Question about nursing home job offer

[NobodyDPM]

This is my final reply, as we have been rightfully called out for polluting this post with banter.

1) While I won't share specific numbers, my salary + benefits package has me satisfied. I may not be making 500k+ like some vascular surgeons, but I do quite well for myself, I will leave it at that.

2) Vascular surgeons do not do Charcot reconstruction, that is a big part of what I do here. The other big part being skin flaps.

3) What am I going to do if they end up getting rid of me? Thankfully there are ample books, coding seminars, and plenty other opportunities to learn how to do your own billing if I decide to go that route. People don't magically wake up one day and learn how to bill, the same way you learned, I will learn too. One of the things I sought out when choosing a fellowship was practice management, I am not walking into any situation completely blind sighted and ignorant.

4) Yes, I am getting plenty of cases for board certification. I am not getting much elective forefoot from where I'm at, but I have one day a week where local podiatrists refer cases to me to meet diversity criteria.

Bolded mine. Interesting. So you get referrals from local Podiatrists to do surgery on their patients. While they cut toenails and cultivate your surgical volume. Irony much?

Also, after being out 5-10 years, it becomes increasingly difficult to find a practice that will hire someone like you. Particularly with the pay you will come to expect. Just some food for thought.

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[HardRoadPaved]

45% isn’t bad. I would shoot for at least 50% or even 65% assuming there are no benefits. You are part time, 1099?

i heard one contract was 30-35% of whats billed out. id assume these companies keep the numbers close to medicare rates to keep reimbursement low to you

 

[air bud]

Ahhhh, so you work with a vascular group. So rather than hire a Vascular Surgeon to do limb salvage, they hire a Podiatrist, pay him a lot less than a Vascular Surgeon, and get the same service from him.

Now, when they get rid of you for whatever reason in 5 to 10 years, what are you going to do? You won't have a clue about running a practice and won't have real World experience cultivating your own practice. Maybe only then will you realize the value of what nail care has to offer. Are you getting the diversity of cases necessary for Board Certification?

I don't think these vascular clincis last 5 years...

 

[ExperiencedDPM]

So you're saying you gain more of a rapport with a patient you've seen once for an office visit than for a patient I see every 62 days? Who willingly returns to see me, over a few years? And sends every other family member to me, as well? Ooooookay...

Wow, this again?

Other physicians who are doing US guided injections didn't milk the cow dry and then whine when there was no cow left. Podiatry does this time and time again.

And your question of some specialties getting paid more...well, if you are in a group of 30 doctors, practicing the same specialty, you have some leverage and can negotiate BY CONTRACT for those things. From EACH PAYOR. It is ILLEGAL to do this on a per physician basis. If you have intimate knowledge of one doctor getting paid more for doing a bunion that you, please make it public by sending a letter to both the Federal government and your payors.

This, btw, is where podiatry is seriously behind the 8 ball. We can't get along as a group long enough to force payors to pay us more. I betcha Hal Ornstein's group, Chris Hyer's group and Weil's group have negotiated higher rates than are paid to the individual podiatrist in their area. Strength in numbers, brother.

Seems to me you have very little practice management experience. And talk to me in 20 years about that nail cutting thing.

I know several people in each group mentioned, and I’m afraid that you may be disappointed to hear none of those groups have negotiated better payments from insurers. Hyer’s group is a split with DPMs, MDs and DOs. I’m sure that Weil’s group and Ornstein’s NJ group May have negotiated deals with labs, suppliers, etc., but none of them are big enough to negotiate a deal with the insurers. That happens with groups of providers of 100 or more doctors in a group that is statewide.

And it’s an insult to Lowell Weil to mention his name in the same sentence as Ornstein. Weil’s “group” is all one practice. Ornstein does not have a large private practice, but essentially has a group practice without walls. So his hand is in your pocket.

 

[ExperiencedDPM]

Only reason I thought you were a student was because it says so in your avatar.

And I have a lot more experience than you do. Yet, you talk to down to me like you are superior. You come across as very aloof, yet don't really have the knowledge to back it up. Your comment about different pay shows that glaringly well.

You'll find that I treat others the way they treat me. You think my condescending demeanor isn't becoming? Look in the mirror. That's how you come across. Fix you, and I'll fix how I respond to you.

Actually he is correct. Unfortunately in some states and geographic areas, DPMs are reimbursed at a lower level than MDs and DOs. This is factual as I have been an expert witness in lawsuits over this issue.

I personally would refuse to practice in a state that doesn’t have payment parity. But it does exist.

