Destroyed in Seconds

There is a show on the Discovery Channel called Destroyed In Seconds.  Essentially, the program shows video footage of disasters that seem to have come out of nowhere.  In one episode, the viewers could enjoy a helicopter crash that happened with shocking rapidity.  In another episode, a speed boater loses control of his craft and in an instant is gone.

In medicine, good relationships can evaporate in seconds as well and we seldom see it coming.  In this first episode of "Destroyed in Seconds: Urology Edition" I am going to present some instances where a perfectly good doctor-patient relationship can get "destroyed in seconds."

• A previously passive patient receives an unexpected bill and calls the office ranting and raving about it: relationship destroyed in seconds.
• A patient receives an unexpected phone call regarding the need for additional pre-surgical testing and is inconvenienced.  His frustration and vehemence gets turned upon staff and you and the relationship is destroyed in seconds.
• A patient being followed for rising PSAs is told by a "friend" that he should have been biopsied and he accuses you of negligence: relationship destroyed in seconds.
• Above patient has biopsy done by you and is negative for cancer: relationship restored in seconds.
• Above patient has terrible complication from above biopsy that you initially advised against and relationship destroyed in seconds.

Medicine is a crazy business.  We walk a fine line between hero and goat. 

And any doctor patient relationship can be "Destroyed in Seconds."

(Disclaimer: the above examples are fictitious and do not represent actual encounters.  Any similarities are purely coincidental."

Leaving a practice? The Essental List

Sometimes the group thing just does not work out and people find themselves with no other option than going solo.  Follow these essential rules and you'll land on your feet.

1. Determine your short term intermediate, and long term goals and list in backwards order how you plan to attain each of them.
2. Leave your old practice on good terms, this will only serve to help you in the future and trust me, you WILL need them in the future.
3. Develop a plan to attract your old patients, so long as it does not ruin your relationship with the old office, and separate plan to attract new patients.
4. Organize all credentialing material and higher someone, even per diem, to assist you with credentialing.
5. Look for an office or sublease on a temporary basis.
6. Go electronic, even a web-based ASP model for an EMR and PM/scheduling system.
7. Get a website, just don't pay a lot for it.
8. Get a blog and start posting to it.
9. Look for staff (personally, I recommend Craig's List.)
10. Get a phone and answer it 24/7.

If you follow these 10 steps, you'll be up and running in no time flat.

Good luck,

The IU.

The Copay Sign

In this day and age, every dollar matters.

While I find that 99% of people pay their copays without problem or complaint, 1% will ask for it to be waived. We simply direct them to sign above and that answers their questions succinctly, forcefully, yet with some humor.

Joe the Plumber vs Rich the Urologist

I did a vasectomy today on a plumber from Long Island.  Like Joe, the plumber from last night's presidential debate, this plumber is in business for himself.  As I was performing the vasectomy on my patient, I was talking to him about his business.  Here's what I learned from my "Joe the plumber."

• Plumbers are not licensed by the state but by the town in which they do business. 
  
• Each town in which the plumber works requires the plumber who owns the business to be licensed.
• Each town in which the plumber does work requires the plumber to be insured.
• Plumbers in Long Island must carry 1 million dollar policies per occurrence.
  
• Most towns require the plumbers to carry an additional million dollar policy in order to get a permit for any specific job.  This extra-policy protects the town in case a civil action is brought upon the plumber and threatens the town as well.
  
• In Long Island, the plumber's first insurance layer--the initial 1 million--costs $12,000 per year.  The second layer--the one each town needs--can add as much as $7500 per year onto the plumber's yearly overhead.  Thus on Long Island plumbers pay $19,500 per year in liability insurance.  Urologists in Long Island pay as little between $22,000 and $57,000 depending on the policy type and the urologist's loss history.
• Plumbers must pay workers compensation and unemployment insurance as well.
• If the plumber has employees, they may wish to carry employer liability insurance as well, which covers for things such as harassment law suites and wrongful termination suits.  This costs ~$2500 per year.
• Some plumbers are in business for themselves yet contract with larger, national companies, so that they can get more business.  The national companies take hefty commissions from the local plumbers who actually do the jobs.
• Some plumbers are W-2 employees of these larger companies and are paid salaries, yet they must still carry and pay for their own liability insurance.
• When a plumber's work results in a person's bodily injury, law enforcement typically investigates the incident and files criminal charges.
• In Long Island, a plumber who offers health insurance to his employees shells out $12,000 per year for family coverage, $6000 per year for single coverage and is often forced to pass an increasing percentage of this cost onto the employees.
• On Long Island, the plumber must bring in at least $1000 per day in revenue to survive.

