Practice mix as an attending

[DoubleBogey]

I know there are a few on this board with a few years of practice under their belts post residency and wanted to hear about their experiences as an attending.

I’m out of residency for a couple of months practinging in the outpatient setting - building up my practice with acute visits, referrals for clearance, physicals, well exams and est care visits. I just got an opportunity to start doing nursing homes/SNFs and personal care homes.

I was wondering if any other attendings here have had experience with nursing homes. What are the pros and cons? I understand that patients and families can be demanding, but this can be said about general outpatient.

Do you feel it is financially beneficial? Are you doing TCMs? Have you taken on a medical directorship?

I enjoy inpatient, but currently haven’t done any inpatient moonlighting - current employer doesn’t allow “traditional” physician setups (rd inpt then do clinic and have APC do admissions afternoon/evening). My employer does offer extending outpatient hours, which compensates very well for an 8hr/d.

What other opportunities, clinically, do you do to increase income?

I appreciate any thoughts/comments

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[deleted87716]

The options are similar for us, although we also have a couple of hybrid outpatient/hospitalist programs, so it’s possible to do some inpatient, as well. My two partners see patients in the nursing home. Two of our other colleagues are the program directors. I could do it, but I don’t consider the additional income to be worth the aggravation, so I choose not to. I could also do some shifts in our after-hours clinic, but I don’t like seeing other people’s patients, so I choose not to. I’d rather be at home, anyway.

We do encourage new physicians who are building their practice to work the after-hours clinic, however. In addition to the extra income, it can help with practice building, as some of the patients seen there do not have PCPs.

Other things that some people have done include medical examiner and hospice directorships. Neither of these are particularly good for practice-building, but it’s additional income.

You mentioned TCMs. We bill those, and we also do AWVs. They’re lucrative. Our group partnered with a third party to do CCM, where the other company makes all the phone calls and handles the documentation for roughly half the monthly reimbursement (the physician keeps the initial signup fee). I haven’t found the income-to-aggravation ratio very favorable, personally, and I question the value of CCM for most patients (and so do they when they have to pay their portion). Some of our docs are doing them so much that they’re considering bringing them completely in-house (e.g., having their staff do the phone calls and documentation) so they can keep the full monthly fee. No, thanks.

 

[DoubleBogey]

The options are similar for us, although we also have a couple of hybrid outpatient/hospitalist programs, so it’s possible to do some inpatient, as well. My two partners see patients in the nursing home. Two of our other colleagues are the program directors. I could do it, but I don’t consider the additional income to be worth the aggravation, so I choose not to. I could also do some shifts in our after-hours clinic, but I don’t like seeing other people’s patients, so I choose not to. I’d rather be at home, anyway.

We do encourage new physicians who are building their practice to work the after-hours clinic, however. In addition to the extra income, it can help with practice building, as some of the patients seen there do not have PCPs.

Other things that some people have done include medical examiner and hospice directorships. Neither of these are particularly good for practice-building, but it’s additional income.

You mentioned TCMs. We bill those, and we also do AWVs. They’re lucrative. Our group partnered with a third party to do CCM, where the other company makes all the phone calls and handles the documentation for roughly half the monthly reimbursement (the physician keeps the initial signup fee). I haven’t found the income-to-aggravation ratio very favorable, personally, and I question the value of CCM for most patients (and so do they when they have to pay their portion). Some of our docs are doing them so much that they’re considering bringing them completely in-house (e.g., having their staff do the phone calls and documentation) so they can keep the full monthly fee. No, thanks.

Thank you for the reply! The AWVs I find pts trying to bring up acute stuff where you’re really suppose to address preventive medicine. I usually address them just to keep the visit moving, but tell them to f/up in a couple of weeks.

Medical directorship compensates in my area about $1k/month, add some pt encounters at the facility ($15k/yr), and it totals about $30k/yr.

