Monday, December 3, 2012

How To Make Money as a Family Doctor

     Since the feds seem to think I made a good living by illegitimate means, and because I would like every burgeoning doctor or wannabe ought to know how to succeed at the business of family medicine, I provide here my instructions for wild success--at a price--as a family doctor.

      Helpful Prerequisites:  
          1.  A burning desire to succeed.
          2.  The necessity for success, or you won't eat.
          3.  Children to take care of, because no one else will.
          4.  Lots of debt, accumulated from a costly education.

          Find a location to practice.  Ideally, this would be a place where there are lots of people and no doctors.  Don't worry about whether it's been a successful location in the past.  Don't worry about the demographics of the population.  You can adapt your clinic to your patients' needs.
          If you have access to loans, borrow money.  Put up your own property as collateral, or ask someone who believes in you to co-sign.  Don't tell yourself you want to wait until you know you'll be successful to construct the clinic that will be successful--that's putting the cart before the horse.  You must know right from the start that you will be successful, no matter what.
          Plan to buy land and a building.  Don't lease or rent, if you don't have to.  There are so many clauses in lease arrangements that you're bound to end up ensnared by one of them--after all, leasing companies make money by getting people like you to make it for them.  Why do that?  Ignore your accountant, when it comes to this.
          Consider what equipment you can install.  This should be based on your skills.  If you don't have skills that might be useful to your patients, acquire them.  For example:  learn to perform and interpret x-rays, ultrasounds and CT scans;  figure out how to set up an in-office lab, and apply for a Level 2 or 3 CLIA designation;  make sure you are able to do a variety of skin surgeries, including plastic repairs;  offer Holter, ambulatory blood pressure and nocturnal oximetry testing;  consider doing sleep studies;  do Pap tests, endometrial biopsies, Implanon, IUD's and colposcopy;  learn the usefulness of nerve conduction studies;  set up IV stations;  do wound care and Unna boots;  learn how to do hemorrhoid banding, cryo and infrared surgery;  learn to do stress tests.
          Read the CPT code book and circle every procedure that might benefit your patients.  Learn the procedures you don't know but would like to offer.  Then print out from the Medicare website the ICD-9 codes that will support those procedures.  Make an encounter form that represents all the procedures you plan to offer, with the most common diagnostic codes alongside each procedure code.  Create "macros" in your software system, so that entering charges and procedures is a streamlined process.  Whenever you see a patient, you want to make it easy to identify what you did, and why, at the visit.  Your billing personnel should not be responsible for figuring out what you did and how to code for it.  As the owner, you should know more than anyone about coding and billing for medical services, because in the end you are responsible for everything.
          Give up the idea of doing hospital medicine.  The invention of "hospitalists" liberates you from having to waste time traveling back and forth to the hospital, a trip which is unlikely to be convenient if you decide to practice in a rural area.  Your goal should be to keep patients out of the hospital.
          Make sure you are up-to-date on immunization guidelines.  The CDC changes these every six months.  It's important to know, however, that the CDC's recommendation that a certain population be immunized an immunized doesn't mean the insurance companies will cover the cost of immunization.  Examples of such lacunae are:  Medicaid does not cover flu shots;  Medicare doesn't cover the shingles vaccine, and Medicare doesn't cover Tdap.  While this doesn't make sense, it's a waste of time to argue with insurance companies.  At some point, you may wish to become involved in the politics of medicine, but right now you just need to be successful.  Remember, your kids won't eat if you fail.
          Market your practice.  The most important way to do this is to have an office that markets itself.   Your practice should be a place that attracts patients because it provides excellent healthcare and one-stop shopping. Your biggest source of referrals will be your patients.  If they're happy, they will tell all their friends and relatives to come to you.  If not, you're doomed.
          Look at your office.  Is it clean, neat, organized, and representative of your ethics?  Are there many ways for patients to learn about their own health?  Does the waiting room have a play area for children, as well as a quiet section for folks who don't like children?  Are your employees warm, compassionate, intelligent people?  It's worth paying for an excellent cleaning crew to come after hours and keep your office sparkling.  Contract with a floor-waxing company, software-repair people, and hazardous waste removal.  Make sure you have a way to get every piece of equipment serviced the moment you need it--having equipment that is out of order make you seem ill-prepared.
          Visit the local post office and arrange to have flyers placed in every mailbox for the zip code areas your clinic will serve.  Ask someone who knows computer graphics to design an informative, professional-looking flyer to send out.  Include a coupon for $5 to $25 off the first visit if the recipient brings the flyer in--that way you can track how well this advertising mechanism works.  Place an ad in one or more of the small newspapers or coupon-papers that are distributed locally.  Print out business cards and give them out to people you meet, as well as to other local businesses.  Find out when the Chamber of Commerce has meetings, and attend them.