Now Rich the Urologist.  My overhead is similar to Joe's in all respects yet I think I have a higher earning potential.  In addition, my licensing requirements are statewide rather than town by town.  Like Joe and his town permit requirements, each hospital in which I work requires that I carry $1 million of insurance and be credentialed, yet they don't (yet) make me purchase additional insurance per procedure or admission.  Like Joe, I can either be an employee or self employed and can contract with larger corporations for an increase in business.  Like the plumber, contracting with these companies (insurers) comes at a price.

That's it.  Joe's got it rough, even rougher than Rich the Urologist.

Good luck Joe the plumber,

Sincerely,

Rich The Urologist.

How it Works: Getting Paid That Is.

When you go to a restaurant, you order the food, eat, the bill comes, and you pay for the meal either with cash or credit card.  If you use an accountant, they do their work, send you a bill, and you send them a check.  If you purchase a sweater on-line,  you supply the merchant with your credit card or paypal information, hit submit, and then the merchant processes the order.  In general, the process is pretty straightforward and transparent.

In most medical practices, the process is much more complex, less transparent, and more open to error.

In medical practice, from the instant a patient calls to make an appointment, a cascade of events gets initiated that results several weeks to several months later in a payment into your bank account. 

Here's the steps that follow the "I'd like to make an appointment with Dr Schoor" phone call:

1st: Insurance: yes or no

• No: Straightforward fee for service, just like restaurant

2nd: Yes, Insurance

1. Determine type
2. Referral needed
3. Verify eligibility
4. Give appointment

3rd: Patient in office

1. Obtain insurance ID card
2. Determine copay amount
3. Determine method of payment, ie cash (great), cc (OK), check (risk of bounce)
4. Give receipt
5. Room patient

4th: After physician sees patient

1. Determine diagnosis codes (ICD9)
2. Determine procedure codes (CPT)
3. Determine level of visit (1-5)
4. Manually or automatically via EMR/PM charges and codes are sent to biller/billing software

5th Billing

1. ICD9 and CPT codes are entered (manually or via computer) and a claim is generated
   
2. Claim is edited either manually or via PM program to make sure that all demographics are correct, NPIs are correct, PTANS of present, if needed, and ICD9 and CPTs match, and more.
3. Claim is then either printed on a HICFA 1500 form and mailed directly to insurance company or submitted electronically to a clearinghouse (middle man)
4. Clearinghouse adjuticates claims (further processing for all above) and then either rejects claim or forwards it onto the pertinent insurance company either electronically or on paper.
5. Insurance companies review claims and either: authorizes claim "as is" and remits check for contracted amount, down codes encounter and remits check for lesser amount, or does nothing (which then requires you to track down the claim).
   

6th Payment

1. Payment comes in the form of an EOB, or explanantion of benefits and a check.
2. Checks can either be attached to the EOB (paper) or issued via ETF (electronic transfer of funds).
3. Check amount must be verifed against EOB.
4. Practice can then either accept payment "as is" or re-submit claim with a dispute.

And that is for a simple office visit.  The process varies a bit for things like hospital consults and procedures or for procedures performed in any out-of-office setting.  In addition, each payer and each plan, within the plan, within the plan, has slightly different rules, policies, and procedures, and these can muck up the reimbursement's timeliness and accuracy for the doctor. 

And what about copays?  I have not even dealt much with this easiest part of the whole thing, that is the copay.  Some people have them and some don't.  Some plans have a flat copay amount for all visits, while others have different amounts depending on the type of visit, e.g. primary care, specialist, ER, hospital, lab, etc.  To make everything even more complex, not all ID cards indicate the copay that fits the particular situation.  In this last instance, the only way to know the copay amount is get it off the EOB in the box that reads "patient responsibility."  Then you must, contractually, go after the patient.

Going after the patient, for even as little as $3, is not always easy.  Even though the majority just pay with no fuss, some patients get very upset at receiving a bill for any amount.  For all patients, the practice must send statements, ie bills, and this costs 41 cents, plus envelope, per bill plus staff time for each patient per statement period.  When the patients return their payments, the cycle is complete. . .unless they have secondary insurance. 

And that is a whole other discussion.

