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

[Guest guest]

I have been rounding in Nursing homes for a little over a year now,

and am ever so grateful for this income stream, and the unmatched

flexibility, just like the author of the Memag article states.

My experience at the first NH I was at was much like Kathy's

experience--innumerable phone calls and faxes consumed my attention

most of the day for the 6 six patients I was given. After the nth

phone call I got about " elevated RDW, AST is too low!! " I was ready

to scream. Also they were selective in giving me patients, and after

I joined told me they expected me to slowly " build a practice " there.

I learned about another NH closer to my office, and decided to try

it out---it is terrific!!! The staff is much better qualified, the

nurse managers are on top of everythimg, and this is what makes the

biggest difference in physician lifestyle. They are careful to bunch

up calls, I get about 8 calls on an average all day, less on

weekends, on the almost 100 patients I have there. They have to

notify me about all " falls " --they do not wake me up at night unless

the patient is injured--I get 1 call at 6-30am about them if any,

and I let my voicemail pick it up.

It is much less stressful than hospital work, as I can call back

after a half hour even, and not be under constant fear of missing

calls and crashing patients. I actually gave up hospital work, and

markedly reduced my stress, and am able to do more with my daughter.

No faxes to the office--I go there 2 half days a week, and sign

everything while there. I am usually able to do the admissions when

I am there. I do go in many weekends for a couple of hours to finish

up notes or get caught up with admissions.

But the beauty of it is--I don't HAVE to go go there at a certain

time--I can even adjust my time and run errands during the day,

without canceling office patients. I can give orders over the phone,

nurses do all the work.

Many physicians turn up their noses at NH work--true the physicians

apparently did poor quality work, and the NH I go to had the State

DOH breathing down their necks, writing them up constantly. 6 months

after I started, the State was surprised, and asked them how they

turned everything around! And I was only providing the usual care.

Anyway, it may not be glamorous, but is has been very rewarding for

me.

--Padma

>

> It is low overhead but high in unpaid work, or it was for me. I

gave it up

> and it was the best feeling in the world as it had become the

thing that

> gave me the most grief.

>

>

>

> 1) So many phone calls and faxes daily re the patients,

weekends and

> weekdays. That takes up your staff time too. Answering service

charges,

> etc.

>

> 2) High hospitalization rate and then readmission with strict

time

> limits so that you have to get there on unplanned days.

>

>

>

> I would think these things are universal. At the nursing home I

was

> admitting to, they weren't giving me new patients as they

preferred their

> own medical director and the psychiatrists husband's group. The

last straw

> is when they gave my patient from my office to another doctor when

he was

> admitted there. And the ambulance always refused to bring the

patient to my

> hospital saying they were " too critical " and had to go to the

closest

> hospital.

>

>

>

> All I am saying is it's not all good, you need to look at it all.

>

>

>

>

>

> Kathy Saradarian, MD

>

> Branchville, NJ

>

> www.qualityfamilypractice.com

>

> Solo 4/03, Practicing since 9/90

>

> Practice Partner 5/03

>

> Low staffing

>

>

>

>

>

>

>

> From:

> [mailto: ] On Behalf Of Locke's

in

> Colorado

> Sent: Wednesday, January 09, 2008 12:42 AM

> To:

> Subject: Nursing Home - Low Overhead --> RE:

Re: To

> take insurance or not. & other ways to make it work financially

>

>

>

> I don't recall if it was on this list or another, but I believe

that nursing

> 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 help

>

> 3. Blood draws can usually be done at the nursing home -- no need

to

> maintain 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't

> been over 25 percent in years. That's unheard of in a typical

office-based

> practice, where the usual cost of overhead is 45-60 percent. All

you need is

> a car, a communication system (phone, cell phone, beeper, and

exchange),

> malpractice insurance, and a billing system. If you're presently in

> practice, you already have all of these prerequisites, so adding a

nursing

> home or two won't increase your overhead. The facility provides the

> patients, the rooms for exams, the charts, the nursing personnel,

the

> secretarial staff, etc. How can it get any easier? Just show up,

see your

> patient, write your note, and you're done. If you're just starting

out and

> don't open a traditional office, a nursing home practice will save

you about

> half the cost of customary overhead. That's roughly three months

of income

> you don't have to spend on rent, staff, and the like.

