Home Forums Discussions Feedback and Recommendations how do you know when it is time to hire more staff

OK-so I started my solo practice(FP) 11months ago. I am now seeing 30-40 per week, pt base is about 400. I have become affiliated with 2 nursing homes(have about 4 pts) and am doing some laser hair removal in conjunction with a local spa. I have one LPN and myself and we are balancing the phones, pts, pre-auth/referrals and billing. I am starting to feel a little burn-out. Between seeing patients, managing the business, billing and figuring out pre-auth/auth/referrals/fighting claims etc-I am a little tired!

I guess my questions are:

1) when do you know you need more staff members? Would you add a receptionist/biller/lpn/multitasker?(what would you suggest)

2)When do you shift your schedule to accommodate other things like Nursing home rounds or in my case-laser procedures?(I am trying to make myself available as much as possible and I start to feel guilty when I am not available)

3)Any solo practioners have any suggestions as far as practice management/hours of operation etc? (I am currently open 8:30-5 MWF, Tue 12-8 and Thurs 11-7 and one Sat a month from 8:30-12:30)

4)any billing suggestions? when should I outsource if at all? I could totally use a better tracking software-Amazing charts and Office ally just aren't cutting it!

Thanks for your help. All of your suggestions are appreciated!

Great questions: They are the type of things we all wrestle with every day. We are looking at them all the time as well. In our area like most, the paperwork out paces the payment of staff needed to handle the volume of that paperwork. We could really use one more person here to kind of help deal with the phones, allowing the MA more time to assist, start visits and the like.

I would look for a multi person myself as this is what we are considering too. A bit of phones, a bit of filing, and bit of insurance companies garbage, kind of float around as needed but certainly not a real medical person like an RN or the like.

Imagine your lawyer doing all this paperwork for you based on the professional work he had performed or was going to perform for you. Whether his admin assistant or his paralegal did it, you know it would certainly end up on his itemized bill, probably calculated by clock hours. It simply amazes me how we in on this side of the business are coersed by the cartels to do all this management and paperwork on the house for them. They continue to bill the employer customer for care management, but they never seem to get around for paying our side for our share of said paperwork or managment....

Anyhow, good luck in the choices you face..... Love to hear how you are handling them....

Sfernandez,
I am solo FP, on my own for 3 years and in practice a total of 5 years. I started like you did, bare bones. but when you feel the growing pains it's time to losen the belt so to speak. I have built my practice up to around 2,000 patients and have been closed to new patients (except close family members of existing patients) for nearly 2 years.

Since you asked specifically about hours of operation, 8:30 to 5 is pretty good. To capture the working class folks, consider opening very early or staying later. I am open 7AM-4PM, and will stay as long as patients need to be seen, as late as 5:30 or 6PM seeing patients (acutes). I work only until noon Fridays. I ALWAYS fill the early morning slots with working folks, because they can see me before work and don't have to use sick time or lose money. Alternatively you could be open 10AM to 7PM, for the same purpose as what I achieve by opening early.

I do my inpatient hospital rounds either before office hours or after the day is done, depending on the situation. I see nursing home patients once weekly on Sundays, and therefore don't lose money taking clinic time out of the office for low reimbursing Medicare SNF patients.

For billing, I use Emedware by Sage Software. I have a fulltime biller. You could probably get by with a good billing software system and a all-in-one, biller/secretary type person. You don't need more clinical staff until your practice is bigger.

Some questions I have for you: if it took 11 months to build only 400 patients and you see 30-40/week, what is the market for solo FP's in your area? Are PCP's needed there, or is the market saturated with PCP's? Do you have a concierge type practice or cash only model that allows you to afford seeing so few? I only have perspective from my location in rural Maine where we are really hurting for FP's, and we turn away 4-10 people per day who call seeking to establish w/ me. I had to close to new patients within 9 months of opening. If the market is really poor, it might be worth considering changing to a different location where the need is higher.

I hope this helps generate some ideas for you. Good luck!

Hockey, you know they pay you for the paperwork1 You know how they pay you about 1/3 of FMV for your work (wel, your wife, my sister) Well, its included in that!

And you know the psychological evaluation you had to perform because the patient insisted they had a lump of mucus in their throat? Well, since you did it during a preventive visit, that's included too! See, its covered. Oh, but if they didn't have a physical symptom and just said they felt depressed, then its not covered since you aren't credentialed with the separte Mental Health Group.

