RE: Nursing Home - Low Overhead --> RE: Re : To take insurance or not. & other ways to make it work financially

[Guest guest]

HI Melody! Where are you? I though you were in Bingham with

on?

Jean

Re: To take insurance or not. & other

ways to make it work financially

I joined recently and have read every post with fascination (well,

most). Thank you all, I'm enjoying it.

The issue is not necessarily about taking insurance or not as an

absolute, but being VERY selective about which to take. You might find

this strange in other areas of the country, but I take traditional

Medicare almost exclusively, refusing everything else.

All others pay less now, here in my patient population. I couldn't have

the high quality time-intensive practice that I have any other way.

I do, however, find other ways to supplement my income, and have done so

since I started in practice 14 years ago. All of those ways are FUN and

low-overhead. They include nursing home and outpatient rehab physician

administration, program development, paid lectures, hospice medical

directorship and medical expert witness. Every one of them takes real

time and effort, not just " kick-backs for patient referrals " kind of

money. But it's a good way to be able to pay the bills if patient

visits aren't enough, or you want to limit your practice volume. Plus,

it has allowed me to enact quality changes at a systemic level, not just

at the individual patient level.

I am a geriatric rehab doc who specializes in the most frail, complex,

disabled elderly. Every person who gave me advice before I started in

practice told me I'd never make it financially. They were all wrong- I

made a profit from day one! I just did things very differently from the

norm, like most of the people in this group of docs. I have no employees

and no office, and I started that way in

1994 (back then it was because I was down to my last $500 & couldn't get

a loan).

I'm curious, though, how many of the docs on this listserv are

specialists? I've only seen a couple of posts from neurologists.

There is great potential for micropractice beyond primary care. Think

big, bigger! The patients who need the most time, the elderly, need all

sorts of quality docs; the only way they'll have them is through the

low-overhead movement.

Think outside the box, you people are great!

Rotenberg, MD

Melbourne, Florida

_____

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[Guest guest]

I still see pts in the Bingham area but no longer work for HealthReach. One of the deciding points in taking that position was no "non-compete clause" so I was able to keep many of my geriatric patients. Melody wrote: HI Melody! Where are you? I though you were in Bingham with on?Re: Nursing Home - Low Overhead --> RE: Re:To take insurance or not. & other ways to make it work financiallyI provide care in 2 small rural nursing homes about 25 miles apart andprovide home visits to "homebound" patients in the area exclusivelyMedicare. The population density of the facility makes up for what Iloose in home visits that can be very time consuming, mostly becausethese people get very little company and I'm often asked to share teaand cookies. The problems with nursing calls and faxes can beoverwhelming at times but with persistant education and use of standingorders It has become manageble. I might get a middle of the night callonce every 3 or 4 weeks. I do like using the fax machine as for me it isquicker than a phone call. The down

side is I havn't quite figured outif I can access it from my cell phone and being on the road I might notget to them till later in the day, but much of it is not acute and theyall know to call my voice mail for acute issues. Unlike many docs thatdo nursing homes I keep much of the pt record electronicaly and so donot have to ask the nurse what their last creatinine is and can fax backan order that is not lost in transcribing a telephone order. Overall itsa good mix of acute and fairly stable long term care pts. I have alsobuilt a practice of home visit pts that were admitted to the NH forrehab and went home and kept me for their PCP. This area has a severeprimary care shortage and I am at risk of becoming spread too thin. Ihave had to turn down patients as I am behind on bookeeping/billing andnow trying to think about taxes. I have found this list serve veryeducational and motivational over the last few months and its

certainlynice to know there are other like minded souls and I am not totally MADfor leaving a regular paycheck. Like anything else nursing home care isprobably not for everyone but I enjoy it and certainly have found myniche.Melody Pratt DOSolo/no staff 7/07Amazing Charts Locke's in Colorado <lockekcomcast (DOT) net> wrote:I don't recall if it was on this list or another, but I believe thatnursing home care was promoted as a low overhead option for docs.The idea was....1. Don't need office space -- can see the patients at the nursing home.2. Don't need nurse -- nursing home as nurses to help3. Blood draws can usually be done at the nursing home -- no need tomaintain supplies, etc.4. Don't need blood pressure cuff, etc -- nursing home has it.Overhead is extremely low. My practice overhead is 24 percent and hasn'tbeen over 25

