I think that this (my new practice) is what medical practice is supposed to be like. People choose to come here because it suits their needs, not because we take their insurance. They think about how much things cost, and ask good questions about what is really needed, and what the options are. I have enough time now to add some new services and procedures, and to take the time to investigate them. I don’t feel so utterly exhausted every single day. I’m not always on time, but it is better (you can’t always completely manage variety!).
We are getting a lot of return business, but also getting plenty of new patients every day. These new patients are people we would have had to turn away in the past, because the schedule was “log-jammed”. A lot of them do not need anything ongoing, just needed a visit or a procedure. Most of our referrals are from other patients, rather than from other physicians. The biggest challenges are now normal business challenges, of managing resources, optimizing work flow and service, getting the word out, constantly looking at how to improve, keeping the business financially healthy.
I remain very involved in physician-led efforts to have real health care reform (meaning trying to get obstacles and red tape out of the way, focusing on what patients need and want on an individualized basis, and on achieving much better value). It is too bad that it is so politicized. I also feel that it is a shame that so many people seem to think that there is one magical solution, that one size fits all, or that government knows best. I feel that if we pruned back the strangulating regulation, we could innovate our way out of this mess. After all, we are Americans, and that is what we do best: innovate. We need more freedom to do that, not less. There are a lot of agendas out there besides what is best for patients and the practice of medicine. I like the idea of “creative destruction”; meaning that if something isn’t working, we shouldn’t subsidize it and enlarge it, but scrap it if necessary and find a better way! If we could achieve much better value (and we could!), the need for the safety net would be smaller.
I am still really irritated that many commercial health insurance companies are so resistant to reimbursing patients without CPT codes. We are completely up-front with patients about this. CPT coding is incompatible with transparent affordable pricing, so I don’t do it. Out-of-state companies seem to reimburse without difficulty, though. To me, it is about honoring their contract with their subscriber, even if it is inconvenient for them. Patients certainly expect that their insurance company will pay them under “out-of-network” coverage, but they don’t expect their insurance company to balk at this because the doctor chooses to bill based on time.
http://par8o.com/wordpress/the-cpt-conundrum-essential-to-healthcare-or-the-downfall-of-medicine/
Our practice is doing very well. We have an issue with some of the commercial insurance companies refusing to reimburse patients without CPT codes. We have a write-up in The Lund Report on this issue. I can’t put CPT codes on, with all their little non-nonsensical rules, when I do time-based billing. CPT makes transparency and affordability impossible!
Medicare continues to be in a frightening situation; I’m glad that I am out of it. They are making it impossible to practice medicine properly within it; more so with some specialties and in some areas than others.
I apologize for not updating the Forum or having a Facebook connection; we have been very busy getting the new practice open. We have had a lot of spam get into the Forum, and I think that I will close that part of the site.
Anyway, we have been open for three weeks, and it is going great! I am so happy not to have to follow bureaucratic rules that don’t make sense to me. We have had many comments on our beautiful facility. I feel happy practicing this way. More later….
There are still many, many details left, even though the office renovation is pretty much complete. We have met with a great person to do our window treatments. I have to do the Opt Out of Medicare affidavit and send it to the local Medicare carrier (Noridian). This is very critical, and has to be sent in before 30 days prior to the opt out date, which has to be the first day of a quarter (our date will be July 1, and so it has to be in before June 1). I have to put together a price list, which I have started, and which will be posted on the website. My husband is working on the website and doing a great job. He has gotten phone numbers for the office. We are still working on choosing a sign for the building. Everything costs money!!. Due to my husband’s foresight, the office has a great alarm system, closed circuit television for security, outside lighting for safety at night. We are having the small courtyard landscaped. Gaps in the concrete at the entrance have been repaired. We have purchased the last of four exam tables through e-Bay, which is a Ritter 75 Evolution motorized surgical table (second of two, with other two rooms having non-motorized tables).
There are many banking details, including refinancing our building and getting it under the name of our company. We have had an attorney help with some of those details, as well as our banker.
I have been giving out letters to patients at their appointments, but will soon need to mail out letters to all patients, especially notifying them about opting out of Medicare, as that is a requirement. There is so much bizarre stuff going on at the state level, that I am just so glad that I am doing this. All these ever-increasing rules and regulations cannot be helpful to patient care! Discussing the changes with patients at appointments is time-consuming but important. I have been utterly amazed and overwhelmed at how supportive most people have been, including my Medicare patients. I think that many of them know that the status quo is going to disappear under what is happening with Medicare, and that currently good care is being given with increasing difficulty! Well, back to work on forms, price lists, etc.
The new office is going to be beautiful; not extravagant but well-planned and very functional and nice. We have excellent contractors, electrician, plumber, carpenters, cabinet-makers, etc. The floor plan looks great. The carpet, paint, vinyl flooring, laminate for cabinets has been chosen, and it is a pleasing color scheme. The money has been going out like crazy, but the end-product is going to be right. It is good that we have been careful with our resources, or we would not be able to do this. We should end up with very little debt, hopefully. We shall see.