Oh my goodness! I don't usually spout off like this. Must have had a bad day. May an insurance company did something to set me off.

Wayne,
Ya know these abusive insurance companies, collectively known from here on as "The Cartel"; and their bundling and claiming what they didn't pay for is still yet a "covered" service really remind me of two things.... First off, the old "Orwellian New Speak" we have spoken of many time in the past. But they also remind me of the old Soviet Union commrade, "they pretend to pay us and we pretend to work". Pretty pathetic....

Let's stop highjacking this decent thread with our bitchin' and let's take it to my "CARTEL" thread instead... Keep the faith my friend...
Paul

sfernandez:

Before hiring more staff, consider staying small and lowering your overhead further, as in the Ideal Micro Practice model.

Here are some resources related to this concept:

Articles by Gordon Moore:
http://www.aafp.org/fpm/20020200/29goin.html
http://www.aafp.org/fpm/20020300/25goin.html

There is an excellent Yahoo listserv group devoted to this concept. You have to sign up for the group, but if you pose this question there, I guarantee you will get a lot of great answers:

http://health.groups.yahoo.com/group/Practiceimprovement1/

One more related site:
www.idealmicropractice.org

Brian,
You posted a few others that I read the other day and they really got me thinking... As a matter of fact Nancy and I are going to have a "meeting" to discuss some of what you laid the seeds for... Either you have lead us to a more enlightened place and we will be forever in your debt, or we will fall flat on our faces with this big change in business model, and be oh so much more deeper in debt... lol

Anyhow perhaps you could post those links as well because they were good food for thought too.... I'm having trouble finding them now.... Been a long weekend and a couple of days around here. But I think that this thread would be the perfect place for those other links....
Paul

Paul:

I think you are talking about Dr. Horvitz' blog. He has a practice like the ones described in the above article.

http://drhorvitz.blogspot.com/

Here's his main website:

http://www.DrHorvitz.com

If this is not it, let me know.

Let me throw my 2 cents in. I have been in practice for 20 years, solo for 10. Keep your payroll as small as you can for as long as you can because it is your biggest overhead. On the other hand, you need to have a practice that flows well and does not appear stressed. Patients pick up on that and are not always so understanding when it takes days and days for you to get back with them on tests or results or questions. Personally, I believe a small practice has to have people who are cross-trained. All of my employees can do most of everyone else's job except the finer intricacies of the billing. If I were hiring a new person (as I just did) I would hire a primary biller, maybe even just start them out part-time. Once they have mastered your billing system, expand their duties so they can answer the phone, make appointments, get referrals, call patients back. Also teach them to deal with the vendors, perhaps handle payroll, and take over some of the duties which are now bogging you down. Then teach them how to bring patients back, do vital signs, enter info into AC. And, although hiring people with experience is sometimes nice, don't refuse to consider people with absolutely no experience. Sometimes it is better to train them yourself, do it right the first time, the way you like. I hired my sister (absolutely no medical experience) 7 months ago and she can almost do anything I need in this office (although she prefers giving shots to horses more than to people!) The benefits of cross-training are obvious. When one employee is on vacation or is ill, the others can cover adequately for them. My two full-time employees alternate weekly front or back office in order to keep their skills sharp. It also provides each with variety in duties (good thing) and a fair sharing of the "grunge" tasks. I have just hired a new part-time person who is learning the billing (with the object of replacing eventually my long-time biller who will be retiring soon). But, she will also learn the front and back office at least well-enough that she can cover if needed. The other benefit to cross-training is allowing for checks and balances. I often surprise employees by asking them to switch tasks unexpectedly. For instance, I may ask Lindsay to open the mail and make the deposit (not her usual daily job), and then have Ann post. This "shake-up" keeps people on their toes and, I believe, also reduces the threat of improprieties. Having only one person opening mail, posting and making the deposit can be a set-up for embezzelment.

Anyway, good luck whichever direction you go. Long Live the Solo Practitioner!

Leslie

Leslie,
Well said and well thought out... Just wish we could afford those people on the CCHIT they pay around here for fees... But I must say I really like your model and perspective...