Physical Networking in a Virtual World

It used to be that doctors socialized with each other.  This is no longer the case.  The practice of medicine and its economic realities have made it difficult for doctors in a community to get to know one another and become friends.  In the recent past, circa 1990's and before, one could go into the doctor's lounge and immediately find colleagues, engage them in debate or small talk, or even hold an impromptu journal club about someting innane written in the NEJM.  Specialists could put names to faces of their primaries, and vice-versa.  If a physician needed a quick consult or simply a pep talk, he could find it in the lounge. 

Until recently, the hospital itself served as the hub of all social activity amongst physicians.  The yearly hospital galas in those days were part prom for the doctors and their wives and part fundraiser for the hospital and its board.  Though these galas still exist, doctors can no longer afford the $500 per person ticket price for admission and few attend.  I have been to one or two of these myself--on someone else's dime--and I was amazed at how few doctors were in attendance.

Not so long ago, outside the hospital doctors would socialize with each other at the local country club or tennis club.  Their wives would become friends and so would their kids.  It was nice time; a time that I only glimpsed from the outside during my medical school days and that subsequently vanished while I was still in training.

No doubt due to abuses to the system during a bygone era, the pendulum has swung way over to the other side with PHARMA having eliminated the only remaining locally held social activities available to the community doctor; the drug dinner and the sponsored grand rounds.     

The demise of this important social network has had some profound implications for the business side of medicine, some for its betterment and some for its detriment.  I suppose that a strong social network prevented the development of Medicare until 1965 and I can almost see doctors in the lounge working each other up to a tizzy about the "red evil" that was coming in the form of socialized medicine.  On the other hand, the network probably served as a catalyst for doctors' acceptance of commerical payers, especially as their colleagues, one by one, signed onto the plans.  On a more personal note, it has become difficult, to say the least, for young doctors to meet other young doctors and establish new lines of referral and make friends.  Since networking goes hand-in-hand with business development and practice building, the absence of this network system makes it more challenging to grow a practice. On the flip side, with few in-roads available for networking, well thought out and skillfully excersised networking tactics can produce significant positive results.

Networking still exists and is as important as ever, but it is no longer conducted as much in the physical world as in the virtual one.  Your trick, as a solo doc, is to find a way to use the virtual network community to augment your own local, personal network group.  It can be done.  Just ask some of the people who have done it.

Thanks and good luck,

The IU.

I stand corrected

Minyan is a quorum. Minion is "a servile follower." Thanks to Kishkes for the correction.

October is upon us and it is time for some Q4 planning.

Tomorrow is the last day of the 3rd quarter of 2008.  Wednesday marks the first day of the last quarter in 2008.  I never really understood the significance of quarters until I went into solo practice, but now I do.  For business owners, the 4th quarter means planning and preparation because Uncle Sam wants his money and $10,000 on December 31 is worth only ~$6000 on January one.  Unfortunately, the $10,000 insurance bill remains $10,000 and the $2500 rent remains $2500, and even goes up due to tax increases.  So I recommend planning and preparing.

• Pay January bills in December
• Hold check-posting reimbursements in the last few December week's until January
• Max the 401K
• If no 401K, you have several weeks to start a Simple IRA and the rest of the year to max it out
• Pay off high interest debt with profit
• Invest in new equipment now
• Invest in that marketing project you have been considering before years end
• Pay down some of your business line of credit
• Of course pay off credit card debt
• Make any office capital improvements that are needed between now and December 31

And the rest, take in profit and pay Uncle Sam-->Wall Street.

The IU

Fall

Looking forward to the change of seasons and the final quarter.

Not bad!

15 people responded to the quiz and 11 of the respondents had a similar understanding of regulated waste as my own.

Essentially most items belong in regular trash. The only exceptions are gauze or gowns that drip with blood, body tissue, and sharps. While this may vary by state and locale, the results of my quiz suggest there are some national standards.

Of course with an n of 15, my study lacks any power and we must accept the results with caution.

I will place the pole on the side bar and see if we can get some more responses.

Thanks for the help.

Still waiting for a "minion."

I am still waiting for a sufficient number of people to respond to my queary to provide the results. In the meantime, check out a new post and pole at http://schoor-urology.blogspot.com/.

What is regulated medical waste?

If you ask 5 people "what is regulated medical waste?" you'll likely get 5 answers. Everyone knows that sharps are regulated and they belong in a sharps box. But how about the following?



Let me know, so that I may know. After I have "a minion" of responses, I'll post my understanding based on discussions that I've had of late with experts in medical waste management.

Knowledge of where waste rightfully belongs is important for 3 reasons:

• Safety of the environment
• Safety of the public
• Cost to you, the business.

