SOLO private practice, how do you handle call and vacations?

Are you ALWAYS on call? Do you never leave town? Do you shave with other solo guys?

Also, how much prescribing do you do? Do you push most of this off to the PCP in the form of "recommendations", or do you manage patient's meds yourself?

I'm asking because I'm considering starting my own private practice straight out of fellowship, and I will be going solo, for at least one year, until my expected partner finishes his fellowship in 2010.

 

[Tenesma]

for the record, i NEVER shave with other solo guys 😀

i am solo - i take call 24/7 --- however, the only way to get me on the phone after hours, the patient has to be either in the ER or an inpatient... the patients are educated that all other calls/issues can be left as messages on voice mail, and that we will address those issues during business hours and schedule an earlier F/U if necessary/appropriate.

most hospital by-laws don't create the expectation that you will be available 24/7 - especially if you are the only guy in your specialty... so the deal for my PCPs/referring docs is: i am available 24/7 whenever they need me (they get my cell #), but when i am on vacation I become unavailable - i send out a letter to everybody about 2 weeks before anticipated time off.

i don't RX controlled substances - so when i am on vacation, it really doesn't affect anybody should they run out - they can call their PCP.

 

[mille125]

for the record, i NEVER shave with other solo guys 😀

i am solo - i take call 24/7 --- however, the only way to get me on the phone after hours, the patient has to be either in the ER or an inpatient... the patients are educated that all other calls/issues can be left as messages on voice mail, and that we will address those issues during business hours and schedule an earlier F/U if necessary/appropriate.

most hospital by-laws don't create the expectation that you will be available 24/7 - especially if you are the only guy in your specialty... so the deal for my PCPs/referring docs is: i am available 24/7 whenever they need me (they get my cell #), but when i am on vacation I become unavailable - i send out a letter to everybody about 2 weeks before anticipated time off.

i don't RX controlled substances - so when i am on vacation, it really doesn't affect anybody should they run out - they can call their PCP.

I am also solo and do things similar to tenesma. The only difference is that I do manage controlled substances if they are indicated (tenesma and I have talked about this ad nauseum in other posts and we agree to disagree). If the hospital ever suggests that I need to by available 24/7 then that is the day that I resign my hospital privileges because I really dont need them.

 

[brori]

My patients and answering service understand my policy of no refills after hours. When I go on vacation, there is another doctor that takes my call. Going solo requires good business sense and courage (you certainly have that by considering going solo straight out of fellowship). However, if being solo suites your character/personality, you will love it.

You might consider going solo if:
1. you enjoy networking, marketing, selling yourself
2. have a history of starting companies
3. enjoy multitasking (you will not just be practicing medicine, but running a business)

 

[powermd]

My patients and answering service understand my policy of no refills after hours. When I go on vacation, there is another doctor that takes my call. Going solo requires good business sense and courage (you certainly have that by considering going solo straight out of fellowship). However, if being solo suites your character/personality, you will love it.

You might consider going solo if:
1. you enjoy networking, marketing, selling yourself
2. have a history of starting companies
3. enjoy multitasking (you will not just be practicing medicine, but running a business)

I do enjoy these activities. I have had a lot of business ideas over the years, and have a few works-in-progress that had to be put on hold for residency and fellowship. I have a master's in health administration (for what it's worth), and have read books on how to start a business, but I have never gone all the way with one of my ideas. I do think I would enjoy the responsibility (and power over my destiny) that comes with having my own shop. I love taking care of patients, but I also think i may get even more satisfaction from creating a place of work that employs other people and gives them a rewarding career.

My solo venture may not end up solo in the end (nor do I want it to be). I have a colleague who will be completing fellowship a year later than me, who has some very aggressive and fleshed out plans to create a multidisciplinary practice that includes a medical spa, and possibly a small ASC. He's even got VC guys ready to give him a lot of money. We have spent a lot of time talking about putting this thing together, but I certainly couldn't do it alone while he's in fellowship, and I'm not 100% sure I could find someone else I trust to jump in with me right away. I do have a few candidates in mind, however.

What I'm trying to sort out now, in addition to my own due diligence of studying the demographics, competition, and reimbursement landscape of my prospective locations, is just how much of a critical mass I need to maximize potential for success, while minimizing investment, and risk early on. For example, how large an office, how many support staff, how much equipment, etc, beyond the bare minimums. I would like to keep my operation scalable, so I can grow when we have the money to invest. I feel that to maximize my chances of success, I need to be able to go to potential referring doctors and offer something more than just good pain diagnostics and injections. My prospective locations have other pain doctors around, but not in large number. I'm wondering if I should pursue getting on local hospital committees to increase my networking opportunities and local clout.

Regarding courage to strike out on my own right away- I feel as though working for someone else for a year or more would be valuable in some ways, ultimately it may be wasted time (since my goal is to eventually have my own practice). If starting a practice right out of fellowship is possible, I should make every effort to make it happen now, before the market becomes any more saturated.

