Private Practice thoughts, 5 years out

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heybrother

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Hopefully this will be more amusing than talking about nailcare.

1. Be wary of making long term decisions based on short term financial incentives.

2. A private practice essentially requires all of its members to work at full steam. A podiatrist is either collecting or you are carrying them.

3. Collections are important - but controlling costs is a millimeter behind. A lean office doesn't need a fortune in collections.

4. Toxic partners can make you physically ill. They create a myriad staffing and patient care issues.

5. What you will tolerate as a new graduating podiatrist and what you will tolerate as an established, skilled podiatrist should not be the same thing.

6. Be wary of problematic partnerships rooted in financial convenience. Partnership borders on a marriage.

7. Old podiatrists do not change.

8. Staff will ghost you. The kind of people who will work in a podiatry office are often poor, high school-at-most educated, women. When I see their paychecks I don't know how they survive. They make $10-20 an hour. They could probably make more money at McDonalds. They'll leave you for $2 more an hour, better lifestyle or not having to clean your exam rooms at the end of the day. Your staff will share their salaries with each other and they will begrudge other employees who make more money if that employee doesn't pull their weight. They know how hard they've worked at other offices or how little at better staffed offices. They know that some other doctor gives $$$ upfront to every employee for their 401k or that the general surgery office has a stocked break room for their employees. They know the family medicine doctor treats all of his employees and their family for free. They'll leave the office because it changed its paycheck structure from 24 to 26 pay periods and it threw off their budget. They are interviewing and looking for something better even though they are showing up every day. Send someone home early to control costs because their doctor wasn't in the office and you blew their budget and they can't make their rent payment. They'll look for a new job. Staff will tell you on Friday they aren't coming Monday. Training a replacement? Putting in 2 weeks? Probably not. Medical assistants don't have to build a resume of quality work. The kind of people who hire them are just like you - looking for someone to start on a Monday because someone else just ghosted them. They don't share in the profits of the office so their only incentive is money and occasionally a feeling of loyalty to their doctor. They don't think they should have to wait a year to get a $0.50 raise - they can get a raise by moving to a new office on Monday that pays more if they can find it. They don't believe in seniority or that people who have been there longer should earn more money. Everyone's doing the same job and they've been an MA for 5-10-15 years somewhere else. They will cut the best deal they can get.
*I actually think most of my practice's staffing issues are self inflicted, but I've seen some funny stuff. I can't blame MA who are often living hand to mouth for cutting a better deal. If we could all walk away and start something better that next Monday - we would.

9. The amount of money lost by losing a motivated employee greatly exceeds whatever trivial amount of money you lost them over.

10. My stereotypical boomer dad would say - "this whole generation doesn't want to work. They think they deserve too much money." Describing entire generations with a broad brush is dumb. I'm 41 and therefore technically a millenial. The relationship between management and labor has changed. Transparency works against management. Evolve or die.

11. Old practices have legacy costs that are difficult to break or escape. Personal friendships may have influenced business decisions.

12. Old practices can have lingering financial concerns that are difficult to root out like overcollections that haven't been repaid. Don't ask me how I know this.

13. You cannot truly change a practice unless you own a controlling stake in it.

14. Health insurance continues to explode in price. A major health insurance company can raise your practice's office plan rates 8% in a year and simultaneously cut your practice's reimbursement by greater than that. If your employee is a young, single mother with children it is entirely possible that her family can receive a subsidy that will cover the entirety of the premium of a marketplan plan. When Obamacare was passed one of the concerns was that employers would be motivated to drop their employees onto the market place. The financial incentive to do this can actually be substantial. If you were paying $500 a month for an employee's health insurance the savings to the practice would be $6000 and the employee could potentially be covered entirely by subsidy with no cost to themself. *I don't know this but I suspect in certain states your employee could also be placed onto Medicaid which might or might be well received (income, children dependent etc). If the employee is older or has a working spouse of moderate means - you could also be creating a situation where they could owe a substantial component of their premium. When I evaluated the finances of discontinuing my practices health insurance I found that an employee in their 60s would likely owe at least $300 a month because they had a spouse who made $50-60K. We (the practice) would be saving substantial employee premiums, but likely causing a tremendous financial burden for this employee because older employees cost more to insure and family's with more income receive less premium subsidy (especially if they don't have dependents). Market place plans can often have co-pays that employees would have difficulty to afford - for example, $100+ specialist copays.

