Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, September 23, 2006

More About Money

From the comments (posted by a headhunter physician recruiter):
Most physicians who complain about money fall into two categories. The first don't see enough patients and aren't efficient with their schedules. The second live in poverty-stricken areas (either inner cities or remote, rural areas.) There are hundreds of thousands of doctors who do extremely well. What do they do differently than you do?
Here's what some of the hundreds of thousands of doctors who do extremely well do differently than I do:
  • They're not practicing in areas dominated by one or two giant insurers who offer take-it-or-leave-it contracts paying sub-Medicare rates.
  • They're specialists who order and perform lots of procedures, often without regard to their clinical utility.
  • They spend five minutes with a patient and charge for a level III or IV visit using an EMR to generate reams of meaningless documentation.
  • They bring patients back for return visits to review all tests regardless of the results, producing visits like, "The MRI was negative; you don't need surgery on your knee; just keep going to physical therapy" (and then see above.)
  • They use consult codes exclusively, even for follow-up visits and when patients self-refer, when they should be using Evaluation/Management codes (which don't pay nearly as much.)
  • Their malpractice premiums are less than 40% of their net pay.
  • They're practicing "concierge medicine," charging $2,000 per patient a year to do exacty the same things I do for non-negotiable "negotiated" insurance rates.
As for "most physicians who complain about money" falling into two categories:

I have open access and see all patients the day they call, if they wish. Physicals are accomodated within the week. August was great because of this; the phones have been slower this month, so we sit. Don't go talking about marketing to get "more people in the door" because:
  1. There's no money for it,
  2. I'm seeing 1-2 new patients a day on average, because
  3. Word of mouth -- as you know, the best marketing there is -- is going great guns thanks to my patients.
It's not volume; it's revenue per encounter, which in primary care isn't nearly as elastic as you seem to think. Surely you're not suggesting I perform unnecessary procedures or recommend extra immunizations just for the money, all the while justifying it with "creative coding"? As for impoverished inner city and rural areas, are you implying that people who live there don't deserve medical care since they can't pay for it? Or that doctors who take on the challenges of practicing in those areas shouldn't expect to make much of a living?

You are oversimplifying and blaming the victim.

I will not let you pin this one on me.


At Fri Sep 22, 11:43:00 PM, Blogger Dreaming again said...

very good. very good indeed.

At Sat Sep 23, 12:24:00 AM, Blogger D.P. said...

Hmmmm, it seems to come down to ethics. Wish you were my doc, Dr. D. I promise I would tell you all about the migraines . . .

Don't worry about the money--when you do the right thing, things seem to fall into place.

At Sat Sep 23, 06:48:00 AM, Blogger Big Lebowski Store said...

You mean it's not about the money?



At Sat Sep 23, 11:46:00 AM, Anonymous Anonymous said...

Loved reading your response!!!

Um ... does anyone know how to clone dinosaurs? *blink!*

Seriously, that's the difference between medicine as a "calling," and medicine as a "job." Also, your patients can tell which you feel it is ...

At Sat Sep 23, 12:27:00 PM, Blogger MedStudentGod (MSG) said...

This actually sounds an awful lot like a doctor whose clinic I was "indentured" to work teaching, but he used the medical students as free labor to get his patients out the door as quickly, but as profitablly as he could.

I still can't get over ordering PFT tests and nuclear medicine scans just because he had those in his office for someone who clearly had no real problem other than asthma. It was a great lesson on how not to be.

I wish I could have been in a clinic like yours Dinosaur.


At Sat Sep 23, 09:04:00 PM, Blogger Dr. Rob said...

I am with you on this. We are really caught in a bind. It seems like you either are caught with very tight margins, or you feel like you are "gaming" the system. We bought a DEXA recently and have been profitable with it, but you end up finding ways to order more of these. I don't want to be thinking about money, but to cover overhead you have to think about things like draw fees, handling fees, and over-documentation so you can justify a higher charge.

When you do the right thing, taking good care of people, paying attention to quality, you make less money than if you pay more attention to billing details. You find that you must just find what amount of the money stuff you can stomach. It is a sad reality of primary care.

At Sat Sep 23, 11:12:00 PM, Blogger Dex said...

Paying attention to billing, coding, and co-pays by itself is not bad medicine. Unfortunately doctors are not good businesspeople. It's a double whammy--medical business practices are not flexible enough to adapt to changing markets and doctors as a group do not organize well to change policy. Armies of bureaucrats do nothing but create more bureaucracy, ensuring their own survival first. How can doctors change the situation? Go on strike and precipitate a healthcare meltdown? "Downsize" health-care and streamline a la Wal-mart? Is Kaiser's model the answer--integrate providers and insurers? Start a national campaign to raise awareness of end-of-life issues, hopefully reducing the colossal cost of dying? What?!

-the emergencist

At Sun Sep 24, 03:51:00 AM, Anonymous Anonymous said...

Great post!

Here in Mexico, things are not like in the USA, it's harder, later I'll write about that situation here.

At Tue Mar 20, 05:48:00 PM, Blogger ObGynThoughts said...

Very interesting, a physician recruiter questioning a busy family doctor! What experience with the everyday workings of medicine might a recruiter have? He might have spoken on the phone to many physicians and might feel familiar with us, but that does not give him any insight at all into medicine. His educational background could be anything, more likely sales, which is the only thing recruiters do, most likely his background is not medicine. Dear family practice colleague, don't be offended! Recruiters hardly ever know medicine from the inside...
Your Dr. M, ObGyn


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