 

[powermd]

for the record, i NEVER shave with other solo guys 😀

i am solo - i take call 24/7 --- however, the only way to get me on the phone after hours, the patient has to be either in the ER or an inpatient... the patients are educated that all other calls/issues can be left as messages on voice mail, and that we will address those issues during business hours and schedule an earlier F/U if necessary/appropriate.

most hospital by-laws don't create the expectation that you will be available 24/7 - especially if you are the only guy in your specialty... so the deal for my PCPs/referring docs is: i am available 24/7 whenever they need me (they get my cell #), but when i am on vacation I become unavailable - i send out a letter to everybody about 2 weeks before anticipated time off.

i don't RX controlled substances - so when i am on vacation, it really doesn't affect anybody should they run out - they can call their PCP.

What about pump and/or stim patients? How are these patient's covered when you're unavailable? I would think one way to avoid call responsibility on these patients is to never do permanent implants.

 

[mille125]

What about pump and/or stim patients? How are these patient's covered when you're unavailable? I would think one way to avoid call responsibility on these patients is to never do permanent implants.

bingo

 

[Tenesma]

you can avoid implants... that helps w/ call... but you don't have to avoid implants if you set-up a good system

1) if they are out of town and need a tune-up on programming, then they have the device rep phone # and deal w/ PCP for the patient to be reprogrammed by device rep in PCPs office... VERY RARE occurence

2) typically decrease volume of implants a few weeks before intended vacation

3) coordinate back-up coverage w/ a nice neurosurgeon who gets your referrals - that way if there is an issue they can call NS office while you are on vacation - VERY RARE occurence

4) extra back-up coverage w/ a general surgeon who you buddy up with so that if there are ANY infectious issues and NS not avaiable, they can then do an explant or clean-out --- very RARE

5) AVOID at all cost Baclofen pumps as a SOLO guy..

6) i don't believe in intra-thecal opioid pumps (unless for terminal cancer patients) so that REALLY helps.... and EVERY intra-thecal opioid cancer patient gets a print-out for what to do for emergencies and their PCP and Onc/Hematologist gets that print-out as well

7) even when i go on vacation - i still have my CELL phone w/ me, and the PCPs know they can call me in extremis (i have NEVER been called) - and i always make sure i have internet access to check on prescription refills...

 

[Disciple]

5) AVOID at all cost Baclofen pumps as a SOLO guy..

Can you expound on this?

Medical complications of CP/MS?

Baclofen withdrawl?

Thanks.

 

[Tenesma]

baclofen o/d or withdrawal is a royal pain in the ass

not to mention that most ER docs/critical care docs don't know how to manage baclofen pump issues/complications/ODs/withdrawals.... so if you are out of town, then those patients can be screwed.

it's probably better to let the larger neuro/pm&r groups manage those pumps...

 

[PMR 4 MSK]

baclofen o/d or withdrawal is a royal pain in the ass

not to mention that most ER docs/critical care docs don't know how to manage baclofen pump issues/complications/ODs/withdrawals.... so if you are out of town, then those patients can be screwed.

it's probably better to let the larger neuro/pm&r groups manage those pumps...

I agree - I used to manage several of these, and twice, the ER had the nurse who was designated for that shift come to the ER to adjust (decrease) a baclofen pump without calling me. 1 came back in the next day w/ seizures. The other called me the next day with greatly increased spasticity.

 

[Mister Mxyzptlk]

I was unaware that people considered baclofen pumps such a burden.

 

[Tenesma]

just wait until a patient w/ baclofen ends in ED w/ overdose (mis-programming) or withdrawal (motor failure, etc).--- gets intubated, brought to the ICU --- family, ER docs, ICU docs all staring at you to cure/fix the problem...

 

[Mister Mxyzptlk]

What makes you think it hasn't happened to me already? It's not the end of the world.

 

[Tenesma]

i was explaining why I perceive Baclofen as a burden...

 

[Mister Mxyzptlk]

But how often does that happen compared to how much good you can do for people who need them? I'm kind of disturbed about the things I've been reading here lately - stims aren't worth doing, baclofen pumps might blow up on you, etc. Is the specialty evolving into people who just want bread & butter cases?

 

[mille125]

But how often does that happen compared to how much good you can do for people who need them? I'm kind of disturbed about the things I've been reading here lately - stims aren't worth doing, baclofen pumps might blow up on you, etc. Is the specialty evolving into people who just want bread & butter cases?

i will gladly refer all of my baclofen pumps to you as you seem to enjoy them.....

 

[mille125]

But how often does that happen compared to how much good you can do for people who need them? I'm kind of disturbed about the things I've been reading here lately - stims aren't worth doing, baclofen pumps might blow up on you, etc. Is the specialty evolving into people who just want bread & butter cases?

read what tenesma said....he said that it is hard for a SOLO guy to do baclofen pumps....I would have to agree with him....Those in bigger groups have a much easier time at it. Are you solo or in a group?

 

[Tenesma]

i think the reality is that the SOLO guy without adequate coverage is doomed to end up being primarily bread and butter.... i try to spread my wings and do cool things, but my limitations are the fact that I can't be available 24/7 without seriously affecting quality of life and family time.

if i do a baclofen pump (which can be very rewarding) -- and i am on vacation, then that patient is royally screwed... it just isn't fair... to them or me.

