solo vs group

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PWDMD

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Here is my situation; I will be finishing fellowship soon and am looking at two strong possibilities.

1. Join the major private group in a medium city. It is a 60min drive to where I would ideally like to live but I could compromise. There are 5 guys doing mostly bread and butter interventional plus stim trials with both a hospital-based clinic and a community clinic. It is a stable happy group that is aging with some of the members looking to cut down hours in the next few years with retirement possibility in several more years. They have a strong referral base and a full schedule. The office work is totally supervision of midlevels with staffing of new patients and any questions on return patients. The offer is: full benefits and approx 300+K to start x 3years, then 250k buy-in with 750k-1mil partner/yr. All the partners share the net practice income and then split the income based on hours worked.

2. Start a solo practice in a neighboring county (my home county area with a population about 60k) that is devoid of a pain presence. I could reliably get nearly all the PCP referrals in the area of three small cities/towns (approx 14 doctors). There is minimal neurology presence and no spine surgeon presence. The region has a fair-good payor mix. I would be looking at mostly bread and butter interventional with SCS trials and hopefully some kypho and other ancillaries/possibly PT. I have a fantastic consultant that is helping with the details of setting up the practice for a one-time fee. I would pursue a midlevel when the time came to help maintain the office flow while continuing to build the procedural flow.

I have always been interested in having my own business and doing things my way and I am very adaptable to better ways of doing things and wish to minimize delay and institutional hindrances so the solo route seems very attractive. I am certainly not risk-averse but I want to be sure if I start my own practice, that I am not missing out by not joining the group.

From a financial perspective: In my own practice, I would anticipate making slightly less than 300k the first year performing some anesthesia on the side. I would expect that the income would grow rapidly, but the question is how much and how fast given I would aggressively pursue interventional treatments (given the appropriate indications of course). Would my solo practice likely ever equal/beat the group practice monetarily? How likely? How soon? I realized that time spent, stress, and personal equity would be greater but it is something I have always wanted to do and it would give me great pride. I do realize there may be differences in economy of scale for various portions of overhead, greater risk, etc. I know it is near impossible to predict which I should do but I am nearly evenly split with my decision. 55 solo : 45 group

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The solo practice sounds like a great opportunity if you can front the start up costs and do anes part time. The money the group is claiming sounds shady anyway. Not many honest docs make 1 mil/year anymore.
 
To clarify; the production of the group is limited. With fewer partners, each partner works more but takes home more pay. When they add partners, the same overall amount of work is being done but with each doc working a bit less, so they take home less. They also own a small anesthesia business that provides 1 doc 24/7 coverage the labor epidural service. From 3 different staffed positions, they generate a daily grand total of about 72 short procedures (goes down if doing RFA, etc) and and about 48 office visits using the supervised midlevel model. The one partner I talked to mused that it was a block shop.
 
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How does 48 office visits per day generate 72 procedures per day?
 
That is a good question that I cannot answer.
I believe it was actually 60 visits (20x3). Sorry about that.
 
It IS a block shop. Which is fine if thtat is what your are looking for. Reimbursements go down, and you are SOL.
 
Food for thought I guess. I'll have to crunch some data.
 
It IS a block shop. Which is fine if thtat is what your are looking for. Reimbursements go down, and you are SOL.

If reimbursements go down, how are you somehow not screwed if you are not a block shop?

It's already pretty much impossible to make a living off E&M codes alone.
 
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If reimbursements go down, how are you somehow not screwed if you are not a block shop?

It's already pretty much impossible to make a living off E&M codes alone.

Diversify. I may also be screwed, just not AS screwed. Ultrasound, EMGs, injections, etc.

Totally get screwed if you sink all your assets in, and then reimbursements go down.
 
I think I'm going to get into cosmetic botox, microdermabrasion, skin peels, varicose vein treatment etc.... our society is vain enough to always pay cash for those services :rolleyes:
 
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Forget the group practice. Midlevels are for ******* nowadays. Furthermore, are you a pain doc or an Anesthesiologist? Screw that labor epidural BS.

Open your own practice and hire a partner instead of selling out to a midlevel. Sounds like you want to do it, have a good market, and this may be the last chance you have to have your own private practice, as traitor anti-american Comrade Obama is doing his best to destroy all private medical offices. Don't like it? Well, he can kill you, American Citizen, for no reason.

Midlevels are destroying our careers, Comrade Obama will see to it that midlevels eventually replace almost all physicians as they are cheaper and stupid enough/hungry enough to do what the gov't tells them to do.

I'm not joking. Midlevels and Obama are massive threats.
 
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Forget the group practice. Midlevels are for ******* nowadays. Furthermore, are you a pain doc or an Anesthesiologist? Screw that labor epidural BS.