percent in years. That's unheard of in a typicaloffice-based practice, where the usual cost of overhead is 45-60percent. All you need is a car, a communication system (phone, cellphone, beeper, and exchange), malpractice insurance, and a billingsystem. If you're presently in practice, you already have all of theseprerequisites, so adding a nursing home or two won't increase youroverhead. The facility provides the patients, the rooms for exams, thecharts, the nursing personnel, the secretarial staff, etc. How can itget any easier? Just show up, see your patient, write your note, andyou're done. If you're just starting out and don't open a traditionaloffice, a nursing home practice will save you about half the cost ofcustomary overhead. That's roughly three months of income you don't haveto spend on rent, staff, and the like. Anyway, interesting idea and alternative to traditional practice - evenIMP practice.

Locke, MDQuick search of MeMag found...http://www.memag.<http://www.memag.com/memag/article/articleDetail.jsp?id=428769>com/memag/article/articleDetail.jsp?id=428769<http://www.memag.com/> <http://www.memag.com/memag/sitewide/images/localized/close_window.gif><http://www.memag.com/memag/sitewide/images/clear_dot.gif> Print <http://www.memag.com/memag/sitewide/images/localized/print.gif><http://www.memag.com/memag/sitewide/images/clear_dot.gif> 10 reasons I see only nursing home patients<http://www.memag.com/memag/sitewide/images/clear_dot.gif> <http://www.memag.com/memag/sitewide/images/clear_dot.gif> It's more lucrative than you probably think, yet the rewards are morethan just monetary.Honorable Mention 2006 Doctors' Writing Contest<http://www.memag.com/memag/sitewide/images/clear_dot.gif> Jun 1, 2007 By: P. Zydiak, MD<http://www.memag.com/memag/author/authorInfo.jsp?id=38562> Medical Economics What, you don't go to nursing homes? Why not? Takes too long, notreimbursed well enough for your time, not challenging enough, too manyphone calls, too depressing? These are some of the complaints I've heardover the years about practicing in long-term care (LTC). They couldn'tbe further from the truth. I've been in LTC for the last 15 or so yearsand find it to be an ideal environment to combat many of the problemsfacing the typical primary care physician today. I feel so stronglyabout it that I'd like to share some of the reasons why I believe allphysicians should be involved in the LTC arena. 1. The population of seniors is growing rapidly. As our baby boomersenter their golden years, they'll need LTC services in ever-increasingnumbers. According to The

New York Times, the supply of physiciansavailable will not meet the need. ("Geriatrics lags in age of high-techmedicine," The New York Times, Oct. 18, 2006.) This combination of highdemand and low supply means lots of opportunity and steady work forproperly positioned physicians. These proactive providers will bevaluable players as nursing homes and hospitals look to capture thismarket. This doesn't even count the growing numbers of independentliving units that are being built by most large nursing home/skillednursing facilities. Look around your neighborhood: Do you notice a lotof construction around your older, well-established nursing homes?That's what they're building.2. Nursing homes are hungry for good doctors. Historically, the LTCsetting was for aging doctors who were winding down their practice inanticipation of retirement. Some doctors didn't even consider nursinghome work to be real medicine. (I heard this

comment from an internistwho's in a leadership role in my hometown.) Many of these doctors wouldjust go through the motions, and some gave LTC a bad reputation. This isno longer the case. The typical nursing home and skilled nursingfacility (SNF) is being filled with complicated patients needingwell-trained physicians to care for them. These patients used to betreated on the inpatient side, but not anymore. Physicians who completea geriatric fellowship or who are board certified (typically in internalmedicine, family practice, or, of course, geriatric medicine) will havea leg up, but there's room for all those truly interested. 3. LTC is not just long-term patients. The old-fashioned nursing homewith its long-term residents still exists and is still the backbone oflong-term care, but more and more of these people are cared for inskilled nursing facilities. This treatment is short-term (several weeks)for things like

