Dont Be Afraid To Start A Solo Practice

Despite what you read and hear, solo private practice is not dead. Very few private practices fail. If you are a medical student, a medical resident or a dissatisfied physician practicing in a large group practice, go out on your own. You can still hang your shingle and do well.

It is true that the proportion of physicians in solo or two physician practices fell from 40% in 1996 to 32% in 2004. Certain specialties are more amenable than others. Obviously, radiology and anesthesiology would not be appropriate but primary care, pediatrics, dermatology, family medicine, ophthalmology, plastic surgery, rheumatology, Infectious diseases, gI, neurology, surgery, vascular surgery, hematology oncology, and geriatrics to name a few, can all be done, if you understand how to do it. Nowadays, small groups and solo practitioners adapt to a changing environment. They use hospitalists to provide on call hospital coverage, they use purchasing groups to get the best prices on equipment and inventory, they understand how to negotiate insurance contracts, and , best of all, as private practitioners in solo or small group practices, they are their own boss and make more money than their large group counter parts.

For 25 years I have heard naysayers herald the apocalypse of medicine. It is far from true. When I went into private practice, HMO's were going to take over medicine and "physician networks" were going to exclude doctors from seeing patients in certain geographic areas. Nope. Didn't happen. So don't worry. Don't be afraid to take the step into opening your own practice. You won't regret it. Just be prepared.

Liability Reform Proposed in House of Representatives

Georgia Republican Rep. Phil Gingrey, MD proposed a bill sponsored by Lamar Smith R-Texas and David Scott D-Ga to reform nation's medical liability system.

The Health Act H.R. 5 would limit the following:
1. period of time during which plaintiff could file suit
2. limit non economic damages to $250,000
3. require judges to apportion responsibility for judgements in cases with multiple defendants
4. limit the percentage of all damages that could be claimed as legal file.

The AMA and AAD supports it.

This is the most logical bill I have read in a long time. Of course, the lawyers will not let it pass so continued defensive medicine practices will raise cost of medicine for tax payers and doctors will continue to pay exorbitant malpractice fees.

There is an abuse of the lawsuit in America. The mentality of a lawsuit "score" by lawyers and plaintiffs achieved on the backs of doctors trying to help patients in an imperfect world is crushing the delivery of medicine. It is inconceivable to me that any health care reform is not attached to liability reform. This glaring omission is evidenced of partisan politics with health care reform reflecting a continued control of lawmakers but none other than...lawyers.

Physician Signature Rule

CMS plans to rescind the requirement for clinical laboratories to obtain physician signatures when billing Medicare for laboratory requisitions. Labs lobbied hard to CMS to repeal this burden. This was part of the November 29, 2010 Medicare Physician Fee Schedule Final rule. Due to heavy criticism the required implementation was delayed until April 1, 2011. Now it is being completely repealed before ever being implemented. That is a good thing. But....

The real issue here is how much does it cost to continually delay, modify and repeal onerous and burdensome paperwork dreamed up by bureaucrats with little to no clinical experience "in the trenches". Maybe if they listen to the doctors struggling day to day in private practice first, then they would avoid costing taxpayers presumably millions of dollars in "change fees".

The first thing Senior residents and fellows need to do to be ready for private practice

At this point, most senior residents and fellows are thinking about their next move. And, for most, it is joining a group practice or starting their own medical practice.

Private practice is waiting and there are a few critical steps that every fellow or senior medical resident must have in place before they venture out into the real world.

Here are just a few quick bullet points to check off your professional to do list and remember: apply for NPI number, register with PECOS, CAQH, make sure your medical license is valid in the state you will be moving to practice, and apply for a DEA license.

The next step would be interview with professionals that will help you be successful. This includes accountants, board certified health care attorneys, insurance agents, and banks. You should be looking to set up a line of credit with a bank that is familiar with doctors needs.

Watson will change medicine forever

Anyone that watched Jeopardy last week saw Watson handle the best of the best when it came to answering obscure questions in nanoseconds. It was fascinating and scary. Nuance and IBM announced collaboraton on Watson. Healthcare is the most obvious next step. Watson will make a huge difference in diagnostic medicine. Access to a computer that can digest symptoms and instantaneously spit out answers and syndromes, will provide immediate benefit to practicing physicians and to patients.

Watson will not replace the intangible benefit of "healing hands and heart" of a physician patient interaction (at least not anytime soon) but it will immediately even the playing field for patients in remote locations or for those who cannot afford the luxury of the brightest doctors at the best academic centers. If you have ever been sick with a rare set of symptoms, then Watson will help scan millions of data instantaneously to match your symptoms to a diagnosis or at least a set of possiblities.

Medical students will have Watson as a teaching tool and that will also help even out inequalities in teaching.

No one here is saying that Watson will replace the ability of a doctor to interpret a patients symptoms, call for help, or need for intangible emotional care that the best doctors can provide and read into their patients needs. Critics will yell about Watson but they will be wrong. In this case, technology moves forward and will yield overall positive benefits.

