Private Office Location

[Carbon13]

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I'm looking for opinions regarding the location of a solo private practice.
I graduated from an upper level residency program in 2017. Since that time I have been spinning my wheels as an associate working for straight percentage with an older pod in a declining practice. (Same 'ol story...things haven't been anywhere near what I was told to expect).

I haven't left my current position yet. However, I have already walked through a few different potential office lease locations. The "mini" metro area I currently live in consists of 3 different cities all of which are stacked from north to south and closely border each other. The middle and lowest cities each have around 75,000 people with around 6-7 Podiatrists combined. The Northern most city has around 28,000 people and no foot doctors. At this time those residents must drive to one of cities below them (15 minutes highway travel to nearest pod). My goal is to establish a private practice at the base of the northern most city. I hope to initially capture the patients located in the immediate area and then draw from the cities below me which have current pods.

Like many new doctor's, I will rely heavily on marketing at the beginning. I plan to have a truly stellar website as the internet is something I feel a majority of new patients / walk ins are captured by. Over the past six months I have asked many new patient's how they found me. A majority have said: Internet / google / yelp / Siri....etc. (Most of the pods in my area have a very generic website with outdated pictures and overall lack of quality in comparison to other medical specialists). Do you feel that a strong marketing program would allow a doctor to have an office located a few blocks off of the main drag & still pull the customers? I have located a 1,200sq/ft (1350$/mo) suite beside a Dermatologist office. This space was previously used by a PCP so the build out is basically complete. However, this location is not pretty and roadside like so many of the DDS you see around here.

 

[ExperiencedDPM]

I would personally discourage any young DPM from opening a from scratch solo practice. I’m not sure if there’s ever been a worse time to open a solo practice.

There are a huge amount of govt and insurance rules and regs, and it’s not going to get better. There’s a large cost associated with opening your own practice and there is no immediate appreciable income.

I know the story. You want to be on your own and do things your own way. You’re tired of being taken advantage of, etc. But I urge you to reconsider.

One problem with opening on your own is that there is no guarantee you’ll get on insurance panels. If you don’t get on insurance panels it doesn’t matter how much you market. People won’t come to you (as a general rule) if you aren’t on their insurance panel.

Are you ready to fully run an office including the business aspects and billing? Have you considered the cost of equipment and supplies. Did you factor in the cost of malpractice insurance. How about business liablity insurance. How about fire and theft insurance. How about Office overhead insurance if you break you arm and can’t practice for a few months?

Did you remember that you have to pay hospital dues, state license fees, DEA registration?

The list goes on and on.

Sorry if this isn’t what you wanted to hear, but it isn’t easy starting solo and can be a financial burden for YEARS.

 

[NatCh]

ExpDPM brings up some excellent points and they're all legitimate concerns. I'll work under the assumption that you've considered or are considering all of those issues and just go to your question.

I think you can be off of the main drag successfully as long as people can find you easily enough. On the home page people need your address and phone number. That info should be on the front page, not buried. I'd suggest that on your website you have a Google map and photos of your office. All the other info such as mission statement, services, bio, etc. can be layered deeper inside.

Most younger people search on their phone rather than a laptop so make sure your web designer makes your website phone-compatible. They can easily navigate using Waze, Google maps, or any map of their choice. Elderly patients will still have a hard time finding you because that's what they do. We have nursing home across the frigging street and those patients still complain that we were hard to find.

Hire an SEO specialist to get your web presence solid.

 

[podoloco]

The most important marketing you can do is reaching out to family practice offices in your area, as well as the specialists, even ortho. Being next to a dermatology office would be helpful, as long as you keep a good rapport with the practice. If there is a hospital in your area with a professional center, often the rent is cheap and the rooms already have exam chairs and storage space for your supplies. If you have to build from the ground up, consider used chairs and equipment to start. There are alot of good options on eBay and Dotmed for podiatry exam chairs.

Search for local physician credentialing and billing, if you are not ready to take that on yourself. Your hospital system may offer credentialing services, or will likely be able to point you in the right direction since they would be in frequent contact with other practices' credentialing. Practice fusion is free, and an easy way to start. eClinicalworks is very widely used and offers electronic referral and messaging between practices. This can be a big incentive for PCPs to refer to you.

Stay far away from Officite. Its an expensive joke. I can pick out all of the other practice websites that use their service because they all look the same and never update. I did not have a single patient find me in the phone book this past year, so I cancelled the Yellow Page listing, big waste of money. Listing on Google, Yelp, Healthgrades, WebMD... is free. Adwords offers targeted advertising in your area and it is inexpensive.

I would also note, that being in a recently retired physicians office can be helpful with patients finding you. I took a retired general surgeons office, so often the secretary just says that and everyone knows where it is.

 

[ExperiencedDPM]

The most important marketing you can do is reaching out to family practice offices in your area, as well as the specialists, even ortho. Being next to a dermatology office would be helpful, as long as you keep a good rapport with the practice. If there is a hospital in your area with a professional center, often the rent is cheap and the rooms already have exam chairs and storage space for your supplies. If you have to build from the ground up, consider used chairs and equipment to start. There are alot of good options on eBay and Dotmed for podiatry exam chairs.