Ahhhh, so you work with a vascular group. So rather than hire a Vascular Surgeon to do limb salvage, they hire a Podiatrist, pay him a lot less than a Vascular Surgeon, and get the same service from him.

Now, when they get rid of you for whatever reason in 5 to 10 years, what are you going to do? You won't have a clue about running a practice and won't have real World experience cultivating your own practice. Maybe only then will you realize the value of what nail care has to offer. Are you getting the diversity of cases necessary for Board Certification?

Come on, part of your comments are just invalid. You state that they hired a DPM to do limb salvage since it’s cheaper than hiring a vascular surgeon.

I’m don’t think a DPM is ever going to replace a vascular surgeon. I’m not aware of any DPM performing bypasses or repairing aneurysms, etc.

And I think it’s unfair that you keep accusing him/her of not having any clue about practice management.

I know many super successful practices who are very well versed in practice management who do little if any nail care.

Some would argue that those who perform a lot of nail care may not be as well versed in practice management as they believe.

If he/she has chosen not to have a RFC practice and is thriving with doing limb salvage, reconstructive surgery, etc., then he/she has utilized excellent practice management skills.

It’s whatever floats your boat. I personally felt very unrewarded performing nail care. It’s not always about the money. I felt as if my skills and knowledge were being wasted by clipping nails, that literally require no training.

Your idea of being a practice management whiz is getting more nail care in the door. Mine is getting more challenging foot and ankle pathology in the door. I want to treat patients and hopefully heal them.

I’m not satisfied having patients come back every 61 days for their “haircuts”.

That’s why there is chocolate and vanilla.

 

[NobodyDPM]

Actually he is correct. Unfortunately in some states and geographic areas, DPMs are reimbursed at a lower level than MDs and DOs. This is factual as I have been an expert witness in lawsuits over this issue.

I personally would refuse to practice in a state that doesn’t have payment parity. But it does exist.

Come on, part of your comments are just invalid. You state that they hired a DPM to do limb salvage since it’s cheaper than hiring a vascular surgeon.

I’m don’t think a DPM is ever going to replace a vascular surgeon. I’m not aware of any DPM performing bypasses or repairing aneurysms, etc.

And I think it’s unfair that you keep accusing him/her of not having any clue about practice management.

I know many super successful practices who are very well versed in practice management who do little if any nail care.

Some would argue that those who perform a lot of nail care may not be as well versed in practice management as they believe.

If he/she has chosen not to have a RFC practice and is thriving with doing limb salvage, reconstructive surgery, etc., then he/she has utilized excellent practice management skills.

It’s whatever floats your boat. I personally felt very unrewarded performing nail care. It’s not always about the money. I felt as if my skills and knowledge were being wasted by clipping nails, that literally require no training.

Your idea of being a practice management whiz is getting more nail care in the door. Mine is getting more challenging foot and ankle pathology in the door. I want to treat patients and hopefully heal them.

I’m not satisfied having patients come back every 61 days for their “haircuts”.

That’s why there is chocolate and vanilla.

Bold mine. My idea of practice management is taking EVERYTHING that comes through your door and making the best of it. Not poo pooing an important part of private practice because you find it distasteful or that people will laugh at you about it.

And yes, super successful PODIATRY practices that do little nail care are a thing. But the poster I was referring to isn't in a podiatry practice.

I hear what you're saying and very much respect your opinion. Chocolate and vanilla, indeed.

 

[ExperiencedDPM]

Bold mine. My idea of practice management is taking EVERYTHING that comes through your door and making the best of it. Not poo pooing an important part of private practice because you find it distasteful or that people will laugh at you about it.

And yes, super successful PODIATRY practices that do little nail care are a thing. But the poster I was referring to isn't in a podiatry practice.

I hear what you're saying and very much respect your opinion. Chocolate and vanilla, indeed.

In all due respect, you’re stating YOUR practice philosophy. I don’t agree with the philosophy that you take EVERYTHING that walks in your door.

I’ve found that “like refers like”. So the more RFC you do, the more you get. I made a conscious decision that I didn’t spend all those years of training to perform nail care as a technician.

I never had a problem filling my schedule at an average of 48-55 patients daily. With maybe 3-4 nail care patients.

I personally feel that taking everything that walks in the door is a little desperate. Fortunately I worked hard to build the type of practice that suited my needs.

You’ve obviously done the same, though what makes you happy may not make someone else happy. That doesn’t translate into someone not understanding practice management.

 

[DYK343]

I never had a problem filling my schedule at an average of 48-55 patients daily. With maybe 3-4 nail care patients.

I would die. Teach me your ways!

