The DIY EMR: Revisiting an earlier post.

This post was previously published by The IU, but due to recent contacts from readers, I thought I re-post it.

Here are some features of MS Word 2007 that make it so attractive for a homegrown EMR:

• Insert signature line: once inserted, you can sign it with the stylus. The program then locks the document to prevent any changes.
• Built in PDR conversion tool: No need to buy acrobat. PDF is a great format for an EMR for a variety of reasons.
• Insert inbedded files: The user can easily insert inbedded files, like bitmaps, with things such as illustrations, photos, notes, etc.
• Change tracking: This feature is also on older Word versions. Allows the user to make changes with cross-outs, rather than erases. Makes for good transparency, ie spoliation accusation resistant.
• Can easily create templates and record macros.
• Phrase finishing: user can train program to complete phrases and sentences. Useful when documenting encounters quickly.
• User friendly: very little training required.
• Ubiquitous: Is pre-installed on most computers, and is compatatble with google documents and MAC OS.
• Inexpensive.

In other words, it is an excellent tool for the homegrown EMR. AND, from what I've seen from many vendor sold EMR's, the basic platform that they use in their products. Kevin's right: why pay so much more?

Inspirational!

Ball Girl. 2008 US Open

Urologist vs Professional Tennis Player: Revisted

Someone on the way up and someone on the way down

Congratulations to the victor!

Once again, the US Open comes to NY and I love it. I go every year, both to the qualifiers and to the main draw. It is my favorite time to be in NY.

Personally, I think the qualifiers is better than the main draw, at least the first week of the main draw. Aside for the lack of crowds, you get very excellent tennis matches with lots of drama. You see players on the way up, and some on the way down. Most are never-wills. You also get to sit and talk to coaches and parents and player entourages in a way that is simply impossible during the main draw. You can learn some things and see that life is tough all over!

Players in the qualifiers must win 3 matches to make the main draw. Winning only once or twice during this week results in a big fat zero payout. If theplayers win all 3 matches, they make the main draw. Just being in the main draw, even with a first round loss, is worth a couple grand. Most, if not all qualifiers will lose in the first round. So 16 players will work for a solid week--and work very hard--and make only 3 or so grand. Factoring the cost of travel, lodging, coaching, food, clothing, rackets, stringing,etc. . .they don't do so well. The remaining 112 players, those that lost during the Q week, do even worse. They make nothing.

The 2 players in the picture up top are Victor Estrella and Xavier Malisse. Victor, the player on the left, was the victor. He is a young Brazilian on the way up. Xavier, the other player, was a former top 50 player who was considered a real contender at one time. He was a media darling as well, in his younger days, and had long hair and a flamboyant persona. Unfortunately, his career did not turn out as he, and others, had hoped it would, and he has been struggling. I guess his short hair is a symbol of his new-found-focus. Perhaps it is to little to late. I wish him well.

I did peruse the draw and roster of competitors from this years tournament and I did not recognize any players from this year that played last year. Maybe that is good sign and means that all of last years players made the main draw this year.

I doubt it.

I did recognize one name in the Q-tournament draw, Nicholas Massu. He is a former Olympic Tennis Gold Medal winner in 2004 and top men's player. I wonder what happened to him.

In urology, most of my own colleagues are still practicing and most urologists in my area can report higher incomes than last year because of a stregic merger of competing groups. I don't know of a single urologist that has left practice in Long Island due to the competition or external factors such as rising costs of living.

Recently Medicare has not been paying in a timely fashion. I know of one urologist that sees 95% Medicare patients. He has only received $1700 in reimbursements in 2008. For the rest of us urologists who see a mix of patients from a mix of payers, 3 days of work brings in considerably more money than the majority of qualifiers earn in a similar work week.

During Q-week, I watched the qualifiers struggle. I witnesses intense happiness with victory and devastation upon defeat. I saw several players at the end of their careers; no doubt faced with the question that I faced several years ago; "what next."

For me, as I watched the qualifiers compete, I felt comfort in my own situation. I am my own boss and my outlook is positive. I call my own shots. My wins are mine alone, as are my losses.