So please, give me a hand.

Considering an EMR? Look Into VISTA.

I spent much of my urology training at Chicago's Lakeside VA Medical Center.  This was in the 1990s and EMRs were in their infancy.  At that time, the VA had it's own proprietary system, called VISTA.  And VISTA was amazing: simply the best EMR ever made.

And it still is.

VISTA is free.  You can get it from the VA Medical Center's Website.  It requires a MUMPS platform to run, and this requires a license, or it can run for free on a LINUX system.

So basically, to have the best EMR is the world you can rent space on a VPS (Virtual Privacy Server) that runs LINUX, get a techie to configure it for you, and then you have the best EMR in  the world

DIY

Text Messaging Consultants: I'd Like It.

Last week I had a patient in the hospital who had to stay 24 hours longer than I thought she needed to stay because it was difficult for nursing staff to contact all the doctors that were providing her care and clear the discharge home order. Essentially, I came in to make rounds and the patient wanted to go home. She was eating, having BMs, and was in no pain, and she felt that she would get better rest at home. I reviewed her chart and agreed with the patient that she could go home. However, I wanted to coordinate her care with all the other consultants who had helped on her case, such as pulmonary, ID, hospitalist, and general surgery. Aside for writing an order "d/c home if OK by pulm, hospitalists, ID, and general surgery services" I had no efficient way to convert the order to action.

To make a long story short, it took 18 hours to contact all the consultants and to finally get an OK for the discharge and then another 6 hours to make arrangements to actually get the patient home.

I have a better way. Doctors or their services ought to use SMS. I could then send one text message to all 5 consultants-or their services--and then the doctor could simply reply "yes" "no" or "?" to me and then I'd give the order, or not. I think it would save time and simultaneosly improve care to patients and communication amongst consultants and primaries.

Ain't gonna happen, but it would be nice.

5 Ways That Unfaithful Men Get Caught

Men in high profile positions, such as governors, presidents, and senators, get discovered cheating on their wives in very dramatic ways. These men get outed by the media or during a special prosecutor's investigation. Most men, however, get caught by much more mundane reasons. Most men get caught because they contract a disease. If you cheat, here is how you will get caught.

1. Herpes: condoms don't always protect against herpes. As one can imagine, this might be difficult to explain to your wife. A herpes infection is forever.
   
2. Warts: see herpes, but in honesty it is possible, though not probable, that an HPV infection can remain dormant for 20 years. So tell her you must have contracted it from the last woman you dated, 20 years ago.
   
3. Gonorrhea/Chlamydia: men have an encounter, then develop symptoms of pain and discharge and come in for evaluation. The problem is that in the interim between the sexual encounter and the medical treatment, the man had sex with his wife.
   
4. Abnormal pap smear: of course men don't get pap smears, but our wives do. Typically a wife with 20 years of normal pap smears will have an "abnormal one" and the man will come into my office, look very sheepish, close my door, then spill the beans.
5. Fractured penis: yes, that right,fractured penis. Usually the man is on a business trip, has vigorous sex with a woman and oops, the penis pops out of the vagina, then gets thrust upon her pubic bone. It then bends when it is erect and snaps. This is a medical emergency and I suppose it could be difficult to explain the penile bandage to your wife when you return home.
   

So be forewarned and keep your pants zipped.

Going Solo? 10 Pearls For Success

Now that I have been solo for 2 1/2 years and feel that I have traversed the valley of death successfully, I can look back with some perspective and understand some of the important decisions I made that enabled me to get to where I am today.

In no particular order:

1. Start small: preserving capital is critical. Most businesses fail because they run out of money before cash flow starts to take over.
2. Develop a business plan: this will serve as your road map and guiding vision and will help you make important decisions when the future is uncertain.
   
3. Go EMR: whether you purchase one or make your own, these systems have major advantages for small sized practices.
4. Build up a nest egg: For most of people, the decision to go solo is made over years, not days. This should give you enough time to build up a cash reserve that can get you through the first 6 to 8 months. If you can't save it, then getting adequate loans in important. best of all, save it yourself, then take out a loan and use the bank's money.
5. Surround yourself with good employees: staff turnover is lethal. When you find good people, reward them and retain them.
6. Invest into the practice: as money starts coming in, rather than take a vacation, invest some of it back into the practice, say, for new billing software, new equipment, advertising, etc.
7. Network: This is not only important as a good source of referral business, but you can learn from others who have "done it" and have overcome challenges that you now face.
   