15. This forum spends a lot of time discussing associate contracts, but very little time discussing partner contracts. Partner contracts are dramatically more complicated. Make no assumption. You may think you are buying out a podiatrist who is supposed to be retiring - and you may desire to leave before they do.

16. For whatever reason it is very difficult to teach management type employees to understand how insurance works. I have had plural conversations with "educated" individuals who believe that increasing the prices of your fee schedule will increase reimbursement from insurance companies. This is true under a very, very, very limited number of circumstances. The vast majority of your reimbursement will be determined by a fixed value in an insurance fee schedule. You can set your practice's fee schedule to $1,000,000 for a 99203. It will not increase your reimbursement.

17. I wrote a post about insurance years this years ago but I'll hit the highpoints again with a new weird thing

-Get your fee schedules from each insurance company and understand them. Find the variations. Create a master table of your most common codes for every insurance. Insurance companies will sign a contract with you and then underpay you on the contract. You'll be sitting there rendering the service believing you've got a great rate only to find out it never materialized (if you aren't looking you won't catch it) and it takes forever for them to reprocess. Knowing your fee schedules backwards and forwards allows you to catch these issues, spot the outliers etc. Get your contracts. The time to find out what you are paid is not after you've rendered the service.

-Most insurance plans reimburse some variation of the Medicare fee schedule but it may not be current year. Most insurance companies did not take the 2021 E&M update into account. Medicare in my area routinely reimburses E&M higher than almost all major commercial insurance companies. A recent increase in one of my fee schedules for CPT codes was accompanied by no change at all in E&M values which remained moderately sub-Medicare even thought the CPT codes are solidly positive over Medicare.

-There is no correlation between how private practice (collections) and how hospital podiatrists (RVUs) are reimbursed and brooding on it won't make you a penny.

-A "good" insurance plan elsewhere may be a trash plan in your area. In the state of North Carolina it appears Aetna has a transparent Medicare positive reimbursement that is posted freely online (like 165% of Medicare). Meanwhile in Texas, Aetna is now my second worst payor (soon to be worst) and reimburses all codes sub-Medicare. They also routinely deny all 25 modifier follow-up encounters now matter the appropriateness.

-Insurance companies can set your prices however they choose without any basis. They can reimburse 20550 and 20551 $30 apart. They can reimburse percutaneous flexor tenotomies higher than open tenotomies even though the Medicare fee schedule values are the reverse. They can reimburse a 17110, 11042 at $50 if they want to even though that is less than 50% of Medicare and 17110 has a 10 day global. They do not have to be consistent. Its whatever the schedule says.

-On some fee schedules a 20550 can be worth more than a 99213 and on others the reverse. Will that influence how you deliver care?

-I have literally seen a fee schedule where podiatry-centric codes were devalued - where codes around them were specified as based on Medicare x % and podiatry-centric codes were annotated as reduced due to policy.

-Insurance can specify that they will reimburse the lesser of (Medicare x %) or (Fee schedule - 20%). If you set your fee schedule values at the former, you'll lose 20% to the latter.