I think I am better off as urologist than a professional tennis player, aside for the fact that I really not very good at tennis. As a pragmatist, I know my earning potential, even with the current reimbursement landscape, is better than for 99.999% of tennis players.

So for now, I practice urology by day and play tennis by night.

And go to The US Open every August. . .the best show in NY.

What do you do with all those radiology CD-ROMs?

In the past, doctors, especially surgeons, would request radiologic images on films and would review them on light boxes in their offices. However, in the past 5-7 years, actual films have become somewhat of a rarity. Instead, CT scans and other images can be viewed either over a secure internet connection or via a CD-ROM that contains the images and the software necessary to view them. Personally I have found this changed approach to the viewing of radiological studies as a huge plus, with one exception.

What are we supposed to do with all the CD-ROMs that patients hand to us?

When I had paper charts, I used to simply staple the jacket that contained the disk to the patient's file. This worked ok. But now I have electronc charts. So now what?

Here's how I do it now.

1. Place the disk in the drive
2. Go to My Computer and open it up
   
3. Right click on the icon for the image viewer in the DVD-CD reader
4. Click Explore to open the files on the CD-ROM
5. Select ALL, then Copy
6. Create and label a new folder in the pertinent patient's folder
7. Paste the files into the new folder

And now you have the images saved and you can shred the CD-ROM.

Alternatively, you can ignore the CD-ROMs since you are under no obligation to save them in your files. The radiologist is the one responsible for ensuring that the images remain available for the time period specified by state laws.

However, I find that when comparing old studies it is nice to have images saved in a location that allows for rapid and effortless recall.

The "Green" Consent: Consent Foms On-Demand

I have developed a simple method to get written informed consent from patients in way that completely eliminates paper waste and ink usage while simultaneously maximizing efficiency and the "wow" factor.

Here's how it works.
I composed 5 or 6 consent forms for the various procedures that I do in my office. These procedures include cystoscopy, prostate biopsy, testicular biopsies, and penile duplex scans. I developed the consent forms myself and worded them in English rather than legal-ese. Since I am neither crazy nor stupid, I did have them approved by an attorney.

I keep the consent forms in a directory called "CONSENTS." The documents are MS Word 2007 files. Word 2007 has a great feature: it enables documents to have multiple signature lines. In my consent forms, the documents have 2 signature lines. One line is for the patient to sign and the other line is for me to sign.

After the patient and I have our informed consent discussion, I copy and paste the consent form from the "CONSENTS" directory into the patient's folder. I then type in the patient's name and date and then here comes the cool part. I swivel the tablet PC so that I can use it like it's a piece of paper and I slide it across the desk to the patient. He/she then reads the document right on the Tablet PC and if he/she agrees and understands it, they sign it. Then I take the tablet back and sign it as well.
After my signature is completed, the document locks so that no further changes to it are possible.
Done.
5 goals have been thus accomplished:

1. A necessary legal consent form has been obtained.
2. The consent has been placed in the chart forever.
3. The process was done efficiently, inexpensively, and with considerable "cool" factor.
4. It was accomplished with off-the-shelf software.
5. Not a shred of paper was used!
   

I like it. How about you?

Want to negotiate with insurers? You better have these characteristics.

I had a conversation the other day with an expert on negotiating insurance contracts on behalf of doctors, groups, and hospitals. Here is what she told me:

"I am going to be brutally honest doc, because I don't want to just take your money, but you don't have a chance in hell."

Essentially, what anyone needs to successfully negotiate is leverage,which is what doctors in NY-metro just don't have. There are simply too many of us in every specialty. In fact, this woman told me that the panels are over filled already and that she spends most of her time just getting new doctors accepted into the plans under any terms. While it is not impossible to get a better-than-average contract, it is difficult. Essentially, you need to be special to do so. Here are some of the key elements as I interpreted them based on my conversation with the negotiator.

