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!

Poor Babies!

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

Exxon: You Have Been Targeted For Termination

I sent this letter to 1000 of my patients. Please pass it along to everyone you know.

Dear friends,

Gas prices are at an all time high and only going higher. The high gas prices affect everything that we do and buy and are making economic survival difficult for millions of Americans. The current administration and the oil companies are to blame, period. We can beat them. Here’s how.

I call for the week of June 1^st to be “Pick on Exxon Week”. Our goal is simple: cripple Exxon and send a message to other oil companies. Why Exxon? Why not Exxon. Shell Oil, you’re next.

Please pass this email to others in your contact list and let’s make a difference together.

Richard A Schoor MD FACS

Smithtown NY

http://www.drschoor.com/

Car trouble, eh?

Car trouble is popular excuse for tardiness. I've noticed, for many
employees that I've had the experience of working with over the years, car trouble happens with surprising frequency. I drive a car with 106,000 miles on it, twice that of any of my employee's cars, yet it gets me there just fine. My medical assistant was an ~hour late this morning. She told my office manager that she had car trouble. What am I to say, she does drive an old car, and who knows?

The funny thing about car trouble is that it seems to only happen on the way to work. Never once, in the 8 years since I have been in practice, or in the 18 years that I have been in the work force, has any employee ever had car trouble after work. Never once has an employee of mine been stuck in the parking lot after work. Nope; after work their cars seem to start right up, no matter the temperature, barometric pressure, humidity or aridness. When the whistle bell rings, the ignition works just fine. When the alarm clock goes off, well, that is another story.

Is there is something peculiar about cars in that they only break down unidirectionally; that is on the way to work?

Powered by ScribeFire.

So you we think we have it bad.

The following was sent to me from a colleague. I find it disturbing and puts suffering into perspective. I've included the entire email:

Thought I would share with you all.

This is an Email from my cousin to his mom back in NYC.

He is a peds resident at Columbia U. He was on a medical mission trip in Uganda.

Pardon
some of the profanities, but I believe it adds to the overall feel of
the Email and what he is trying to express. I am sure he would die if
he knew I was forwarding this on, but it shocked me back awake today
and I thought I should pass it along.

Amberly

Subject: thoughts on lilian

hi pretty girl. its 5pm
here - sitting at the computer lab in the mulago hospital library.
feedback was good on the first update, so i added some more people to
the shout out list.

feeling pretty broken down...

yesterday
on rounds, we met lilian, a 10 year old girl whose dad brought her in
the day before w/ severe belly pain, fever and an inability to pass
urine. at that time, a short discussion was had about renal failure,
blood pressure control and how she needed dialysis but wouldn't get it.
her father helped her to the floor and placed her over a plastic tub. i
heard a whimper and a small splash - dad turns to us and reveals what
looks like milk inside. i realize that she is peeing frank pus and ask
whats being done to control her infection. after a bit about the
utility of urine studies, i was reassured that she was receiving the
proper antibiotic therapy.

as
per routine, the attending dictates her 'findings' and 'impression' to
the resident, and we move on. the 'plan' is also transcribed but
remains nebulous "continue antihypertensives, monitor urine output". i
remain stunned and fall behind in rounds.

this
morning she looked awful. her face was swollen such that her eyes were
2 black creases. she was foaming at the mouth; unresponsive. apparently
her potassium was in the 6's and the serum urea was through the roof.
Dad was instructed to go to the pharmacy and buy lactulose (to induce
diarrhea so she stools out some of the potassium she is unable to
excrete by urinating). Dad says in a soft voice that he is afraid he
will get lost. He is reassured that he will not, and rounds continue on.

i'm
figiting with my camera when i notice the nurse pushing a clear liquid
through a syringe into the IV in lilian's hand. i ask what it is and
she replies 'adrenaline'. i grab lilian's wrist and feel for a
pulse...none. i grab the medical student who had been examining lilian
- "what the hell is going on?" He looks at me wide-eyed and stutters:
"we were listening to her chest and she just stopped breathing. I asked
for help and they brought this adrenaline."

The
group, which had moved on to the next patient, was slowly and without
any hesitancy making its way back to lilian's bed. i raise and place my
hands on lilian's chest (as in "news flash people i think we need to DO
SOMETHING" here) but before i even apply pressure, i realize that i'm
the only one moving. the attending reassures me, "there's no point in
resuscitating her. even if we did, we have no ventilator". she then
chastised the resident for ordering the adrenaline and moved on with
rounds.

i
believe doctors care for patients to the best of their ability given
the availablity of resources. but i'm like "F you lady, you could have
at least tried!"

i
know i don't know jack about their world. i'm a american white guy,
raised in the suburbs who has no concept of the reality of life for
doctors and patients in uganda. and who am i supposed to hate for the fact that they have no ventillator?

lilian's
father never left for the pharmacy and saw the whole thing go down. i
tried putting my hand over his shoulder and muttering "i'm so sorry",
but i never saw one break in his face. the man just lost his daughter
and he was completely flat. not shocked, just flat. he told me in a
quiet voice that he was going out to make a call. two sisters
(nurse-nun types) dressed all in white came and wrapped lilian up in
her bed sheet. i remember them tying a piece of gauze around her head
and chin to keep her mouth closed. they folded the mattress and carried
her out of the ward, the other parents following with their gazes.

life
is so different for different people. you can never, ever judge or even
claim to really understand. the only truth i consistently come back to
is this: life is fucked up sometimes. it is not our fault - situations
may be made worse by generations of damage and corruption, but to
expend energy on assigning blame is wasteful and non-constructive. and
it is most certainly not God's will, for the sun shines on both the
righteous and the wicked.

but
i have faith in the perseverance of the human spirit. we should strive
for a world where basic needs are met and where people can share their
thoughts and feelings freely. i'm probably just on some africa shit right now, but i believe that we can achieve this goal in our lifetime.

its
weird but even though the context has changed, it hurts the same way -
i feel awful for lilian's father. no parent should ever have to bury
their child. not in new york city, not in uganda.

if
you've made it this far, thanks for sticking with. i miss you tons and
will be in touch. as emily would put it, expect more politicking. hit
me back w/ thoughts (like dude you talk to much..!)

-clem

Powered by ScribeFire.

A Guiding Vision

I'd never heard it described quite like that, but guiding vision perfectly describes the concept that I have been trying to convey in several The Independent Urologist posts of recent and past.

A guiding vision.

I like the sound of it. I like its imagery.

A guiding vision, as described to me today by a remarkable coach, Philippa Kennealy MD, represents your long range vision or ultimate goal. This vision guides you and helps you make decisions in the face of uncertainty. It can help you decide where to spend valuable resources or when to join a group or when to leave one.

I have understood the concept for the past 2 years--and it has served me well.
But the words, Guiding Vision; tremendous.

Thanks, Philippa.

The IU.

Powered by ScribeFire.

The 5 A's of error free medical practice

Errors cost money. Errors result in bad outcomes, unhappy people, and stress. Many errors, if not all, are preventable. Here are 5 things that you can start doing today to become an error free medical practice.

• Automate: Any process that can be parred down and automated ought to be.
  
• Assure: Quality assurance plans will help you nip problems in the bud and to avoid them altogether.
  
• Audit: Inspect your work randomly before someone else does it for you.
• Ask: Ask your patients open ended questions and let them answer in their own words.
• Aspire: Aspire to become better at what you do, and how you do it.

You'll find that you perform better, more effortlessly and efficiently, and with less cost.

Good Luck,

The IU

The 10 immutable laws of start-up medical practice

1. Formulate a vision statement
2. Compose a mission statement
3. Write a business plan
4. Secure financing
5. Start small, but not too small
   
6. Determine your core strengths & weaknesses
   
7. Know the marketplace
8. Develop a competitive strategy
9. Market, market, market
   
10. Answer your phone

Only 10 laws critical to your success. Sure, easier said than done, but not too hard either.
Good luck,
The IU

Powered by ScribeFire.