-Historically there was a variation of something called a "Silent PPO". A patient presents with an insurance company card (usually some sort of small 3rd party company you've never heard of) that doesn't specify the network. When the charges are submitted, the insurance company would submit the charges to a "discounter" who would reduce your fee schedule based on the lowest contractual rate you had with any network. Theoretically, your reduction in fee schedule is based on an insurance contract where the insurance gives you patients and you give them a discount. Since this insurance and discounter have no relationship with you there is no reason for them to deserve a discount. Some states have outlawed this, but there are still slight "variants" of this. What essentially happens now is a patients present with an insurance that sends claims to a discounter you've never heard of that treats all claims as "In network but subject to their fee schedule". For example, patients were presenting to my office with an insurance card listing both a company I'd never heard of and "ClaimDOC" - a company in Des Moines. This is actually slightly transparent as I've also received insurance cards with no company or network name on them anywhere. I initially contacted the insurance company on the card asking for their fee schedule only to finally be directed to ClaimDoc who told me they are "open network" and reimburse all claims at 125% of Medicare. They told me this over the phone ie. I'm not sharing some sort of contractual secret. There is no reason for me to offer these patients a discount. I am not in network with ClaimDOC. A similar company was "Sana" who literally have to coach their patrons to tell the doctor's office "don't worry - we're "open network" and the claims will be taken care of". In my area, most physician offfices figured out that "open network" means garbage reimbursement and refused to see their patients. It seems that ultimately Sana added the Healthsmart network because no one would see their patients.
*What's the lesson to learn here - tell patients with insurance cards (a) that have no network (b) or have a network you've never heard of that you are out of network and they need to pay cash they won't be seen. The second you submit to these companies they reduce your fee schedule and there isn't much you can do. An out of network provider who declares / informs the patient of this ahead of time should be able to balance bill a patient - but that isn't happening here because of how the claims are being processed.

-Its been discussed previously, but its entirely possible that if you accept some garbage payor - you may be the only doctor in an area seeing them. I recently confronted "FirstHealth" about their garbage fee schedules. It turns out in my area that FirstHealth is owned by Aetna and that no one accepts it. This is essentially legacy baggage as a result of being in an established practice. Maybe back in the day FirstHealth was a real insurance that paid something. Maybe it never did, but whatever the process the practice signed up for it. We do not see a lot of patients with this insurance, but going forward we will be seeing zero.

18. At times it very much feels like you can't possibly afford enough employees to deal with insurance company shenanigans. Reviewing my practices "held" claims I do find problematic submissions (not mine), but I also find claims that are simply denied because the insurance company can. For example, a Medicare Advantage plan claiming that the kenalog in a patient's plantar fascial injection is not covered by the plan. A plan refusing to pay 28113 unless you submit a letter of medical necessity.

19. Small insurance companies that reimburse at high values often will process their claims so slowly that unless you capture a substantial deposit up front it becomes hard to get patients to pay their balance.

20. Patients do not seem to care anymore about being sent to collections. The credit score law change has taken all of the bite out of the process. Calling patients after the fact and asking them to pay their bill has a very low yield with every minute that passes from the date of the service.

21. I'm sometimes told that its a good idea to be in a wealthy area. I won't discount the value of this, but patient wealth doesn't increase what Medicare pays to an office. If you are offering self-pay services like shockwave or laser then perhaps there will be people who can afford it. However, a multi-millionaire with Medicare will still be worth Medicare's fee schedule if all you bill is covered service. Perhaps wealthy people are more likely to pay their claims or pay for uncovered service, but "utility" or "federal" employees with Cadillac BCBS plans seem to be what keeps my practice in business.

22. A devil's advocate argument against higher paying commercial insurance (where the patient may owe the bill) is that Medicare patients with a secondary require almost no effort to be dedicated to collections because their plans + secondary pays the entire claim even if it is not excellent reimbursement. There is a start of the year deductible and some patients will claim that they "never had to pay this before". In my office, a Medicare 99203 + 73630 etc beats out a dramatic number of commercial insurances. It doesn't beat BCBS or Cigna most of the time, but it beats most of the other large payors. You'll sometimes read online that "doctors offices receive more money from commercial insurance than Medicare". Your mileage may vary on this, but that's not the case for me.