1. Unique: If you are the only one of your specialty in a 20 or so mile radius, you may have some leverage.
   
2. Efficient: If you can save the insurer money by operating at a lower cost to them, such as by doing in-office procedures, or with less errors due to an EMR, you may be able to make a case for the insurer to cut you a piece of the action in return.
3. Desirable: If you are one of few doctors who does something that people want or need and will pay more to the insurance company for it in the form of premiums or plan selection--then the insurer may cut you into the action as well.

Notice that large size is not on the list. Size can work for you if your group becomes so large that it controls the market place. In a larger market place, such as NY, reaching this critical size can be difficult if not impossible. In addition for most large groups, lets say a 50 person group or larger, operating expenses become so high that they can become unable to sacrifice a contract worth 20% of their revenue. They simply could not survive the acute loss of revenue. Well managed groups, ones that know their numbers inside and out, may be able to determine if they can play hardball with an insurer and survive for the year or so that is needed to recoup the lost patients that will follow the lost contract. So know your numbers!

Finally, if you do successfully negotiate, don't brag about it: that could cost you the contract. . .and more. Most plans make their "special" docs sign strict confidentiality agreements with draconian penalties for non-compliance. So the next time you hear a doctor in the lounge bragging about his great negotiating skills know that he is either crazy or full of crap.

Therefore, don't feel like you are the only schmuck on the block that takes whatever contract is offered you. If you live and practice in an over saturated market and don't have one of the big 3 characteristics in my list, you simply must sign on the line and work like a dog.

Good luck.

The IU.

Can't get affordable insurance? Start your own company.

Four years ago, an emergency medicine physician in south Florida was asked to pay liability premiums that represented greater than 1/3rd of his entire revenue and he could simply no longer afford it. Rather than flee the state, grin and bear it, or bitch and moan, this physician studied the issue and came up with a solution. He started his own insurance company. Fours years later EMPAC, the company founded by that physician, has become a very successful and profitable liability insurance company-RRG that underwrites emergency medicine physicians only.

2 years ago, a urologist, Ernie, in Nevada became fed up with double digit increases in his premiums that made it difficult for him to simply remain in business. Rather than flee the state for a more hospitable environment, he drove himself to the offices of the Nevada Department of Insurance and "ranted and raved." He wanted answers. He wanted solutions. A persistent individual, Ernie was not about to give up until he had a solution. Ultimately, an official in Nevada's insurance office gave him a name of someone in Florida who started an RRG for emergency physicians.

Ernie called him. And he called him again. And again. And again.

Over an 8 month period Ernie would not go away and he would not take no for an answer. After 8 months, Ernie had convinced this person in Florida to help him start a new company with him. The new company was to be called SCRUBS. Ernie's Florida contact was the founder of EMPAC; the man who started that company out of his own necessity.

Ernie and the EMPAC founder along with his EMPAC founding partner, personally risked $500,000 to fund the cash reserve requirement needed to obtain an insurance operating liscence in Nevada. They hired outside consultants to administer the plan and they flew around the country to meet with urologists and urology administrators and to promote the new product. In order to operate as an insurance company, SCRUBS would need at least one policy holder. Ernie risked once again and dropped his traditional policy to become SCRUBS first and only policy holder. The entire company, all 3 or them, prayed that Ernie would not get sued.

Both Ernie and SCRUBS survived that first year and looked to grow the company in 2008. The 3 managers of SCRUBS knew that New York's urologists were ripe for the taking and they concentrated promotional efforts on this group. SCRUBS' management obtained a list of practicing urologists in New York and elsewhere and sent a flier.

While the 3 SCRUBS managers worked on their problems, I had problems of my own and was facing the double digit increases in insurance premiums that most of my urology colleagues faced. At these 15% rates of increase--compounding of course--our premiums were to double every 3 years and would have crossed the $100,000 threshold by 2010. At the current rate, many of us had to work without a paycheck for 3 to 4 months just save enough for July's premium, its increase, and any additional surcharges that often accompanied them. By 2010, I'd be done without intervention from Albany or elswhere.

In February and March and I attended medical staff meetings and joined grassroots efforts to effect change at the capitol. I became an activist, I pleaded with Albany and begged "them", to not let us doctors go under.