Open your own practice and hire a partner instead of selling out to a midlevel. Sounds like you want to do it, have a good market, and this may be the last chance you have to have your own private practice, as traitor anti-american Comrade Obama is doing his best to destroy all private medical offices. Don't like it? Well, he can kill you, American Citizen, for no reason.

Midlevels are destroying our careers, Comrade Obama will see to it that midlevels eventually replace almost all physicians as they are cheaper and stupid enough/hungry enough to do what the gov't tells them to do.

I'm not joking. Midlevels and Obama are massive threats.

Midlevels are here, regardless of whether you want them or not. Either learn to work with them, or bury your head in the sand and congratulate yourself being in such a good spot in there that you cant see them. its too far out of the box for midlevels to ever go away.


hire a partner entails a lot of concerns. if you dont know if you can make it on your own, then it is illogical and a huge leap of faith that you would make it with 2. then again, if your head is in the sand...


imho, go solo for a year - no partner, no midlevel. see what the market is really like. many a store goes out of business when reality strikes.

see what your reimbursements are like. if you are making 800K a year after all expenses are accounted for, then get a partner by all means. if you are making 200K, have a 3 month wait time, and are hoping you can push it up to 500K, then think about a midlevel.

but hire a good nurse or two, a good secretary, and even a good practice manager first.
 
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midlevels are here, regardless of whether you want them or not. Either learn to work with them, or bury your head in the sand and congratulate yourself being in such a good spot in there that you cant see them. Its too far out of the box for midlevels to ever go away.


Hire a partner entails a lot of concerns. If you dont know if you can make it on your own, then it is illogical and a huge leap of faith that you would make it with 2. Then again, if your head is in the sand...


Imho, go solo for a year - no partner, no midlevel. See what the market is really like. Many a store goes out of business when reality strikes.

See what your reimbursements are like. If you are making 800k a year after all expenses are accounted for, then get a partner by all means. If you are making 200k, have a 3 month wait time, and are hoping you can push it up to 500k, then think about a midlevel.

But hire a good nurse or two, a good secretary, and even a good practice manager first.

1+
 
I think I'm going to get into cosmetic botox, microdermabrasion, skin peels, varicose vein treatment etc.... our society is vain enough to always pay cash for those services :rolleyes:

I will be working with an integrative medicine group practice (FP, IM and Chiro) and doing mostly cash based PRP, prolo and OMT few days a week as I build my practice. They have a large patient base which helps. They already do cosmetic botox, laser hair removal, anti aging etc. In my opinion cash based practice is the way to go.
 
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you can make a living off E&M codes --- just look at any non-surgical/non-diagnostic specialty...

in fact medicare pays as much for 99214 as it does for 64483....
 
I did the deed yesterday. I turned down the group and am going full steam ahead with the solo practice. Right now I'm scoping out real estate. Currently, there is a ton of buzz in the community regarding my arrival. Any ideas for a good business name? "Xxxx pain and spine"

Thank you for all the excellent advice so far! :thumbup:
 
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I did the deed yesterday. I turned down the group and am going full steam ahead with the solo practice. Right now I'm scoping out real estate. Currently, there is a ton of buzz in the community regarding my arrival. Any ideas for a good business name? "Xxxx pain and spine"

Thank you for all the excellent advice so far! :thumbup:
_____ (insert state/county/city name) spine institute/specialists. I would stay away from adding pain to the title.
 
I did the deed yesterday. I turned down the group and am going full steam ahead with the solo practice. Right now I'm scoping out real estate. Currently, there is a ton of buzz in the community regarding my arrival. Any ideas for a good business name? "Xxxx pain and spine"

Thank you for all the excellent advice so far! :thumbup:

I'm also going solo; I've incorporated as XXXXXX Pain and Spine Physicians. Most of the "spine" in my future town is chiropractors so I wanted to make the medical nature of my practice clear. It's also been a personal mission of mine to use the term "physician" instead of "doctor," in this age of noctors and PToctors and Dr. Chiropractors.
 
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I did the deed yesterday. I turned down the group and am going full steam ahead with the solo practice. Right now I'm scoping out real estate. Currently, there is a ton of buzz in the community regarding my arrival. Any ideas for a good business name? "Xxxx pain and spine"

Thank you for all the excellent advice so far! :thumbup:

Vicosomaxanax Laser Institute of America.
 
I'm also going solo; I've incorporated as XXXXXX Pain and Spine Physicians. Most of the "spine" in my future town is chiropractors so I wanted to make the medical nature of my practice clear. It's also been a personal mission of mine to use the term "physician" instead of "doctor," in this age of noctors and PToctors and Dr. Chiropractors.

Chiropractors can call themselves physicians. For the common public it is really difficult to differentiate who is a MD/DO vs Doctor. We might want to consider adding M.D. into the title somewhere.
 