I like the hospice directorship idea - if I didn’t have wife/kids I would do a fellowship in palliative care as I enjoy that aspect of medicine.

There’s one doc in our area who does home care visits, which reimburse nicely. The area I live in is somewhat rural which makes for a lot of driving - pts love this service, but not sure how to effectively incorporate this type of care (not even sure I would want to).

Inpatient reimburses well and certainly generates a lot of RVUs, which gets you quicker to bonus territory, but I’m kind of liking just outpatient for now.

 

[VA Hopeful Dr]

Thank you for the reply! The AWVs I find pts trying to bring up acute stuff where you’re really suppose to address preventive medicine. I usually address them just to keep the visit moving, but tell them to f/up in a couple of weeks.

Medical directorship compensates in my area about $1k/month, add some pt encounters at the facility ($15k/yr), and it totals about $30k/yr.

I like the hospice directorship idea - if I didn’t have wife/kids I would do a fellowship in palliative care as I enjoy that aspect of medicine.

There’s one doc in our area who does home care visits, which reimburse nicely. The area I live in is somewhat rural which makes for a lot of driving - pts love this service, but not sure how to effectively incorporate this type of care (not even sure I would want to).

Inpatient reimburses well and certainly generates a lot of RVUs, which gets you quicker to bonus territory, but I’m kind of liking just outpatient for now.

The hospitals in my area tack the AWV onto existing appointments. Patient comes in for HTN check "By the way, would you like your free Medicare preventative visit today in addition to your scheduled visit?"

Works pretty well for them.

 

[deleted87716]

We add on AWVs during regular visits. We don’t even ask. Since it costs the patient nothing, few object.

Home visits take you out of the office, so you pretty much have to do those after hours, or it’s not financially advantageous.

 

[VA Hopeful Dr]

We add on AWVs during regular visits. We don’t even ask. Since it costs the patient nothing, few object.

Home visits take you out of the office, so you pretty much have to do those after hours, or it’s not financially advantageous.

That's likely to be my approach when I re-enter FFS land

 

[FrustratedFamDoc]

I'm now in year 5 post residency and have had to build my own practice from scratch. Looking back, here's what I have and/or would of done to get things going faster than how they went:

1. Accept anybody and everybody. Should of done this sooner. Mcaid/Care/Self pay. It doesn't matter. Just get butts in your door. It doesn't mean that you have to write anything they want, and it doesn't mean that you won't have your fair share of Xanax/narc fights, but at least you won't be seeing 7 patients a day.

2. Cozy up to every ER and urgent care doc in town. "So listen, I'm new, I'm pretty good and I don't turn ANYONE away. Send me business and I'll try to cut down on your frequent fliers."

3. Work the free clinic(s).

4. Advertise.

5. Set up shop close to a hospital. That building is full of well insured employees who desire the same thing you do. Short med list, quick visit, see you in 4 months. Makes sending patients to the ER if need be, a piece of cake. Even better, they'll send family members and patients that they take care of your way if you do a halfway good job. An acute visit for them... you're literally a 10 minute walk from where they are.

 

[DoubleBogey]

I'm now in year 5 post residency and have had to build my own practice from scratch. Looking back, here's what I have and/or would of done to get things going faster than how they went:

1. Accept anybody and everybody. Should of done this sooner. Mcaid/Care/Self pay. It doesn't matter. Just get butts in your door. It doesn't mean that you have to write anything they want, and it doesn't mean that you won't have your fair share of Xanax/narc fights, but at least you won't be seeing 7 patients a day.

2. Cozy up to every ER and urgent care doc in town. "So listen, I'm new, I'm pretty good and I don't turn ANYONE away. Send me business and I'll try to cut down on your frequent fliers."

3. Work the free clinic(s).

4. Advertise.

5. Set up shop close to a hospital. That building is full of well insured employees who desire the same thing you do. Short med list, quick visit, see you in 4 months. Makes sending patients to the ER if need be, a piece of cake. Even better, they'll send family members and patients that they take care of your way if you do a halfway good job. An acute visit for them... you're literally a 10 minute walk from where they are.

