Saturday, May 24, 2008

Doc vs World

Imagine being safe in group practice then walking into work one day only to find yourself out of a job. Happens everyday. This is the economic equivalent to being in a shipwreck and stranded on a desert island. What would you do?

Your first priority is to not panic. Panic will prevent you from calling up all your survival skills learned in school, training, and life. Time is of the essence since cash reserves will quickly dwindle away and if you don't start generating cash flow, you'll die. Panic just gets in the way and prevents you from developing a survival strategy.

Your first step is to make a business plan, set-up shelter, ie an office, and start foraging for food, that is customers. All this must happen simultaneously and in a timely manner. The survivor's business plan is a simple and rough one. You can revise it later. Just jot down your long term goals, your short term goals and needs and strategies to achieve them; should take about an hour. Your office can be virtual rather than physical and foraging for food really means to do what it takes to get customers. On a desert island, make a fishing pole or net. In start-up, get on the web and start answering your phones. I can't tell you how to make fishing gear out of bamboo, but I can tell you how to set up an effective and inexpensive web presence in under 1 hour.

I was inspired last night when watching Man vs Wild, on the Discovery
Channel. Aside from having to eat carrion, opening up on you own has
many elements of pure survival. I hope you enjoyed the first
installment of my new series, Doc vs World: Surviving Your Start-up.

Good luck.

The IU.

Thursday, May 22, 2008

A hidden cost of an EMR

EMRs are energy suckers. If you have and manage your own server, the energy requirements can be enormous. I have 5 work stations, all networked, and they all remain on 24/7. I can turn them off, but I often need to access them remotely. I don't have a server and am thankful for that. Servers require large amounts of energy to run, cool, and maintain.

If you use windows based workstations, you may wish to adjust the power schemes to save money.
Here's how:
  1. Start
  2. Control Panel
  3. Power Options
  4. Power Schemes
  5. Select the one you want
I tend to put the lesser used computers into hibernation mode after 20 minutes of idleness. Hibernation allows the computer to stay on, but at lower power-usage. The computer does not need to be re-booted and it will save projects between hibernation cycles.

In this era of rapidly increasing energy expense, little things will go a long way.

The IU.


When it comes time to pick an office, size matters. An office that is too large can be problematic for obvious reasons, namely that you will be paying for square footage and utilities that you don't need. Conversely, when the office is too small, the working environment can become cramped and unpleasant, and, even worse, you may not be able to maximize revenue producing business because you simply lack the room. However, all things considered, when it comes to office space I feel that smaller is better.

Here are some advantages that small offices have over large ones.
  • No need for expensive intercom systems
  • No need for dumb-waiters or tube transport systems
  • Easier inventory control
  • Lower rent
  • Lower maintenance costs
  • Lower utility bills
Let me explain some more. I can overhear every conversation in the office when my office door is open. This comes in handy when situations arise between staff and staff and staff and patients. If I need something from my MA, I can intercom her, but I typically revert to a more vocal paging method.
During a patient encounter in an exam room, everything that I could possibly need is within my arm's reach. Last year, my electric costs were ~$50 per month. Now, thanks to our current energy predicament, I pay $150 per month. If I had a 3000 square foot office, I'd probably pay double or triple. I don't have storage room for much, so I order supplies "on-demand." Whether that saves money or not, who knows. But it works for DELL. My office can be cleaned by my staff in 20-30 minutes. This is important for 2 reasons: costs me less and makes my office more secure.

See, small is better, at least for office space and now automobiles. Prerequisite: EMR.

Good luck.

The IU.

Monday, May 19, 2008

Doctors have it better than fisherman. . .for now.

I went fishing this weekend in Montauk--Long Island's eastern-most tip. I went on a charter full of amateurs and pleasure seekers. The boat was staffed by pros; fisherman that had done everything from "swording" on the grand banks to crabbing off the Aleutians. I am a terrible fisherman and have not ever caught a fish, but I love talking to people and learning about what they do and how they earn a living.

The man in the picture is a professional fisherman. He has fished on commercial boats all over the Atlantic. From talking to him, I learned that I have it pretty good as a doctor, even when I was a resident. Fishing boats are generally under corporate ownership yet the crews that staff them are independent contractors; that is they are 1099-ers. Like independent contractors anywhere else in the US, fisherman must fund 100% of their health insurance benefits, retirement accounts, and business expenses, yet have very little in the way of the tax advantages afforded to other corporate structures. On top of that, in a quirk unique to maritime law, the owners of the fishing outfit do not risk the financial losses that can occur in the event of a poor fishing season. The crew takes that risk.

For example, as I was told, if the ship brings only $15,000 worth of fish, but the expenses for the expedition were $20,000 , the crew owes the company $5000. The employers don't lose the money, the employees do. In the case of a good haul, the owners can keep up to 60% of the profits, and the crew splits the remaining 40%.

The employees risk not just life, but money, on every outing. The employers risk nothing.

Contrast that to my life. I have 3 employees and I'm the employer-owner. My overhead is in the $16,000 range per month, often up to $20,000. On good months, when I exceed the overhead, I take it all the money. On months that I fall short, I eat it all of the loss. My employees get paid regardless of the profits or losses in any given period. When times are great, perhaps they are envious of me. When times are bad, they make more than I do. With the exceptions of maritime law and CEO pay, this type of arrangement is true for all businesses in the USA.

So what I took away from the fishing trip--other than some fluke--was that doctor-employees typically have it better than doctor owners at present. Fisherman employees have it far worse than doctors or boat owners. Doctor-owners and fisherman face similar challenges; namely an environment that is largely outside their own control and one that is only getting less bountiful.