But there is no "they", and what "they" there is does not care about "you"; well certainly not about me.

In mid-April 2008, I recieved a flier from a company called SCRUBS, an RRG that only underwites urologists. Fed up with "them" and "they" and and a future that in the absence of course-change, would lead to certain demise 4 to 5 years hence, I responded to the letter and sent in an application. Several weeks later my life changed, or at least my outlook changed. SCRUBS had answered me. SCRUBS had agreed to underwrite me at considerable savings now, stable premiums into the future, and the possibility of premium reductions as the company grew.

In July 2008, I joined Ernie and became SCRUBS second policy holder, and the first in New York. As of today, I am one of 45 urologists across the nation who decided to take a chance and change course; to take control of our destinies. Our future is still uncertain, only now it is hopeful.

Wish us look and good fortune.

The IU.

Referral Pads or a Plate Full of Feces?

The following story is true.
It is in no way exaggerated.

I had some referral pads made up recently. I personally like referral pads. I use them in my own office and a good one can influence where I send my patients for referrals, tests, and studies. For me, a good pad fits easily on a corner of my desk, has just the tests that I want in check box format, room for the patients name and my name, and how I want the results reported. Several of the labs and imaging centers that I use have referral pads that fit these criteria and I admit that I send more than a fair share of patients to these centers, rather than other ones, because of the pad. Of course, these centers do quality work as well.

Because of my own use for referral pads, I had some made for Richard A Schoor MD PC. The pads met all my criteria and were professionally designed and printed. They costs me ~$1000, total. My plan was, and still is, to distribute them to referring docs and potential referring docs via a practice rep, ie Janet.

Yesterday, I had some slow time and I learned of a new doctor that recently started practicing in an office next door to mine. She is an OB and joined a doctor that I have excellent relations with and view as a friend. So I stopped by myself to see them both. Now I no longer typically do this because one, I'm too busy,and two, I don't like being mistaken for a Pharma rep. But on this day, why the hell not!

I went to the reception desk, said hello I'm Dr Schoor, is the new doc here, or something to that effect. The staff was very friendly and replied that the new doc was not there but that she would be in the next day.

So I left my calling card and then asked the receptionist if she had any use for a referral pad, as I slowly extended my arm with pad in hand.

The receptionist immediately recoiled. In one motion she rolled her chair back 2-3 inches, put both hands behind her back, turned her face to the left, and said "no we don't use those."

It was like I had handed her a plate of feces. Incredible really.

I had to look back at the pad to make sure nothing was on them, like urine, blood, etc. Of course, the pad was pristine, all white and blue.

I wonder what I did wrong here. . .

Wine as gifts for doctors

I like this piece.

Doc vs World: How to Survive Long Term

The cost of running a medical practice has skyrocketed over the years. In this same time period, the reimbursement for our services has declined tremendously. While many of us may generate the same or more gross revenue than we did years ago, we have done so only by increasing our through-put; ie the number of patient encounters that we see per year. Clearly, this compensatory mechanism is limited, unsustainable and ultimately very costly to us doctors both personally and professionally. In addition, our patients pay a high price as well in terms of their declining satisfaction, decreasing access, and an increase in adverse outcomes. Like being on an desert island with a limited water supply, if you want live for many years to come, you better get off the island. If you are a doctor and want to be around and happy in years to come, get off the island while you still can.

My name is Richard A Schoor MD FACS and I am The Independent Urologist and a solo practice survivalist. I have been in some tough jams over the past few years and have come out stronger and more resilient than ever. Recently, I and many other doctors, survived a 10.6% Medicare pay cut. Of course the actual income loss, factoring in decreased reimbersements from private insurers that were sure to follow Medicare's lead, would have been closer to 20%. For many of us, that would have been death. What does this mean?

It means that the future is clear. It means that you best start building your raft and planning your escape.

How do you do escape? You plan.