Search for local physician credentialing and billing, if you are not ready to take that on yourself. Your hospital system may offer credentialing services, or will likely be able to point you in the right direction since they would be in frequent contact with other practices' credentialing. Practice fusion is free, and an easy way to start. eClinicalworks is very widely used and offers electronic referral and messaging between practices. This can be a big incentive for PCPs to refer to you.

Stay far away from Officite. Its an expensive joke. I can pick out all of the other practice websites that use their service because they all look the same and never update. I did not have a single patient find me in the phone book this past year, so I cancelled the Yellow Page listing, big waste of money. Listing on Google, Yelp, Healthgrades, WebMD... is free. Adwords offers targeted advertising in your area and it is inexpensive.

I would also note, that being in a recently retired physicians office can be helpful with patients finding you. I took a retired general surgeons office, so often the secretary just says that and everyone knows where it is.

Good advice. One of the problems with a company such as Officite is that they often use “canned” templates for information. When using a search engine, you are “spanked” for using unoriginal content. Your ranking when someone searches for you is based on a lot of factors, one of which is original content. In essence you are penalized for using unoriginal content and that will impact you when people search for you.

I’m not referring to stealing content from another site. I’m referring to a company such as officite who uses the same thing for many clients. Content that will not be original or unique to you.

And of course do not plagiarize info from another site. I was doing a google search on a topic and found a website where the doctor literally cut and paste EVERY page we had on our website regarding foot and ankle conditions. Guess he liked what we wrote and was too lazy to write anything himself. This clown also replicated our logo and plugged in his name. A letter from our attorney changed that quickly.

Please also remember to use key words that will optimize the search process. Some patients will search you by your name. Some will search by using DPM. Some will search the term podiatrist. Some will search for foot doctor. Some will search for a specific pathology.

So make sure your front page contains your name, Otis Hirts, DPM and also has you mentioned as Dr. Otis Hirts. Use keywords on your front page as well as your address and phone number as previously recommended.

There’s lots more to a quality website and what I’ve mentioned is just a quick start to increase search optimization.

 

[NatCh]

Otis Hirts! You're so good at those.

 

[Carbon13]

Wow! I posted my question and got a rapid response from a few of the experienced people on this board. Thanks, Doctor's!

ExpDPM- I'll have to admit that you're response is a little disheartening. However, I have considered a majority of the setbacks associated when starting a solo practice as a new doctor. Why am I even considering this option? I'll answer that question in a separate post.

Rent- I have located what I believe to be a nice 1,200s/ft office with little build out needed. $1,300 month with no triple net required and owner may decrease price depending on build out request & contract length.
Staff- I plan to have one front office person. I will bust my tail in the back until business allows an MA. I actually feel slowed down by a back office MA if I'm seeing less than 12 patients a day. I would almost rather have 2 people up front.
Insurance Provider status- Although I'm currently working under a group Tax ID / bill under group name. I do have my own Medicare number. One of the largest local commercial insurance representatives states that I should have no problem creating my "own" provider status with them if I choose to leave. Also, probably 40 of the "other" insurances around here are managed by a special hospital group, this group "claims" to negotiate better fee schedules than you could achieve individually, I believe the fee is $600 yearly but they also have a yearly renewal with each company which saves the headache of 40 different contracts. But yes, insurance may be a beast to deal with.
Equipment- Used, Used, Used. I don't want all Pakistani instruments but I have no problem locating a refurbished POD chair. I may even consider a non electric / ortho table at the beginning, I'll just have to sit in a chair more. Same goes for autoclave and digital X-ray. I plan on Xray being the biggest expense (I would love to have a dual plate Xray for speed). I'm thinking basic phone system and decent fax machine which may even be leased i think. Various other junk will come from the Henry Schein catalog.
EMR- I've heard mixed reviews on PracticeFusion. But,,,,,,it's FREE if you don't mind ads. Decent ability to create templates is all I really desire. I'll even hand write all Rx if needed. As far as paying for EMR's, I've heard good things about MediTouch, eClinicalWorks, and TrakNet is ok I guess. I would love to find an EMR that works with Apple/Mac.
Billing- I currently enter my diagnosis codes, link them to the proper CPT & add Modifiers as needed before I submit to our biller or clearinghouse. I am also able to see what gets kicked back which has helped me in linking codes in the proper way to ensure reimbursement. Additionally, our current office has been collecting deductibles at the time of visit if possible. I would still not consider doing my own billing at first. I would need to find a decent company to do this, preferably someone local. What billing company links well with Practice Fusion?
Malpractice Insurance- Unfortunately my first year is 1/2 over. It's my understanding that PICA increases quite a bit during the 2nd year. DEA license is sorta expensive ($700?) but only every 3 years I believe. I honestly don't know about small business insurance and a few others you mentioned.
Website- Officite is horribly generic. I know first hand. It is a template based program & there is nothing unique about it. If I'm really banking on a good website for marketing I don't mind paying around $7,500. Also don't mind spending a little money on SEO help during startup.

My next step is to sit down with a spreadsheet and tally up these expenses. The same officer that setup my home loan has referred me to a good commercial loan officer who is OK with having a casual discussion somewhere outside of the bank prior to serious decisions being made.

My reason for even attempting all of this (AKA sob story) will follow.

