Home Forums Discussions General Discussion help keeping myself afloat

OK-so here is my "situation". Let me pick your brains.
Was recruited by a regional hospital to open up a practice in the area
(NJ). The area is still rural but growing. They had a space all ready
for me that was left over from a previous practice. Although the
space was a little too big for me, they promised they were going to
get someone to sublet the space from me to "help out" Part of the
recruitment agreement includes $25K/mo to cover overhead for 2yrs and
then the loan is forgiven if I stay in the hospital catchment area
for another 3yrs.

Here's the catch. One year out-I am running a tight ship-one staff
member, doing all of my billing etc. They have NOT found anyone to
sublet the space for me. I have about 550pts, but am only bringing in
about $12k per month. I really cannot afford or justify keeping my
office space at $3400/mo(utilities included). however the hospital
placed me in a lease for 3yrs(not 2).

I am stressed out. I am working long hours in order to accommodate my
pts and bring in more money, I am doing cosmetic procedures to help
supplement(no botox cause that costs money) and I am looking for
supplemental jobs like increasing my Nursing home pts and doing
physicals at the local addiction center. Being solo-I am not seeing
great reimbursements(as I am sure you all know)even though I am a
member of an IPA. I don't know where to take it from here. I am
worried about the future and quite frankly am beginning to feel a
little burnt out.

Any suggestions?

Have you tried to recruit a:

-- podiatrist
-- chiropracter
-- psychologist
-- nutritionist
-- dentist
-- or some specialist physician that may benefit from your referrals (s.a. a gastroenterologist, pulmonologist, oncologist, rheumatologist, etc)

There are many possibilities. I'm currently considering subleasing to a dentist.

Note: once the lease is over, you should look for a property to BUY. Since I've purchased my next-to-hospital office in 1995, it's gone up 300% in price (it's now worth ~ $1 million, even in a depressed market), and at the end of next year my 15 year least ends, which is when life gets really good! I've been able to offset the mortgage payments with rental income in about 7 of the 12 years, which is great.

My father, a surgeon, rented for 30 years an office which I took over upon his death, and I too rented for 5 years. After 35 years of property usage, we had absolutely NO equity, and I was paying $5000 a month for a 1500 sq ft office from 1990 thru 1995. I'm now paying ~$3000 to pay off my mortgage and to pay condo fees on this 2100 sq. ft property. Don't stay a renter for life. Look for a decent purchase option. You can discuss the situation with the hospital and see if they are willing to sell you the office.

Good luck!

AL

I would consult a lawyer to see if you can break your lease under the condition that the hospital did not hold up their end of the deal. Even if it is not in the actual lease agreement, I believe you would have a case of false promises being made. I would also push the legal envelope and see if you can get out of the entire contract with the hospital. Take your 550 patients and head for the hills! And, DO NOT RENT!! Like Al said, buy, buy, buy. Also, look into mobile services such as bone density scans, Echos, Holters and other vascular studies. If it is a really rural area and you are not close to a large pharmacy like Wal-Mart, look into dispensing your own generics from your office (check your state laws first). I can give you a few tips there if you want to PM me.

Leslie

Leslie,
I like the idea of the moble stuff but was always a little unclear as to how this all would work. There are lots of hang us up anti-kickback laws, so how does having someone come by with their moble unit work for us in offices such as ours. Are you adding some "value Added" service or what?

Purchasing is possibly a good thing in most markets but here values don't move that much and one still needs enough money in the bank to afford the down payment, closing costs and the like to be able to afford the purchase in the first place. Ya know, those damn rich doctors! lol

Paul

Paul,

For the mobile studies (again check your state laws), you actually lease the service. You provide the site, the equipment and the techs by contracting with a vendor. For the vascular studies you then charge for the technical component of the exam while the cardiologist who reads them (in my case this is all worked out by the vendor) charges for the reading. I then pay the vendor a per-test rate for using his equipment and techs. For bone densities, I charge the commercials the whole fee...technical component and readings and then pay a per exam rate to the vendor. For Medicare, I charge only for the reading. The vendor charges for the technical component. I have been doing bone densities like this for several years. I have been doing the vasculars/holters for about 8 months and I have to say, I believe this additional revenue has been very important in keeping my head above water. As far as the argument that one will order more tests if one makes money off them is perhaps a valid point. However, let me also say that I have picked up an enormous amount of disease that would otherwise gone undetected because I am more apt to do the tests. I have picked up 3 critical coronary artery disease patients this month alone because their ECHOs were abnormal (symptoms were minimal and EKGs were non-specific). All 3 ended up with either stents or bypass. Also, there are some commercials, Humana for one, who urge their subscribers to have studies done in the office rather than the hospital which is much more expensive...by about 30%.
I also had concerns initially that the cardiologists would take offense at my doing "their" exams. However, their meat and taters are the caths and stents and if my doing the tests initiate more referrals to them them we should all be happy... and they are.

Leslie

Leslie,
Thanks for that informative reply. This really sounds like something most of us micro primaries should be looking into more. I for one am certainly going to run this by Nancy.

I'm curious about something. Do you have any idea how much your testing rate has changed since you have started this model of testing? It would be neat to see what the increase in testing for was for what kind of increase in picking lurking problems earlier.

I ask because I am attempting to make the argument like other IMP'ers that really good access to high quality primary care, costs more and should pay much better to the primaries on the front end, but in the end will pay major dividends in saving on the back end in less expensive care in ER's and specialists now attending to issues run amuck. Increased access to good care should save money down the road no less improve outcomes and improve over all general health...