8. Study: read business books and do your homework. It will pay off dividends.
9. Get on the web. Web presence is critical.
   
10. Have fun: if you don't enjoy the process, you will certainly fail.

Good luck.

The Key To e is C

Though I went electronic a few years ago, I finally figured out the key to e.  It is simple: just go with the flow.

Most EMR or e-Rx modules have a certain "flow" of their own.  The programs seem to force users to adopt to how they are written rather than to how the doctor herself might do things with pen and paper.  Many of these electronic flows, or e-flows, seem to follow a different logic, a different algorithm, than we as doctors are used to, say, from being human or from having been practicing for many years prior to the software's development. 

While many vendors try to engineer the software to be intuitive and analogous to a typical doctor's doctoring "process", the software really can't be everything to everyone.  Most of us will have to change in order to use an EMR to its maximal efficiently.  And that is a good thing.   Just because an EMR forces a user to adapt, does not make it a bad product.  In fact, if the change improves accuracy and completeneness of data collection, promotes mistake proof ordering and prescribing, and allows for efficient data review, then I am all for it.  If adaptation promotes survival, it is a good thing.

E-prescribing for me has been difficult to adopt because writing a prescription on a traditional pad is quick and easy.  Traditional prescribing works like this: I see patient-->discuss treatement options-->recommend medication-->discuss side-effects-->write prescrion-->hand it to patient.  The whole process takes minutes.  E-prescribing requires significantly up front more time and effort for me and I simply cannot do it while the patient sits in front of me in my office.

However, I have found that e-prescribing results in so much less aggravation on the back-end that it is really worth the time and effort to do it.  I just had to change my methods to fit the new technology.  Now that my metomorphosis is complete, I find that I am more efficient overall than I was before the change.  I can see more patients, more easily, and with less aggravation.  Things like, "Oh doctor, can you do 90 pills instead of 30" just don't happen to me any more.  I have successfully found a method to e-prescribe that works for me and now I like it.  Like my grandfather said when he got an answering machine as he turned 89, "Vichie, how did I ever live without one."

So if there are any managers out there frustrated because docs are resistnant to change, maybe try to convince them that once they adapt, they'll be amazed that they ever survived without the technology.  Tell them that the key to e is C(hange).

Good luck.

Protect Your Online Reputation: 10 Steps

One of my employees has a doctor that she worships, so one day I Googled the doctor's name.  He had several listings, but all were from sites such as Ucompare, Healthgrades and some other local doctor rating sites.  I pulled up one of the free reports and found two ratings; one glowed while the other seethed with anger and hate.  And that was all that this outstanding doctor had to represent him to the online world.   

In these days, doctors must be proactive in managing their online reputations.  Any person with an ax to grind and access to a computer and internet can really damage your hard earned reputation.

Here are some things that I do and I recommend you do to manage your online reputation:

1. Blog and blog often.
   
2. Have your own website, even if you are part of a group.
3. Link your blog and website.
4. Publish articles, such as review articles, in medical journals and periodicals.
5. Post comments on other peoples blogs and allow them to post on yours..
   
6. Get your name in the media via interviews (see blogging and blogging often).
   
7. Google yourself on a regular basis.
8. Contact content providers that allow subscribers to post malicious writings about you and request that that they remove the comments.
9. Have a lawyer contact the content services or the offenders themselves with threats of litigation.
10. Seek help from online reputation management experts (yes they exist).
    

So protect your online reputation and remember that no one has a right to malign you unjustly and falsibly.  The first Amendmant does not protect people who do this from civil damages.  Do not be afraid to enforce your rights and fight for your reputation.  Your very livelihood could depend upon it.

Good luck.

Tau Epsiilon Phi 1990

My fraternity brothers 1990.
Life, uncomplicated.

A Weekend With The Boys

I'm taking the weekend off and I'm going to my Alma Mater, The University of Maryland College Park. The weekend plan seemed to come out of nowhere, but actual was made possible by Facebook.
Beginning in August, someone from my college mentioned this weekend as the TERP reunion weekend on Facebook and due to speed of information dispersal over the net, over 100 guys that I went to school replied, excitement grew and the party is going to be tremendous. It's going to be a great time.

As a solo urologist, I have some challenges to overcome so that I can go. One, I had to get coverage. This was easy and I arranged it with a local urologist whom I cover on a prn basis.

The next challenge is how to balance being in touch with being away. I plan to use voicemail and email as my predominate means of communicating; text message as well.

The next challenge is family. This was more difficult than office coverage and well, costly.

See ya next week.