 

[NatCh]

EMR: our office has used Practice Fusion along with Kareo billing for the past several years. The price is right. Electronic medical records costs are ridiculous. Do not pay if you don't have to. That it's a cloud-based system means that you don't have to pay for technical support, which for some EMR systems runs $500 per month or more. What a racket.

I believe Practice Fusion is compatible with iPads, but I don't have an iPad to confirm. I am able to access my medical records through my iPhone and my Macbook though. I bet you can use it on an Apple desktop computer. You can electronically prescribe through the EMR.

Practice Fusion billing partners:
What billing partners is Practice Fusion integrated with? – Knowledge Base

Malpractice insurance: ask if they have a part-time discount. I don't use PICA but my malpractice company gives a 50% discount if you work 20 hours per week or less, 25% discount if you work 30 hours or less per week.

Extra insurance: you can talk to a local insurance agent about office general liability insurance, fire/theft insurance, short term/long term disability insurance, etc.

 

[bunNfxr]

Go back to what Exp DPM said. This is a really bad time to open an office. I wish you well. But a few things to consider all of which vary by location.
As far as marketing. When I started, google ad words and facebook was super cheap and very effective. In a short time everyone in the community seemed to have seen the ad with a great + reception and patients poured in.
Hospital administrators would recognize me from the ads , in the cafeteria, usually after my cases and compliment my style and reach, as my ads targeted well. The next year the same ad words cost 100x as much and if you plugged them into the search engine the same hospital that seemed congratulatory, eclipsed my ads on the fist page of every search engine. I could not afford a $20 click to investigate bunion surgery, but the hospital had no problem owning that or the other 50 words I previously dominated on local search engines.
They also opened a wound care center staffed with hospital employed physicians only.
They owned the only surgery center in the area and had it both ways. Any surgery I had, they made money on. Meanwhile, they were able to harvest the majority of new business and make more money. Without a lecture on ACOs, these give the hospital more control over your practice without having to spend any of their money to buy you out. And, you are forced to join under MACRA (or start your own, which is not likely a feasible proposition)
New legislation burdens are added every 10 years or so and the new MACRA laws are not slated for repeal, despite dog and pony shows about ACA repeals.
Audits of podiatry are going way up, and even if you do everything right they will drain your time and staff away from making a living.
Public perception is veering away from quaint 1200 sq ft off the road offices, and more towards big pretty buildings in or across from a hospital with lots of vinyl upholstered chairs and plastic wall bumpers and mass produced artwork on the walls.
If you can, open your office with some hospital support to keep them vested in your success. You will likely need to have some larger friends in the next few years to remain relevant.
These are just a few thoughts off the top of my head

 

[ExperiencedDPM]

Go back to what Exp DPM said. This is a really bad time to open an office. I wish you well. But a few things to consider all of which vary by location.
As far as marketing. When I started, google ad words and facebook was super cheap and very effective. In a short time everyone in the community seemed to have seen the ad with a great + reception and patients poured in.
Hospital administrators would recognize me from the ads , in the cafeteria, usually after my cases and compliment my style and reach, as my ads targeted well. The next year the same ad words cost 100x as much and if you plugged them into the search engine the same hospital that seemed congratulatory, eclipsed my ads on the fist page of every search engine. I could not afford a $20 click to investigate bunion surgery, but the hospital had no problem owning that or the other 50 words I previously dominated on local search engines.
They also opened a wound care center staffed with hospital employed physicians only.
They owned the only surgery center in the area and had it both ways. Any surgery I had, they made money on. Meanwhile, they were able to harvest the majority of new business and make more money. Without a lecture on ACOs, these give the hospital more control over your practice without having to spend any of their money to buy you out. And, you are forced to join under MACRA (or start your own, which is not likely a feasible proposition)
New legislation burdens are added every 10 years or so and the new MACRA laws are not slated for repeal, despite dog and pony shows about ACA repeals.
Audits of podiatry are going way up, and even if you do everything right they will drain your time and staff away from making a living.
Public perception is veering away from quaint 1200 sq ft off the road offices, and more towards big pretty buildings in or across from a hospital with lots of vinyl upholstered chairs and plastic wall bumpers and mass produced artwork on the walls.
If you can, open your office with some hospital support to keep them vested in your success. You will likely need to have some larger friends in the next few years to remain relevant.
These are just a few thoughts off the top of my head

Couldn’t agree more. Excellent post.

 

[Carbon13]

There's not much support on this thread for a new office startup. The truth hurt's I suppose.
I feel this will create an even more difficult situation for new residency grads. Yes, hospitals provide a faster way to get up on your feet. However, how many hospital jobs are there? Answer, not enough & the handful of hospitals in my area have no current desire to hire a new podiatrist. This leaves options including joining a group or becoming an associate of a solo practitioner in the hopes of a buy out situation.

Speaking of which, here's how I got to my current situation.

