Interview with NY State Assemblyman Raia

Thanks so much to Assemblyman Raia for your time.

Interview with medical liability insurance expert

 Thanks so much for Scott Palde from Cornerstone Consultants for the incredible interview.

A discussion with a health care attorney about practice acquisition

Thanks so much to Gary Herschman of Epstein Becker Green for his terrific wisdom on private equity acquisition of medical practices. 

An interview with Dr John Phillips

Dr John Phillips: For more information on Dr Phillips.

In this interview we discuss:

1. prostate cancer screening
2. advocacy
3. medical education
4. life

1: Control.  One must have control of day to day, week to week and have decision making ability.  We all have constraints, but within their confines we need to be able to make meaningful decisions to be happy

2: Meaning: whether one lays brick, cleans floors, or does surgery, one must have the feeling that what they do has meaning and importance in the broader sense of life, to feel as though you will have left a positive mark, and that one's time here on Earth was not wasted.  One must feel as if their work is critical to the success of their organization's mission, whatever that role maybe.  

3: Respect: one must feel as though peers feel positively about your career and skills and that such skills are valued above and beyond a paycheck.  One must feel that their patients respect them as well.  Skills ought to cultivated and nourished.  

4: Academics: medicine demands a decades long learning process.   When a physician no longer finds learning fun, professional and personal happiness will suffer. 

5: Compensation: once basic needs are met, happiness is not increased by absolute W2 income levels.  While important, W2 is not everything.  Compensation ought to be linked to effort but without the other 4 elements to satisfaction, professional satisfaction and happiness will always remain elusive.

Remaining Solo: 5 Strategies

1: Go micro: go super small.  One doc.  One staff or no staff.   EHR, patient portal, no phones.  No insurance.   Good option for family doc. 

2: Go concierge: charge extra fees.  No insurance.  Good option for family doc

3: Go super special: cosmetic, anti aging, infertility.  Easier said that done. Good for plastic surgeon and derm.

4: Go non par: take no insurance.  Bill at crazy out of network rates.   Good for neurosurgery, Ortho, general surgery

5: Go stupid busy: how the rest of us do it. Take everything.  See everything.  Work everyday, everywhere.   Not sustainable. 

For option 5: rethink contracts.  Get in with IPA. 

Any other options? PM me.

5 Threats to Independent Care

Independent practice is under inexorable assault.  Here are the 5 latest threats.

• MACRA/MIPS  This is a very complex endeavor.  No one who I have spoken to really knows precisely how to proceed.  It is also a zero sum gain: the bonus payments from successful practices come from the deductions from the unsuccessful ones.  
• Cyber security  If you use any electronic resources, which includes electronic claims submittal, you are at risk for malicious cyber attack.  Protection in the form of best practice IT solutions and insurance cost $$$
• Cost sharing/deductibles  Even for patients with insurance, the dollar amounts of deductibles have risen dramatically over the past 10 years, far outpacing wage increases.  This translates to fewer patient visits and more expensive collection efforts
• Consolidation   Health care has become consolidated over the past 15 or so years.  In some markets there is only one payer. On the provider side there has been a major shift to employed models into larger and larger entities.  This means drying up referral networks combined with declining reimbursements to offices and increased premiums for employee health insurance.
• Income inequality  The majority of increases in wealth, income, and standard of living have gone to the top 1%.  Most doctor practices cater to the lower 99%, who struggle to pay bills and as such, put off health care as long as possible.  

Sorry for the doom and gloom but it is what it is.  Solutions in next post.

Thanks for listening.

The IU.

The latest and greatest tools

Always important to have the latest and greatest tools. You know the saying: with the right tools any job is easy.  

Dr Schoor

urologist

I am back!

I could find my login for this blog but just remembered it. I am back. Sorry for the delay. I have nothing else to say.

Hiking the AT

Left today for my 50 mile AT trek.  As I lay here tonight in my tent, wide awake, I reflect on the day.   

My partners and I left the hotel at 8 or so to drop off one of the cars at the end point, a trekker hostle in TN.  

Then we returned to the start point to begin the hike, which started at 12:06 pm.   We were joined by 3 others, Jeff, Elena (husband and wife) and John, age 75, and the most experienced of us all.  

