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.

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.