RE: Advice for a newbie

[Guest guest]

Tito:

They are also allowed to forgive your student loans. I would include $20 per year or $100,00 over the 5 year commitment in years one and two.

Note this forgiveness comes at price of taxes so talk to your accountant.

Good Luck

Subject: Advice for a newbieTo: Date: Tuesday, December 23, 2008, 8:16 PM

I am contemplating an IMP post residency and have the opportunity to be supported by a hospital system in the area that I am looking at starting my IMP. They are offering an income guarantee (i.e. Income loan) for 2 years and 3 year loan forgiveness period. However, I am concerned about moving forward in the current economic atmosphere especially since I am the primary bread winner for my family at this time. ( I have a family with 3 young children cared for by my stay home spouse) I have significant amount of student loans that will be coming due also which further heightens my concerns. I was wondering would it be wiser to settle for an employed position with prospects of starting an IMP later or just go ahead and jump in the IMP river now? The other concern is that I am feeling quite overwhelmed by the sheer amount of information on what needs to be done to start a practice whether it is an IMP

or not. Should I be looking at a practice management consulting group to help with this initial phase to help ease the feeling of being in way over my head? I would appreciate some wise counsel on this issue?Tito Wion

[Guest guest]

A number of folks on the list have

explored hospital subsidized practices, so I’m hoping some with personal

experience weigh in and give their own pros and cons.

Some of the cons that I’ve heard:

1: Overpopulation of your practice with

disproportionately low paying insurance contracts. Hospital owned practices

often get a subsidy to care for Medicaid & uninsured folks (Federal 330

grant). E.g. The Medicaid rate for hospital practices in upstate NY is about

$110 per visit, but a private practice gets $23 per visit, well below survival.

The state is essentially saying “private practices should not take

Medicaid patients.”

If your contract says you are an owned

practice of the hospital, then you may be eligible for this generous subsidy

and do fine. If you are being set up as a private practice, then you must be

VERY cautious on what percent of your practice comes in at a charity care

level. I think we all ought to give back to our communities and having a

percent of your practice as “give away” is great, but don’t

go beyond a certain point or you won’t survive.

If the hospital says “you’re a

private practice but we dictate your patient panel and which contracts you have

with insurance” then walk away – it’s not possible to survive

long term.

2: Practice management

Hospitals have no idea how to run IMPs.

If they give you free reign, then fine. If they want to dictate panel size,

staff configuration, hours of operation, or any other basic management issue in

your practice, walk.

3: Office space

I’ve read too often on this list

that the gift horse of subsidized hospital owned office space is more of a

Trojan horse. Comments I have read on this list include:

”The hospital just told me that they want my space – out of the

blue! – and I have to move in three months!!!”

“They promised me that I’d

have someone else share the space so I agreed to this large office, but I’ve

never gotten a partner to come in and I’m stuck paying a rent that I can’t

afford and taking home nothing. I feel like all the work I’m doing is

for the hospital.”

Remember the basic premise: if it sounds

too good to be true it is. (A basic philosophy that we badly need to remember

when discussing anything with financial experts, realtors, and stock market

mavens.)

Gordon

From: [mailto: ] On Behalf Of Egly

Sent: Wednesday, December 24, 2008

6:03 AM

To:

Subject: Re:

Advice for a newbie

Tito:

They are also allowed to forgive your student loans.

I would include $20 per year or $100,00 over the 5 year commitment in years

one and two.

Note this forgiveness comes at price of taxes so

talk to your accountant.

Good Luck

From: dewlions

<dewlionsgmail>

Subject: Advice for a newbie

To:

Date: Tuesday, December 23, 2008, 8:16 PM

I am contemplating an

IMP post residency and have the opportunity to be

supported by a hospital system in the area that I am looking at

starting my IMP. They are offering an income guarantee (i.e. Income

loan) for 2 years and 3 year loan forgiveness period. However, I am

concerned about moving forward in the current economic atmosphere

especially since I am the primary bread winner for my family at this

time. ( I have a family with 3 young children cared for by my stay home

spouse) I have significant amount of student loans that will be coming

due also which further heightens my concerns. I was wondering would it

be wiser to settle for an employed position with prospects of starting

an IMP later or just go ahead and jump in the IMP river now? The other

concern is that I am feeling quite overwhelmed by the sheer amount of

information on what needs to be done to start a practice whether it is

an IMP or not. Should I be looking at a practice management consulting

group to help with this initial phase to help ease the feeling of being

in way over my head? I would appreciate some wise counsel on this issue?