The hike began with a 1500 or so foot scent up to the ridge line.  Some of the views were amazing, see below:

but most of the day was spent in thick forest.  

We got to the campsite, the No Business Shelter, at about 4pm.  We had to locate water.  The stream was 0.3 miles away.  

Not so easy but I had the right equipment to get the job done.  

Through the rest of daylight, more hikers passed through and set up shop.  Everyone has been quite nice and an interesting mix: professionals, ex-military, a retired Reverend, a finance guy etc.  

This is bear country so we had to take precautions to protect ourselves and our food.  All food gets hung in the air far from the camp.  

I am sleeping in a tent.  I am warm and comfy.   Unfortunately, the ground here is slanted so I am having difficulty sleeping. Oh well.  Could be worse.   

Tomorrow we do 10 miles to Big Bald Shelter.  Should be fun. 

Am I glad I went: not so sure yet.   Will let you know.   

AT Day 4

16 + miles.  Too much.  Exhausted. Tomorrow last day.   Here are 2 pictures. 

AT DAY 5

Today is the last day.  As I write this, I am in a shelter 2/3rd of the way from last nights shelter and THE END.

We calculated yesterday's walk to be 17 miles.  Very tough indeed.   

I feel good today though have no appetite.  Zero.   Wonder if I have a parasite?   

Is raining today.   Pouring in fact.  I am dry. 

Already did 6.8 miles.  I have another 4 miles until comfort and safety.   

All in all did I enjoy it?  At the time of this writing: no.   I feel a sense of great accomplishment but who friggin cares.  

Day 3 AT

Too bad I only post at night, when I am cold and tired.  Today was nothing short of spectacular.  The day began with a hike to the top of Bald Mountain where we had amazing views.

There was even a couple that braved the winds to camp on the peak.   

Then we descended a couple thousand feet through forest of several varieties. 

Ultimately we hit Sam's Gap, which bisects I 26.   I saw a cab.  I can't say I was not tempted to haiil it and head to Asheville, given my exhaustion and the change in weather for the worse.   

Now it is raining lightly but we have a nice fire.  

Tomorrow we do a 14.7 miler.  I am nervous but have been assured it is not too hard.   Yeh right.  The remaining 2.5 miles to tonight's area was very tough.   Of course, it was up hill for ~1000 feet.   

On balance, has been great.   As we stand here this minute, I'd like to be home.  Miss my family.   Oh well.  Tuesday it is.  

AT over and out

Got off the trail at 1:35 and re-entered civilization shortly thereafter.   Wow!  I can just go into a convenience store and get food and water.   Trash cans: I love you.  I no longer need to carry my trash everywhere I go.   Indoor plumbing: marry me!  Civilization: I ain't leaving you anytime soon.  

How would I rate my experience?   Awesome and amazing and life-changing and reaffirming all at once.  But also, the experience was exhausting and frightening and lonely (at times).    We walked 6 miles on day 1, 11 on day 2: 10.2 on day 3, 16 on day 4, and 10.8 on day 5.  Elevation changes were as folllows: day 1: 1800 to 4200.   Day 2: 4200 to 1800 then back to 5000.  Day 3: 5000 to 5600 then to 1800 then back to 4200.   Day 4: 4200 to 4600 then down to 1800 then back up to 4900.  Day 5 4900 down to 2000.  

Getting water was an ordeal in itself. Water sources, or streams, were either encountered 0.3-0.7 miles from shelters/camp sites or encounter but water needed to be carried and filtered prior to drinking.  On day 2 I made the mistake of filling up in a terrific steam at 2000 ft then had to carry the water up to 5000 ft. Water was 2.2 lbs per liter and I had 3 extra liters that day in my bag.   Many sections of the trail require bordering.  This is a slow process and it requires tremendous concentration and energy expenditure.  Downhill, easy right?   Wrong.  The trail has many wet leaves that are treacherous. They not only cover rocks and roots, but they are slippery.  Treading here required enormous energy expense as well.   Until day 5, I averaged 1.5 to 2 miles per hour. 

Frightening

I found a great deal of the experience to be either stressful or downright scary. One slip or bad fall could result in a fracture.  Most of our locations were remote and lacked any cell phone reception.  Simple medical emergencies like ankle fracture could prove fatal.   