23. I sometimes hear stories about difficulties that doctors offices have with insurance. I've heard stories in the past of patients not being allowed to have nail surgery without prior authorization. I have not experienced that ie. most things in the office don't seem to require any sort of effort (other than collecting payment). MRIs and CTs do often require a "peer to peer" for commercial insurance, but I often am able to bypass the physician by simply telling the review nurse why I'm ordering it. The "denials" are often for trivial things like "didn't perform x-ray" - even though we did. Anthem BCBS seems to always require IM and HV angle measurements to authorize bunion surgery. Anything done with United should jokingly be prior authorized twice because they'll deny it after the fact in a heartbeat and claim you didn't prior authorize it. Securing payment after the fact is probably issue #1. HMO plan patients showing up without a referral is issue #2. Established HMO patients don't seem to understand that their referral runs out. They believe their referral lasts forever and it doesn't. Trivial, but getting bone stimulators covered is a nuisance.

24. I'm currently out of network with 2 area Medicare Advantage plans with a new one dropping soon. My experience billing MA plans out of network is that you ultimately receive Medicare level reimbursement, but the patients owes a higher co-pay. I will be out of network with United very soon and I'm curious to see how they'll process the claims. Your mileage may vary, but if your office is receiving sub-Medicare reimbursement from MA plans then going out of network may address some of the underpayment issues albeit at greater expense to the patient. There was a person on Iped recently claiming that a MA plan was going to pay them 120% of Medicare, but another doctor's office sabotaged the agreement by agreeing to a lower rate. I would love to see that exchange.

25. No insurance that I've dropped has ever asked me to stay or offered to negotiate.

26. No insurance that has ever negotiated has offered more than 10% over what they offered to begin with.

27. I recently got United Healthcare to agree that they had not paid me at my contractually indicated rate - for like 2-3 years. They ultimately sent me an enormous excel of underpaid claims which was full of non-sense data and inappropriately calculated. Its only a partial portion of the data. I immediately knew they were trying to underpay me because I had performed rough calculations of my total United collections and knew a ballpark of what the claims were worth. I contacted their rep and said the values were non-sense - there was never a question in our prior discussions of what I was owed but suddenly they want me to agree to settlement in 10 days on non-sense before a vacation. The rep refused to ask their team to reprocess the claims unless I commented on every single line what was wrong with the process. I was then forced to manually pull Medicare fee schedule data into excel, create a vlookup table in excel and provide the actual Medicare fee schedule values for the entire table along with the underpayment value. I also manually went through my EHR counts and codes to try and determine if the data included all of the claims I should have been paid for. It didn't. After spending hours doing this, United then agreed that they'd pulled the table wrong and ultimately they did it right the second time and my reimbursement doubled. I had a certain skillset from a prior career that allowed me to disassemble their data, but this is the kind of thing that will kill your spirit in private practice. No one my practice has ever employed could have done what I did. The check I'll be receiving is for thousands of dollars. Hospital employed podiatrists are not doing crap like this. The time, effort, cost of managing a podiatry practice is substantial and essentially uncompensated.

28. I occasionally hear people discussing "famous podiatrists" who demand cash up front. The question often asked is - "why can't I demand $2000 for a bunion up front". The answer is - your insurance contract. If you want to charge patients your fee schedule price - go out of network.

29. Do everything you can to avoid practice expenses that take a set percentage of your collections. Your expenses should ideally be as close to fixed as possible so that increasing revenue results in increasing keep. I would strongly recommend against Athena though I acknowledge many billers appear to have a %-of collections approach.

30. Its very easy for a practice to only be "forward looking". See the patients. Solve their problems. Book the surgeries. Do the work and move on - there's always someone to work on, something new to be doing, a note to be written. Insurance companies often process and deny claims so slowly that its hard to look back and say - did we get paid for that? You could literally have a long follow-up with a patient over months and still not have their surgical claim processed during that time. The best time to take money from a patient is either (a) before you do the surgery (b) or while they are still coming to your office. Once they are discharged and not following up its like squeezing water from a rock.

31. If all of your surgical reimbursement is Medicare or less - you are probably wasting your time. A substantial portion of your surgeries need to pay at 2-2.6+ x Medicare to be an actual revenue contributor to your practice unless you personally own shares in the surgery center or receive some sort of distribution.