          Offer to do free health talks at places like the Rotary Club, Lion's Club, churches, schools, library, nursing homes and Town Hall.  Bring your flyers and business cards.  Contact the local home care and oxygen supply agencies, since you'll need their help anyway--they can get the word out that you have a new clinic.
          Hire employees based on their ability to communicate with patients.  You can teach almost everything else.  Write job descriptions for every position in the office.  Determine how much to pay by looking up the standard pay rates in your county and state, and paying more.  Set up a monthly bonus scheme based on attendance, acquisition of new skills, and job performance.  Take notes throughout the month on employees, paying attention to when they add value to the practice as well as when they fall short, and let them know in writing each month why they received one bonus amount rather than another, and how they can do more for patients and for you.
          Always do what's best for the patient, even if this won't add to your bottom line.  It is never right to sacrifice people for profits.  As an old friend of mine once said, "If you do good work, you'll always have work."  If you don't care about people, and if you can't feel your way into your patients' problems, you should not be in medicine.  Make sure every employee shares your concern for the well-being of your patients.
          Work very hard.  Consider putting in 80 to 100 hour weeks.  Keep your office open 24-hours a day, 365 days a year, if possible.  This will mean hiring one or two other physicians, and several mid-level providers.  Your overhead won't change much--but your productivity will--if you use your office space maximally.  Patients will appreciate knowing your office is open when they get fish hooks stuck in their backs at 7 pm, cut themselves with chainsaws and know you can do x-rays and sutures, have abdominal pain at 11 pm, or stay up all night with a feverish child, and want to be seen at 5 am.  At the very least, keep your clinic open from 6 am to 10 pm seven days a week.  Knowing that you'll reopen at 6 am usually allows patients to wait until morning to see a doctor.  Most patients prefer never to go to the emergency room, and this is appropriate.
          Do house calls.  Learn how to determine whether a patient needs a house call or not, and whether  insurance companies cover them.  Patients are neverendingly grateful to doctors who will come to their homes when their circumstances are dire.  House calls are interesting ways to accumulate information about patients,
          Don't fall prey to the notion that because you have your own business you can come and go as you please or get lax in other ways.  Check out every area of the office multiple times a day, including the patient restrooms, waiting area, exam rooms, and supply closets.  Show up on time for work every day, and keep an eye on every work station.  Schedule mini training seminars for employees within certain areas, giving them updates on current treatment guidelines, teaching them how to administer tests properly, or giving them health information that they can pass on to patients.  The smarter everyone is, the better the clinic will function.
          Teach everything you know, at every opportunity.  When you get home at night, read journal articles--at least several a day-- so that you may continue to learn about your field, because medicine is an every-changing business.  Keep abreast of coding and documentation guidelines, as well as insurance rules about coverage for procedures.  Stop doing procedures that aren't covered by insurance or permissible as self-pay services, and add new procedures based on what will be useful to patients and covered by their insurance policies.  Be aware that many services you provide on a regular basis as part of an office visit may be billable as separately identifiable services, with their own CPT codes--for example, substance abuse counseling, smoking cessation, toenail debridement, diabetic neuropathy foot exams, counseling for depression and anxiety, critical care, emergency and prolonged office visits, and house calls.  If you learn how to use modifiers correctly (especially -25, -79, -59, and -51) these services are often covered in addition to office visits, boosting your charges and reimbursing you for all your extra work.
          Above all, be ethical in all your actions.  When there is a choice, be generous.  Don't use collection agencies, and don't charge patients for missed visits.  Don't reprimand them for being late, and always take walk-in and same-day patients--you never know how sick they may be, and they are especially thankful to you for not having strict rules.  Donate to local charities and fund-raising efforts--at least $100 to anyone who asks.  Buy girl scout cookies, candy bars, and trinkets from students who are trying to pay for uniforms and trips to historic places.  Give children prizes at every office visit, and listen to adults when they tell you they have financial problems.  Don't deny important medical care to patients just because they don't have money.  Don't prescribe controlled substances except under clearly defined circumstances.  Be prepared to handle drug and alcohol abuse, as well as domestic and child abuse issues with love, compassion and firmness.  Be the kind of doctor you would like to have as your doctor.  Don't forget that everything comes right back to you, good and bad.


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