Tito Wion

[Guest guest]

Agree - esp with Medicaid payment --> yes, $23/visit, really really (I dropped after 2-3 years, and even before that was very careful whom I would take on.

Matt in Western PA

Advice for a newbieTo: Date: Tuesday, December 23, 2008, 8:16 PM

I am contemplating an IMP post residency and have the opportunity to be supported by a hospital system in the area that I am looking at starting my IMP. They are offering an income guarantee (i.e. Income loan) for 2 years and 3 year loan forgiveness period. However, I am concerned about moving forward in the current economic atmosphere especially since I am the primary bread winner for my family at this time. ( I have a family with 3 young children cared for by my stay home spouse) I have significant amount of student loans that will be coming due also which further heightens my concerns. I was wondering would it be wiser to settle for an employed position with prospects of starting an IMP later or just go ahead and jump in the IMP river now? The other concern is that I am feeling quite overwhelmed by the sheer amount of information on what needs to be done to start a practice whether it is an IMP or not. Should I be looking at a practice management consulting group to help with this initial phase to help ease the feeling of being in way over my head? I would appreciate some wise counsel on this issue?Tito Wion

[Guest guest]

thank you very much. I really really appreciate again everyone who is pitching in information to help me along. It has been very helpful in the decision making process.

Tito Wion

Since we're in the midst of repaying our hospital, I thought I'd chime in. We had a 2 year guarantee with a 3 year repayment from the local hospital. Due to STARK laws, what the hospitals can legally pay you and what advice they can give is very limited. Our deal let us set up our own practice, they basically footed the bill for the first 2 years and now we are repaying them. Without giving out too much info about the details, here are the pros and cons:

Pros:

If you absolutely cannot survive for 2 years without an income guarantee, this is one way to be able to set up your IMP practice, with help from the hospital.

Allows you to be able to prove "income" when you are self-employed (necessary in the current credit crunch).

Speaking of the current credit crisis, loans are hard to come by. Steve had 6+ years of practice outside of residency, a very good credit rating, and no debt outside of our home, 1 car, and small student loan debt and we had a hard time 4 years ago securing a business loan. I think it would be next to impossible now to get a loan without going SBA, which is about 2" of paperwork that we didn't need at the same time as credentialing paperwork.

Cons:

Feeling like you "owe" the hospital – and you do for a period of time.

Just when the practice is starting to really get going, you end up having to pay back the hospital whatever part of the loan will not be forgiven.

Feeling 'stuck' in the location – for the length of the agreement – to you don't have to pay back the hospital.

Regarding a practice management consultant, we hired one specifically for contracting and all he wanted to do was marketing. We ended up doing all of our insurance contracting ourselves. So interview the consultant (if you decide to go that route) and hire one that fits what you want – get references from other physicians in the area. We have a lot of doctors in the area that are very happy with the consultant that we originally hired, but we were able to see past the BS and ended up firing him because he wasn't working on what we asked him to work on – probably because he really wasn't qualified to help in that area.

If we had to do it all over again, I'm not sure that we wouldn't have gone with an employed position. Being your own boss has it's perks – but also stresses that you don't have when you're not the one involved in making the financial decisions. We are very happy with our location, our kids are happy in the schools, and we make the decision when we work. But it can also lead to burnout if you're not careful – know yourself.

If there is a part-time position that will allow you enough income to support your family and work part-time setting up your own IMP practice that you could gradually shift to full-time, that would be the "best of both worlds" (to quote Hannah Montana).