The trail is well marked and easy to follow  yet at times I had difficulty finding markings and felt lost.   The area is so vast that getting lost would be terrible indeed.   But wasn't I with my friends?   Not usually.   Everyone hikes at a different pace.   On the trail, they say that everyone must do their own hike.  I guess that is true in life as well.  Still sometimes I found it scary and stressful.   

Lonely: see above.  Plus I missed my family terribly. 

What did I like about the experience?   

The views are spectacular.  The  physicality required was amazing.   The challenge comquered: how can my words describe that. To do this justice I'd need to be poet.   

So on balance how would I rate this experience?   Friggin amazing. 

Min parting I'll leave you with some photographs.   Enjoy,

The IU

 

AT day 2

Awoke at 7:30 am.  Had to take a big dump.  Have never dumped outside before.   Not fun. Not easy.   But I survived. 

Hike stated at 9:30.  Stunning views.  Easy walk for first few hours.  

 Absolutely delightful.   

And then the afternoon hike hit.  1800 foot to 5000 foot climb with 37 lb pack.   Brutal.  If it was beautiful, I never noticed as I was too tired.  Had a nice lunch though at 4200'feet.   

From this point it took me another 3 + hours of challenging hiking to the shelter.  

Now all is good.  Had a nice meal.  Then a good fire.  

Temp tonight will be high 20s.   Hopefully I'll stay warm.   

So far so good.  

Urology Radio Episode 1: Sex Ed

Join me every Saturday at 10:30 for UrologyRadio

Starting August 22 at 10:30.  This is urologist Dr Richard Schoor. I'll be discussing the most important topics that concern men and their sexual partners.  Join me.  UrologyRadio on 103.9.  

Stop complaining to me about your copays and deductibles!

 Patient: "Are they [the radiologist] going to charge me for the x-ray?"

Me: "Probably.  Why would they not?"

Patient: "It is ridiculous.  I pay thousands of dollars a year in premiums and I get sick once and I'm going bankrupt.  It is bullshit."

Me: "I agree.  These high deductible plans are terrible."

Patient:  "It is because we are paying for all these smokers and sick people."

Me: "No, it is because we are paying for the high level executives to fly personal jet between their mansions and yachts."

"Patient: "Huh?"

Me: "Don't worry about it.  You can take comfort in the fact that your hard earned dollar, when spent on your health care, is funding an executives super-high end lifestyle.  You should feel good about that."  [sarcasm seething from my lips]

No folks, the doctors are not the problem.  Nor are the immigrants.  Nor are the sick people.  Nor are the poor people.  The problem is that we all pay, via super high premiums, for a very few, well connected people, to live unbelievable lifestyles and to make so much money that they can, in turn, purchase are politicians.

Answer: Medicare for all.  Demand it.  Now. From your government.  And stop complaining to me.

Join the movement:  PNHP

A Simple Question, A Complex Answer

A colleague of mine contacted me with the following question:

 "Can you tell me real quick how to do a semen analysis?"

OK.  Where do I even start?

Semen analysis is a complex diagnostic lab test.  As such, it is a highly regulated endeavor.  To do even a basic semen analysis requires a license from both federal and state agencies.  Your lab must submit to both routine inspections and random inspections and must comply with regulations regarding quality testing, quality control (QC), and quality assurance (QA).  Accuracy testing must also be performed a constant basis. The results of all QC and QA must be maintained for 7-10 years. The lab must have detailed operating  and policy and procedure manuals.  These are very complex items to develop.  The lab must have safety manuals that meet OSHA standards.  Other regulations include data security and backup, disaster planning, staff training and CME.

Oh yeah, and then there is how do the test itself, the semen analysis.  But that description is for a different blog.

Sustainable Advantage

Every business wants a sustainable competitive advantage; something they have that customers want that another firm cannot easily produce and sell.  Most firms play the leap frog game.   Firm A makes a great smartphone and firm B makes a better one.   Sushi restaurant A makes Crazy Roll and sushi restaurant B makes a Really Crazy Roll.  In health care, this happens as well.

One doc does anti-aging and then gets copied.   A plastic surgeon does a breast augment and another one does them for less.  So what is the way out?

You must acquire a sustainable advantage: something so hard to do, so expensive or something that requires so much expertise or better yet a really hard to get license, that very few doctors can ever do it.  

Think about what that can be for you.