During the winter of my senior year of residency I contacted a few of the DPMs in my target city of my home state. The metro area population is approximately 525,000 with about 10 DPMs 1 Fellowship FA ortho & 1-2 ortho's who have decided they are the foot specialists for their group.
One of these DPMs informed me that he had been in solo practice for the past 27 years and had been considering hiring on an associate prior to his departure in a few years. His gross revenue the past few years has been 575-600k while averaging 20-25 patients/day in a heavily orthotic driven practice with occasional forefoot procedures & alot of C/C in between. He informed me that he was limiting himself to seeing 6 new patients per day & that he was much busier than he could manage. Regarding my pay, he initially suggested a straight 40% cut with a small CME allowance. I was used to seeing a salary + bonus structure in regards to my friends contracts but ultimately agreed to the 40% offering since the patient load was thought to have been present. He assured me that the patients would be there, asked me how soon after graduation I could start, could I see at least 12 patients a day to start as the demand was not currently being met. He estimated a 200k "buy in" sometime after one year which would then leave me at "eat what you kill" and split overhead. I would eventually have the option to buy him out for an additional 200k (charts, equip, no real estate). I thought to myself "those are big numbers but let's see what happens".

As a soon to be residency graduate I was more than excited to have things beginning to line up for myself. I focused on boards and passed all portions of the ABFAS on the first attempt. I found a house in the area and my wife landed a good job making around 150k.
I started seeing patients in July. I started out seeing around 12 patients per day, completed a few of his stowed away rearfoot cases and seemed like I had a good thing going. This lasted around 1.5 months & then thing's went SOUTH. For some reason the patient's stopped coming in to the practice. Up till this point I was seeing mainly new patient's (up to 6 new pts daily). He quickly decided that he needed to see all new commercial paying patients to meet his bottom line & that I was to be delegated only new patients from the VA overflow system or people that directly requested myself. New patients are now down to 2-3 daily, total.
I rounded on several of the local PCP offices over the next few months. Ok, it was now time to turn the marketing machine into overdrive to advertise myself as a new practitioner to the public. Big problem,,,the office manager (AKA Owner's wife) did not believe we needed a new website to display to the public that we had progressed from 2003. Nor did we need to update the sign on the front of the building to include my name on it (been 6 months). When inquiring about these topics I was just answered with "we know things aren't what we had planned but we are losing money here, too. We could be seeing those patients of your's"

So, here I am at 6 months. On track to gross 50K this year. Working in a practice that feels completely stagnant. Looking back, I now feel that this owner was just completely content on seeing his 22 patients a day and thought that he would make another easy 400k out of a new grad over the course of a few years while slowly phasing out. In reality, did he just have no idea what it would take to create a 2 man practice out of a 1 man practice? This has definitely been a learning experience for me & I've kept a ton of notes. But, WOW!

 

[podoloco]

There's not much support on this thread for a new office startup. The truth hurt's I suppose.

It all depends on your own situation. Everyone has an opinion. It doesn't make it right or wrong. You should heed the warnings given, and make sure all of the obstacles being listed are dealt with appropriately.
My opinion is that if you have the means and motivation to work for yourself, it is worth the risk. It sounds like you put your time into researching some essential aspects of getting started.
I have 5 pods, including myself, in a town of 25K, with a regional feed of around 40-50K. There is more than enough work to go around, at least in my setup. I am non-stop busy and have already absorbed 2 other area practices that have closed down, and hired a part time associate to take some of the work load, who will soon need to be full time as well. I see others struggling to keep up with the changing environment and hear the same arguments against running my own practice at pretty much every academy meeting and seminar, but I keep growing and I am doing very well, especially for only being a year out.
I would encourage you to start credentialing while you are still working for the other provider. You can be credentialed with multiple practices. Medicare and medicaid will transfer right away to your tax id. The private plans may do it right away, or may take time. Each one is different. Having a part time gig while you get up and running pays the bills.

 

[ExperiencedDPM]

There's not much support on this thread for a new office startup. The truth hurt's I suppose.
I feel this will create an even more difficult situation for new residency grads. Yes, hospitals provide a faster way to get up on your feet. However, how many hospital jobs are there? Answer, not enough & the handful of hospitals in my area have no current desire to hire a new podiatrist. This leaves options including joining a group or becoming an associate of a solo practitioner in the hopes of a buy out situation.

Speaking of which, here's how I got to my current situation.

During the winter of my senior year of residency I contacted a few of the DPMs in my target city of my home state. The metro area population is approximately 525,000 with about 10 DPMs 1 Fellowship FA ortho & 1-2 ortho's who have decided they are the foot specialists for their group.
One of these DPMs informed me that he had been in solo practice for the past 27 years and had been considering hiring on an associate prior to his departure in a few years. His gross revenue the past few years has been 575-600k while averaging 20-25 patients/day in a heavily orthotic driven practice with occasional forefoot procedures & alot of C/C in between. He informed me that he was limiting himself to seeing 6 new patients per day & that he was much busier than he could manage. Regarding my pay, he initially suggested a straight 40% cut with a small CME allowance. I was used to seeing a salary + bonus structure in regards to my friends contracts but ultimately agreed to the 40% offering since the patient load was thought to have been present. He assured me that the patients would be there, asked me how soon after graduation I could start, could I see at least 12 patients a day to start as the demand was not currently being met. He estimated a 200k "buy in" sometime after one year which would then leave me at "eat what you kill" and split overhead. I would eventually have the option to buy him out for an additional 200k (charts, equip, no real estate). I thought to myself "those are big numbers but let's see what happens".