32. A newly started practice may be well positioned to control costs because there are no legacy costs that are simply being paid without consideration. It is very hard to leave an EHR, even if its overpriced. Everything can be questioned. That said, the "grandfathered" nature of the insurance system can potentially create situations where an old practice down the street is better reimbursed than a new practice. IPAs can be helpful, but their benefit is sometimes mixed. None of the most problematic (low) payors (United, Aetna) had contracts with any of the IPAs I spoke to.

33. We speak about the devalued nature of the work we perform, but in the end the primary basis for our rates is Medicare. It is for most practices a substantial payor, the basis of commercial insurance reimbursement, and in many cases declining in value yearly.

34. Since I like to have it both ways. Depending on your payor mix, it sometimes feels like we live in a world that is worse than Medicare for all. If you see a strong mix of sub-Medicare payors - Humana, Aetna, United, Blue Cross "marketplace" etc - you are literally living in a sub-Medicare world where you also still have to collect your balances from the patients, get referrals, perform prior authorization. I obviously I have no idea what a true Medicare only world would feel be like but one of my motivations for dropping certain payors is that simply anything would better than them.

35. No one has ever asked me what board I am certified by.

36. Cash pay services are interesting. I added shockwave by purchasing a used device. I've actually had very positive outcomes. The simple truth though is that the backbone of revenue remains higher reimbursing commercial insurance. If you gave me the choice of offering people shockwave or simply having more good commercial nail surgery walk through the door - I'd take nail surgery. You don't have to sell it to patients. The vast majority of infected or painful nails are agreeable to doing something definitive.

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Didn’t read all of it. I’ll come back to it later but already know this is a goated post. But I read to the staff one and as someone else in PP all I can say is staff always want to stir up drama amongst each other, and that might even or usually involve the office manager.

People underestimate how tiring that drama can be on your day to day life and how things operate. Even as an associate, although their squabbles aren’t your responsibility to manage you usually feel some sort of effect from it
 
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Great post. I figured you would touch on the Change Healthcare fiasco. Were you affected?
 
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8. Staff will ghost you. The kind of people who will work in a podiatry office are often poor, high school-at-most educated, women. When I see their paychecks I don't know how they survive. They make $10-20 an hour. They could probably make more money at McDonalds. They'll leave you for $2 more an hour, better lifestyle or not having to clean your exam rooms at the end of the day. Your staff will share their salaries with each other and they will begrudge other employees who make more money if that employee doesn't pull their weight. They know how hard they've worked at other offices or how little at better staffed offices. They know that some other doctor gives $$$ upfront to every employee for their 401k or that the general surgery office has a stocked break room for their employees. They know the family medicine doctor treats all of his employees and their family for free. They'll leave the office because it changed its paycheck structure from 24 to 26 pay periods and it threw off their budget. They are interviewing and looking for something better even though they are showing up every day. Send someone home early to control costs because their doctor wasn't in the office and you blew their budget and they can't make their rent payment. They'll look for a new job. Staff will tell you on Friday they aren't coming Monday. Training a replacement? Putting in 2 weeks? Probably not. Medical assistants don't have to build a resume of quality work. The kind of people who hire them are just like you - looking for someone to start on a Monday because someone else just ghosted them. They don't share in the profits of the office so their only incentive is money and occasionally a feeling of loyalty to their doctor. They don't think they should have to wait a year to get a $0.50 raise - they can get a raise by moving to a new office on Monday that pays more if they can find it. They don't believe in seniority or that people who have been there longer should earn more money. Everyone's doing the same job and they've been an MA for 5-10-15 years somewhere else. They will cut the best deal they can get.

BASED.

9. The amount of money lost by losing a motivated employee greatly exceeds whatever trivial amount of money you lost them over.
NOT-BASED.
 
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Great post. I figured you would touch on the Change Healthcare fiasco. Were you affected?
We were impacted though I'm not sure to what extent. I have Athena and they were apparently seeking every sort of alternative process to route claims around Change ie. Availity. What surprised me was the interconnected nature of the system. I found a VA patient with a series of unpaid claims going back to December of 2023 who was listed as impacted by the Change Healthcare event. Interestingly, all of the outstanding claims paid on 3/16/2024 of last week. Glad to see it go through as this patient was worth $700. I haven't seen any commercial United patients in forever so I suspect that helps our situation as presumably they used their own utilities.
 