I'm going to give you a practice consultants view on this. Even though I do manage my sisters practice, I'm growing my consultancy.

Leslie hit alot of it right on the head. But after 20 years, she wouldn't still be in practice if she didn't.

Now, you're going to sense when you NEED to hire someone, because things won't be working quite right. In fact, it will be darn stressful. The trick is to anticipate this in advance, plan your growth and hire for the anticipated manpower needs.

As Leslie said, you want people that can work in different roles as needed, even if one particular task is their primary duty.

Keep that payroll as small as is practicle. But its better to pay a really capable person a little more than to pay a marginal person a lot less. That capable person will pay off in spades. We finally have a kick-[censored] MA and she is worth her weight in gold. I remember when I hired her. She had gone to one of these MA programs and was working as a receptionist for a chiropracter. She wanted something more clinically based. I interviewed her for 15 minutes, excused myself, and came back 10 minutes later and gave her a verbal offer. And offered more than we had planned because we couldn't afford another--I don't want to say it. But you know what I mean. Anyway, Dr. Coghill returned from her trip and I said "Meet Aneka, our new MA."

Use technology to automate anything you can. Get the lab interface for AC. Try out IMH. If it doesn't work for you, stop using it. But its good to see if you can use it to streamline operations, especially if you have a website.

I am a big believer in outsourcing. Peter Drucker coined a phrase that businesses should "stick to the knitting." Do what you do best, and let others do the rest. This includes billing. (a round of "boooo" is heard.) But you must be very careful about an outside biller. Very very careful. It seems that it is better for small practices to go with a small biller and have a close personal relationship with that person. And keep tabs on them. But if you can't find a reliable outside biller, then you have no choice but to bring it in house.

If you have a decent MA program near, you can try out some MA interns. Cycle through them till you get one that is really good, then hire that one! WARNING WILL ROBINSON! YOU WILL GO THROUGH A LOT OF BAD EGGS TO FIND THE GOLDEN CHILD. Make sure the program puts them through their paces. If you draw blood in the office, the MA program should require the students to complete 15 successful blood draws to pass the class. (25 is better). If its only five--leave that school alone! And remember, the intern is not there just as free help--they are there to learn. Take time to teach them what you need. The first two weeks they will be more hindrance than help. But after that, they are actually contributing and happy to do it (well, the good ones are. )This coincides with Leslie's statement about not being afraid to hire someone w/o experience.

You know, that crosstraining thing is REALLY important. I'd recommend that your receptionist be a medical assisant that perhaps is more geared toward (or just is competent in) administrative tasks as opposed to clinical. They will better understand how to schedule patients. And they can go take vital signs and do an EKG too. This will free up your LPN to do other higher-level tasks (when your volume get up).

As far as hours, I'd only say to have at least one day where you are open early(8 AM) and one when you are open late (6 or 6:30 last appointment. Maybe later). Otherwise, it depends on your specific practice and what you want to do. If you are an FP or Ped, you might want to have at LEAST 1 Sat a month. Internist seeing adult only. May not need the Saturday (not in NY, anyway).Depends on the clientele.


I could keep going, but I'm hungry.

I skimmed through this. I thought Adam would touch more on this.

I would add the following in order of importance:

1. Biller
2. Biller
3. Biller
4. Biller

and then and only then, would I add a

5. Biller

No, in all seriousness, you can work from 7AM until 11PM, but as Paul and Adam and everyone else will tell you, if you don't have an experienced biller to do the forms correctly and follow up, you are nowhere.

I have only done this solo thing 15 months completely taught by Adam and my practice consultant, but I think a biller/code who can do reception and secretarial is better than a secretary who can learn billing. I would rather the appointment be done wrong than the HCFA. (Is that the right term?)

When you are feeling burnt out, that is a clue. Maybe cut back on the nursing home -- again, Adam and everyone -- how lucrative is that versus seeing four more patients in the office.

Consider temp agencies and get employees for little money without benefits. See how it goes. You aren't committed to them.

CAVEAT: I know little about this stuff. My practice consultant does all of it. But, I am getting there.

I have followed this post for a few days - it is important to make sure you are utilizing staff for what they do best - the billing person is probably the most important ancillary staff you can hire. I like many others have my spouse doing this - she cares about revenue and has a vested interest in the office doing well.