You know what the future will bring if you stay the course, so that is not an option. But you probably know others who seem to have your "dream practice" and these doctors' practices can serve as templates for you to emulate. Simply call them and ask them "how'd you do it." More likely than not, they'll tell you, especially if you are not among their direct competitors. Ask them how they built their practice, which marketing vehicles were beneficial and which stunk, if they negotiated with payers or just took the cash-only plunge, how they dealt with referral sources; anything you can think to ask them. In my experience, these people are proud of their accomplishments, as they should be, and are glad to talk to about themselves. If you have a blog, offer them a guest post. If they don't have time to write, you offer to write about them and to provide their website with inbound links and a favorable web-plug.

When you have done your homework, then you must develop your own plan. And you must commit your plan to pen and paper. Once your plan is written down, it will take on a life of its own and become a reality. If nothing else, at least you'll feel like your fighting and not just being swept along, for whatever that is worth.

January 2010: a storm is coming. Will it kill you or will you be prepared?

Make the plan. Be prepared. Live. Thrive.

Thanks.

The IU.

Reunited with an old friend

I was recently reunited with an old friend, a very good old friend in-fact, that I had lost touch with several years ago. I'll call him The Kid, and he was my college roommate. He stood at my wedding and I at his and we shared many terrific memories over many years. He was always a loyal friend and I know we both regret that we lost touch 5 years ago. In any case, water under the bridge.

I think that many people would say that I was good role model for the kid. I think that Kid's parents felt that way. Maybe I was. But I saw things differently. It was kid that was my role model.

Kid was our fraternity's social chairman, and he was the best one we had ever had. he approach the job with passion and zeal and a business plan. Yes that is correct: a business plan.

After graduation he went to work for his dad and then his dad sold the company and the kid found himself without a job. He moved home and into the bedroom of his youth, complete with twin bed and "Marc" on the door. Not a very glorified life for a college grad. But the kid was not phased. He got a separate phone line and he promptly started a business. It was called Marc Photo and Marc was the only employee. Kid would answer the phone that was next to his twin bed "studio." It was hysterical. When I drove with him in his car, he'd be playing audiobooks on business topics. While other friends of ours thought it was pathetic and would joke that Kid couldn't read, I thought it was terrific. I saw Kid as hungry, clever. He'd be on the road so much promoting his business, that he used the time as productively as possible, hence the audiobooks. It was brilliant,really. I never doubted that he'd be a success in business. Within 5 years Kid had transformed his bedroom company into a multimillion dollar commercial photography and design business.
Though far from Kid's multimillion dollar company, I have my own successful urology practice now and I've become very busy in my office and life. On top of work and an old house, I have 3 kids, i.e. children, of my own, and I have very little time or energy to read, whether it is for pleasure or business. What have a done? I have taken The Kid's lead and have turned to the audiobook. Phenomenal! I can download the books from the internet and listen to them on my desktop at work, on a iPod as I lay in bed with Emma and wait for her to fall asleep, and on CD while in my car. It has really been nice and in the past few weeks I have "read" 5 or 6 books and have learned some new things. Sure my wife makes fun of me because I'm not really reading, but I assure you I know how to read just fine.

Kiddo, it was great seeing this weekend and thanks for re-entering my life. I can learn a lot from a guy like you. You've been a huge success in business and many of the things I've done that have worked, I learned them from you.

Let's keep in touch buddy-boy.

Waiting with baited breath.

How will they vote?

Waiting for our leaders to lead. . .we will remember in November!

Doc vs World Episode 4: Risk Avoidance

If you don't parachute, your risk of dying in a sky diving accident is zero.
If you don't let your children swim unattended in a pool, you can minimize the risk of a drowning incident.
If you stay in your home between 11PM and 5AM, your risk of injury from an alcohol related incident can be significantly reduced.
If you perform surgeries that are well within your skill set, you can minimize your risk of an adverse event and resulting legal issues.

My name is Richard A Schoor MD FACS and I am urologist in solo practice in Long Island. As urologist and physician I am well versed in risk and each day that I awake, I face plenty O'it. But I don't take unnessesary risks.

While risk is unavoidable, unnecessary risk is avoidable.