Thank you for the insight.

I’m only 2+ months practicing and some days my schedule is light - initially only 5-7pts. I’ve opened up my slots to accommodate more. I’m getting a lot of ED referrals which is nice, but they certainly have a higher no show rate. Additionally, the pts who do show up no show on follow up appts (finding that initiation of new meds can be risky/difficult to monitor after).

Now I’m seeing 10-14/d, but would like to have consistent 20pt/d to meet RVU requirement and get into bonus territory (although my contract has no penalty if I don’t meet RVU base for the next couple of years). Since I’m RVU based it doesn’t really matter what insurances I see, as I’m compensated on what I bill for. Guaranteed salary for a couple of years let’s me build up a nice base without being penalized.

Starting to get some advertising through news articles, which should help buildup awareness of myself being a new provider in the area (finding out I can’t rely on ghe group to provide adequate exposure).

Much more narc/BZ seeking pts I’m seeing (more than in residency). Learning that since I have the DEA that I don’t have to rx these meds. Previous docs have told me in the past they were able to “screen “ some of these pts, but that practice is not allowed by our group anymore.

 

[VA Hopeful Dr]

Thank you for the insight.

I’m only 2+ months practicing and some days my schedule is light - initially only 5-7pts. I’ve opened up my slots to accommodate more. I’m getting a lot of ED referrals which is nice, but they certainly have a higher no show rate. Additionally, the pts who do show up no show on follow up appts (finding that initiation of new meds can be risky/difficult to monitor after).

Now I’m seeing 10-14/d, but would like to have consistent 20pt/d to meet RVU requirement and get into bonus territory (although my contract has no penalty if I don’t meet RVU base for the next couple of years). Since I’m RVU based it doesn’t really matter what insurances I see, as I’m compensated on what I bill for. Guaranteed salary for a couple of years let’s me build up a nice base without being penalized.

Starting to get some advertising through news articles, which should help buildup awareness of myself being a new provider in the area (finding out I can’t rely on ghe group to provide adequate exposure).

Much more narc/BZ seeking pts I’m seeing (more than in residency). Learning that since I have the DEA that I don’t have to rx these meds. Previous docs have told me in the past they were able to “screen “ some of these pts, but that practice is not allowed by our group anymore.

10-14/d is pretty good 2 months out.

You'll find it you don't prescribe the meds they won't, not only will they not come back but word will get out and they'll stop coming in.

 

[deleted87716]

Previous docs have told me in the past they were able to “screen “ some of these pts, but that practice is not allowed by our group anymore.

We don't screen officially, but we're pretty good at sniffing out new patients who are just looking for pain meds based on their reason for the visit. Some of our offices actually have new patients fill out what is, in essence, an "application," which the doctors review and either accept or reject. Personally, I would find that offensive as a patient, and I won't do it. If one sneaks through occasionally, I'd rather see them (and bill for the visit) and just tell them I can't do what they want me to do.

 

[JustPlainBill]

And for the other side -- keep your business cards in your pocket -- every new patient gets a few -- I tell them it's my rookie baseball card and will be worth something someday which usually evokes a laugh -- and then I flat out tell them that I'm building a practice, taking all comers and would appreciate any referrals if they've know someone looking for a doctor. Then they get a "Thank You" card sent to their work address -- why? Well, 1)it's unusual to get a Thank you from a doc 2) they'll likely comment on it to their coworkers and bingo...

I'm at 10-12 per day at the end of one month in a new location....

 

[deleted87716]

And for the other side -- keep your business cards in your pocket -- every new patient gets a few -- I tell them it's my rookie baseball card and will be worth something someday which usually evokes a laugh -- and then I flat out tell them that I'm building a practice, taking all comers and would appreciate any referrals if they've know someone looking for a doctor. Then they get a "Thank You" card sent to their work address -- why? Well, 1)it's unusual to get a Thank you from a doc 2) they'll likely comment on it to their coworkers and bingo...