 

[heybrother]

I know several people in each group mentioned, and I’m afraid that you may be disappointed to hear none of those groups have negotiated better payments from insurers. Hyer’s group is a split with DPMs, MDs and DOs. I’m sure that Weil’s group and Ornstein’s NJ group May have negotiated deals with labs, suppliers, etc., but none of them are big enough to negotiate a deal with the insurers. That happens with groups of providers of 100 or more doctors in a group that is statewide.

And it’s an insult to Lowell Weil to mention his name in the same sentence as Ornstein. Weil’s “group” is all one practice. Ornstein does not have a large private practice, but essentially has a group practice without walls. So his hand is in your pocket.

Interesting. We've started down the road of trying and perhaps it will be hopeless since we're tiny. I wonder if we'll simply end up dropping payors one at a time and then regrouping.

 

[HardRoadPaved]

I never had a problem filling my schedule at an average of 48-55 patients daily. With maybe 3-4 nail care patients.

I would die. Teach me your ways!

If you have 10-12 working clinic hours in a day, that's 10-13 min per patient. You must have one hell of a support staff or have an insane payroll to keep that afloat. (lets also ignore the time and energy to do notes unless you have a scribe too!)

 

[NobodyDPM]

In all due respect, you’re stating YOUR practice philosophy. I don’t agree with the philosophy that you take EVERYTHING that walks in your door.

I’ve found that “like refers like”. So the more RFC you do, the more you get. I made a conscious decision that I didn’t spend all those years of training to perform nail care as a technician.

I never had a problem filling my schedule at an average of 48-55 patients daily. With maybe 3-4 nail care patients.

I personally feel that taking everything that walks in the door is a little desperate. Fortunately I worked hard to build the type of practice that suited my needs.

You’ve obviously done the same, though what makes you happy may not make someone else happy. That doesn’t translate into someone not understanding practice management.

I'd agree with this.

That being said, a new practitioner should focus on building a practice. Cherry picking your patients at that stage of the game...good luck paying your rent and your student loans.

 

[NobodyDPM]

@ExperiencedDPM

Let's put this another way. You have to hire an associate. You have two candidates, both with equal training, both well spoken and good in an interview. One says there is no way they are cutting nails, the other says they are willing to do any work available to build their following.

Which one do you hire?

For me, the choice is a no-brainer. Assuming that associate stays with you for years, eventually they can shift their focus. But at first?

 

[HardRoadPaved]

Which one do you hire?

No brainer. The one willing to take that 75k base and 10% bonus starting at 400k with DME costs subtracted!

 

[ExperiencedDPM]

I would die. Teach me your ways!

You don’t want that volume. The stress level is beyond comprehension. I’d get home at night and take a run at 9 pm just to wind down a little.

It’s not something to envy.

 

[ExperiencedDPM]

If you have 10-12 working clinic hours in a day, that's 10-13 min per patient. You must have one hell of a support staff or have an insane payroll to keep that afloat. (lets also ignore the time and energy to do notes unless you have a scribe too!)

Yes, our support staff and number of employees was/is off the charts. Our assistants performed a lot of functions, though I never had ANYONE but myself remove or change a dressing. Just my idiosyncrasy.

I know how to balance things and get notes done. 90% of the time, by the time the patient leaves the office, the notes are completed.

I’m very focused, disciplined and anal. Having incomplete charts isn’t part of my make up.

And many of those patients are coming in for a relatively quick check up. I never had one patient complain that they felt rushed. I gave every patient the time needed.

 

[Steveington]

Yes, our support staff and number of employees was/is off the charts. Our assistants performed a lot of functions, though I never had ANYONE but myself remove or change a dressing. Just my idiosyncrasy.

I know how to balance things and get notes done. 90% of the time, by the time the patient leaves the office, the notes are completed.

I’m very focused, disciplined and anal. Having incomplete charts isn’t part of my make up.

And many of those patients are coming in for a relatively quick check up. I never had one patient complain that they felt rushed. I gave every patient the time needed.

Do you use a scribe? or do you do some/all of your charting in the room with the patient?

 

[ExperiencedDPM]

Do you use a scribe? or do you do some/all of your charting in the room with the patient?

No scribe. Been there and done that and it didn’t work as well as anticipated or expected.

Interestingly we had computers in the rooms and our patient survey results had a common concern. Patients felt that the doctors were spending more time “talking to the computer” than them. They felt it was a negative distraction. And in reality, they are correct.

The set up and size of our office allowed a dedicated and private space outside the treatment rooms, which was logistically easy for each provider and convenient.

Patients responded very favorably and it worked out very well. This must be done with planning to assure the screen is not in a vulnerable area that can be viewed by others.