 

[Mister Mxyzptlk]

read what tenesma said....he said that it is hard for a SOLO guy to do baclofen pumps....I would have to agree with him....Those in bigger groups have a much easier time at it. Are you solo or in a group?

Solo, & currently managing quite a few baclofen pumps.

 

[Mister Mxyzptlk]

i think the reality is that the SOLO guy without adequate coverage is doomed to end up being primarily bread and butter.... i try to spread my wings and do cool things, but my limitations are the fact that I can't be available 24/7 without seriously affecting quality of life and family time.

if i do a baclofen pump (which can be very rewarding) -- and i am on vacation, then that patient is royally screwed... it just isn't fair... to them or me.

You could extend this argument to just about anything. I can think of plenty of scenarios other than a baclofen pump that could leave your patient royally screwed.

I'm on call 24/7 every day of the year, even on vacation. It doesn't intrude into my family life at all, nor does it diminish my time off, and I take time off pretty much every month. I get maybe 1-2 calls at home/week, and usually those are consults being called in. A lot of weeks go by with no calls.

OTOH, I enjoy a good relationship with other pain docs in my area so if one of my cases blows up I can rely on them to help me out. Those kinds of relationships are often hard to develop and maintain, but I would recommend that anyone in solo practice do so. If there is a complication while you're gone you want those folks inside the tent pissing out, not outside the tent pissing in.

 

[Tenesma]

i hear you... but then again you are in a large metropolitan area...

i am solo... in a semi-rural town... with some pain guys within 40 miles who are basically untrained and can basically do series of 3 injections and prescribe narcs... while my hospital has an ICU --- they basically put anybody who is ruling out for an MI into the ICU and everybody else gets transported out to a real ICU about 45 minutes from here...

my local pain guys are useless, and my hospital only allows coverage by physicians credentialed at the hospital (which they are not)...

 

[mille125]

i hear you... but then again you are in a large metropolitan area...

i am solo... in a semi-rural town... with some pain guys within 40 miles who are basically untrained and can basically do series of 3 injections and prescribe narcs... while my hospital has an ICU --- they basically put anybody who is ruling out for an MI into the ICU and everybody else gets transported out to a real ICU about 45 minutes from here...

my local pain guys are useless, and my hospital only allows coverage by physicians credentialed at the hospital (which they are not)...

similar situation here....

 

[Jcm800]

next to kypho/vertebroplasty, baclofen pumps are my favorite procedure. I am doing more an more. I typically dont have a problem. I do have a partner, but still...it could be dicey, but so could many things...

You could extend this argument to just about anything. I can think of plenty of scenarios other than a baclofen pump that could leave your patient royally screwed.

I'm on call 24/7 every day of the year, even on vacation. It doesn't intrude into my family life at all, nor does it diminish my time off, and I take time off pretty much every month. I get maybe 1-2 calls at home/week, and usually those are consults being called in. A lot of weeks go by with no calls.

OTOH, I enjoy a good relationship with other pain docs in my area so if one of my cases blows up I can rely on them to help me out. Those kinds of relationships are often hard to develop and maintain, but I would recommend that anyone in solo practice do so. If there is a complication while you're gone you want those folks inside the tent pissing out, not outside the tent pissing in.

 

[Grundel76]

So if you are spending 30 minutes on initials and 15 on follow-ups, are you billing initials as level 3 or 4? I spend about 45 minutes on initials and usually end up generating a level 4, but I am getting pressure to do it in 30 minutes.

FYI - I work with a bunch of orthopods who see up to 40 patients a day who I assume are only billing at level 3.

I just started fresh pain center in ortho group and seeing about 8-9 initials a day...

 

[Tenesma]

if you can keep pace of 8 initials per day you will be super busy in no time...

billing can be based on time... poor decision in my opinion

billing can be based on documentation - learn all the criteria that separate level 3 from 4 from 5 from 2.... i can do a 10 minute initial and hit all the criteria for a level 4, or i can have a 20 minute initial and still only meet criteria for a 3.

45 minutes for an initial probably means your patient is VERY chatty and circumstancial or that you are chit-chatting w/ the patient...

also learn how to do as much of your exam during the interview -- i will typically ask questions while checking their reflexes, etc..

 

[Disciple]

next to kypho/vertebroplasty, baclofen pumps are my favorite procedure. I am doing more an more. I typically dont have a problem. I do have a partner, but still...it could be dicey, but so could many things...

Do you ever punt any to neurosurg? e.g. the kids with severe CP who a twisted up like a pretzel.

 

[Jcm800]

most of mine are MS or post-stroke sent over by a neurology group who WANTS to manage them. So I implant a fair amount, not an excessive amount, but only manage some. I put in and manage some of my own for various reasons, usually MS. It is a time consumptive process of titrating up to the right level. U can only increase so much at a single setting, and it takes a while to get to stable dose.


so do i punt them? Not typically, but i would, hahha...

Do you ever punt any to neurosurg? e.g. the kids with severe CP who a twisted up like a pretzel.