Going solo? Develop a QA plan.

Quality assurance--QA--represents everything that you do, or do not do, that makes your practice run better: less mistakes, less re-do's, less call-backs, less adverse outcomes, less mistakes, and ultimately less cost.

Quality assurance is process, rather than a one time event. I actually have a written plan that I purchased, then I customized it for my own usage. Here's how the QA plan works:

1. Divide the year into 12 months
2. Each month = a QA activity
3. Document the activities and corrective actions in a book or e-book
4. Follow-up on corrective actions

Here is an example of a QA plan that you may wish to implement:

• January: Chart audit for appropriateness of coding levels
  
• February: Chart audit for labs and studies filed, signed off, and acted upon
• March: Assure that employee documentation is in order
• April: Make sure that all insurances are in-force and up to date
• May: Financial audit
• June: Repeat chart audit for appropriateness of coding levels
• July: Repeat chart audit for labs and studies filed, signed off, and acted upon
• August: Review marketing plan and ROI; adjust accordingly
• September: Check in-office lab reagents for expiration dates
• October: Perform and document equipment maintenance and calibration
• November: Financial audit
• December: Chart audit for labs and studies filed, signed off, and acted upon

When you have this QA plan and document the activity, you'll find that "things" just seem to go better and more smoothly. You'll be doing work once, correctly, rather than re-doing over and over again. You'll also find that your operating costs will decrease and your profits will increase. Finally, you'll just be a better doctor.

Let me know how it goes,

Dr S

A reader question: How long to positive cash flow in start-up?

One of my readers (not my mom) asked me a question that deserves an answer. Hopefully, she will read this post.
The question was:

When does the
cash-flow usually come in after starting a practice?


Answer: Depends

Medical practice is a business and start-up is start-up. Most start-ups will fail in the first year for one simple reason; they run out of money before cash flow can cover expenses. When these businesses will run out of money depends on a variety of factors. The most important factors are access to capital, type of business, competition, and payer mix. Business that start-out with less than $5000 cash will usually fail in the first year, while those that have access to $100,000 or greater, will most likely live beyond their one year anniversary. If you want to survive, I recommend raising money, and lot's-o-it.

The type of practice you have makes a difference as well. Some practice's have inherently high start-up costs while others can be started with significantly less money. For example, I started my urology practice with $40,000 down and access to $150,000 in case the unowhat hit the fan. An internist may be able to start-up for even less, while an OB-Gyn in NY will need in excess of $200,000 to start-up. But the start-up costs only tell part of the story. A urologist may have high costs compared to an internist, but we also have higher revenue potential. A plastic surgeon or dermatologist in start-up can have very low up-front costs yet have a high earning potential and could thus become cash positive in a very short time. Contrast that to a primary care physician: they'll have relatively low initial costs but very little real income generation potential in today's climate. Plus, as they get busier, their costs escalate much faster than their revenue.

The third factor is competition. If you are the only urologist in town, you'll do well. If you are like me, one of 100s, you'll have to struggle a bit more to make money. A plastic surgeon in start-up on Long Island may have lower costs than, say, I did, but he/she has much fiercer competition than I faced. As for primary care; out here they are dime-a-dozen.

The fourth factor is payer mix. If your patients are insured, and you have enough of them, you'll start to make money. If you practice in a very well-off area and can go "out of network" you'll make the same money with less work and in less time. If you deal with predominantly Medicaid, you'll probably have to move because you'll never get there.

As for me, my cash flow turned positive after 9 months of hemorrhage.

I started in April 06 with a $40,000 initial investment and was prepared to pour another $150,000 of my own money into the practice to "float it" in a worse case scenario. Initially I estimated a loss of $30-50K in year one and a break even point by end of year 2. I felt that by end of year three I'd start to make in excess of $100K per year. In actuality, I broke even by end of year one and made a modest, yet respectable, profit by end of year 2. This year I have been doing quite well. While I had to dip into my savings, I repaid those loans quickly.

Caveat:

While I have already recovered my initial investment and have been making some money, I am still greater than $200,000 in the hole if you factor in loss of income during my first 2+ years of start-up compared to what I'd have earned had I stayed an employee. So be forewarned: the freedom to be your own boss comes at great cost.

So good luck Rose and please feel free to contact me.

The IU.

Where NY State chooses to spend its money

I just finished having a nice conversation with a friend. His son is a criminal attorney fresh in private practice. His clients typically pay cash. What I found interesting was the following:

While this attorney is not a public defender, NY State will send him clients that need defense and pay him $200 per hour.

$200 per hour!

Now let's see how that compares to NY State's Medicaid reimbursement for physicians. I just treated a man with suspected Fournier's Gangrene, a life-threatening infection that requires many hours of intervention by multiple highly skilled and trained medical personnel. I spent 4 hours yesterday—in-total—working on this patient. I will be lucky if I get $100 in reimbursement from Medicaid.

So that is where NY State's priorities are.

The IU

Now they've gone too far!

Insurance companies control much of what we do in medical practice; where we send patients for labs; pre-certs for radiology tests; referrals for visits. Crazy. But this takes the cake.

One major carrier just sent me a letter that dictates how my semen analysis patients can procure their specimens.

• PPO patients can use DVDs
• POS patients can only get magazines
• HMO patients get National Geographic
• Out-of-network patients can use an escort

This has just gone too far. We must make a stand!!
Have a nice April 1st.
The IU.

Powered by ScribeFire.

The Value of a Slow Day

While busy is great, an occasional slow is ok too; as long as it is only every so often. Here's what to do on a slow day so that you can stay productive and proactive.

1: Do your bills—always important

2: Refine your processes—take the slow day to think about your inefficiencies, mistakes, and successes over the past few weeks and then refine your processes for the better. For example, you may find that patient flow improves simply by eliminating one form or another or use the time to record some new macros or templates

3: Pick-up a book—not Tom Clancy (who I love), but a business school book and use it to learn about marketing, business development, business strategy etc

4: Do some CME—perfect way to turn 2-3 slow hours into CME credits

5: Check your back-ups—use the time to make sure your back-ups are running as planned

6: Perform QA—run a random chart audit, check to may sure your insurance policies are in-force, make sure your reagents aren't expired, etc

7: Review your P&L statement—use the time to find areas in which to cut costs

8: Call your post-ops—where good doctoring and good business intersect

9: Market—an on-going process

10: Blog—of course

Thanks,

The IU

Now I've seen it all!

A hair salon for dolls. This is at the American Girl Doll Store in NYC. Upstairs, on the 3rd floor is "the hospital" where broken dolls can be fixed. And no, they don't take inurance.

How to compete with the big boys

Just because you are new to the community does not mean you can't survive, even thrive. As a new entrant into the market place, you may have several advantages over the established practices.

1: Flexibility—you can be flexible, adaptive, and change-ready. These are important characteristics to possess in the face of shifting reimbursements schemes, regulations, and managed care rules on top of major advances in communications and health information technologies.

2: Cream-skimming—also known as cherry picking, this allows you to actively pursue more profitable diagnoses and treatments since you are not bogged down with a sicker, more labor-intensive, and—unfairly—less profitable patient base.

3: Tech-saavy—you'll have access to low cost, yet powerful technology that is designed for smaller operations. This technology will enable you to be efficient, more cheaply.

4: Alternative delivery methods—you'll be able to find new, creative ways to see patients and deliver care and also develop alternatives ways to get new patients. Just ask Jay Parkinson MD. IM, Video Chat, text messaging, e-mail, web-site; all this will allow you to capture a sizable segment of the patient base that other established groups are not reaching.