As a soon to be residency graduate I was more than excited to have things beginning to line up for myself. I focused on boards and passed all portions of the ABFAS on the first attempt. I found a house in the area and my wife landed a good job making around 150k.
I started seeing patients in July. I started out seeing around 12 patients per day, completed a few of his stowed away rearfoot cases and seemed like I had a good thing going. This lasted around 1.5 months & then thing's went SOUTH. For some reason the patient's stopped coming in to the practice. Up till this point I was seeing mainly new patient's (up to 6 new pts daily). He quickly decided that he needed to see all new commercial paying patients to meet his bottom line & that I was to be delegated only new patients from the VA overflow system or people that directly requested myself. New patients are now down to 2-3 daily, total.
I rounded on several of the local PCP offices over the next few months. Ok, it was now time to turn the marketing machine into overdrive to advertise myself as a new practitioner to the public. Big problem,,,the office manager (AKA Owner's wife) did not believe we needed a new website to display to the public that we had progressed from 2003. Nor did we need to update the sign on the front of the building to include my name on it (been 6 months). When inquiring about these topics I was just answered with "we know things aren't what we had planned but we are losing money here, too. We could be seeing those patients of your's"

So, here I am at 6 months. On track to gross 50K this year. Working in a practice that feels completely stagnant. Looking back, I now feel that this owner was just completely content on seeing his 22 patients a day and thought that he would make another easy 400k out of a new grad over the course of a few years while slowly phasing out. In reality, did he just have no idea what it would take to create a 2 man practice out of a 1 man practice? This has definitely been a learning experience for me & I've kept a ton of notes. But, WOW!

I’m sorry you’ve had this experience. I’m also sorry to say that I’ve heard this story over and over again.

A doctor may be slightly too busy for his own comfort and hires a new associate with the thought that the practice will suddenly become busier with a new associate. The first flag is the current patient volume of the hiring doctor. If s doctor is “maxed out” seeing 22-25 patients a day, then that doctor is either clueless, lazy or both. No doctor who sees 22-25 patients daily needs an associate.

Addituonally, the second you visit an office and you find out the office manager is the doctor’s spouse......RUN, don’t walk in the other direction.

 

[med2345]

I’m sorry you’ve had this experience. I’m also sorry to say that I’ve heard this story over and over again.

A doctor may be slightly too busy for his own comfort and hires a new associate with the thought that the practice will suddenly become busier with a new associate. The first flag is the current patient volume of the hiring doctor. If s doctor is “maxed out” seeing 22-25 patients a day, then that doctor is either clueless, lazy or both. No doctor who sees 22-25 patients daily needs an associate.

Addituonally, the second you visit an office and you find out the office manager is the doctor’s spouse......RUN, don’t walk in the other direction.

Do you feel that these stories are just some cases of bad luck or is this becoming common? I just want to make sure the job market is well and good after I graduate/finish residency

 

[dtrack22]

This is exactly why docs telling you not to open your own practice make no sense to me. You went into a practice that would have cost you $400k to become the owner of. $350k of that was money for charts (and not many of them). You could have started off on your own for half that amount at most and been seeing just as many patients daily 6 months in as you are now.

Worried about insurance panels? Don’t practice in the northeast where a Pittsburgh DPM likes to remind people they practice communism. Pay the money to join an independent physicians group that already has contracts in place with commercial payers if you’re real worried about not getting approved.

Worried about overhead? Use a free EHR, run lean from a staffing standpoint, pick Natch’s brain...

If your option is to open up shop in an area with a population to support another podiatrist or work for another DPM and end up paying a lot more to “buy in” and/or “buy out” the practice, starting your own is not nearly the impossibility certain docs in certain geographic locations would make it seem.

 

[SterlingMaloryArcher]

This is exactly why docs telling you not to open your own practice make no sense to me. You went into a practice that would have cost you $400k to become the owner of. $350k of that was money for charts (and not many of them). You could have started off on your own for half that amount at most and been seeing just as many patients daily 6 months in as you are now.

Worried about insurance panels? Don’t practice in the northeast where a Pittsburgh DPM likes to remind people they practice communism. Pay the money to join an independent physicians group that already has contracts in place with commercial payers if you’re real worried about not getting approved.

Worried about overhead? Use a free EHR, run lean from a staffing standpoint, pick Natch’s brain...

If your option is to open up shop in an area with a population to support another podiatrist or work for another DPM and end up paying a lot more to “buy in” and/or “buy out” the practice, starting your own is not nearly the impossibility certain docs in certain geographic locations would make it seem.

Are there any medical schools that offer a single class on practice management?

 

[SterlingMaloryArcher]

Skip to the bolded portion if you're in a hurry.

I'm looking for opinions regarding the location of a solo private practice.
I graduated from an upper level residency program in 2017. Since that time I have been spinning my wheels as an associate working for straight percentage with an older pod in a declining practice. (Same 'ol story...things haven't been anywhere near what I was told to expect).

I haven't left my current position yet. However, I have already walked through a few different potential office lease locations. The "mini" metro area I currently live in consists of 3 different cities all of which are stacked from north to south and closely border each other. The middle and lowest cities each have around 75,000 people with around 6-7 Podiatrists combined. The Northern most city has around 28,000 people and no foot doctors. At this time those residents must drive to one of cities below them (15 minutes highway travel to nearest pod). My goal is to establish a private practice at the base of the northern most city. I hope to initially capture the patients located in the immediate area and then draw from the cities below me which have current pods.