BASED.


NOT-BASED.
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Thanks for this post. Very insightful and informative.

Do you think these issues are more prevalent with podiatry specifically or a problem with medicine in general? I know it’s a vague question but generally speaking?
 
We were impacted though I'm not sure to what extent. I have Athena and they were apparently seeking every sort of alternative process to route claims around Change ie. Availity. What surprised me was the interconnected nature of the system. I found a VA patient with a series of unpaid claims going back to December of 2023 who was listed as impacted by the Change Healthcare event. Interestingly, all of the outstanding claims paid on 3/16/2024 of last week. Glad to see it go through as this patient was worth $700. I haven't seen any commercial United patients in forever so I suspect that helps our situation as presumably they used their own utilities.
Change did 100% of our insurance eligibilities. I have no cashflows right now and am applying for short term assistance. If that doesn't work, I've got backup plans through our banking, but hopefully this un-screws itself soon
 
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Change did 100% of our insurance eligibilities. I have no cashflows right now and am applying for short term assistance. If that doesn't work, I've got backup plans through our banking, but hopefully this un-screws itself soon
I'm sorry to hear that. That is terrible. When I think about things that can go wrong for my practice - the pipeline system of payment breaking down isn't the first thing that comes to mind.
 
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Most of this is very good.

...I would say paying the MAs/desk clearly on the high end of your locality is worth it 90% of the time. You get less turnover, higher satisfaction. You do have to get good at interviews and training (I use pic-heavy manuals) and quickly fire the clear duds.

You are absolutely right that they're always looking to jump ship (even if high paid)... but if yours is pretty clearly the best ship in that city/suburb, you will get more de facto loyalty and longevity. Even moreso if you do good pay as well as little gifts, staff lunches, outings, etc.

It is just not worth re-training, re-hiring, more call-ins, and all of the hours lost doing that. Even worse, all hours are less productive with avg pay and mediocre staff... and nearly all of the good ones will quickly find greener pastures. It is better to just pay $3 or $5 more per hour (10-20% over area norms) and have staff who are rock stars relative to area peers and stay awhile.

If they aren't solid or miss days despite good pay, then with the higher wage, you will have NOOOO trouble finding plenty who want the chance very fast. My phone and email gets completely blown up whenever I have posted a position (and I don't even list quite what I'd pay a good exp candidate to start). It is sad but true that all kinds of current med office staff are perpetually looking for a new gig.
 
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My strategy for the MAs is that we have 3 higher paid ones, but they do everything ranging from MA stuff to admin work. We have a floater system as well where the rest of the MAs rotate through each location but they are paid at just market rate. The office manager is paid a salary instead of hourly. The 3 plus the office manager are my core staff.
On days where we experience lack of staff the higher paid ones will voluntarily substitute in and the office manager would help as well. Days like these can get hectic but still worked until we find the replacement for another MA.

I have been debating whether or not we should hire a NP for nail care and even wound debridements. Works great for the practice financially but it does hurt the profession and the local job market in the long term. Part of me already surrendered to being a TFP, but a bit of me still wish the best for this profession to advance. Hard decision.
 
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My strategy for the MAs is that we have 3 higher paid ones, but they do everything ranging from MA stuff to admin work. We have a floater system as well where the rest of the MAs rotate through each location but they are paid at just market rate. The office manager is paid a salary instead of hourly. The 3 plus the office manager are my core staff.
On days where we experience lack of staff the higher paid ones will voluntarily substitute in and the office manager would help as well. Days like these can get hectic but still worked until we find the replacement for another MA.