5: Patient preference—as a solo person or a small group, you'll find that patients will be choosing you preferentially over the faceless, big name group. Who'd you chose?: Suffolk Urology, North Suffolk Urology, Central Suffolk Urology, Western Suffolk Urology, or Richard A Schoor MD PC-Urologist.

6: Regulatory changes—No question that in this regard, the advantage tends to go to the new entrant. Inertia that is always present in established practices will make operational change slow in the face of mandates such as P4P-PQRI, HIPAA, etc. In addition, large groups will respond more slowly to changes in payer mix and ironically, can be less adept and handling cash paying patients.

On the balance, as a new entrant, immature, and upstart practice, you're not as disadvantaged as you may feel you are.

Thanks,

The IU.

Customer Service, Customer Service, Customer Service

I don't care what type of business you have, if you deal with people then customer service is important. This is what I like to see in a variety of businesses:

--Pizza place: have reading material for me, since I often eat lunch alone.

--Doctor's office: see me reasonably on time, be reachable & competent

--Contractors (all types): be honest, come in on budget, complete the job satisfactorily, and clean up after yourself

--Accountants: give me honest advice, be reachable

--Lawyer: see accountant

See, I don't expect much.

So much for NY Tort Reform

Our advocate has done what? See link.

Barriers to entry? Few.

Though the costs associated with starting and operating a medical practice have escalated rapidly over the years, in many ways the times and present environment have actually made it easier to start-up on your own. Why is this? The answer is that there are now fewer barriers to entrance into the market place.

Any industry has businesses that have been first to market, even Google within the search engine industry. Remember Netscape? In any marketplace, the established businesses will resist the newer ones from entering and competing. Medicine is no different. Since there is no longer a frontier, the possibility of being first in a community is essentially zero. Fortunately, in today's market, this is no longer as important as it once was. While far from being easy, a solo urologist or ENT or PMD can open a new office in an established, mature community and still survive and even thrive.

Patients come to doctors today by 4 ways: referrals from other providers, word of mouth referrals, insurance rosters, and external marketing efforts, such as advertising, yellowbook, etc. In the past, professional referrals were critical to a specialist's survival. Referring doctors had all the power and could make or break a new doctor. This is no longer the case. Insurance companies, whether intentionally or not, have made this happen.

Here is how it works today. Many patients may feel, for example, that if they need to see an ENT specialist, and they can turn to their insurance company list first. Even those who do turn to their primary initially will then turn to the insurance list. It is the rare patient that will go with a professional recommendation without first verifying that the specialist is "in-network." In addition, patients feel that the insurance company has done the ground work in verifying the doctor's credentials and that if he is "on the list" he must be OK. And for the most part this is true.

What this means is that essentially, a new entrant into the marketplace can have the same standing in the eyes of patients as an established doctor or group simply by being on the same insurance panel. The implications of this for the medical market place are nothing short of incredible—in both the good and bad sense of the word.

To a new doctor in a community, it means they can make a living--not a great one but a good one—simply by contracting with insurance plans.

To an established doctor or group, it means that there is little they can do to prevent competition and an erosion of their own advantages.

To an insurance company, this means that few doctors can ever become so powerful that they can increase their fees unilaterally.

Perhaps this is another paradigm shift in the business of medicine.

Again, just my observation.

The IU.

QA,QC,TQM,6-sigma,IU

They say that a chain is only as strong as the weakest link. Medical practice is no different. The best surgical care can be undermined by an overlooked laboratory value and perfect outcome ruined by a mis-filed lab. I’ve learned over the years quality assurance and total quality management are every bit as important as is history taking and the physical exam. Here are some of the things I do routinely in the realm of QA:

--Outbound test and study tracking
--Re-call lists
--No-show lists
--Equipment maintenance and mainetenance logs
--Random chart audits
--e-prescribing
--fax-tracking
--electronic medical records
--A written QA plan

My patients do well. I sleep well at night. Everybody wins.

The novice. . .the expert. . .the master.

The most incredible advances in medicine have not come out of cancer research or robotics or nanotechnology. No, instead, the greatest advances in modern medicine have been the creativeness in the stories told by drug seekers. There are 3 categories of drug seekers:

The novice: allergic to IV contrast, can't take toradol. Very easy to defeat these days due to non-contrast CT scans. Just send them to the ER or for a CT.

The expert: was in pain "while in Vegas", went to hospital, has no insurance, can't afford CT scan. More difficult here, but the trick is to pin the patient down on the exact name of the medical center, the dates of service, and demand a faxed report from the ER or treating physician. If they are unable or unwilling to provide you with that information, they are most likely drug seekers.

The master: Actually has a stone—even better if they have blood in the urine as well—but the stone is not obstructing and not causing their pain. These cases of tough ones and many-a-physician has been tricked into treating, even to the point of surgery, these patients. The key test here is to get either an IVP or a lasix renal scan to prove that there is no obstruction and then refer them to "the experts" at the university. Typically, these folks will get you for a couple narcotic scripts before you figure them out. They are THE MASTERS!!

Going solo? Use all your resources

This morning I was busy. I had 5 follow-ups, 1 scrotal sonogram, 1 penile duplex scan, and 3 semen analyses. The patients that I saw generated 3 new prescriptions and 2 refills. In addition, an established patient of mine moved and requested that her chart be sent to her new urologist.
In other words, a lot of grunt work.
Fortunately, my inexperienced staff can do the lion's share of it because of training and technology.

• My MA electronically queued all the prescriptions while I was doing the duplex scan. She made 2 mistakes, but the system will not allow her to actually send the prescriptions, so patient safety was never compromised. When I had a break, I pulled up the queue, made corrections, hit approve, and the prescriptions were sent to the pharmacies.
  
• My MA with no andrology lab experience was able to do the semen analyses for me on my automated system. I was able to verify their accuracies by reviewing the image and motility files. Plus, she calibrates the instrument daily and performs quality control on known samples. All this while I was doing a scrotal sonogram.
• My receptionist printed out the chart of the patient that was leaving us and placed it on my desk. I reviewed it to make sure that she printed out everything--which she did not--and then I signed it. She then scanned the signed copies back into the patient's chart into a sub-folder named "record releases", dated the entry, and then faxed the paper copies to the new doctor. All this while I saw the follow-up patients.

By 10:15 AM I was finished and on-time and all grunt work was done with accuracy and completeness. I then logged onto my blog, The Independent Urologist, and wrote the above.
Good morning!
Thanks,
The IU.

A Day Off

Took some time off today with the family.

More uses for technology in medicine

Today I:

• e-prescribed
• remotely completed medical records
• used a greenlight laser
• performed a TESE in conjunction with ICSI
• roasted a chicken
  

Good day

Powered by ScribeFire.

My automated semen analyzer

I recently invested in a new and somewhat expensive technology to automate my semen analysis process. The instrument, called the Sperm Class Analyzer or SCA System is a very sophisticated software program that links by computer and camera set-up to my microscope in my in-office, COLA accredited andrology lab. The SCA System adapts to my methodology of semen analysis and quality assurance and is really a very useful adjunct to my lab. Aside for basic features such as concentration and motility analysis, the software can also analyze sperm velocity, progressive motility, morphology by Kruger and WHO criteria, and sperm DNA integrity. In fact, these cumbersome and complex analyses have become so easy that I have been able to train my MA to do them.

From a technology perspective, the system fits in well with my general electronic office design. I can access the system remotely and review the saved analyses from home, generate a report, and digitally sign it, all from the comfort of my home. I can even do it from the road via my lap top. If I have a doubts as to the accuracy of any particular report, I can even re-run the analyses, since the digital images and motion analysis data are archived.
I can then convert my reports to PDF files with a keystroke and fax them electronically to referring doctors.