Like many new doctor's, I will rely heavily on marketing at the beginning. I plan to have a truly stellar website as the internet is something I feel a majority of new patients / walk ins are captured by. Over the past six months I have asked many new patient's how they found me. A majority have said: Internet / google / yelp / Siri....etc. (Most of the pods in my area have a very generic website with outdated pictures and overall lack of quality in comparison to other medical specialists). Do you feel that a strong marketing program would allow a doctor to have an office located a few blocks off of the main drag & still pull the customers? I have located a 1,200sq/ft (1350$/mo) suite beside a Dermatologist office. This space was previously used by a PCP so the build out is basically complete. However, this location is not pretty and roadside like so many of the DDS you see around here.

Answering the bolded question. Yes, especially a specialty office where patients will be referred.

 

[ExperiencedDPM]

This is exactly why docs telling you not to open your own practice make no sense to me. You went into a practice that would have cost you $400k to become the owner of. $350k of that was money for charts (and not many of them). You could have started off on your own for half that amount at most and been seeing just as many patients daily 6 months in as you are now.

Worried about insurance panels? Don’t practice in the northeast where a Pittsburgh DPM likes to remind people they practice communism. Pay the money to join an independent physicians group that already has contracts in place with commercial payers if you’re real worried about not getting approved.

Worried about overhead? Use a free EHR, run lean from a staffing standpoint, pick Natch’s brain...

If your option is to open up shop in an area with a population to support another podiatrist or work for another DPM and end up paying a lot more to “buy in” and/or “buy out” the practice, starting your own is not nearly the impossibility certain docs in certain geographic locations would make it seem.

There are many reasons that I don’t recommend opening a solo practice. And I’m not alone in my opinion. Most practice experts and business journals are very concerned about the practicality of solo private practice, especially in the current environment and with a from scratch practice.

Most young docs are already in debt from school loans. Banks aren’t handing out money to docs who already have a few hundred grand in loan debt. We aren’t plastic or orthopedic surgeons. Our stats aren’t as impressive when they are deciding on those loans.

And of course there is no immediate income when you open from scratch but there ARE immediate bills and financial responsibilities.

I’m not sure how many of you have actually started a practice from scratch. I believe NaTCH has, but he’s in a unique situation where he can work 15 hours a week and live the lifestyle that works for him.

I did start from scratch and it ain’t easy. I had a LOT of lean times and worries despite my skills and aggressiveness and willingness to work long hours. Fortunately, my hard work has had it’s rewards, but the path wasn’t without lots of bumps.

I still not believe it’s wise at this time to open from scratch in most areas. I would certainly shy away from working for any DPM. Multi specialty groups would be my first recommendation.

 

[air bud]

No that's what Hal Ornsteins fellowship is for...

 

[ExperiencedDPM]

No that's what Hal Ornsteins fellowship is for...[/QUOTE

No that's what Hal Ornsteins fellowship is for...

If you think he’s bad, go on the FABI website and look at the PATHETIC videos of LSW Jr trying to sell you on signing up for his program. It’s like the worse infomercial. First there’s one of him at the family compound in Mexico, telling you how important it is to have time to spend with your family. Yeah, we all have a friggin compound in Mexico. Next video he pulls up in an expensive care in front of a large fortress which is presumably his home. And he stands there telling you how to sign up for his course. Next video, he’s standing in his foyer so you can see his nice home. Wow, I’m really impressed and maybe someday I can be like him. The most recent video he’s in his kitchen making pasta for more quality family time. He forgets to mention that his daddy had a huge practice that he walked into. And now he’s exploiting colleagues to learn the magical and mysterious “10 modifiers” to make you rich.

Pathetic. And what is more pathetic are the fools who pay to go to the meeting he’s hawking.

Did I say pathetic yet?

 

[dtrack22]

I would certainly shy away from working for any DPM. Multi specialty groups would be my first recommendation.

Sure, that would be great. But if you want to avoid working for another podiatrist and multispecialty/hospital jobs aren't widely available and you shouldn't open your own practice...what are you supposed to do?

Off topic, here is the 2016 MGMA data for surgical podiatrists ($30-50k higher in each %-ile than "general" podiatrists but hey, RFC pays well right?). Everyone can again remember why they dislike their contract and job as an associate in a podiatry office/group.

percentile / compensation
10th $182,995
25th $234,268
50th $279,696
75th $384,000
90th $467,309

 

[dtrack22]

The numbers can change drastically from year to year depending on how many responses.

MGMA 2015 (same percentiles as previous, though these are broken down by years in practice)

3-7 yrs in practice
$179,301
$200,309
$266,005
$359,059
$478,888

8-12 yrs
$203,202
$240,378
$276,904
$305,560
$434,088

13-17 yrs
$197,136
$253,766
$340,040
$434,567
$480,219

Doesn't look like it changed at all from the previous year. Median in 2014 was in the $250's if I remember correctly. I haven't seen a drastic change in the last 4 years that I've been paying attention to the yearly MGMA data.

 

[dtrack22]

MGMA surveys include results from 300-400 podiatrists every year. Pretty normal sample size compared to other specialties. F&A ortho had data from 79 providers in 2016.

 

[ExperiencedDPM]

I could never understand why the APMA numbers and other surveys seem to be well below the MGMA numbers.

 

[air bud]

OMG how does these threads always turn into how much money does a podiatrist make?