I agree about nursing homes - I do them, but I consider that one of my contributions to the greater good - I don't make any money doing them.

I think technology is great - use amazing charts, scan things in, learn to use the e-mail in AC, but don't get caught up in a technology craze and spend a fortune. I use lots of very inexpensive computers in my office and they work well.

Take all of our advise and use what you can - I have been self employed for over 6 years and learned it all as I went along. The one person I had to help was an experienced biller who helped us set up and get our billing program going.

Steven,

Good advice. I do what you do with a slightly different take. I use inexpensvie computers where I can while brand new very expensive and very fast computers lie dormant in the corner of my office.

I'll wait for Adam to comment on this one.

Bert,

You are a genius! My mentor and brother in Christ, you have reached a completely new level of ingenuity.

Who would have thought that the cheap, old, and slower computers would have more utility than the very expensive, newer, faster computers? You are Da' Man!

What I am most amazed about is how similar you are to Alborg. He's always posting those pictures of his computers half-way taken apart. When I was in your office, I noticed your server was all apart and in pieces, just like Al's.

Does it work better when your server is in pieces?

Help me figure out how to take mine apart, please?

Adam, you are so misguided. The advantages to having your server in a hundred pieces are many. First, it is much easier to disconnect the SATA cables and power supply to each hard drive than to power the computer off from the Start button. The fans also keep things much cooler in the office when they aren't blocked by the annoying case. Don't like what you see on screen? You have to push the monitor button which takes at least ten seconds. Much easier to just pop out the video card. And, what better way to keep your NVRAM flushed, then to pop out the system board battery. And, that $80 battery on the RAID controller fits perfectly in my cell phone. So, there are your advantages. If you see any disadvantages be sure to let me know.

Only one disadvantage Bert that I can see.

With the case wide open to the elements, what do you do when you spill coffee DIRECTLY ONTO THE CPU/MOTHER BOARD?

The advantage though of dumping your coffee INTO the server, I suppose by short circuiting all of those annoying switches, transistors, chips, and processors, the electrical conduit can simply go every all at once......making for a much faster computer? Am I right on this one?

Well, close. Actually, I did spill coffee on it once but luckily Dunkin' Donuts screwed up again and put sugar in the coffee. This protects the circuitry. It doesn't really matter, though. as I have 24 hour onsite HP support, and they can come clean up the coffee spill and throw in another mobo.

And, I am sure people love that we have "hijacked" this thread, lol.

What's new, pal??

Actually if you'd saved a donut for mop-ups, that should work too! (Professional advice from a biller/coder, always go for the experience!!)

It's like I said. Biller, Biller, Biller. I just give my biller/coder coffee and donuts and she collects all day.

Pardon me for asking, but you also actually give her a paycheck as well?? That will help with her gastric bypass expenses.

Paycheck? Is that the rectangular piece of paper with the stub at the end? If it is, then no.

I am bitterly disappointed in you, Bert. And I was going to apply for a summer job with your office! Forget the donuts, I want lobster...

Oh, now that's a different story altogether. Name your price. Any salary plus all the Maine lobster you can eat. Plus, the donuts.

You DO know that I have dozens of witnesses to that, right? Are you putting me up in a nice B&B with a view room? This is getting to be very tempting!

Right over the Penobscot. And, please keep up the banter, because Adam is trying to catch me on the posts, lol.

Sounds like a new full-time job for our friend Adam! But you have led the way with your pithy posts. And it always helps when you reply to your own posts! But, as you request, I will hold my end up, at least until Adam makes a better offer!

that's a great deal, she bills and collects for you all day, and you only have to feed her coffee and donuts.
Geeze, I have to PAY my biller.....
I must be going about this all wrong.

Could you guys just get a hotel room and get it over with already?

See Bert and my Nancy have got us.... It's all in the flirting. I was gonna say something but these two opposite sides of the country flames do need to get on with it already... Glad someone said it first...

Hey Donna does Bert have "enough life in him"??? Thank goodness the closest of the two of you is at least 400 miles away or I'd be running for the hills....