Automated semen analysis has some advantages over manual analysis. Perhaps the biggest advantage is reproducibility of results and decreased inter-observer variability. Accuracy is not compromised in anyway, since the instrument is calibrated daily and verified manually for accuracy by a trained andrologist, a guy by the name of Dr Richard Schoor MD.

Apparently, I am the only lab in NY to have the system, though several of the largest IVF groups in the nation have recently adopted the technology for their own usage.

If you need a semen analyses, please contact me:

Thanks,

The IU.

My high tech snow day

Despite global warming, the weather brought snow today to Suffolk County Long Island, where I have my urology practice. Fortunately I had a slow day in the office and was not really disrupted much by the snow. My biller however, was unable to get into the office. No biggy. Here's what we did:

• Encounter forms were delivered to my biller by my MA, who lives in the same town as my biller. We could have faxed the biller the encounters or emailed them as well, though delivery was just as easy, and HIPAA compliant.
  
• My biller VPN'd into the network, entered the charges, and submitted the claims electronically, just as if she was at her post in the office.
• I left early as well and had phone calls forwarded to my cell phone.
• From my cell phone and blue tooth wireless, I called in a prescription for antibiotics while I drove and deposited checks in the Commerce Bank drive-through..
• When I arrived at home, I e-prescribed for another patient and electronically signed off on some labs via the VPN connection to the work station in my own office.
• At one point, I was on the phone with my biller, who was remotely accessing her workstation from her home while I was remotely on my work station from my own home.
• While I was at home, where I get little cell phone reception, I received a call from a local doctor's office. They called my office main line which forwarded to a VONAGE line in my home office. Had I been on the road, the VONAGE line would have simul-ringed on the cell phone. Since I was home, I simply picked up a cordless phone,and took down information on a new patient.
  
• I did miss one call, but the number was logged on VONAGE, and I easily returned the call.

Maybe mundane to you, but I think it is pretty cool.
Thanks.
The IU.

E-Rx: A Good Use for An i-Phone

I don't have an I-phone but I may get one soon since I just discovered a new use for it that would fit in well with my practice: e-prescribing. E-prescribing has some advantages over traditional paper prescription writing. To name a few such advantages, e-prescribing decreases Rx dosing errors and insurance formulary and tier-ing issues, not to mention handwriting problems. Though I'm still slow at it, I can see that e-prescribing willmake my practice more efficient.

In NY State at least—which is fast becoming the most physician unfriendly state in the nation—only licensed practitioners such as RNs and MD/Dos can call in prescriptions to a pharmacy on behalf of the doctor. As you might imagine, a busy doctor, especially a generalist, can easily become overwhelmed by prescription management. In comes e-prescribing. With this new high tech tool, my high school educated MA—or anyone else with no medical training for that matter--can queue up all the prescriptions and refills for me that come in throughout the day and then I can review, edit, and approve them with a simple keystrokes from anywhere. My MA does not need any specific training in prescription writing or drug-drug interactions and she really can't make a mistake that can get my patients and me into trouble. Yet she can do the lion's share of the work for me.

Beautiful and just what I need.

Here is where the i-Phone comes into play. I was in the OR today and forgot my Rx pads. I did several cases on patients, all of whom had different pharmacies and I had have to call in some scripts for them. Now with hold times and phone trees and formulary related call backs etc, calling in prescriptions to pharmacies can be a royal pain and not something that I relish. Instead, I asked to borrow my friend Mike's i-Phone. With it, I logged onto my e-RX network, located my patients' profiles, selected the meds and doses from drop down menus, selected their pharmacies, hit approve all and voila', done.

Not bad. I can see other nice uses for the i-Phone as well, but this one is among the best.

Now if I could only use an i-Phone to reach Governor Spitzer to beg him for relief from this ridiculous med-mal environment that Long Island's docs have entered.

As always, join me on legislative day in Albany, March 4^th.

The IU

Going Solo? Develop A Competitive Edge.

What makes you so special? Why would patients go to you over someone else? While it may be difficult to compete with an established group or a large group, you can try to level the playing field--or perhaps tilt it a bit in your own favor--by developing a competitive advantage the amplifies your strengths and exploits your competitors weaknesses. Having Saturday hours when others do not may represent one such competitive advantage. Here are some others:

• Have office hours others do not
  
• Offer a service others do not
  
• Learn a new procedure that others are not yet doing
  
• Treat diagnoses that others find undesirable or less profitable
• Answer your own phones, and do it 24/7

As you grow, you can adjust your practice's competitive advantages accordingly. That is the fun part of solo practice.
Good luck.

The IU.

Powered by ScribeFire.

Tell me this is a joke, please.

From today's NYTimes: Congress is preparing for the switch, allocating money for 33.5 million $40 coupons to defray the cost of set-top converters, which retail for about $50-$70. Each U.S. household is entitled to request up to two coupons, redeemable at a certified retailer within 90 days.

 

Do the math: That is 2 billion dollars for health care—Oh I'm sorry, for digital TV.

Yeh, that is what we need in this country.

Am I nuts, or is that just bonkers? Someone, please tell, what am I missing.

The IU.

Where is Dr Carl?

Pillitieri Ob-Gyn has been delivering babies in Suffolk County NY for 50 years. The practice was started by Dr Pillitieri senior, and it was ultimately inherited by his sons, Carl and Mark, and his daughter Eileen, a nurse practitioner. I got to know Carl first, and then Mark, Mother's Day 2003, when I was on call for my urology group. Carl called me first and asked that I see his patient who was in pain from a kidney stone while pregnant. I said sure. About 30 minutes later, Mark called to ask where I was because his patient was in pain.

Who are these guys? And why do they torture me thus?

Several months later, when my wife became pregnant with our second child and we needed a new Ob-Gyn, the Pillitieri's were the first and only number that I called. I only knew them from that interaction and one or two more like it, but I could tell that these guys were patient advocates to the n'th degree. Their commitment to my wife and me from beginning to end confirmed my initial belief.

I have come to know Drs Mark and Carl, as they are called, and "Dr" Eileen, pretty well over the years. They send me patient referrals from time to time and in fact kind of supported me in my early years as a solo urologist in start-up. Their patients are nothing short of fanatical about them as doctors; almost cultish in their reverence for the 2 docs and nurse. On several occasions I have treated mother-daughter-baby combos all of whom were patients of Drs Mark and Carl. From an unassuming office, the Pillitieris practice outstanding patient care and safety combined with state of the art medical treatments. They are the real deal.

They are also dying.

Dr Pillitieri senior left practice in the 90's after being on the losing end of a multi-million dollar lawsuit. Dr Carl left practice after 15 flawless and lawsuit free years in practice to relocate to Maine, where his liability insurance premiums dropped by 66%. Dr Mark has remained behind in the Deer Park NY office, along with his sister Eileen. They are committed to the practice and the community that they love. Mark takes call everyday and has not had a single day off since Carl, left 2 years ago. Now that is devotion!

This year, Mark paid the standard rate for Ob-Gyns in Long Island, which happens to be $180,000. Unless legislative action in Albany intervenes, Dr Mark will be forced to pony-up another $56,000 in July 2008, in addition to his $180,000. If he cannot do afford the rate increase—and who really could—he will be forced to close his doors to new obstetrical patients.

There is a real human drama unfolding here on Long Island—a crisis in the making.

You have the ability to avert it. Contact your local state senator and assemblyman. Join me in Albany for legislative day on March 4^th.

What affects Dr Mark affects me and affects you.

Act Now!

The IU.

An Activist is Born

Liability rates in NY are rising dramatically. Many obstetricians in my own community, have already either given up OB or have left the state entirely. Who will deliver our children?