BTW the answer is less than Dtrack makes on Bitcoin

 

[dtrack22]

BTW the answer is less than Dtrack makes on Bitcoin

I have made more money from cryptocurrencies than I have as a podiatrist...and since I work for a podiatrist I make more trading than I do in salary. Slowly my notes are getting worse and routinely undercode because it’s less work, mostly just on the patients I’m seeing under my boss’s name and not getting credit (collections) for. Gives me more time to keep up on news and watch/read crypto charts.

air bud is too chicken but if you hodl, pm me. Let’s exchange ideas.

 

[dtrack22]

just an example of good days...I made .4 BTC (you can multiply current BTC value by .4 to get USD gains, but currently its a little less than 1 months worth of salary at my crappy job) while I slept last night. 3 of the coins are longer term hodls so I will continue to let them ride (1 has an upcoming hard fork that I'm excited about), normally I take profits and roll them into new alts when I find a chart I like.

 

[ExperiencedDPM]

I have made more money from cryptocurrencies than I have as a podiatrist...and since I work for a podiatrist I make more trading than I do in salary. Slowly my notes are getting worse and routinely undercode because it’s less work, mostly just on the patients I’m seeing under my boss’s name and not getting credit (collections) for. Gives me more time to keep up on news and watch/read crypto charts.

air bud is too chicken but if you hodl, pm me. Let’s exchange ideas.

Why would you treat patients who you didn’t receive any credit for in your employer’s practice? If that’s the case, he’s in essence committing fraud.

 

[dtrack22]

Why would you treat patients who you didn’t receive any credit for in your employer’s practice? If that’s the case, he’s in essence committing fraud.

I don't disagree

 

[ExperiencedDPM]

I don't disagree

And someday someone will have to explain the entire bitcoin concept to me. I’m not sure I “get it”.

 

[bunNfxr]

 

[ExperiencedDPM]

Somehow I knew someone would post that video!

 

[NatCh]

But if you want to avoid working for another podiatrist and multispecialty/hospital jobs aren't widely available and you shouldn't open your own practice...what are you supposed to do?

That was the question going through my mind. While ExpDPM and bunNfxr make compelling arguments against opening a practice, the OP has to do something. He or she can't just sit there lamenting the current state of affairs.

Carbon13, I'm really sorry to read about your practice situation. It kind of sucks when reality doesn't match the brochure. While being in medicine in the U.S. kind of stinks overall right now, I can tell you that I know several colleagues who have started from scratch and are doing well now. Perhaps you could find a colleague who is in a similar situation and team up to share effort and expenses? Best of luck to you.

 

[Carbon13]

That was the question going through my mind. While ExpDPM and bunNfxr make compelling arguments against opening a practice, the OP has to do something. He or she can't just sit there lamenting the current state of affairs.

Carbon13, I'm really sorry to read about your practice situation. It kind of sucks when reality doesn't match the brochure. While being in medicine in the U.S. kind of stinks overall right now, I can tell you that I know several colleagues who have started from scratch and are doing well now. Perhaps you could find a colleague who is in a similar situation and team up to share effort and expenses? Best of luck to you.

Yes, what do I do? There are no hospital or MSG opportunities in my location.
There's a strong chance that my current situation would improve..... given enough time. Meaning that the patient load would pick up over the next year or two as would my income. I would also be doing this without the risk of being an owner. But, do I want to wait around that long and then fork over another several hundred $K to buy in?

My opinion is, NO. If things were really beginning to pick up speed by the 6 month mark and I could see a bright future I wouldn't be posting right now. At this point I'm asking myself why I didn't setup shop from day one. However, I have learned some valuable information about private practice. My residency was high surgery volume & "elective" office / clinic.

I'm surprised there haven't been more threads like this one. Maybe there's alot of DPM grads out there willing to put up with garbage or just don't know any better. I've been doing my homework & I'm sure that I will succeed. I know a few younger guy's that are doing the solo practice thing with success.

 

[greenscrubs07]

I still not believe it’s wise at this time to open from scratch in most areas. I would certainly shy away from working for any DPM. Multi specialty groups would be my first recommendation.

What are the advantages of working for an MSG compared to a group of Pods if the MSG group's never offers a partnership?

 

[ExperiencedDPM]

What are the advantages of working for an MSG compared to a group of Pods if the MSG group's never offers a partnership?

My experience has been that DPM groups rarely offer fair and equitable partnership buy in. Their financial demands are often unrealistic and they rarely offer equal partnership vs just selling you some shares. I don’t really want to hear about the exceptions, since my observations are based on well over 20 years of experience. The rate of young DPMs actually buying in and becoming full partners is no where near what it is in other specialties. Sweat equity doesn’t seem to count in Pod practices. Depending on the state, you can be a partner in a MSG group or at least a shareholder.

 

[JAJE]

What would be the best way to change this paradigm in podiatry?

 

[ExperiencedDPM]

What would be the best way to change this paradigm in podiatry?

The paradigm won’t change until DPMs start opening their eyes and realize that many of the “leaders” and those who they respect are some of the greediest, most unethical, self serving thieves in the business. It’s time to wake up and smell the toast burning and stop admiring frauds.

 

[NatCh]

The paradigm won’t change until DPMs start opening their eyes and realize that many of the “leaders” and those who they respect are some of the greediest, most unethical, self serving thieves in the business. It’s time to wake up and smell the toast burning and stop admiring frauds.