postoperative care of patients who undergo orthopedicprocedures, or stroke patients needing rehabilitation services. Those ofyou old enough to remember used to see these people in the hospitals'rehab units. Now they go to SNFs. This is just another growing areathat's also in need of good physician care. The volume and constantturnover of these patients makes it a very dynamic and stimulatingenvironment.4. You don't have to participate in managed care. Yes, it's true.According to CMS and The Competitive Edge from HealthLeaders-InterStudy,the penetration of managed care in the long-term care/geriatricpopulation is far below that of traditional medical care. Even inCalifornia, total managed care penetration is only about 65 percent. Iwouldn't expect that percentage to increase much in the coming years,since this frail and sickly population is difficult for insurancecompanies to profit from. Personally, I've never

participated in anymanaged care plan (meaning any capitated or non-fee-for-serviceproduct). Can you say that? 5. LTC practice is more predictable than an outpatient practice. In LTC,patients are seen once a month (on average) and as needed. You must showthat the visits are medically necessary, but in most cases you can billfor at least 12 visits a year per patient, one of which is an initial,readmit, or annual visit. This visit frequency is much higher than thatof your average office outpatient. On the SNF side, most patients aregenerally sicker and rate at least weekly visits-sometimes more incomplicated cases. This provides a steady and predictable patient visitvolume with less month-to-month variation, and therefore more businesswith less stress. 6. LTC practice offers a forgiving, flexible work schedule. LTC visitsare not by appointment. Whenever you can show up you're on time. You canspend as much time

as you need because there's no set schedule.Facilities are open 24 hours a day just like a hospital. The majority ofvisits do take place during the day or early evening, but it's all up toyou. The flexibility of this set-up is wonderful. It forever eliminates thestress of being late or falling behind-no more waiting rooms filling upwith angry patients! It's possible for me to knock off a little early,without advanced planning. If I want to skip nursing home rounds and gofishing for bluegills, I can make rounds the next day. I don't do thattoo often, but I can without any fuss. No phone calls to rescheduleappointments, no double or triple booking to make up for the missed day.Did I mention that I take my kids to school each morning and have foryears? Now that's the life. 7. Overhead is extremely low. My practice overhead is 24 percent andhasn't been over 25 percent in years. That's unheard of in a

typicaloffice-based practice, where the usual cost of overhead is 45-60percent. All you need is a car, a communication system (phone, cellphone, beeper, and exchange), malpractice insurance, and a billingsystem. If you're presently in practice, you already have all of theseprerequisites, so adding a nursing home or two won't increase youroverhead. The facility provides the patients, the rooms for exams, thecharts, the nursing personnel, the secretarial staff, etc. How can itget any easier? Just show up, see your patient, write your note, andyou're done. If you're just starting out and don't open a traditionaloffice, a nursing home practice will save you about half the cost ofcustomary overhead. That's roughly three months of income you don't haveto spend on rent, staff, and the like. 8. LTC offers a conduit to many other opportunities. LTC ispredominantly a multidisciplinary affair. You get involved with

homehealth, physical therapy, hospice, and other ancillary services. Many ofthese entities offer opportunities for administrative duties and medicaldirectorships for physicians already involved with LTC. Nursing homesall need a medical director to comply with the regulations of thefederal Nursing Home Reform Act. These offer a welcome diversion intononclinical components of medicine as well as provide new streams ofincome unaffected by insurance regulation and controls. You can chargeand receive whatever the market will bear. While the majority of nursinghome medical directorships are part-time jobs, there are some full-timepositions available. Office-based practitioners who don't make nursinghome rounds aren't offered these opportunities, ever. 9. The practice model is a natural fit for the use of NPs and PAs. Theshortage of physicians in LTC is expected to grow as fewer doctors aregoing into geriatric fellowships.