Bert has life in him, this I know.....not that I know from personal experience however....(not that there's anything wrong with that!) <<JOKING>>

Now Adam you're supposed to say that in a chorus like fashion with NYC Jewish (takes one to know one) Accents.... "Not that there's anything wrong with that"

Now Donna Nancy and I used to be in a hard rock band together as kids and young adults, that's how we met as teenagers. Anyhow, we used to keep trying to get this song together called: "A Good Man is Hard to Find" and the chorus went like this:

"A Good man is hard to find, and a good man is hard, I'll tellin' ya baby I'm the man for the job...."

Our old singer Mike used to love it, but we could never put the finishing touches on it, to make it "right" for playing out, but we used to love to jam it late at night.

Cheers
Paul

Uh Adam, consider yourself lucky. Have you seen how many donuts Donna can eat?

Donna, I bet you think that post was about you, don't you?


Just in case anyone forgot, this thread was about how many staff do you need.

Lauer:
Demographically, I am in a "needs" area of NJ. It is rural Western NJ. I was recruited by a regional hospital with a forgiveable loan in order to drum up buisness for them in this catchment area. I did do the research and the demographics. Apparently, all of the physicians in the area are "slow" right now. NJ is a more competitive market than where you are. I did do some marketing-advertising, yellow pages,church bulletins, health fairs.I accept all of the major carriers/insurance except for Medicaid. I do a well baby clinic in town once a month for the working poor. Many of those families do eventually get insurance and have come to me. I also am doing cosmetic procedures at a local spa as well as work in 2 nursing homes. SIGH
I don't know what else to do to get the people in the door.

I appreciate all the input regarding the staff issues. I am going to hang tight for right now. I have MA students that will start rotating here for free starting in July-that should be some free extra help.

M.A. students is a great idea, especially if things are QUIET. There, I said the "Q" word, the one we were taught to NEVER say in the E.D. But I am hoping that my superstition will work in the intended manner....drum up more work for you. So you should go to work everyday and say, "Gee, it sure is quiet around here." Before you know it, you'll be turning new patients away.

I've used M.A. students, I don't like them because they take away from my staff whom are busy. Therefore that slows me down when staff can't tend to my every need. (Yes, Bert will tell you I'm a prima donna)

If you are having loans paid, then that's a huge piece of overhead you don't have to cover.

In 5 years of clinical medicine, I have found the most dramatic advertising is word of mouth. If a doctor dedicates him/herself to the patients and demonstrates caring, then patients will tell a FEW friends/family about the doc. However if the doc is rude or uncaring to them, they will tell EVERYONE not to go there.

Nearly all of my new patients have come as personal referrals from family or friends that are patients of mine. Rarely has someone every come in who said, "I'm here because you are on my insurance list."

Sfernandez, sounds like you are doing everything you can to attract new business. Keep up the hard work, and have faith that things will improve. Hang in long enough, and they will.

SF,
Here's an interesting thing to check. The first year we opened, Excellus the BC/BS Cartel in our area didn't get Nancy in almost any of their product books and even dropped the ball on some of their web listings too, although that was better.

So like they would sign up a new employer group, hand out these books with docs to pick from and we weren't in there, so nobody knew to even try us! I was pissed to say the very least. So make sure if you are going to dance with the devil, at least you get what you were promised which is their promotion of you in all of the right places that they do so.

Also, try and get your local paper, even some of the smaller Pennysaver, or small town specific type ones to do an article about you and your practice. Try to figure out a hook about you or your practice. What is unique, important or different about your practice. Like the fact that you have been brought in for the purpose of bringing quality care to this underserved area. That sounds really good and casts you in a positive light. We told our personal story about fighting to stay in CNY even as the economic winds (they closed her residency in mid training, what an F'ing nightmare that was) were trying to get rid of us. And that Nancy is just a mom next store type, who wants to be that old fashioned local family doc.

First off this will make it more likely that they will do a story on you, and two try to make that "hook" fit the patients or people that you are really trying to get in. I used to run ads a lot at the begining when things were "slow" or "quiet", but nothing made the phone ring more than journalism. It really gives you a chance to show who you are and what you're all about. And I think part of it, whether the public is aware of it or not, is that an article about you gives you an air of "legitimacy" verses advertising. Anybody willing to pay can take out some ads, but you have to be somewhat "worthy" to get some free ink. And there is no advertising like free advertising....

Try it you'll like it..... Now my media consulting fee for this consultation is.... Break a leg.
Paul