>

> Anyway, interesting idea and alternative to traditional practice -

even IMP

> practice.

>

> Locke, MD

>

> Quick search of MeMag found...

>

>

>

> http://www.memag.com/memag/article/articleDetail.jsp?id=428769

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> <http://www.memag.com/>

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> Error! Filename not specified.

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> Print

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> 10 reasons I see only nursing home patients

>

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> It's more lucrative than you probably think, yet the rewards are

more than

> just monetary.

>

> Honorable Mention 2006 Doctors' Writing Contest

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> Jun 1, 2007

>

>

> By: <http://www.memag.com/memag/author/authorInfo.jsp?

id=38562> P.

> Zydiak, MD

>

>

> Medical Economics

>

> What, you don't go to nursing homes? Why not? Takes too long, not

reimbursed

> well enough for your time, not challenging enough, too many phone

calls, too

> depressing? These are some of the complaints I've heard over the

years about

> practicing in long-term care (LTC). They couldn't be further from

the truth.

> I've been in LTC for the last 15 or so years and find it to be an

ideal

> environment to combat many of the problems facing the typical

primary care

> physician today. I feel so strongly about it that I'd like to

share some of

> the reasons why I believe all physicians should be involved in the

LTC

> arena.

>

> 1. The population of seniors is growing rapidly. As our baby

boomers enter

> their golden years, they'll need LTC services in ever-increasing

numbers.

> According to The New York Times, the supply of physicians

available will not

> meet the need. ( " Geriatrics lags in age of high-tech medicine, "

The New York

> Times, Oct. 18, 2006.) This combination of high demand and low

supply means

> lots of opportunity and steady work for properly positioned

physicians.

> These proactive providers will be valuable players as nursing

homes and

> hospitals look to capture this market. This doesn't even count the

growing

> numbers of independent living units that are being built by most

large

> nursing home/skilled nursing facilities. Look around your

neighborhood: Do

> you notice a lot of construction around your older, well-

established nursing

> homes? That's what they're building.

>

> 2. Nursing homes are hungry for good doctors. Historically, the

LTC setting

> was for aging doctors who were winding down their practice in

anticipation

> of retirement. Some doctors didn't even consider nursing home work

to be

> real medicine. (I heard this comment from an internist who's in a

leadership

> role in my hometown.) Many of these doctors would just go through

the

> motions, and some gave LTC a bad reputation. This is no longer the

case. The

> typical nursing home and skilled nursing facility (SNF) is being

filled with

> complicated patients needing well-trained physicians to care for

them. These

> patients used to be treated on the inpatient side, but not anymore.

> Physicians who complete a geriatric fellowship or who are board

certified

> (typically in internal medicine, family practice, or, of course,

geriatric

> medicine) will have a leg up, but there's room for all those truly

> interested.

>

> 3. LTC is not just long-term patients. The old-fashioned nursing

home with

> its long-term residents still exists and is still the backbone of

long-term

> care, but more and more of these people are cared for in skilled

nursing

> facilities. This treatment is short-term (several weeks) for

things like

> postoperative care of patients who undergo orthopedic procedures,

or stroke

> patients needing rehabilitation services. Those of you old enough

to

> remember used to see these people in the hospitals' rehab units.

Now they go

> to SNFs. This is just another growing area that's also in need of

good

> physician care. The volume and constant turnover of these patients

makes it

> a very dynamic and stimulating environment.

>

> 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/geriatric

population is

> far below that of traditional medical care. Even in California,

total

> managed care penetration is only about 65 percent. I wouldn't

expect that

> percentage to increase much in the coming years, since this frail

and sickly

> population is difficult for insurance companies to profit from.

Personally,

> I've never participated in any managed care plan (meaning any

capitated or

> non-fee-for-service product). 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 show

> that the visits are medically necessary, but in most cases you can

bill for

> 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 that of

your

> average office outpatient. On the SNF side, most patients are

generally

> sicker and rate at least weekly visits—sometimes more in

complicated cases.