I have been debating whether or not we should hire a NP for nail care and even wound debridements. Works great for the practice financially but it does hurt the profession and the local job market in the long term. Part of me already surrendered to being a TFP, but a bit of me still wish the best for this profession to advance. Hard decision.
NPs jump ship from actual good jobs just as quick as MAs. I think you’d be hard pressed to find an NP who wants to spend their days clipping nails when they have so many other better opportunities that are less…gross.
 
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...The office manager is paid a salary instead of hourly. The 3 plus the office manager are my core staff....
Yeah, I do all of mine on salary. I wouldn't have it any other way.
It is just a lot easier than fixing time clock errors or having them milk the clock almost daily.

It's gotta be at least $36k (roughly $18/hr... but it's NOT hourly, it's exempt) or something around that for fed limit for exempt hires. That - or significantly more - is the rate even new hires should be getting in the vast majority of areas to attract and retain good ppl, though. I give them a raise at 90d or fire them (usually sooner than 90d)... annual evals afterwards.
It seems a bit risky initially to salary new hires (only because I do sign bonus) and you need to write your job descriptions and company policy to support exempt (salary) jobs with decision making duties, but it wakes some of them up as it's a "real job" with salary and self-starting... different from their past worker-bee jobs. Many also like the standard paycheck to budget from. You can always sack them if they don't work out.

That salary hire obviously only works for full-time employees, but you have no shortage of those apps if the pay is good for the area. I would never say never, but I don't feel the training and potential for chemistry/drama/dependability issues is worth it for part time hire. Jmo

...I have been debating whether or not we should hire a NP for nail care and even wound debridements....
NP is way overkill (and way expensive) for the office imo... I'd just go lead MA or LPN or RN at most.
I really doubt you are planning to be in diff building with NP not having any DPM in the same office??
If you or one of the docs will be in the same clinic as NP, you could get RN + MA or three or four MAs for the same price. The NP is more for hospital hire (they suck at efficiency, used for seeing tons of post-op, doing a good amount of procedures without same-office supervision). Just have RN or MAs cutting nails or seeing post/ops while you're in other rooms? Also, as mentioned, NP will turn over also... and they need tons of training. I would spread out the risk among a few hires... should get much more productivity for the $ (by boosting docs more).

Besides, for the price of NP, you can get DPM associate non-op.
We will have all the annual threads complaining of no good jobs in autumn. :)
 
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NPs jump ship from actual good jobs just as quick as MAs. I think you’d be hard pressed to find an NP who wants to spend their days clipping nails when they have so many other better opportunities that are less…gross.
I think the NP job market is also regional. Where I am at NPs are actually competing with the MD residents for the same jobs, therefore driving down the salary for all. I hear our family medicine residents complain about this all the time. Most all end up taking the same FQHC jobs in town. NPs are also being pumped out like crazy with these online FNP and DNP programs. I was lurking in the NP subreddit and also their job forums as well. It looks like it's quite similar to podiatry. The top takes all the great hospital based or government jobs. The rest needs to fight for whatever is left. Of course they can always fall back on shift work as a RN I guess.
Of course this is just a specific region of California. I am sure NPs are likely much higher in demand in some other places.
 
Besides, for the price of NP, you can get DPM associate non-op.
We will have all the annual threads complaining of no good jobs in autumn. :)
Haha, that's not wrong. NPs are 120k + benefits, DPMs are 150k + benefits for our hires. With NPs I am looking at their more extended scope and perhaps incorporate more value based reimbursement in the future.

But again I may just go into trades if all of medicine is going into capitated and value based models.
 
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Thanks for this post. Very insightful and informative.

Do you think these issues are more prevalent with podiatry specifically or a problem with medicine in general? I know it’s a vague question but generally speaking?
Both MDs and DPMs in private practice would say these type issues seem to keep getting worse and worse with insurance plans. MD groups sometimes negotiate for better rates on the same plans. Both MDs and DPMs would also tell you other sources of revenue like ancillary income sources and cash pay services are becoming more important every year.

The real difference between podiatrists and MDs is…..SATURATION.