+1 on the business cards. We have business card holders at the check-in and check-out counters, and also in each exam room. New patients are mailed a "welcome" card with a hand-written message from me, and I tuck another business card into that. We've also sent bunches of business cards to people who are in a position to refer patients to us (my dentist got some, for example).

 

[DoubleBogey]

+1 on the business cards. We have business card holders at the check-in and check-out counters, and also in each exam room. New patients are mailed a "welcome" card with a hand-written message from me, and I tuck another business card into that. We've also sent bunches of business cards to people who are in a position to refer patients to us (my dentist got some, for example).

I love that idea and did that today in my clinic - thanks for the advice! Got to hustle a little.

Our extended clinic this Saturday I have 22pts booked - doesn’t ct towards RVU, but certainly will test my efficiency at this stage in the game.

 

[Bacchus]

I love that idea and did that today in my clinic - thanks for the advice! Got to hustle a little.

Our extended clinic this Saturday I have 22pts booked - doesn’t ct towards RVU, but certainly will test my efficiency at this stage in the game.

Uh...let’s say 40% 99213 and 60% 99214 and lets take the middle of the road compensation at my institution for wRVU bonus:
9-99213 = 8.73RVU
13-99214 = 19.5RVU

28.23RVU X 40 = 1129.20 dollars.

Better freaking count for something!

 

[DoubleBogey]

Uh...let’s say 40% 99213 and 60% 99214 and lets take the middle of the road compensation at my institution for wRVU bonus:
9-99213 = 8.73RVU
13-99214 = 19.5RVU

28.23RVU X 40 = 1129.20 dollars.

Better freaking count for something!

Pays $2k gross for 8hrs if I see 10 or 20 pts

 

[Bacchus]

Pays $2k gross for 8hrs if I see 10 or 20 pts

Not shabby. Just making sure you’re not being raked over the coals.

 

[DoubleBogey]

Not shabby. Just making sure you’re not being raked over the coals.

I appreciate it. You bring up an interesting point regarding billing:
I’ve been told to not “over bill” by billing too many/high % of level 4 est visits and have more level 3 est visits. However, I’m finding with chronic disease management that level 4s are justified- curious as to what is common practice with you and others.

 

[Bacchus]

I appreciate it. You bring up an interesting point regarding billing:
I’ve been told to not “over bill” by billing too many/high % of level 4 est visits and have more level 3 est visits. However, I’m finding with chronic disease management that level 4s are justified- curious as to what is common practice with you and others.

I’ll save @Blue Dog the hassle. http://www.unc.edu/~vreddy/index_files/Medical Resources/ICD-9_Coding/31howt.pdf

I’d say 60-70% of my notes are 99214. A minimal amount are 99215 (either time or sent to the ED) and the rest 99213s.

 

[deleted87716]

Yep. I code accurately, and I do mostly 99214 (roughly 2/3 of my visits, vs. 1/3 that are 99213). 99212 and 99215 are trivial in comparison.

Don't undercode. It won't keep you from being audited, and it robs you of money that you've earned.

Are You Undercoding Out of Fear of an Audit?

 

[Bacchus]

Gotta love Epic.

I ran my October report, had 300 encounters.
99213 = 79 = 26.3%
99214 = 127 = 42.3%
99215 = 4 = 1.3%
99203 = 8 = 2.6%
99204 = 13 = 4.3%
99205 = 2 = 0.67%
993** (Physical) = 40 = 13.3%
99495 (TCM-M) = 8 = 2.6%
99496 (TCM-H) = 1 = 0.34%
G0439 (MWV) = 15 = 5%

That leaves 3 appointments as "misc."

What did I learn? I'm not aggressively billing my 99214s, but my physicals and MWV probably made up for it.