If you have a PA or NP on staff, thisshortage provides an opportunity for your practice to fill the gap. Anoffice-based physician who already uses these extenders can expand theiruse to the LTC setting. (Some Medicare rules apply to who can visitwhen, as well as to reimbursement.) If you don't do it, someone elsewill. 10. Reimbursement for nursing home work is more than adequate.Reimbursements for LTC care allow the typical physician to easily makeat least as much, if not more, than the median total compensation forinternists and FPs, which are $157,000 and $150,000, respectively,according to Medical Economics' latest Continuing Survey<http://continuing%20survey%7c~www.memag.com/memag/article/articleDetail.jsp?id=379594> . This is not only possible but almost guaranteed, ifyou take into account the low

overhead, the number of visits, theincreased frequency of patient visits on skilled units, and theopportunity for other nonclinical income from medical directorships andthe like. There are so many opportunities to generate income it'sliterally impossible to fail. Bonus. LTC patients are among the most challenging, interesting,colorful, and grateful you'll ever encounter. This may not be importanteconomically, but emotionally it's priceless. I've learned more from my"old folks" (they don't know it's politically incorrect to say the word"old") than I ever have from my middle-aged and younger patients. Mosthave been through several wars and a depression, and have a differentmindset of self-reliance and resilience that's lacking in subsequentgenerations. Their generation helped save the world and I find greathonor and pleasure in serving them now. They're a lot more fun to dealwith and much more appreciative. I hope

this article convinces you to give nursing home care some seriousthought. You don't have to switch to a 100 percent nursing homepractice, as I have, but could simply add one or two nursing homes orskilled nursing facilities to your practice. The personal as well as thefinancial rewards are there for the taking. It really is that simple.Give it a try. If you'd like to discuss this topic further with me, you can reach me atgzydiaksbcglobal (DOT) <mailto:gzydiaksbcglobal (DOT) net> net. -----Original Message-----From: [ mailto:Practiceimpr<mailto: > ovement1 ]On Behalf Of schoolrotenbergSent:

Tuesday, January 08, 2008 9:19 PMTo: Subject: Re: To take insurance or not. & otherways to make it work financiallyI joined recently and have read every post with fascination (well,most). Thank you all, I'm enjoying it.The issue is not necessarily about taking insurance or not as anabsolute, but being VERY selective about which to take. You might findthis strange in other areas of the country, but I take traditionalMedicare almost exclusively, refusing everything else. All others pay less now, here in my patient population. I couldn't havethe high quality time-intensive practice that I have any other way. I do, however, find other ways to supplement my income, and have done sosince I started in practice 14 years ago. All of those ways are FUN andlow-overhead. They

include nursing home and outpatient rehab physicianadministration, program development, paid lectures, hospice medicaldirectorship and medical expert witness. Every one of them takes realtime and effort, not just "kick-backs for patient referrals" kind ofmoney. But it's a good way to be able to pay the bills if patientvisits aren't enough, or you want to limit your practice volume. Plus,it has allowed me to enact quality changes at a systemic level, not justat the individual patient level.I am a geriatric rehab doc who specializes in the most frail, complex,disabled elderly. Every person who gave me advice before I started inpractice told me I'd never make it financially. They were all wrong- Imade a profit from day one! I just did things very differently from thenorm, like most of the people in this group of docs. I have no employeesand no office, and I started that way in1994 (back then it was because I was down

to my last $500 & couldn't geta loan).I'm curious, though, how many of the docs on this listserv arespecialists? I've only seen a couple of posts from neurologists.There is great potential for micropractice beyond primary care. Thinkbig, bigger! The patients who need the most time, the elderly, need allsorts of quality docs; the only way they'll have them is through thelow-overhead movement.Think outside the box, you people are great! Rotenberg, MDMelbourne, Florida_____ Looking for last minute shopping deals?<http://us.rd.yahoo.com/evt=51734/*http://tools.search.yahoo.com/newsearch/category.php?category=shopping> Find them fast with Yahoo! Search.

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