Key Provisions related to Medicare and Medicaid Extenders Act of 2020-Physicians get reprieve

In December Physicians averted at 24.9 % cut in their income as a result of a last minute passing of The Medicare and Medicaid Extenders Act of 2010. Here are the key provisions:
1. Replace scheduled cuts with a freeze in Physician payments from 2012 to 2020.
2. Direct CMS to develop an improved physician payment formula.
3. In order to make sure CMS establishes a new formula on a timely basis, the annual reductions could be reinstated in 2015 until CMS establishes new payment.

These major provisions are a step in the right direction but our a "day late and a dollar short" as so much of tax payer money could have been saved if Congress acted on this years ago rather than perpetually delaying the cuts with last minute legislations.

Medical Student loans and Tax Forgiveness

The new tax law provides an added benefit for doctors with medical student loans. If your loan is forgiven and you work in an "underserved" area, you may be entitled to tax free treatment on the forgiveness of the tax free loan. This was not always the case.
In the past, often the trade off of practicing medicine in an underserved areas, albeit rewarding emotionally and intangibly, typically did not create the income to offset the benefit of the forgiven loan. In other words, it was more cost effective to keep the loan and practice where you could make money that far exceeded the amount of the loan. However, in today's changing health care landscape, that is not always the case anymore. So, when weighing your options, the intangible benefits plus the tangible cost benefit of a forgiven loan plus tax free treatment of that forgiven loan, may be enough for some people to actually take advantage of this offer and practice in underserved areas.

Medical School Debt- Cost of Education Must be Subsidized

Medical students may no longer have the earning potential of the preceding few generations of physician graduates before them. Simply put, the cost of a medical school education may be too high to recoup given the changing landscape of health care. Between decreasing reimbursements, commoditization of physician practices, and increasing overhead, and the cost of debt service, medical students will find themselves struggling to get ahead.
On the medical school side, the costs of providing an education are increasing and schools are finding themselves in budgetary binds with faculty restrictions, layoffs, and salary stabilization.
What's the solution?
If the government wants to dictate to physicians what their reimbursement will be for services provided and simultaneously continually increase the overhead expense of a doctor by regulatory compliance burdens, then the government must subsidize medical school education.
I am all for less big government so the other alternative (which obviously is not happening), would be that government does not dictate fees and reimbursements nor regulatory expense burdens for doctors, natural free market forces do and then in that scenario medical school costs would not be the responsibility of government.

The Reasons to E prescribe

Medicare providers have a few good reasons to start E prescribing. Of all the initiatives relating to health care and technology , the one most likley to get adoption is e-prescribing. It is easier for the office than meeting all the EHR criteria and it makes sense for the patient. The hurdles for EHR adoption for more established older physicians seems less likely and more obtrusive but e-prescribing shouldnt be as intimidating.

Here are a few reasons to do it:
1. Avoidance of 1 percent penalty on claims if providers e-prescribe ten times in 2011.
2. Avoidance of 1.5% penalty on claims if providers e-prescribe at least 25 times in 2011.

Dont forget that to be eligible the physician would need to report the G code, G8553 along with a denominator code such as new and established patient visit codes.

Potential Impact of Medicare Payment Reductions on Staffing of a Medical Practice

Nice report in January 2011, Dermatology World, that graphically represents the impact of Medicare payment reductions as a function of practice staffing and EHR implementation. In general, a 5-7% cuts in payments to physicians will translate to 20% of doctors reducing staff and 56% freezing staff hiring. And, also, a 5-7% reduction to physician payments will result in 33% of docs delaying EHR implementation and 29% indefinitely postponing.

Bottom line is private practice is small business and as soon as government intervenes with further reductions in payments it results in the unintended consequence of delaying other government initiatives such as EHR implementation and employment. Physicians have taken too big of a hit already and employ significant amounts of the labor burden. You cannot continually increase practice expense burden with regulatory obligations, etc and then at the same time make reductions in income and expect no impact on "initiatives". Docs are too tired and beat up to help here.

Medical students, doctors and medical residents are not taught about the Human Resources component of their career

In medical school and in medical residency we, as doctors entering the business world, get no training on HR (Human resources). Doctors are not instructed one iota on how to evaluate, hire, and fire employees. This can be a daunting task and doctors and medical students should be given some expectation of what running a business, ie a private practice is really like. One important aspect of private practice in medicine is knowing when and how to hire staff and when and how to terminate bad staff. There are legal ramifications for both actions. Critical to hiring is defining the role and responsibilities with a job description for each position you fill. (You can find a typical job description for the employees you would need to hire in the book, The Medical Entrepreneur). Having the employees and staff understand their role, responsibilities and job description will help them understand where they need to be focusing their efforts, so they can be more productive. Your staff will appreciate that clarity. Also, whom the employee reports to...such as the office manager in most cases is very important to define from the first day of their job. Also, the job description itself will serve as a benchmark by which you can objectively evaluate their performance. This is particularly important when an employee is not meeting their expected roles and responsibilities. If an employees are not working out, you should understand the process to correct this or if not, to let that employees go as soon as possible.

