Solo private practice

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Apr 5, 2024
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Hey guys, long-time lurker here in my mid-40s. I've been a solo employed general ENT in a small town for several years. I'm extremely busy, with very strong reputation and referral base, but hospital administrators are making conditions toxic and unsustainable. I'm planning on leaving but need to figure out my next steps. I'd like to run my options by you and get some opinions.

Option 1: open my own private practice in the same small town as long as I can get my non-compete waived. I would continue to operate at the same hospital. I would be immediately busy from day 1 with 25-30 patients a day with the same great referring docs. My biggest issues are I have zero experience running a practice, and learning it would eat significantly into my personal time. I'm also concerned about our payer mix. We have a very high medicaid and medicare population. I've looked at the rates and figuring overhead at 50% or so, I'm concerned I would take a huge pay cut. This is also why the hospital has become toxic. They're losing a lot of money and we're being accosted about production and "numbers".

Option 2: there is another solo private practice person in his sixties in town. I've thought about approaching him with the intention of eventually acquiring his practice. I figure that a couple of years of mentorship and a turnkey operation may ease the transition. That still doesn't solve the payer mix problem...

Option 3: leaving the town altogether and joining a not-too-far-away large single specialty ENT private practice with ancillaries and ASC. Better payer mix, and the large group would allow for further efficiencies of scale, way less call, but ultimately less control. After having no control for so long, I need more control in my professional life.

Option 4: doing a sleep fellowship and doing sleep telemedicine along with ENT locums. That's the ultimate lifestyle change after being so busy for so long.

Any thoughts?

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I can say that my first step would be to approach the established guy in town. Tell him you might be interested. Definitely tell him you’re not certain yet what you’re going to do so he doesn’t get the wrong idea. Ask him a lot of questions about how he deals with his overhead, payer mix, what he’s seeing in AR from different insurances, and depending upon how friendly he is, how he’s doing financially.

Here’s the thing: either he’s interested in someone joining and buying his practice or he isn’t. If he isn’t, it’ll be a short conversation.

If what he says is too good to be true, it probably is, but if you joined him you could always leave before you buy in. After all, in that case he sold you a turnip cart.

If what he says sounds terrible, then he’s either trying to get rid of you or it’s not a great idea to stay locally.

All this being said, if you go to him and then end up starting your own practice in the same town, he might not be extremely happy about it. Depends how much time he has left working.

That conversation would probably help me decide where to go next. And I’m assuming you want to stay where you are, otherwise why not move?

The sleep fellowship/locums idea is basically just changing careers. I’m not $#!tying on it, but it’s almost another path entirely.
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Good advice above. All of your options are potentially viable. Without knowing any additional info, I agree that option 2 is likely preferable to option 1 if you want to stay in the same town. Obviously, your personal/family situation and your financial net worth play a big role in your decision too.

One thing to keep in mind re. payer mix: Medicare and Medicaid may pay less than some private plans (Medicaid more so than Medicare), but at least they actually pay for all/most of the service. More and more private insurance plans carry high copays, high deductibles and max out of pockets, and your patients can and will balk at paying hundreds or many thousands of $$$ out of pocket for scopes, audios, and procedures. Many of my patients with "good insurance" cancel surgeries when they find out how much it costs (usually the facility fee is the issue more than my fee). This is not an issue with Medicare or Medicaid. The best of both worlds is good private insurance with good benefits- people who work for govt or huge corporations are more likely to have those types of plans.
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I'd agree with the others. Reach out to the other guy in town and pick his brain. It will give you a reasonable idea of the landscape and what your next steps might be. If he's late career, I doubt he cares if you stay or go from a competition standpoint. He's got his own thing going and he's likely just biding his time. But he might be very interested in a transition plan. If it's an "undesirable" area he may jump at the chance to unload his practice to a willing buyer.
If you've been established in this small town for years, there is little to no advantage to buying this guy's practice. You can certainly aquire the assets (office endoscopy equipment, real estate, chairs, scopes, etc.) but there is no need for goodwill as you already have an established referral base.

When I started solo someone wise told me - 'if you can learn to operate, you can learn to manage a practice'. Start your insurance credentialling 6-12 months before you jump ship and it will make your life much easier. Just don't count on getting your non-compete waived. Those things can be nasty.