> This provides a steady and predictable patient visit volume with

less

> month-to-month variation, and therefore more business with less

stress.

>

> 6. LTC practice offers a forgiving, flexible work schedule. LTC

visits are

> not by appointment. Whenever you can show up you're on time. You

can spend

> 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 of visits

do take

> place during the day or early evening, but it's all up to you.

>

> The flexibility of this set-up is wonderful. It forever eliminates

the

> stress of being late or falling behind—no more waiting rooms

filling up with

> 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 go

fishing for

> bluegills, I can make rounds the next day. I don't do that too

often, but I

> can without any fuss. No phone calls to reschedule appointments,

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 for years? Now that's the

life.

>

> 7. Overhead is extremely low. My practice overhead is 24 percent

and hasn't

> been over 25 percent in years. That's unheard of in a typical

office-based

> practice, where the usual cost of overhead is 45-60 percent. All

you need is

> a car, a communication system (phone, cell phone, beeper, and

exchange),

> malpractice insurance, and a billing system. If you're presently in

> practice, you already have all of these prerequisites, so adding a

nursing

> home or two won't increase your overhead. The facility provides the

> patients, the rooms for exams, the charts, the nursing personnel,

the

> secretarial staff, etc. How can it get any easier? Just show up,

see your

> patient, write your note, and you're done. If you're just starting

out and

> don't open a traditional office, a nursing home practice will save

you about

> half the cost of customary overhead. That's roughly three months

of income

> you don't have to spend on rent, staff, and the like.

>

> 8. LTC offers a conduit to many other opportunities. LTC is

predominantly a

> multidisciplinary affair. You get involved with home health,

physical

> therapy, hospice, and other ancillary services. Many of these

entities offer

> opportunities for administrative duties and medical directorships

for

> physicians already involved with LTC. Nursing homes all need a

medical

> director to comply with the regulations of the federal Nursing

Home Reform

> Act. These offer a welcome diversion into nonclinical components

of medicine

> as well as provide new streams of income unaffected by insurance

regulation

> and controls. You can charge and receive whatever the market will

bear.

> While the majority of nursing home medical directorships are part-

time jobs,

> there are some full-time positions available. Office-based

practitioners who

> don't make nursing home rounds aren't offered these opportunities,

ever.

>

> 9. The practice model is a natural fit for the use of NPs and PAs.

The

> shortage of physicians in LTC is expected to grow as fewer doctors

are going

> into geriatric fellowships. If you have a PA or NP on staff, this

shortage

> provides an opportunity for your practice to fill the gap. An

office-based

> physician who already uses these extenders can expand their use to

the LTC

> setting. (Some Medicare rules apply to who can visit when, as well

as to

> reimbursement.) If you don't do it, someone else will.

>

> 10. Reimbursement for nursing home work is more than adequate.

> Reimbursements for LTC care allow the typical physician to easily

make at

> least as much, if not more, than the median total compensation for

> internists 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, if

you take

> into account the low overhead, the number of visits, the increased

frequency

> of patient visits on skilled units, and the opportunity for other

> nonclinical income from medical directorships and the like. There

are so

> many opportunities to generate income it's literally impossible to

fail.

>

> Bonus. LTC patients are among the most challenging, interesting,

colorful,

> and grateful you'll ever encounter. This may not be important

economically,

> 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. Most have been

through

> several wars and a depression, and have a different mindset of

self-reliance

> and resilience that's lacking in subsequent generations. Their

generation

> helped save the world and I find great honor and pleasure in

serving them

> now. They're a lot more fun to deal with and much more

appreciative.

>

> I hope this article convinces you to give nursing home care some

serious

> thought. You don't have to switch to a 100 percent nursing home

practice, as

> I have, but could simply add one or two nursing homes or skilled

nursing

> facilities to your practice. The personal as well as the financial

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 at

> gzydiak@...

> .

>

>

>

>

>

> 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

>