Shots fired!!!

 

[ExperiencedDPM]

Shots fired!!!

Damned right. I tell it as it is.....it’s really time to realize that the people who many DPMs admire are really the slime of the profession. If these docs knew the “truth” they’d be astounded.

The truth? I don’t think you can handle the truth!

I’m just so sick of DPMs charging for courses to let you know the “secrets” of success and billing and the 10 “secret” modifiers we all need to know. These docs capitalize on the sheep that follow them and the docs who make you pay to learn this crap are some of the biggest abusers of fraudulent billing.

 

[ExperiencedDPM]

How are they getting away with it?

They often aren’t billing for procedures not performed, but “embellish” a procedure performed. They also unbundle procedures. If the insurance company doesn’t have the software to run CCI edits on a claim (most insurance companies DO run these edits) they can get away with billing 4-5 codes for one actual procedure that includes those codes.

Unbundling is not benign and is punishable via the Fraud Act.

This is seen a LOT with the DPMs who perform multiple nerve releases. They “decompress” the common peroneal nerve. To access the nerve and free up tissue they must cut into the fascia. So they then bill for a decompression fasciotomy which is really a procedure to decompress a true compartment syndrome, not to snip into the fascia to reach other structures. Cutting tissue to access your surgical site is inclusive to the procedure since it’s part of the approach.

And I assure you, soon they will NOT be getting away with this crap. But you have to love the fact that some of these guys now have courses to teach their sleazy ways.

Just because you may get reimbursed doesn’t mean it’s correct and that you won’t eventually get caught. And if I have anything to say, you’ll get caught.

 

[dtrack22]

My experience has been that DPM groups rarely offer fair and equitable partnership buy in. Their financial demands are often unrealistic and they rarely offer equal partnership vs just selling you some shares. I don’t really want to hear about the exceptions, since my observations are based on well over 20 years of experience. The rate of young DPMs actually buying in and becoming full partners is no where near what it is in other specialties. Sweat equity doesn’t seem to count in Pod practices. Depending on the state, you can be a partner in a MSG group or at least a shareholder.

for example my likely new job (ortho office) has no "buy in" for partnership. If you want shares of MRI, real estate holdings, surgery center (in the office) then you pay the market rate for those. Otherwise after the first year you keep all of your collections after you've paid your overhead. You don't have to give them hundreds of thousands of dollars just for the "privilege" of keeping the money you earned.

 

[NatCh]

for example my likely new job (ortho office) has no "buy in" for partnership. If you want shares of MRI, real estate holdings, surgery center (in the office) then you pay the market rate for those. Otherwise after the first year you keep all of your collections after you've paid your overhead. You don't have to give them hundreds of thousands of dollars just for the "privilege" of keeping the money you earned.

Score!

 

[MyAnklesAreBroken]

What does paying market rate mean?

 

[MyAnklesAreBroken]

for example my likely new job (ortho office) has no "buy in" for partnership. If you want shares of MRI, real estate holdings, surgery center (in the office) then you pay the market rate for those. Otherwise after the first year you keep all of your collections after you've paid your overhead. You don't have to give them hundreds of thousands of dollars just for the "privilege" of keeping the money you earned.

What does paying market rate mean?

 

[air bud]

What does paying market rate mean?

Uh....what the market says something is worth????? You don't pay for your fresh salmon at the Seattle fish market based on what the old fisherman wants to sell it to you at. You buy it based on what the local community determines it is worth at that time. It's like block chain technology, everybody knows what something is worth because everybody knows what somebody paid for it.. see what I did there?

 

[Weirdy]

Uh....what the market says something is worth????? You don't pay for your fresh salmon at the Seattle fish market based on what the old fisherman wants to sell it to you at. You buy it based on what the local community determines it is worth at that time. It's like block chain technology, everybody knows what something is worth because everybody knows what somebody paid for it.. see what I did there?

HODL'in

 

[that1guyfromFL]

Banks aren’t handing out money to docs who already have a few hundred grand in loan debt.

This simply isn’t true.

Wells Fargo, TD Bank, Suntrust and several smaller community banks all said yes to exactly what I asked for.



Edit reason: reduce sarcasm

 

[ExperiencedDPM]

This simply isn’t true.

Wells Fargo, TD Bank, Suntrust and several smaller community banks all said yes to exactly what I asked for.



Edit reason: reduce sarcasm

Well......

Edit reason: reduce extreme sarcasm.

 

[dtrack22]

I read the pre-edited response and I don’t doubt that the experiences are real. I think it may be more of a regional phenomenon though. As a younger doc I’ve had colleagues or classmates experience zero issues in getting loans from banks (with very favorable terms) to start practices in the following locations:

FL (Tampa and central FL)
TX (DFW and Houston)
WI
MN
UT
WA
ID
LA
OH

It’s a small sample size (10-15) and does not include the northeast (though personally the healthcare market up there sounds less than ideal), but I don’t know a single person that couldn’t find a bank in their area to loan them money to start or purchase a practice.

Before the job opportunity I had in my 3rd yr of residency got pulled out from under me, I had zero pushback from a local bank when discussing both a business loan and line of credit. If someone wasn’t able to get the money I would blame them as opposed to the banks until I have evidence or experience of the contrary.