Finally, be careful about promises from the hospital that they will start a "hospitalist" program. We interviewed in one location whereby the local doctors were the "hospitalists." What that hospital did was rotate each of the 6 or 7 doctors on 1-week "hospitalist" shifts. They didn't work in the clinic that week, only in the hospital. Since Steve wanted NOTHING to do with working in the hospital, we chose an area that had a well-established hospitalist group already set up. Where we came from, the hospital wasn't able to hire enough hospitalists for the demand, and the local doctors ended up still having to do admissions. If you're willing to do inpatient work, not a problem, but if you really don't want to do that, I'd look for something that can guarantee today that you won't have to.

Good luck in whatever your decision!

Pratt

Office Manager

Oak Tree Internal Medicine P.C

Roy Medical Associates, Inc.

From: [mailto: ] On Behalf Of L. Gordon

Sent: Wednesday, December 24, 2008 7:56 AM To: Subject: RE: Advice for a newbie

A number of folks on the list have explored hospital subsidized practices, so I'm hoping some with personal experience weigh in and give their own pros and cons.

Some of the cons that I've heard:

1: Overpopulation of your practice with disproportionately low paying insurance contracts. Hospital owned practices often get a subsidy to care for Medicaid & uninsured folks (Federal 330 grant). E.g. The Medicaid rate for hospital practices in upstate NY is about $110 per visit, but a private practice gets $23 per visit, well below survival. The state is essentially saying "private practices should not take Medicaid patients."

If your contract says you are an owned practice of the hospital, then you may be eligible for this generous subsidy and do fine. If you are being set up as a private practice, then you must be VERY cautious on what percent of your practice comes in at a charity care level. I think we all ought to give back to our communities and having a percent of your practice as "give away" is great, but don't go beyond a certain point or you won't survive.

If the hospital says "you're a private practice but we dictate your patient panel and which contracts you have with insurance" then walk away – it's not possible to survive long term.

2: Practice management

Hospitals have no idea how to run IMPs. If they give you free reign, then fine. If they want to dictate panel size, staff configuration, hours of operation, or any other basic management issue in your practice, walk.

3: Office space

I've read too often on this list that the gift horse of subsidized hospital owned office space is more of a Trojan horse. Comments I have read on this list include:

"The hospital just told me that they want my space – out of the blue! – and I have to move in three months!!!"

"They promised me that I'd have someone else share the space so I agreed to this large office, but I've never gotten a partner to come in and I'm stuck paying a rent that I can't afford and taking home nothing. I feel like all the work I'm doing is for the hospital."

Remember the basic premise: if it sounds too good to be true it is. (A basic philosophy that we badly need to remember when discussing anything with financial experts, realtors, and stock market mavens.)

Gordon

From: [mailto: ] On Behalf Of Egly Sent: Wednesday, December 24, 2008 6:03 AMTo:

Subject: Re: Advice for a newbie

Tito:

They are also allowed to forgive your student loans. I would include $20 per year or $100,00 over the 5 year commitment in years one and two.

Note this forgiveness comes at price of taxes so talk to your accountant.

Good Luck

Subject: Advice for a newbie

To: Date: Tuesday, December 23, 2008, 8:16 PM

I am contemplating an IMP post residency and have the opportunity to be supported by a hospital system in the area that I am looking at starting my IMP. They are offering an income guarantee (i.e. Income

loan) for 2 years and 3 year loan forgiveness period. However, I am concerned about moving forward in the current economic atmosphere especially since I am the primary bread winner for my family at this time. ( I have a family with 3 young children cared for by my stay home

spouse) I have significant amount of student loans that will be coming due also which further heightens my concerns. I was wondering would it be wiser to settle for an employed position with prospects of starting

an IMP later or just go ahead and jump in the IMP river now? The other concern is that I am feeling quite overwhelmed by the sheer amount of information on what needs to be done to start a practice whether it is

an IMP or not. Should I be looking at a practice management consulting group to help with this initial phase to help ease the feeling of being in way over my head? I would appreciate some wise counsel on this issue?

Tito Wion