If you are a urologist, for example, you can get into trouble during a surgical misadventure, an informed consent issue, missed diagnosis, or a failure to act on an abnormal lab. If you are a urologist, these problems are not completely avoidable, but they can be minimized. For example, many a urologist has had problems arising from failing to act on a positive lab test, such as a PSA or cytology, namely because they never saw the test. This type of error happens for several reasons:

• the patient fails to go for test
• the test result is never sent to the doctor
• the test result is sent to the doctor and filed without the doctor's knowledge
• the doctor sees the test and chooses to not act upon it for some reason, though never documents the rationale for that action
• the doctor and patient have a discussion about the lab test, and that discussion is not documented

In a significant portion of the above instances, it is the patients themselves that fail to go for the test. The easiest way to eliminate this risk is simply to do the test in your office or to obtain the specimen in your office. If you want the patient to have a PSA, draw it yourself.

Risk minimized.

In today's environment of zero tolerance for medical errors and high liability rates for doctors, it is simply imperative that doctors avoid taking on any extra-risks. You can examine your own processes and identify areas in which you are assuming extra-risk that is simply unnecessary.

Get rid of it.

The IU.

A butcher without an advantage

My son is turning 1 and my wife and I are having party. Not anything fancy, mind you, just a barbecue by the pool with family. This weekend while driving on 25A in St James we noticed a new butcher that had opened next to our favorite pizza place. Looking for something unique for the party, we decided to stop in see what the butcher had.

He had what every local supermarket had to offer, hamburgers, hot dogs, steaks, chicken breast, ribs. Nothing different. Nothing unique.

How is this place supposed to survive?

What is his competitive advantage?

Perhaps if he had very high end cuts of meat that I could not get at the Stop & Shop. But he didn't.

Perhaps if he had unusual meats, like impala or a TurDucken, but he did not.

Perhaps if he specialized in free range, organic, or local only animals. But he does not.

How does he plan to compete? Beats me.

Maybe he should get a competitive edge.

Location, Location, Location

A perfect night for fireworks.

A terrific view.

Blocked by the 59th Street Bridge. When it comes to real-estate, BPH, and now fireworks. . .it is all about location.

The Medicare Cuts

Now everyone calm down. The sky is not falling in and the world is not ending. What has happened is that the Republicans, led by our fearless leader, has screwed us. But all is not bad. You know why?

Because if you can survive without Medicare then maybe you can become independent of Medicare. And then just maybe you can drop them on your own terms.

Just maybe this whole thing is a blessing in desguise.

Think about it. Plan for the next time. Transition your practice to be independent. You may not be able to fix the system, but perhaps you can fix your own lot.

Just thoughts.

Even a solo guy can take some time off

A tail gate party and salza dancing at Sunken Meadow Park, Kings Park NY.

Fisnhing on the pier, Sunken Meadow Park

BobBob and The Beeshee boy. . .my little boy. It is good to get out, see the community, and gain some persective.

Doc vs World: Episode 3

My name is Richard A Schoor MD FACS, and I am a urologist in solo practice in Long Island. In this day and age, the solo practictioner is the medical equivalent of the eco-survival specialist: without the proper skills, knowledge, and a bit of luck, you can die out here. Like my true survival specialist-alter-ego, Bear Grylls, I have amassed quite a bit of experience in survival, only in the harsh medical landscape rather than the jungle, the desert, or the tundra. While I have not had to eat bugs, snakes, or carrion to survive, I have had to eat a lot a crap!

Today, I will be trying to survive the double digit increases in malpractice insurance liabilty premiums that are facing New York's physicians. Of course New York is not the only state in crisis. Just ask any doctor in Florida, New Jersey, Massachusets, or Pennsylvania and they can tell you that thriving is no longer the goal. Economic survival is the name of the game.

Here's how to survive dramatic rises in liabilty rates.