Jeebus and PWDMD,

I'm glad you guys decided to start up your own shop from scratch and I hope you guys have good luck with it. It would be great if you 2 could make a sticky or some kind of blog to keep us updated on your progress. It would be great to hear about the ups and downs of starting a practice from scratch so we could learn from your successes and mistakes
 
I wish you the best of luck with the solo practice, please keep the forum updated with how things go! I am in the process of applying for pain fellowship, still optimistic about the future despite the doom and gloom rumors stirring around
 
apparently 75% of solo practices will be gone by 2014 (NASS editorial)....
Sorry man, the doom/gloom is real.
good luck.
 
I did the deed yesterday. I turned down the group and am going full steam ahead with the solo practice. Right now I'm scoping out real estate. Currently, there is a ton of buzz in the community regarding my arrival. Any ideas for a good business name? "Xxxx pain and spine"

Thank you for all the excellent advice so far! :thumbup:

"Stick it to em LLC":laugh:
 
Xxxx county interventional pain management group inc
Or
ninguna clínica del dolor
If you have Spanish patients.
Good luck. I am happy that physicians like you are taking in this challenge and stick it to the big corporate hospitals.
 
Xxxx county interventional pain management group inc
Or
ninguna clínica del dolor
If you have Spanish patients.
Good luck. I am happy that physicians like you are taking in this challenge and stick it to the big corporate hospitals.
Well, it looks like the challenge they took was over two years ago. Any update?
 
Well, it looks like the challenge they took was over two years ago. Any update?

Still in business. Growth is slower than anticipated but it is growing. There are a couple of pain doctors in my area who I expected to retire already but are still busy working, one is 75 years old! They are well-respected in this community so it's hard to redirect their referral base. Once they retire I think things will pick up quite a bit. Surgeon referrals have been directly correlated with my referrals to them, so this should grow along with the rest of the practice. It's a saturated area but a great place to live and raise a family, and my income is slowly increasing.

I'm glad I had the balls to do this out of fellowship. I don't think I could have made the transition from a guaranteed paycheck to this, but now that things are a little more stable, I think it would take a lot of money for me to give up being the boss.
 
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Still in business. Growth is slower than anticipated but it is growing. There are a couple of pain doctors in my area who I expected to retire already but are still busy working, one is 75 years old! They are well-respected in this community so it's hard to redirect their referral base. Once they retire I think things will pick up quite a bit. Surgeon referrals have been directly correlated with my referrals to them, so this should grow along with the rest of the practice. It's a saturated area but a great place to live and raise a family, and my income is slowly increasing.

I'm glad I had the balls to do this out of fellowship. I don't think I could have made the transition from a guaranteed paycheck to this, but now that things are a little more stable, I think it would take a lot of money for me to give up being the boss.

What do you think your greatest challenges were in the beginning? Anything you wish you had known when you started?
 
Still in business. Growth is slower than anticipated but it is growing. There are a couple of pain doctors in my area who I expected to retire already but are still busy working, one is 75 years old! They are well-respected in this community so it's hard to redirect their referral base. Once they retire I think things will pick up quite a bit. Surgeon referrals have been directly correlated with my referrals to them, so this should grow along with the rest of the practice. It's a saturated area but a great place to live and raise a family, and my income is slowly increasing.

I'm glad I had the balls to do this out of fellowship. I don't think I could have made the transition from a guaranteed paycheck to this, but now that things are a little more stable, I think it would take a lot of money for me to give up being the boss.
Good for you. I have been solo for 15yrs after 8 yrs in academics. Trying to hang on to my autonomy.
I wish you the very best of luck. You made it happen during very tough times. I'm impressed.
 
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Midlevels are here, regardless of whether you want them or not. Either learn to work with them, or bury your head in the sand and congratulate yourself being in such a good spot in there that you cant see them. its too far out of the box for midlevels to ever go away.


hire a partner entails a lot of concerns. if you dont know if you can make it on your own, then it is illogical and a huge leap of faith that you would make it with 2. then again, if your head is in the sand...


imho, go solo for a year - no partner, no midlevel. see what the market is really like. many a store goes out of business when reality strikes.

see what your reimbursements are like. if you are making 800K a year after all expenses are accounted for, then get a partner by all means. if you are making 200K, have a 3 month wait time, and are hoping you can push it up to 500K, then think about a midlevel.

but hire a good nurse or two, a good secretary, and even a good practice manager first.
OP...your area seems perfect for you to open up a place with minimal competition. ...its always better to be your own boss . You can never get fired !!
 