If MDs see their income drop in an area due the area becoming depressed economically or for whatever other reason they just get a job at/sell their practice to the local hospital. Podiatrists can occasionally be acquired by hospitals, but this is really the exception. Most MDs are booked out weeks or months in advance. Podiatrists often advertise same day appointments are available. There are many more podiatrists in private practice that accept HMOs and other poor insurances that most MDs do not accept. Poor insurances mean more paperwork for less money. Podiatrists are frequently on PM News complaining about these insurance plans and their shenanigans, but relatively few of these complaining podiatrists drop those plans.

Some podiatrists are doing very well, but the typical podiatrist has to worry more about the margins between revenue and expenses. If they do not they will not thrive or in some cases they will not even survive. Podiatrists who are owners have to make it work even if they are in a difficult market. What are their other options? Bankruptcy and going to work for another podiatrist as an associate? Not a great option in our profession. Most associate jobs are not great. There are not many hospital jobs and they are competitive, especially in desirable locations. Starting a practice elsewhere with poor credit? Good luck.

To say MDs do not worry about their income would be a big lie. They absolutely hate to see their income drop even if it is still a very high income. Even absolute worst case scenario if an MD filed bankruptcy and had to move they could fairly easily get another job making their specialties average salary with moving expenses and a signing bonuses.
 
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Even the MD/DO are not immune to poor leadership and basic economics. Ask the rad onc docs how things are going.
 
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Question about tip 17

You advise us as doctors to obtain our fee schedules. Once I do this, what am I supposed to do?

For instance let’s use your flexor tenotomy example where the percutaneous pays more than open. Let’s say I only ever did open ones before. Are you saying I should learn to do the percutaneous procedure? Let’s say I know the patient would likely benefit more from an open procedure. Should I still go the percutaneous route?

This is a genuine question coming from a young inexperienced doctor. Thank you
 
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Question about tip 17

You advise us as doctors to obtain our fee schedules. Once I do this, what am I supposed to do?

For instance let’s use your flexor tenotomy example where the percutaneous pays more than open. Let’s say I only ever did open ones before. Are you saying I should learn to do the percutaneous procedure? Let’s say I know the patient would likely benefit more from an open procedure. Should I still go the percutaneous route?

This is a genuine question coming from a young inexperienced doctor. Thank you
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I had to use ChatGPT to try to understand what's being asked here.
 

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Haha, that's not wrong. NPs are 120k + benefits, DPMs are 150k + benefits for our hires. With NPs I am looking at their more extended scope and perhaps incorporate more value based reimbursement in the future.

But again I may just go into trades if all of medicine is going into capitated and value based models.
Your group is too nice... most just give DPM associates$150k and fake benefits:
  • token CME $1k or $2k or whatever
  • 2-3wk vaca/sick (at or a hair above whatever the state minimum requires)
  • vaccinations required by hospitals as "health benefits"
  • malpractice and hospital dues and license fee and as "benefits"
  • meals as provided by reps in the break room :)
 
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Your group is too nice... most just give DPM associates$150k and fake benefits:
  • token CME $1500 or $2k or whatever
  • 2-3wk vaca/sick (at or a a hair above whatever the state minimum requires)
  • vaccinations required by hospitals as "health benefits"
  • malpractice and hospital dues and license fee and as "benefits"
  • meals as provided by reps in the break room :)

That’s generous of you to say “most” give DPM associates 150k that is for sure on the high side for an associate job…
 
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My strategy for the MAs is that we have 3 higher paid ones, but they do everything ranging from MA stuff to admin work. We have a floater system as well where the rest of the MAs rotate through each location but they are paid at just market rate. The office manager is paid a salary instead of hourly. The 3 plus the office manager are my core staff.
On days where we experience lack of staff the higher paid ones will voluntarily substitute in and the office manager would help as well. Days like these can get hectic but still worked until we find the replacement for another MA.

I have been debating whether or not we should hire a NP for nail care and even wound debridements. Works great for the practice financially but it does hurt the profession and the local job market in the long term. Part of me already surrendered to being a TFP, but a bit of me still wish the best for this profession to advance. Hard decision.
How much would you pay an NP to perform those services?
 
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