Great suggestion there for those of us struggle out here. And if it is a better level of care, then all the better. Shame they just won't pay you folks to do what you actually do so well and work so hard at....

Paul

Sofia,

I do inpatient work to help supplement my practice (actually at this point it has provided the only two checks that my new little business has received, LOL). I know this isn't practical in most cases-I'm just hoping it will help get us through this first year.

I will be praying for you and your situation. Please take time to take care of yourself-get a massage, exercise, etc. That time for renewal will help you through this tough time.

Blessings,
Vicki

SF...could you explain further for me? You are receiving 25,000 in loans per month for the first two years? You are now bringing in 12,000.00/month. It sounds as if you are following a low overhead model and have keep all controllable costs low, except the lease.

The hospital recruited you but strapped you with high ofice overhead. They obviously wanted you. You mentioned that you are in a rural area? Is it a physician shortage area? Can you set up a rural health clinic and bill at cost reimbursement? You are one year into your package. Prior to pulling out the legal begals, can you renegotiate with the hospital for half rent until your practice is up and running, and remid them of their promise to recruit other tennants. Do you know any of the Hospital board members who might have a sympathetic ear to your plight? Can you work the ER to help build your practice? The hospital obviously wanted you in the rural area, it's in there best interest to help you become successful. Can you start a local health column in te local paper? or raio spots with a health moment from Dr. Fernandez?

Staring as a solo is not easy, but you are doing it. I've been solo for 19 years, from the start. It can work.

Tom

Paul,

I do not have the numbers comparing my practice habits before and after the mobile testing but I know I order more now that the tests pay me something. My threshold for referring for these tests is definitely lower and my antennae are much more tuned to symptoms, family history, etc. which might prompt me to order the tests. Also, watch what tests are being done on your patients when they go to the hospital or the ER. Many get a multitude of tests whether they need them or not. At least I do use some medical judgment before ordering and I do have to sleep at night with an unburdened conscience. So I make sure there is justification and good medical reason do order the tests. Personally, I think I am providing better medical care. As I am sure all of us know, it gets hard day after day to listen carefully to patients and to sometimes not just say "Oh, I don't think that is anything to worry about" and send them out of the office with nothing. Now, I seem to be paying more attention to what otherwise might be trivial complaints and uninteresting family history. For instance, I just sent a patient for carotid endarterectomy after finding a 90% lesion on doppler. Her only symptom was mild dizziness which wasn't even the reason for her appointment. I might have otherwise dismissed this but the antennae went up and I also learned her younger sister just had an endarterectomy and her brother had a stroke last year. So, I feel like having the ability to do these tests has benefited my patients as well as me. Do a Google search and see if there is anyone offering these services in your area.

Leslie

Leslie,
Very cool indeed. I'm not razzing you. It's just that I am making a pitch to a fairly ethical carrier here to perhaps be the revolutionary one to pay the primaries really well to slow down a lot, let us do our job, and in the long run outcomes on the back end for ER, specialists, disease run amuck will start to kick in and there are some interesting pieces of research that indict that such a model could and and should work.

So if we were to start testing more often I would love to be able to analys it in such a fashion... I will probably be in touch with you about this more as this seems like a very legitimate way to increase care and revenue at the same time and so it is appealing to both myself and Nancy... Thanks for your sharing and tips....

Paul

OK, that's it. I am asking Jon for a personal jet called AC-1. I could fly around the country helping ACers everywhere with any issues they may have. The added bonus being I could fly to Indiana for my healthcare needs with Dr. Strouse (have to call her that if she were my doctor). Of course if she were booked, I could fly over to Dr. Roberts. They are just very good doctors.

Now I don't want to get audited by writing anything self incriminating, but I just don't feel that guilty for upcoding to a 14 when I am getting paid what little I am getting reimbursed.

DISCLAIMER: THIS IS NOT TO SAY THAT THE REST OF THE DOCTORS IN AC LAND ARE NOT GREAT DOCTORS.

(Hangin' my head and shufflin' my boots in the dust...) Gee willikers, Mr. Bert, I ain't all that special. I's just trying to keep my hands on the front end of the heifer so's they don't end up stuck in the back end. But even when you got a holt of the front end them horns can still stab you in the eye!

Leslie "Annie Oakley" Strouse

crest-The way the recruitment agreement works is they give me "up to 25K". I have to hand in my reciepts so, if I made 12k in a month, they would only give me 13k etc.
Believe me, I have done all the marketing you could think of...the newspaper column, etc. People are coming in, just not at a rate that is satisfactory. I am negotiating with the hospital...just not too hopeful...they are "under economic stress" as well...or so they say!

Are there any older physicians around where you are who might be looking to retire soon? I was finally able to get over the hump in terms of volume when I picked up several patients from 2 friendly physicians who gave up practice and gave my name out. Also, hospitalists can be a good referral source, as several patients (with good insurance) will end up in the hospital and not have a physician to follow up with. NO DOC call in the ER used to be a good source, yet you are at higher risk of acquiring patients you may not want (i.e. uninsured substance abusers).

Also, what other physical space is available to you. Are you in a building where other suites are available? If so you may be able to negotiate a move without breaking your lease (My position would be "Downsize me or I'm bankrupt and you have nothing.") If that option is unavailable, what is the penalty for breaking your lease? Hopefully, you used a lawyer to review everything, but if not, you may want to retain one to see what exit strategies are available to you. Best of luck.