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.

Doc vs World: Episode 2

Imagine this:

• You're an orthopedic surgeon and part of a group. You have 3 partners, 2 of whom have been in the practice for 15 or more years. You are a partner, but not a managing one. What that means is that you come to work, do your thing, and get "partner's pay." One day, the managing partners call a meeting. In the meeting, they ask that all employees go 2 weeks without a paycheck because the practice is out of money. The partners, they say, will go without pay "until further notice." What do you do?

You don't believe this scenario? Believe it. This exact thing is happening in an orthopedic group with which I am familiar. So, again what do you do?

Well first, as a partner you must make it your business to know about the financial health of your business. You are a partner and it is your right. In this case, however, your options will depend on your answers to several questions.

1. Do you have savings?
2. Do you have another source of income?
3. Do have good credit and can you get a loan?
   
4. Are you willing to relocate?
5. Have you planned for this contingency?

If you have savings or a source of income that can last 1 year, you can go off on your own. Otherwise, I don't believe that this is a viable option, unless you have an established practice, a loyal patient and referral base, and an unenforced no-compete clause. In that instance, you may be able to become cash positive in 2-4 months. Here's how to start.

1. Get phone.
2. Get a box.
3. Get an address, even if it is a PO Box.
   
4. Get all your provider ID information and credentialing information gathered and organized.
5. Put all of the above information into the box.
   
6. Set-up a new PC or LLC.
7. Get a biller, even if you need to out-source it.
   
8. Change your provider IDs to your new location and your NPI to your new address.
9. Find office space or sublease on a per diem basis if need be.
10. Collect all copays.
11. Do not submit ANY claims until all provider IDs and your NPIs have been confirmed as switched, unless of course you want your old employer to get all the money.
12. Answer your phone 24/7.
13. Tell your kids they ain't going to camp.

Good luck. But there is a lesson here. Whether you are a partner or not, as a doctor you are a small business man. You must know the details of your business and you must have an exit plan. This disaster plan must be in place even during the good times. When the bad times come, they'll come plenty fast and your plan could save you. This plan should include savings, alternative income sources, your own insurance policies, knowledge of the competitive landscape and possible employment opportunities and even a license to practice in another state.

I hope this never happens to you, but if you're reading this intently, I suspect it did. Contact me if you'd like.

Again, good luck.

Doc vs World

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

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

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

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

Good luck.


The IU.

A hidden cost of an EMR

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

If you use windows based workstations, you may wish to adjust the power schemes to save money.
Here's how:

1. Start
2. Control Panel
   
3. Power Options
4. Power Schemes
5. Select the one you want

I tend to put the lesser used computers into hibernation mode after 20 minutes of idleness. Hibernation allows the computer to stay on, but at lower power-usage. The computer does not need to be re-booted and it will save projects between hibernation cycles.

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

The IU.

SIZE. IT DOES MATTER.

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

Here are some advantages that small offices have over large ones.

• No need for expensive intercom systems
• No need for dumb-waiters or tube transport systems
• Easier inventory control
  
• Lower rent
  
• Lower maintenance costs
• Lower utility bills

Let me explain some more. I can overhear every conversation in the office when my office door is open. This comes in handy when situations arise between staff and staff and staff and patients. If I need something from my MA, I can intercom her, but I typically revert to a more vocal paging method.
During a patient encounter in an exam room, everything that I could possibly need is within my arm's reach. Last year, my electric costs were ~$50 per month. Now, thanks to our current energy predicament, I pay $150 per month. If I had a 3000 square foot office, I'd probably pay double or triple. I don't have storage room for much, so I order supplies "on-demand." Whether that saves money or not, who knows. But it works for DELL. My office can be cleaned by my staff in 20-30 minutes. This is important for 2 reasons: costs me less and makes my office more secure.

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

Good luck.

The IU.

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

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

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

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

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

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

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

Again, just my observation.

The IU.

A great use of technology

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

A great model.

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

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

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

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

Again, congrats to the success of the Axiom Firm.

The IU.

25A: The Route of Broken Dreams

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

• A bagel place closed after 3 months.

• A seafood restaurant has closed, after having been open for only 8 weeks.

• A Mexican restaurant across from my sushi place closed after several weeks.

• A "Hooka Lounge" bar just opened, though I've never seen a single car in the lot and I think it'll no doubt close soon enough.

• A coffee shop in Kings Park went under after 6 months.
  

• A cellphone storefront lasted 1 month before going under.
• A printer cartridge retail store in Smithtown lasted 1 year.
• A law office closed and an alarm store took its place. The alarm store closed 2 months later and has been replaced by a real estate agent, all in under 1 year.

That makes 9 failed start-ups in less than 8 miles. . .in an affluent area. Yes the economy is not well and in these times having a job or a business that is simply surviving might have to suffice.

Depressing, yet true.

Good luck out there.

The IU.

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?

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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

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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.

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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

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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