One less administrative headache for practicing medical doctors

Since 2007, another administrative burden loomed large over doctors heads...the "Red Flags Rule". Despite multiple protests from the AMA and other large doctor associations, the legislation persisted as just another threat to increasing administrative burdens for practicing physicians. The FTC delayed enforcement of the "Red Flags Rule" five times since 2007. The rule/bill, which potentially placed compliance cost and administrative burdens on physicians regarding the need for implementing identity theft and notification programs was amended in December to be called the Red Flag Program Clarification Act of 2010, so that health care providers are exempt. It's true, doctors actually caught a break here for the first time since I went into practice almost 20 years ago. I have watched government regulations increase, cost to comply with regulatory demands geometrically increase for practicing physicians, and reimbursement decrease year after year. This little amendment is one small victory for doctors in private practice. Savor it as they dont come often.

The Medical Entrepreneur book advises Medical Residents how to bill and get paid

Billing and getting paid are two entirely different issues. Billing is the act of electronically submitting a charge to an insurance company for services provided. Getting paid is receiving back what the insurance company contracted rate for you may be for those services. Often times, insurance companies defer, delay, or reject initial claims and as a result the billing process results in an accounts receivable that must be followed closely. The Medical Entrepreneur book really covers this area of importance in your medical practice so you can understand that different types of billing software, insurance company policies and procedures, collection of copays and deductibles and accounting processes you need to have in place to run your medical practice smoothly.

At what point should medical students select their specialty?

I changed my mind after two years of residency from one specialty to another. It is difficult for medical students to have a solid basis for long term career specialty selection. Realistically, as medical students, we spend 1-2 months "testing" various specialties. I would say that probably the most influential factor in a medical student's selection for a specialty is the clinical rotation and the attending at that time. If the attending is a mentor and role model that for whatever reason appeals to the student, then that student is more likely to enjoy the rotation and select that career. Good or bad, that is the reality. Do Attending physicians have any idea of the impact they have on shaping a career choice. I remember doing a urology rotation, for example, the surgical attending in the OR was so abusive, that I was compeletly turned off to that as a career choice. Right or wrong, that is how it happens, it is organic and often times subconscious, but it is an interesting variable that often times is overlooked. The career selection process needs to be re-focused and perhaps made a part of the education curricula.

Medical school debt may be greater than earning potential

Health care "reform" needs to more seriously address the issue of cost of a medical education and plot that against current wages for less lucrative specialties such as pediatrics and family practice. It seems that if every college or medical student calculated their potential earnings and plotted that against the cost of attending four years of undergraduate college and then four years of medical school, they would reconsider their selection as a physician. Here are some rough numbers. The average cost including living expenses for undergraduate schools and medical school is approximately $40,000-$50,000 per year. It is conceivable that all of that is borrowed so that upon graduation, a medical student has over $320,000 in debt. If the doctor wants to pay this off over 10 years, he or she will be paying, approximately $4000 per month or $48,000 per year interest and principal payments. This does not take into consideration the cost of those years in medical school of lost earning potential. This is disastrous for medical students, young doctors and the field of medicine. So, when health care reform begins to start chipping away at a doctor's income, and raising expenses for a doctor to operate their business, politicians need to be aware of the cost burdens on our young doctors. Alternatively, the way things are going, we may have no doctors to take care of our kids and our families.

Medical Residents and medical students need help preparing for the real world

Are medical students or medical residents given adequate business training prior to entering the work force? Definitely Not. This is a huge deficiency in medical school and medical residency training.
Before any doctor or medical resident enters private practice and signs any contract with a potential medical group or employer, he or she should read The Medical Entrepreneur Pearls, Pitfalls and Practical Business Advice For Doctors. It was written specifically with medical residents, students and doctors in training in mind. There are contributions by health care and corporate attorneys giving advice to medical residents that will end up saving them money and headaches often associated with joining the wrong practice or starting off in practice without the correct licensures. The book gives medical residents and medical students and easy to read, step by step guide on how to be prepared for entering private practice.

University of Michigan Study: Medical Residents feel ill prepared to run small businesses

Lead author Linnea S. Hauge of the University of Michigan Medical School says medical residents say they lack instruction and feel ill prepared to run the small businesses doctors in private practice must manage.

The study goes on to show that web based learning may be a reasonable option for medical residents to get some education on business.

This is exactly why the book, The Medical Entrepreneur Pearls, Pitfalls and Practical Business Advice for Doctors was written. Medical students and doctors are not prepared in school or during training for the challenges of private practice and business. The book will help medical students and residents save money and headaches that often accompany the difficulties of private practice.

Private practice can be enjoyable and medical residents can now be prepared. The Medical Entrepreneur book is available at Amazon.com for $19.99 or Kindle for only $9.99.