The cornerstone of a free market seems to be freedom for all parties to make choices that are beneficial for themselves, thus achieving the best value. Adding the JudeoChristian ethic in there, we may choose to be charitable out of abundance, not out of martyrdom, and not because it has been stolen for redistribution. So, that is all to the good.
When the government gives special privileges or monopolies to any group (AMA, unions, etc), eventually the money gets tight. The government can’t easily admit that it has over-promised or that conditions have changed, and then there is covert rationing. Teachers, doctors, others who are paid by way of “other peoples’ money” end up being paid more than society can support, and the best ones may make too little and the worst ones may make too much, because it is impossible to measure true value without the free market (try as the government might try to measure excellence with numerous and expensive bureaucratic requirements). Covert rationing then punishes those who need or use more resources. Students who need extra time only get it from teachers who really care about doing a great job. Patients who need extra time only get it from doctors who really care about doing a great job. Virtue on the part of the provider of the service is punished under this system, because the needs of the consumer are at odds with the needs of the provider of services. Any system that relies on martyrdom for excellence will eventually fail.
This is a list of recent things we have done, on the path to opening my new practice, tentatively about four months from now. My practice consultant (my husband!) is busy buying equipment for me, with my input and approval. He is able to get good buys on new or near-new exam tables, autoclave, microscope, etc. on e-Bay, as he purchases on e-Bay for his own company. It is still a lot of money.
We have looked at carpet and vinyl flooring samples, paint chips, and met with a cabinetry guy, in consultation with our general contractor. Floor plans have been reviewed and revised. My husband designed a logo for me, with my input and approval. We met with a sign guy. We have drawn up an affiliate agreement with my current practice. We have registered the business name with the state. We need to have all the legal stuff done (create an LLC) before opening a checking account. We have met with our accountant with a formal business plan. Lots and lots of details, even with a direct pay (cash practice) model. I cannot even imagine opening a practice which deals directly with insurance companies and government!
My husband and I met with the general contractor again today. We have set a tentative opening date, but don’t yet have prices for our building remodel. We do have architectural drawings, and are fine-tuning the floor plan. We will get some price estimates in the next month or so, I think. We are figuring out our finances, and where the money will come from. We are also planning to draw up an agreement for affiliation with my current group. After that, we will start working on how to communicate with various groups, including current patients, potential patients, local medical community, etc. Some word is “leaking out”, but it isn’t really a secret. If people ask me, I’ll tell them, but until we have some more concrete plans, I’m trying not to tell too many people, partly out of courtesy to my group.
Others going to a direct pay (cash model) practice may not be in the position of opening a whole new office. I still hope that at some time, HSAs (Health Savings Accounts) might be a reality for more people, and that might make it easier for other doctors and groups to move to a direct pay model. I’m just not holding my breath to wait for government to make some smart moves! They are instead currently putting in place what will either turn into a tiered system (public health care and private health care, with people in essence paying twice for private care), or a totally single payer plan that doesn’t allow private care. I don’t think that Americans will tolerate a single payer plan with it being illegal to go outside the system.
I am trying, in my spare time, to read “The Road to Serfdom”.
I met with the general contractor and architect today, to plan our space, in the vacant part of the building my husband and I own (along with the bank, of course). I met last week with the administrator of my current group, because the group would like to keep me physically in the building, if possible. I really appreciate that, but I just don’t think it will be financially viable, with a cash model. We will see. I will need money to make the new space usable for a medical office, as well as for equipment and supplies. There are a lot of things to remember to do. The time course is about six months from now. We have a business line of credit, and some other areas we can draw from. It will be tight.
As I think about pricing structure for medical services, while paying my personal bills and making my estimated tax payments, I realize how much my personal tax bracket plays a role in setting prices for services. A significant portion of the doctor fee goes to pay the doctor’s personal income taxes, and my time has to be more expensive because of my tax bracket (kind of Yogi Berra-like, I make too much to charge less). Being in a high income tax state (Oregon), close to half our income goes to taxes. When politicians talk about “the rich”, and people talk about tax rates affecting small businesses, we are talking about people like me and my husband. We feel like we do nothing but work, and yet we have constant concern about how to pay for everything. We are worried about our taxes going up, come January. So many people live on so much less, and I realize how difficult that is for them, but I don’t feel that it is right that we should pay more than we do. Some equity is necessary to start and run a business! You can’t ever accumulate much equity if the tax rate is too high.
I found this great blog, the Covert Rationing Blog,
http://covertrationingblog.com/
when on Sermo, (on-line physician site), at http://www.sermo.com/
Especially pertinent (in the Covert Rationing Blog) is a posting that Dr. Fogoros (Dr. Rich) wrote on July 12, 2010: E&M Guidelines Undermine Patient Care, and That’s The Point. It talks about some very scary issues regarding E&M coding and upcoming RAC audits from Medicare contractors, who are paid as bounty hunters for catching physicians, (who have to play this ridiculous coding and documenting game, if they participate in Medicare).
I go to work, think that everything looks normal, and ask myself why I am changing what doesn’t look broken. Then I think about this RAC stuff, and realize how broken Medicare is. This stuff started before PPACA (Obamacare).
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