MLMIC, one of only 2 liability carriers in NY, paid $500 million dollars over a ten year period to defend claims that never resulted in a single payout to a plaintiff. The trial lawyers say that the defense bar is winning the war, but the cost of that war has been so high that the vitality of the entire health care system in NY State is in jeopardy. For the OB that delivered my Emma, legislative action that occurs in the next 6 months will determine whether or not he stays in business--and he is one of the good guys.

The trial lawyer lobby is strong, but ultimately they in are in-the-wrong. The citizens of NY need professionals that can provide obstetrical care, emergency cardiac and surgical care, and preventive medicine. I know personally several family practitioners in my community that subsidize their own practices with personal savings and debt just so that they may keep their doors open.

There is a misperception, perpetuated by the trial lawyer lobby, that there is no crisis looming; that the problem is the result of bad doctors, and that doctors and insurance companies are just greedy. This is simply not true. The overwhelming majority of doctors consistently do the right thing by way of their patients, and the days of the "country club life" for doctors has long since passed. From a financial perspective, most of us are simply trying to stay in business, provide for our families, and practice the professions that are our passions.

Help avert the impending crisis that WILL come in JULY 2008 unless legislative change happens immediately. Join us in Albany on March 4th for Legislative Day. Contact your local assemblyman and state Senator. Contact me, and I'll assist you in contacting your local reps.

Believe-you-me; when you or your child or your husband or wife or dad or mom is sick and in need of medical attention, you will turn first to your doctor and hospital, not to your trial attorney. You have the power to make sure that we are there for you.

Act now!

Thank you.

The IU.

Develop your long range plan

Medical practice is a business. Like any other business, a medical practice has 4 stages in its life cycle. Stage 1 is the embryonic stage. Like a developing embryo, the new business must develop the basic necessities of life, such as an office, a phone system, a computer system, etc. And like the wonder we feel towards our newborn infant, when we look at our new business, we feel awe and amazement over all that we've accomplished just so that we can open our doors on day 1.

Ultimately, the business will either die in the embryonic phase or will proceed to the next phase, the growth phase. The growth phase is like childhood. It starts out all fun and wonder, but becomes more challenging and stressful as maturity hits. The growth phase will morph imperceptibly into the next and longest phase of the life-cycle, the mature phase. It is during this cycle that the business continues to grow, but it grows at a more predictable level. Cash flow is somewhat stable and daily operations sort of take care of themselves but the stability is often interrupted by head-aches and fires that seem to sprout up out of nowhere. Finally, like life itself, all businesses ultimately die. Businesses end either in bankruptcy, or they get bought out, or they simply disband.

During each of these stages, you'll have outside forces that will push or pull your practice in one direction or another. The chance to make some "quick bucks" with some new equipment, the possibility of hiring a new associate, or perhaps the opportunity for a strategic merger with another group; these, and many more possibilities will avail themselves to you during your career. Since you will not have a crystal ball and will not truly know what to do when faced with these uncertainties, you will need something that can guide you in the right direction. And the only place that you can turn for guidance will be your long range plan.

The long range plan is your vision. It is where you see yourself in 10 years. It is your ultimate dream; the business or practice that you would want if nothing could ever get in your way. Your 10 year vision, or 20 year vision for that matter, is never too large or too ambitious. Nor should it be something that can be reached to soon, for then it would not be big enough.

Recently I have felt a strong pull towards a large group that has formed in my area. The temptation to reach out to them has been great. From all that I've heard, this group will achieve tremendous success and financial glory. They'll have their hands into everything and generate revenue hand over fist. Urologists around me are falling like dominoes and have been lining up—and paying handsomely—just to join. Should I try to get in as well.

My answer: no. To join that group right now would be incompatible with the long range vision that I formed for myself many years ago.

For now, I stay solo and grow on my own terms.

David vs Goliath.

Wish me luck.

The IU.

Business Acumen or Dumb Luck?

I am reading a terrific book now called, The Illusions of Entrepreneurship, by Scott Shane. I started it, and it has already inspired me to write this post. Rather than give advice that is based on anecdotal information, the author uses data to illustrate the differences that lead to success vs failure for a start-up. Here are some:

1. Stay in school: college grads do better that high-school grads. Education I have-a-plenty.
   
2. Don't start to soon: people who work for others, and learn on their employer's dimes, do better when they ultimately do go on their own and start-up. I did that.
   
3. Money matters: Having access to capital early on makes a huge difference. I had significant savings which I used a collateral to get loans.
   
4. Have a business plan. I did that, only I did not realize that I had.
5. Choose the right industry: urology is pretty good, infertility is even better. For me, pure dumb luck! In New York, a start-up OB would be almost doomed to fail. Derm is good!
   
6. Have the right motivation: are you doing it to make money or to have autonomy to "do what you want." If you goal is to generate revenue, you'll do what it takes--like answer the phones 24/7 or have evening and Saturday hours. I did those things because they seemed obvious to me. If your goal is to be able to take a vacation whenever you want, re-think your plan.
   
7. Buy someone else's business: I did not do this, but I guess you can't argue with the logic.
8. Focus on your strengths. I did this. Dumb luck.
9. Marketing: Successful entrepreneurs market their products or businesses early on. Caveat, do it smartly. I wasted a lot of money in my initial attempts.
10. Find unreached customers: I suppose that had I stayed in the same area as my former employers and tried to compete with them, I'd have lost. Dumb luck and restrictive covenant to thank here. If you are starting your own practice, try to identify patients that others are not seeing, such as patients who need weekend or evening hours or patients of certain ethnicities, disease states, insurance types, etc.
    

I'll keep you posted about others.

Thanks,

The IU.

What happens when physicians leave?

The Governor of Mississippi understands this simple fact: doctors are good for the economy. In his state, according to a KevinMD link, each doctor brings in about 20 jobs to a local economy. I don't know if that is or is not accurate, but in my community in Suffolk County Long Island, I believe that there'd be a ripple effect that would look like this after a physician exodus.

• Tough times for accountants
• Loss of revenue for restaurants
• Decrease big-screen TV sales, among other consumer items
  
• The demise of the local tennis industry
• A fall in house values
• Decline in school funding
• Displacement of at least 4 workers for every doctor who leaves
  
• Hospital closures
• Layoffs in law firms, both plaintiff and defense
• Layoffs in all medically related sales forces

On the economic scale, we are below the the high end technology sector and are above retail. We add jobs to a local economy and give people economic opportunities that would be otherwise unattainable.

Our political leaders must wake up and see it for how it is. It really is that simple.
You can't kill the goose that lays the golden egg.

Thanks,
The IU.

Are doctors worth $75,000 per year in income?

Some in Congress believe that the entire health care problem would be solved if doctors would "accept" salaries of $75,000 per year. Let's examine this figure to see if it is reasonable.

First, what do people make in other fields, on average?

    Call center analyst: $36,000

    Admitting director for a hospital: $80,000

    Retail store detective: $35,000

    Bricklayer: $70,000

    Risk Manager: $120,000

    Appraiser, residential: $36,000

    Advertising Account Exec: $70,000

So I suppose that the congressman believes that his personal physician's worth lies somewhere between his bricklayer and the admitting director of his local hospital.

Perhaps until he gets chest pain or shortness of breath or renal colic or a fracture or an elevated PSA .

Now what does it cost to become a bricklayer? Nothing. Bricklayers do apprenticeships.

What does it cost to become a hospital admitting director? The price of a college degree at a state school.

How about a doctor? $250,000, and 12 years minimum of training.

I don't know, but I just don't see it. $75,000! Am I nuts or is that unreasonable.

Thanks,

The IU.

 

 

    

Doctors ARE valuable members of society!

You can hear it the way they say provi-i-i-i-ders. You can sense it in the tone of their rhetoric. You can read it in the policy papers. And you can view it on TV during debates and on c-span. Doctors—I'm sorry providers—have become--in the eyes and minds of the policy wonks--drains on the economy.