Again, just my observation.

The IU.

Thursday, May 08, 2008

A great use of technology

Congrats to the Axiom Law Firm for using technology to lower costs and expand reach. They don''t have an expensive, high rent corporate office. Instead their attorneys' offices are virtual; in their laptop computers. All computers are networked to a central server and attorneys can meet with clients anywhere.

A great model.

Can it work in medicine? Already does. I know generalists that don't have an office and do all work while on the road or by electronic forms of communication. Aside from the insurance implications of this type of practice, from a logistical perspective, the virtual physician office can work quite well.

Can it work for a urologist? I have thought about this long and hard and have yet to come up with a good solution. I simply need an office to do my work. I don't need a big office, thanks to computer technology, but I need an office. While an attorney can talk with a client at a coffee shop with some degree of privacy, I simply have not figured out how to do a prostate exam at Starbucks.

Still, the standard operating procedures for physicians are changing. Large offices and large staffs have now become liabilities. Physicians can share offices, yet have completely separate practices; practice management, EMR, and phone systems, all at low cost, can be set up easily so that they are not shared amongst the doctors. I can see a situation where a urologist has the office Mondays, Tuesdays, and Saturdays, and an ENT takes it the other days. The 2 doctors share physical space only. Staff can be shared, or can be individual. With VOIP and internet telephony, even phones can be completely separate. The urologist can have his EMR/PM software housed on an external server and access it from anywhere; same with the ENT. If the urologist needs to see a patient on one of the off days, he can do so either virtually, in the ER, or by house-call. Financial arrangements can be made in these unique circumstances with enough foresight and planning. Using this technology, the urologist can still be operational and productive when out of the office.

I think this is an exciting time to be young, in start-up, and ignorant of "how thing are done." This way, you may just develop a system that works well in the 21st century.

Again, congrats to the success of the Axiom Firm.

The IU.

Tuesday, May 06, 2008

25A: The Route of Broken Dreams

I drive home along Long Island's route 25A, a historic road that meanders along the fabled North Shore of Long Island. On my 7.6 mile drive home I pass nice homes, busy restaurants and bars, and thriving businesses. I also pass failing businesses. Route 25A has served as a good reminder of how lucky I am just to be in business 2 years after opening my doors. Here's the list of failures of my kindred spirit businesses: those that started around the time I did but have since closed.

  • A bagel place closed after 3 months.
  • A seafood restaurant has closed, after having been open for only 8 weeks.
  • A Mexican restaurant across from my sushi place closed after several weeks.
  • A "Hooka Lounge" bar just opened, though I've never seen a single car in the lot and I think it'll no doubt close soon enough.
  • A coffee shop in Kings Park went under after 6 months.
  • A cellphone storefront lasted 1 month before going under.
  • A printer cartridge retail store in Smithtown lasted 1 year.
  • A law office closed and an alarm store took its place. The alarm store closed 2 months later and has been replaced by a real estate agent, all in under 1 year.
That makes 9 failed start-ups in less than 8 miles. . .in an affluent area. Yes the economy is not well and in these times having a job or a business that is simply surviving might have to suffice.

Depressing, yet true.

Good luck out there.

The IU.

Monday, May 05, 2008

EMail and Money

There are 3 undeniable facts regarding email:

  • Insurers and Medicare do not pay for email communication.
  • Patients want email communication.
  • If possible, doing what customers want is good for business.

EMail is a great way to communicate. Unfortunately, very few doctors have embraced it. I think that email can be used in a medical practice safely and in compliance with HIPAA, and doing so can help the bottom-line as well.

EMail is unobtrusive and permanent. These 2 features make it ideal for the medical doctor. Patients can ask their questions when it is convenient for them to ask and the doctor can reply when they have time to answer. Since email is so considerate of one's time, a doctor that uses it can answer patients without feeling rushed. They can compose their thoughts and answer questions clearly and completely; all from the comfort of their own beds or during a dull 3 year old birthday party. In addition, the records can be saved in the patient chart for all to see, thus
there can never be a "he said-she said" type argument in case of any future adverse events.

Email communication makes sense monetarily as well. First, young and busy patients want it and need it. For them, email is a way of life and for many of these people, time is more valuable than money. These are the kinds of people you want in your practice. These patients also have mouths and talk and will help build your practice with patients like themselves.

Secondly, having people come to your office to discuss something that can be handled quickly by email is, in my view, penny-wise and pound foolish. If the patient's question can be handled satisfactorily by email, doing so will free up a slot for a better paying new patient or procedure. Why spend 15 minutes explaining something for $30, when you can spend 15 minutes doing something for $200? The patient will appreciate that you value their time as well. In my experience, patients are glad to come in and spend their time and money if we tried first to deliver their care by email. Third, new patients often make first contact with me by email and ultimately they often become paying customers of mine. So from an indirect perspective, email can make financial sense.

From a more direct perspective, an entrepreneurial type physician or manager can come-up with a solution so that patients will pay for the privilege of communicating by email. While I don't do any of the following, some practices may charge per email while others will charge a monthly fee, yet others might offer the service as a "premium" type offering. The details of these types of arrangements will vary depending upon payer mix and contractual obligations, but often enterprising, smart people can find a way to make it happen in a way that is both acceptable to patient and insurance company alike.

While email is not perfect, nothing is better either. With email, contrary to commonplace fears, a physician's time will be made more valuable, rather than less.

Let me know how it goes.

The IU.

Finally spring!

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Thursday, May 01, 2008

Poor Babies!

I feel bad for them. Why not just raise the cost of the gas?