Still in business. Growth is slower than anticipated but it is growing. There are a couple of pain doctors in my area who I expected to retire already but are still busy working, one is 75 years old! They are well-respected in this community so it's hard to redirect their referral base. Once they retire I think things will pick up quite a bit. Surgeon referrals have been directly correlated with my referrals to them, so this should grow along with the rest of the practice. It's a saturated area but a great place to live and raise a family, and my income is slowly increasing.

I'm glad I had the balls to do this out of fellowship. I don't think I could have made the transition from a guaranteed paycheck to this, but now that things are a little more stable, I think it would take a lot of money for me to give up being the boss.

Keep your hand in the fire.
 
Started Solo practice after fellowship in Sept 2013... steady going sice then. See about 5-6 new patients, 15-17 followups and 12 procedures including 1 RF / day. AVG 32-35 patients a day. This is M-T. Friday is 5 new and 5 RF's. 1-2 stim trials / month and 1-2 kyphos per month. No pumps. No OxyContin or Soma prescribed ever. Handful of inherited patients more than 30 MED per day. Most patients on 10-15 MED per day.

First Question I ask patients. "Do you ned help with you pain or are you here for Pain Pills." Lots of patients drop off but not worried. No opioid battles. No advertising. Word of Mouth. One happy patient will bring you 5 more. Also one drug seeker who leaves unhappy will tell his other friends. Over the past year, the seekers have sought refuge elsewhere often cancelling appointments after being referred.

PCP's prescribing pills is still a huge issue in my area but I still take patients by referral only.

My consultants name is SDN PAIN MEDINE FORUM.

You will be fine. Follow your instinct.
 
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Having your own small business is the best decision you can ever make....Next would be to own your own property and rent to your self. Finally get some surgical center ownership of possible, to create some linkage.... Hopefully Hillbillary will continue to support backbone small businesses and preserve solo practice ...continue to fight the fight, the ACA is fragile and they will negotiate rates of 150-60% of Medicare , trust me
 
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Having your own small business is the best decision you can ever make....Next would be to own your own property and rent to your self. Finally get some surgical center ownership of possible, to create some linkage.... Hopefully Hillbillary will continue to support backbone small businesses and preserve solo practice ...continue to fight the fight, the ACA is fragile and they will negotiate rates of 150-60% of Medicare , trust me

I don't think anyone puts in the hard work and sacrifice required to graduate from medical school and says to themselves, "I want to work for some a$$hat hospital administrator." But, our profession has caved under pressure and little-by-little sells itself out to the large physician employers. There could be no ACO's or monopolizing hospital groups if MD/DO's stuck together.
 
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I don't think anyone puts in the hard work and sacrifice required to graduate from medical school and says to themselves, "I want to work for some a$$hat hospital administrator." But, our profession has caved under pressure and little-by-little sells itself out to the large physician employers. There could be no ACO's or monopolizing hospital groups if MD/DO's stuck together.
It's not just our specialty... It's all physicians. Remember when the cardiology society tried to sue the government when their reimbursement fell 40%.... Not one lefty news station cared to cover it... That was the beginning of the end of private practice...
stay tuned, Supreme Court decision regarding federal subsidies may be a game changer...
 
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Supreme Court decision regarding federal subsidies may be a game changer...
No it won't. Even if they strike down the subsidies, the Republicrats will pass an emergency patch clause, that allows the subsidies. Obama then signs and ACA sails on smoothly. Hell, they might even do it in secret. They're passing this Pacific Trade bill in secret, right now.
 
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No it won't. Even if they strike down the subsidies, the Republicrats will pass an emergency patch clause, that allows the subsidies. Obama then signs and ACA sails on smoothly. Hell, they might even do it in secret. They're passing this Pacific Trade bill in secret, right now.
The truth of the matter is that I don't mind the ACA remaining a limited option paying a commercial rate( they try to pay a Medicare rate, but have caved ). The real problem is that the deductibles for none subsidized ACA insurance is 6k for my mother, for instance... Not really so affordable.
 
The deductibles on obamacare are so high, I doubt there will be any kind of outcry if "coverage" is lost. Except in the media of course, who will proclaim the apocalypse is upon us.
 
bronchospams and lord jeebus....working hard with 35 patient/day in solo practice...can you give us an idea of your yearly take home or reasonable collections/year, including what is overhead? thinking of biting the bullet to go solo, but don't have the guts yet...!
 
bronchospams and lord jeebus....working hard with 35 patient/day in solo practice...can you give us an idea of your yearly take home or reasonable collections/year, including what is overhead? thinking of biting the bullet to go solo, but don't have the guts yet...!
Those numbers bronchospasm quoted are insane. If I were to guess I would say he's billing well over 300k per month. If his % collections is 50% then he gets over 150k/month. That equals about 2 million per year. Not sure the % overhead but you've got to have a decent amount of help to see those numbers in an 8 hour day.
 
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