I am not sure why this is. I simply don't see it this way.

In my little practice, sparsely 2 years old, I employ 4 people. I provide them with health insurance and a retirement plan. Neither the state nor federal government does this.

I pay payroll taxes for each employee and myself. I pay into unemployment insurance and workers comp insurance funds, as well as into the government mandated disability insurance fund. In fact, these "social" programs are not provided for us by our government but by us, the employers. They are simply mandated by the government and funded by business owners.

For every dollar I earn, 70 cents gets returned into the economy. The revenue that I generate—because I provide services that people want--supports medical equipment vendors, insurance personnel, billers, PHARMA sales reps, hospital employees, home health workers, lab personnel, marketers, lawyers, software vendors, hardware vendors, the cable company, the phone company, and others.

I get none of the tax subsidies that are commonly given to big retail businesses, such as Cabella's Sporting Goods or Walmart.

The income that my employees earn pays for consumer goods, which fuels our US economy. Thirty nine percent of my income gets returned to the federal government, and 7% goes to New York State. Ten percent goes to my retirement savings, and the rest is returned to the economy.

Please tell me, Mr Stark, or any other policy maker, how can you have such disdain for us? I just don't get it.

No, I don't see myself as a drain on the economy in any way. I give back, and I give back quite a bit.

I wish that our political leaders and policy makers would see it this way and stop viewing me as a cost center rather than what I truly am—a business owner and an employer and a valuable member of society.

Thanks,

The IU

How to become a stock broker

I spent last night at a superbowl party at a friend's house. He does very well and owns a brokerage house. We got to talking and I asked him, only half jokingly, how can one become a stockbroker?

"It's easy" he said, "you just have to take the series 7 test."

"How do you get to take that test," I asked.

"Simple" he said. "Just read some of the study material, go to a local testing center, pay 300 bucks, and take it. When you pass, you get a liscense."

"And then I could trade stocks?" I asked, incredulous.

"Yep, it is that easy."

"So theoretically, I could get study material from Amazon, read it this week, and by next week I could be a licensed stockbroker, work for you, and start making money?"

"Yes, only you don't even have to purchase the study material. I'll give it to ya."

Now that is un-@#$%-believable!

A family practice doc, who makes about as much as a mildly successful broker has to go through at a minimum the following difficult gates before he can earn a only a modest living:

• The MCAT (trust me, this test is very challenging). Your score--ie how well you do--determines if you can go to med school and where you can go.
• Step 1 USMLE-the first of 3 parts to our lisensure exam. We can take it only after 2 years of medical school have been completed--the most challenging years. I studied about as much as most students do, which was 15 hours a day 7 days per week for 6 weeks. Like the MCAT, the score means even more than pass/fail and can affect the economic outlook for the rest of your life! This is a very high pressure test.
• Step 2 USMLE-the second part of our lisensure exam. We take this one after we've completed at least 3 years of medical school. By the time you get here, you're pretty much home free.
• Step 3 USMLE-the final test for licensure. You take this test during your first or second year of residency training. Actually it is a difficult test, but for the most part one's score is irrelevant.

After our family practice doc completes 4 years of medical school AND passes all 3 USMLE parts AND completes an accredited residency program, only then can he APPLY for permanent state licensure so that he can start to treat patients on his own.

And there is one more hurdle for most of us, including our family practitioner. We MUST become certified by our respective specialty boards. This entails completion of all the above PLUS an application to simply be allowed to take the exam PLUS recommendations from practicing doctors that attest to our competency and character AND THEN you must pass the exam. And these tests ain't easy.

After all this is done, you have to send proof that you compeleted all the above and send it to the credentialing commitees of EVERY hospital you wish to practice in and EVERY insurance company you wish to participate with and EVERY state you in which you wish to be lisensed.

And you must update it every 1-2 years.

For our family practice doc, if he was to hit no road blocks along the way, the process would take him a minimum of 8 years and cost at least $100,000. For me, a specialist, the process began in 1988 when I began to study for the MCAT and it ended in February of 2003, when I passed by final test for certification by The American Board of Urology. Total cost ~$125,000 and only vague memories of my life outside the hospital between age 26 and 32, when I was a resident in urology.

So here's what I said to my friend.

"When can I start work?"

Good luck.

The IU.

If you want my business, answer your phone!

I need my microscope serviced and I need it serviced in the next week or so. Since I have a contact at Olympus, where I bought the scope, I called him for a recommendation. He gave me a name of a "great guy" named, ironically Guy, who works or owns a Massapequa Long Island microscope company. I was given the name of his company and told to look it up in the book. I never use the book, but I am typically preferential to "great guys", so I set to look up Guy's company on the web. No web site, no real web presence to speak of, but he does have a listing in some non-yellow book, non-yellow pages yellow page. I called it, and got a busy tone. I re-dialed, and now I got an answering machine. I called again, same result.

To hell with Guy!

Guy, if you want my business, answer your phone. It is really that simple.

So here's what I did. I Googled "microscope repair long island" and found ~10 listings on the side-bar, the paid listings. I chose one in the middle of the page that caught my eye because it said the word "service" in it. I clicked on the link and was taken to a nice website. On the index page of the site, I saw the phone number and location of the business, which was somewhat nearby to my office in Smithtown. I dialed the number and low and behold they answered…immediately. Suffice it to say that several minutes later I had an appointment scheduled for an in-office service by a guy named Raul and I was given Raul's pager number. The price was reasonable, though I'm sure that Guy would have done it for less, but he did not answer his phone.

I only do business with people that answer their phones before they have my money. If they don't answer when they want the sale, they will certainly not answer after they've made it.

If you want to compete and thrive, start by answering the phone and being reachable. It is really that simple.

The No-Show-ers

I have become somewhat obsessed with no-show-ers. Who are they and why? Are they rude or just forgetful? Do they think it is no big deal or do they know it's wrong & just don't give a crap? I think that no-show-ers can be placed into several categories and you can almost tell who will no show by examining the details surrounding the appointment booking.

Most—if not all--people who claim to be in pain, yet don't want to be seen that day, will no show. I don't understand this one, but it's true.

No show rates for vasectomies or infertility consults seem to double if the wife, rather than the husband, makes the appointment.

Self-pay patients no show more frequently than do insurance patients, unless it is an uninsured man who sees something on his penis. They always show up.

I have never seen a racial difference, but there is definitely a socio-economic difference; the very poor and the very wealthy no-show equally.

Young people no show more than the elderly. When an elderly patient of mine no shows, I start calling the hospitals!

Working people only no-show on Saturdays or in the evenings. . .or on holidays.

Retired people never no-show.

People who refuse to leave us their cell phone number typically no show.

People whose phone goes right to voicemail no show much more than do people who answer their phones.

People who return your calls never no show.

People that try to get a free consult over the phone while they are making the appointment will almost always no-show.

100% of people who ask for a free vas reversal consult will ultimately no show.

I noticed a trend, p value <0.05, that people who find me via the organic google rankings no show more than those who find me via paid listings.

Requiring intensive directions to my office predicts future no-showage. (And I'm on a major road in a big, well marked and well lit building)

Oh, I have a patient now. Thanks.

Geeze, I'd have figured that he would have no-showed. Oh well.

The IU.