One, you must budget, budget budget. And not just your office finances, but your personal ones too. You may need to float your business with a personal loan in the case of cash flow disruptions in the office and vice versa. In the office this means being an absolute miser. Negotiate for rock bottom fees with vendors, turn off your lights, disallow overtime, hire part-time employees, hold on to bills as long as long as possible; essentially do more with less. Put off that vacation untill things get better.

Two, you must plan for the future. The rates will go up this July. They will go up more next July, and still more the following one. When it comes to liablity insurance rates in NY, the direction is and has always been one way--up. Knowing this, one can plan an escape. In the time frame of a year, any physician can relocate to another state, join a practice, and start again. You may take a loss on your house, but ultimately you'll come out ahead. Even in states with long lines for licenses, the whole process can be completed in 18 months, tops. You should know financially if your practice can survive this July's increase and even next July's, so realistically you have 24 months to get out of Dodge. When faced with certain demise 3, 4, or 5 years hence, or survival with a calculated risk, take the risk.

Three, look for alternative insurance vehicles. In the last few years, deus-ex-machina has come in the form of RRGs. RRG's, or risk retention groups, are insurance mechanisms that cover businesses of similar risk characteristics when tradional insurance has become too expensive. Congress passed the federal law that allows for these RRGs inthe 1980s and since then many have formed in a variety of industries, including medicine. Anesthesiologists have had successful RRGs for many years and while the rates for anesthesiologist with traditional insurance companies have risen , anesthesiolgy rates have actually dropped for those covered with the RRG. There is an RRG for emergency physicians and even one for orthopedics. A new one, called SCRUBBS, is being formed for urologists. RRGs are under ferderal jurisdiction, rather than state control. As a result, insureds can move about the nation and retain their policies. On the downside, since RRGs are not under state insurance rules, insureds have no protection--zero--when these companies go bankrupt. In other words, switching to an RRG is risky, but survival and calculated risk go hand in hand.

Lastly, do not ask for devine intervention, providence, or the good will of others to protect you. In the wild, it is survival of the fittest. Same thing here. Many people I know have said the following: "they can't let doctors in NY go bankrupt." I say bull. This type of logic has led many people, cultures, even civilzations to their downfalls.

Eight years ago I stood among a bunch of obstetricians before grandrounds and listened to them gripe about their malpractice premiums. At the time, they were asked to pay $90,000. "How could it get any worse?" said one. "Albany will intervene" said another. Now these same docs are paying over 200K per year and Albany has done squat.

Albany can let doctors go bankrupt and they will. No help is coming. You're on your own.

But you have the tools to survive. Stay calm and use them.

Good luck.

The IU.

Why is a manager worth their incomes?

I recently posed that question to a bunch of practice managers on a listserve and got some great feedback. A good practice manager is worth their weight in gold, as long as they exhibit excellence in the followings areas:

• Human resource management
• Billing and coding
• Payroll
• Business development and strategy
• Information technology management
• Risk management
• Financial management
• Contract negotiation and insurance company management

I could not agree more. A good practice manager is truly worth their weight in gold and can help you generate income, run a business, and be a doctor.

Thanks.

How can an established medical practice go under? It is easy.

The used to be a saying that went something like this: there are no starving doctors. When I decided to become a physician, in 1987, that was certainly true. Now, established practices that have served communities for 40 or more years are going bankrupt. The question is how can this be happening?

It is actually quite easy. Here's how:

1. Take a practice full of established patients that are older and sicker.
2. Combine that with rock bottom reimbursements especially for that exact patient demographic
3. Add to this brew soaring medical liability premiums and rising payroll costs

. . .and you have a ship on the verge of foundering.

Then throw onto the already struggling business disruptions in cash flow, the inability to get additional financing, ie loans, and rising energy costs and voila, the ship goes down like a rock.
Very easy indeed and it can all happen in the span of 3-4 months.

Here's how to defend your practice from this demise.

1. Have 3 months of operating expenses for the business, minus your salary.
2. Have at least 3 months of savings to cover your personal costs.
3. Develop a 5 year plan for your practice and strive to achieve it.
4. Know your numbers amd metrics inside-out, backwards and forwards.
5. Be lucky!

Good luck.