 

My slowing blog post frequency

My favorite reader, SeaSpray, has asked several times why I have been posting with less frequency in recent weeks. Well, there are a variety of reasons for this, but basically, I write less because I feel there is less need for me to write.
When I first began to write the Independent Urologist blog, my experience with start-up was fresh and raw. Every day brought something new that needed to be published. For me, publishing was therapeutic, like a form a counseling I suppose. It helped me to collect my thoughts and to process the daily peaks and valleys that must occur in every start-up business and that certainly happened in my own business, big time! For me, my first 1 to 1 1/2 years as a solo practice urologist was the most exciting period of my life, far and away. I simply had to write about it or I felt I might explode. The fact that I had an audience made blogging that much more fun.
Fortunately, my practice is doing well now and I have settled into somewhat of a nice routine. It is not boring. Far from it. I just am no longer surprised when I get several new patients in a given day nor am I devastated when I don't. I have a schedule that is relatively constant from week to week. I have my typical busy days, slow days, late nights,and early mornings, and I drive my 3 1/2 year old to and from school 2 days per week, in between patient sessions.
Many of the challenges that I faced early on, such as getting my lab accredited and my office functional, I have overcome. I do a variety of in-office procedures, such a cystoscopies, vasectomies, and prostate biopsies, and I have developed such easy routines for preparing and doing these procedures, that they no longer cause me any stress, any heartache. Even scheduling patients for in-hospital procedures has become routine, automated, easy. Nothing more to blog about there, which is good.
From a staffing perspective, I have 2 people who have been with me from the beginning and a medical assistant, who I trained a few months ago, who are all excellent and loyal employees and they all plan to remain in their current positions indefinitely. As far as I know! So while I no longer have blog topics on staffing issues, I have stability, and that is better than blogging.
My homegrown EMR was a good source of blog topics for a while, but even that is just performing silently and bug-free in the background, as any good EMR should. I just don't feel the need to write about it any longer. With regard to digital back-up, I no longer need to expend mental energy on it, because I finally seemed to have come up with solutions that work for me automatically and effortlessly. It only took 21 months, but with regard to back-up, I have finally started sleeping at night, my infant not-withstanding.
Attracting new patient business, marketing, and practice building were a great source of blog post topics for a long while. Here, however, I have stopped writing for 2 reasons. One, I've become very adept at attracting new patient business economically and I no longer "need" to write about it from a therapeutic perspective. And two, I don't wish to share such valuable information with my competitors. It is that simple.
Medical malpractice is a favorite blog topic of many bloggers, but I never really got into that one. I guess that personal views on that topic are best kept personal. Just ask Flea. Enough said.
I do have much left to do in my still young practice and I plan to continue writing about it. But hopefully, I wont feel the need to write about it. I want stability and yes, even boredom. Those are 2 signs of a mature business, one with a future and in this regard, I feel that I have arrived.
Thanks for listening.
The IU.

On Making Decisions

Perhaps I made a mistake on VONAGE. Perhaps. Only when I Look back 21 months later, with the benefit of hindsight, am I not so sure that I would use this company again. But then again, 21 months ago I was in a bind and VONAGE was the perfect solution at the time. I had just left my old group and I wanted to capitalize on retaining any former patients of mine into my new, fledgling practice. I had no office and was unsure how long it would take me to get an office. Every day that I went without an office was lost money and missed opportunities. I was desperate to get new patients and was unwilling to miss a single one. With VONAGE, I was able to set up shop in my home and function as a business well before I had an office or an exam room or a staff. For me, back then, VONAGE was a key ingredient in my early success.

Some say that VOIP is not reliable for mission critical functions related to business. I disagree. Many businesses use this technology and it works very well. I have friends in the financial service industries—on Wall Street—whose firms have switched to VOIP. What is more mission critical than high finance? The problem has not been VOIP, but customer service at VONAGE. Their technology is fine. It is their service that fails.

It is very easy for people to criticize and second guess the decisions of others. It happens every day. What the critics fail to realize is that we make decisions with the circumstances and the best available information at the time, not years later. I believe the ability to have vision and then use it to analyze a situation, cull the data, and be decisive given incomplete information is what separates successful doctors, lawyers, politicians, and police officers, among others, from unsuccessful ones. Teddy Roosevelt understood this:

"It is not the critic who counts: not the man who points out how
the strong man stumbles or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes up short again and again, because there is no effort without error or shortcoming, but who knows the great enthusiasms, the great devotions, who spends himself for a worthy cause; who, at the best, knows, in the end, the triumph of high achievement, and who, at the worst, if he fails, at least he fails while daring greatly, so that his place shall never be with those cold and timid souls who knew neither victory nor defeat."

Critics will always be out there in the ether doing what they do. My advice to another person who finds themselves solo and unsure of what to do: analyze and think, but don't be afraid to make the hard decisions. And to hell with the critics!

Thanks for listening,

The IU.

VONAGE bites me in the ass!

Several months ago I switched from VONAGE to my local VOIP phone provider due to reliability issues. I ported the number and everything seemed to work out well. I did test to see if the port worked by simply calling the number and voila', it rang in my office, call hunted, etc. Beautiful.
Yesterday I received an email from a former patient of mine. "Dr Schoor, are you still in business? Your phone number has been disconnected for weeks" went the email.
What? The phone had been working fine and was ringing off the hook that very morning. I called him.
Apparently he has a VONAGE system himself and when he called from his cell phone or any other non-VONAGE phone, the call placed successfully. But from a VONAGE phone, the caller would always receive a disconnected message. I called VONAGE.
"Oops, sorry, our bad. We forgot to release the number from our system. I'll do that now. It'll take 24 hours. Sorry for the inconvenience."
Holy shit!!! For 3-4 months, anyone that tried to contact me from a VONAGE phone would not have been able to do so. Un-!@#$%-believable.
Think of the missed opportunity costs. I estimate that I probably missed 3-5 prospective new patients who called, got the message, and went to the next urologist on the list. Being that new patients are worth, over the course of a year ~$400, I can estimate a loss of up to $2000, maybe higher.
Yeh, I'm pissed!
My recommendation: if you are a business, do not get started with VONAGE. Their customer support is just not adequate for a business's needs.

Goals for -08

My 5 Areas of focus, (not in order of imortance)

Process Sreamlining ---Revenue Generation---Cost Containment---Safety---Payer Shift

At the beginning of a new year I like to take stock in what I have accomplished and to focus on goals for the next year. The cycle above represents the 5 major areas that I will focus on most. All are interrelated and of equal importance. For example, streamlining processes will result in increased patient safety and efficiency and help to decrease costs. Revenue generation will follow based on an increase in word of mouth referrals and through acquiring patients with better paying plans and cash pay.
Wish me luck.
The IU.

Just Doing My Part

 

 

Take Action Now!

 

Dear Patients,

New York State is currently in a health care crisis that threatens all of our abilities as patients to get affordable healthcare. The threat comes from a tort system in New York that has run out of control. Jury awards have risen dramatically over the years and are often out of proportion to the nature of the injuries. The problem is only getting worse.

I support tort reform that retains our rights to seek reasonable compensation when injured by a negligent act, but the system must prevent excessively high awards for pain and suffering that is limited in intensity and duration.

I call on you to take action and contact your local representative in the state assembly and ask them to support liability reform. I have pre-printed, addressed, and stamped envelopes; all you need to do is sign.

Please become involved in this grass roots effort to save New York from an impending health care implosion and in doing so, help to lower health care costs for the majority.

If you have any questions, please feel free to contact me.

Sincerely,

Richard A Schoor MD FACS

Taking Notes From a Plumber

I just had a great experience with. . .a plumber! Yes, that is right, a plumber. And I paid $680. How is that. Well, I took notes. Not on his plumbing technique, but on how the business was run. Terrific from first contact to last. Let me tell you about.

We have a leaky pipe in the basement of our house. Though we have a contract with a plumbing service for our boiler and AC, I forgot their name and did not feel like looking it up. Plus, this pipe would not be a "covered" service anyway. As I was about to blow off the whole thing for another day, my wife handed me my 5 month old and a flier from a plumbing company. I get tons of these things, but timing is everything, right. I looked at it and liked the message: on-time service, up-front pricing, no surprise or hidden costs, all credit cards accepted, all work guaranteed in writing for 1 year (that's hell of a global), and a coupon. On the bottom of the flier was their phone number, clearly visible. I called—7:15AM—and, voila, they answered. Sold!

Over the phone, the receptionist had a friendly voice and she offered me a number of scheduling options, that day, or any other day. She had one of those great phone voiced that makes you feel like she is on your side. I should have offered her a job. Anyway, I took an appointment for the following morning, between 8 and 10AM.

At 8:30AM, the plumber arrived. He parked his truck so to not block my car, and when he entered the house, he had his own door mat with him. Nice: makes for good style points. I showed him the problem, along with several others that have been lingering, and after an inspection he came up with a solution, a guaranteed price, and the 1 year guarantee on the work. Plus, he turned off some pipes to the outside, gratis, and wore shoe covers so he would not dirty the rug. Again, nice style points and demonstrated that he was on my side and cared about details.

The work was completed quickly, but not too quickly. He made a soft up-sell on some biological cleaner, and I declined, and here's the kicker: when it came time for payment, we completed the transaction with a mobile, cellular credit card processor. Payment to him guaranteed. No accounts receivable. Not only relatively painless to me, a technological talking point.

Lessons for the doctor.

1: Answer the phones.

2: Hire excellent phone personnel and train them well.

3: Make the patient know that we are on their side.

4: Embrace technological advancements, especially when it comes to accounts receivable.

5: Attend to the details. They really matter.

Anyway, thanks for listening and if you want their number, send me an email.

The IU.

What Medicare cuts could mean

It looks like Congress will not intervene and that Medicare cuts of 10.1% on average are imminent. Urology is slated for an 11% cut. What does this mean in real dollars. Let's take a look.

 

Practice A sees 1200 patients per month = 14,400 visits per year x 25% Medicare = 3600 Medicare visits per year x average visit value of $150 = $540,000 reimbursed per year from Medicare x 11% = [$59,400 - $540,000] = $480,000 lost income if Medicare is dropped completely.

Practice A sees 1200 patients per month = 14,400 visits per year x 10% Medicare = 1440 Medicare visits per year x average visit value of $150 = $216,000 reimbursed per year from Medicare x 11% = [$23,700 - $216,760] = $193,000 lost income if Medicare is dropped completely.

 

Practice B sees 400 patients per month = 4800 visits per year x 25% Medicare = 1200 Medicare visits per year x average visit value of $150 = $180,000 reimbursed from Medicare x 11% = [$19,800 - $180,000] = $160,200 lost income if Medicare is dropped completely.

Practice B sees 400 patients per month = 4800 visits per year x 10% Medicare = 480 Medicare visits per year x average visit value of $150 = $72,000 reimbursed from Medicare x 11% = [$7,920 - $72,000] = $64,080 lost income if Medicare is dropped completely.

 

Practice C sees 200 patients per month = 2400 visits per year x 10% = 240 Medicare visits per year x average visit value of $150 = $36,000 x 11% = [$3,960 – $36,000] = $32,040 lost income if Medicare is dropped completely.

 

So as you can see, the numbers are large indeed whether a group or solo urologist keeps or drops Medicare. However, based on my calculations, a urologist or urology group would still do better remaining par with Medicare. Out and out dropping of Medicare would be tantamount to suicide for the business.

Though it is tough for me as a urologist to admit, Medicare has me by the balls.

Good luck to everyone else.

 

Speak of the devil.

The new HIPAA rules for practices such as mine.

Can't wait to read through them.

Results of my survey

I just sent a survey to an admittedly un-scientific sample of my patients, yet the results were interesting. The survey, sent to 24 patients selected at random, asked respondants 9 questions relating to the practice, the patient's experience here, and asked for suggestions for improvement. Here is a preliminary result that I'd like to share with you, as I find it interesting.

• 16 out of 24 respondants stated that email was their preferred method to communicate with the doctor or staff, and this was not age dependent.

• 24 out of 24 respondants stated that they had NO concerns regarding email security.
• 24 out of 24 would refer me to a friend or famlily member.

Interesting. I am not sure what it means, but I believe that:

• HIPAA is perhaps a bit overblown.
• People want to communicate by email.
• I'm pretty awesome.

I plan to send more surveys to try to get some real scientific data with hope of publishing it here on my blog.

Until then,
The IU.

The Paradigm Shaft

Several years ago a wise man said something to me that really impacted my life. He was a Pharma drug rep, but prior to that, he was an accountant for a financial service company. One day, during his old career, he had an epiphany of sorts when he was conversing with an investment banker. The accountant lamented to the banker, "How come you make so many times what I make?" The banker responded, off handedly, "Because I make money and you cost money."

"Because I make money and you cost money." Wow!

Several weeks later, this accountant left his company and went into sales so he could "make money."

He told me that story over dinner one night and I had epiphany of my own. There are 2 types of people in the world: those who make money and those who cost money. People that make money will always be worth more than those who cost money. Most of us fall into the cost money category. Think about it. The dichotomy really has truth to it. Movie stars, investment bankers, top professional athletes, even top doctors and lawyers, all validate their incomes because they produce wealth for others as well. They make money. Nurses, medical assistance, accountants, teachers, police officers, fire-fighters, in fact most of the rest of us, are in more of a support role and don't really bring in the bacon. Not to say that our jobs are not important. They are. It is just that we cost money, rather than make it.

Doctors used to be in the "make money" category. Throughout the 1960's, 70's, and 80's, doctors not only made money, we were seen as having the ability to generate wealth for others. The perception was that we made money. Beginning in the 1990's--though it's roots actually started under Nixon & Reagan--physicians came to be seen as cost centers rather than revenue centers. This shift in perception, a paradigm shift really, put us in the very precarious position we sit today. In fact, to the extent that there has been the downfall of doctors, this paradigm shift led directly to it.

People that make money are always worth more than people who cost money. It is really that simple.

Again, I don't have a solution for the problem. I only have the observation. I suppose that if you are a physician, you may benefit from re-tooling your practice so that you can be seen as a revenue generator, rather than a cost center.

Remember, 2 types of people exist in the world: those that cost money and those that make money. Try to be the latter.

Good luck.

The IU.

Why I Hate No-Shows

For most of us in the service industry, no-shows are a part of life. For most of us in the service industry, no shows are an exasperating and costly part of life. People that no-show don't think it is a big deal. Here's why they are wrong.

1: Lost revenue: I see patients sparingly on Saturdays, ie I reserve the day for people that really have a difficult time making it to my office any other day. This Saturday, I had office hours from 8-11, staffed by 2 people x ~$28 per year = $84, not including my time. I had 4 no-shows, each worth ~$50 x 4 = $200 lost revenue for that day. I saw 4 other patients, 2 new and 2 follow-ups = $350. Total income for this day was $350- $84- $200 = $66. Now it may be worth my time to come in to the office for $550 - $84 = $466, but not for $66.

2: Increased liability: Unlike people that no-show to a restaurant, established patients that no-show to a doctor's office can cause future problems for themselves and for the doctor. Even though they--adults all, mind you--no-showed, it is our—the physician's—responsibility to make a reasonable attempt to contact them. To do this, we have to pull their charts, review them, make phone calls to the patients, and send them certified letters. What does all this cost? It costs a lot if you factor in the following: chart review = 10 minutes per chart X 4 charts = 40 minutes x my time + staff time to call x 4 + certified postage $5.39 x 4. Plus, a no-show patient that is lost to follow-up yet resurfaces several years later with a tumor that "you missed" can bankrupt you. No, no-show's ain't cheap.

3: Increase in uncompensated work: All of the above work by the doctor is uncompensated.

4: Inconsiderate: I call to cancel reservations at restaurants and for haircuts. It's just the right thing to do.

Thanks,

The IU.