Physician looking to transition out of practice

[Amogh Sahai]

Hello there,

My name is Amogh. I just finished reading the fast lane millionaire and it made me wonder why I didnt get this information any sooner. Time is the most precious commodity, and I have wasted almost half of my life. Anyway, enough with the rant.

I am a 38 year old Physical medicine and rehab specialist who is certified by the American Board of PM&R. It took me a lot of years to get the training and master the craft, but I dont feel happy in my line of duty. Clinical medicine is every day becoming more challenging with the implementation of EHR, the declining Medicare/insurance reimbursement and other things.

The thing this book made me realize is that I dont own a real business because it doesnt follow the 5 commandments. There is a need for the service and high entry level to offer this service. However, I am not in control of the business, but instead a pawn of the big insurance companies who are making money out of me. In addition, I can't scale the business. Furthermore, if I dont go to work I cant generate income. It is even worse than being part of a Franchise company, because I havent agreed with some of the decisions that insurance companies are making in my practice territory. They are always looking for creative ways to save more money and pay the provider less.

Anyway, I am now going to try and leverage my knowledge base to offer some unique value/selling proposition. I am a little more inclined to considering a product based business. But, my main problem is not having a lot of free time. My clinical job steals a lot of my free time. But, I am being more proactive about educating myself in the little free time. I will be doing a 1 week long entrepreneur bootcamp in Babson so that I can accelerate things.

As with any book, there are probably things that I dont agree with 100%. If you look at the statistics, the average age of a successful start up founder is in the 40's. So from a % of probability it makes it a little more challenging for a person in their 20 or 30's to hit it big. That is why real world life experience is important before you decide to go solo. There are also some statistics that show greater likelihood of being succesful in a new business if you still have a job vs quitting your job to start a busines. Statistics can sometime be deceiving, but it is important to look at the numbers when talking about this.

 

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[The Abundant Man]

Welcome!

 

[bambambam]

Welcome- fellow doc here with similar thoughts and dreams. Anxious to see your progress!

 

[MHP368]

Hello there,

My name is Amogh. I just finished reading the fast lane millionaire and it made me wonder why I didnt get this information any sooner. Time is the most precious commodity, and I have wasted almost half of my life. Anyway, enough with the rant.

I am a 38 year old Physical medicine and rehab specialist who is certified by the American Board of PM&R. It took me a lot of years to get the training and master the craft, but I dont feel happy in my line of duty. Clinical medicine is every day becoming more challenging with the implementation of EHR, the declining Medicare/insurance reimbursement and other things.

The thing this book made me realize is that I dont own a real business because it doesnt follow the 5 commandments. There is a need for the service and high entry level to offer this service. However, I am not in control of the business, but instead a pawn of the big insurance companies who are making money out of me. In addition, I can't scale the business. Furthermore, if I dont go to work I cant generate income. It is even worse than being part of a Franchise company, because I havent agreed with some of the decisions that insurance companies are making in my practice territory. They are always looking for creative ways to save more money and pay the provider less.

Anyway, I am now going to try and leverage my knowledge base to offer some unique value/selling proposition. I am a little more inclined to considering a product based business. But, my main problem is not having a lot of free time. My clinical job steals a lot of my free time. But, I am being more proactive about educating myself in the little free time. I will be doing a 1 week long entrepreneur bootcamp in Babson so that I can accelerate things.

As with any book, there are probably things that I dont agree with 100%. If you look at the statistics, the average age of a successful start up founder is in the 40's. So from a % of probability it makes it a little more challenging for a person in their 20 or 30's to hit it big. That is why real world life experience is important before you decide to go solo. There are also some statistics that show greater likelihood of being succesful in a new business if you still have a job vs quitting your job to start a busines. Statistics can sometime be deceiving, but it is important to look at the numbers when talking about this.

Can you hire NP's or PA's / Physical therapsist and CPTA's to do the grunt work and just skim off the top?

When I was a CNA I knew a doctor who did this , NP's seeing the patients all week and he'd maybe show up a few hours fridays to look at charts.

He had np's in half a dozen nursing homes , charged the SNF's a fee for his "practice" underpaid ththe np's by 20 or 30k a year and pocketed that differwnce for himself.

 

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[Real Deal Denver]

Can you hire NP's or PA's / Physical therapsist and CPTA's to do the grunt work and just skim off the top?

When I was a CNA I knew a doctor who did this , NP's seeing the patients all week and he'd maybe show up a few hours fridays to look at charts.

He had np's in half a dozen nursing homes , charged the SNF's a fee for his "practice" underpaid ththe np's by 20 or 30k a year and pocketed that differwnce for himself.

WOW. Love this place. The behind the scenes stories are better than what I see at the movies!

 

[MJ DeMarco]

Welcome aboard.

If you look at the statistics, the average age of a successful start up founder is in the 40's.

So from a % of probability it makes it a little more challenging for a person in their 20 or 30's to hit it big

You're missing the point of my books. It isn't to move to Silicon Valley and found a start-up.

You don't need to own a big "startup" to free yourself through business.

It can be a small company with 1, maybe 2 employees and be totally under the radar.

The word "startup" is loaded, and misleading.

 

[Amogh Sahai]

Welcome- fellow doc here with similar thoughts and dreams. Anxious to see your progress!

Definitely.. We should look at ways to hold ourselves accountable. Maybe set up some time benchmarks on our progress, I am not sure how big the physician community is in these forums.

 

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[Amogh Sahai]

Can you hire NP's or PA's / Physical therapsist and CPTA's to do the grunt work and just skim off the top?

When I was a CNA I knew a doctor who did this , NP's seeing the patients all week and he'd maybe show up a few hours fridays to look at charts.

He had np's in half a dozen nursing homes , charged the SNF's a fee for his "practice" underpaid ththe np's by 20 or 30k a year and pocketed that differwnce for himself.

I have a neurologist colleague who defers a lot of the work to technicians and other people. However, I see some of the EMG/NCS reports that he reads/interprets and they are complete garbage. Sure, if I am just looking for a quick way to make a buck and dont care about the quality of the product/service I give, then I could do as you say. However, I already have a good reputation in the community because of the good product that I put out. But, to be honest, my heart doesnt belong in medicine, and in the long run I need to creat an alternative lane that will take me to a better place.

 

[MHP368]

I have a neurologist colleague who defers a lot of the work to technicians and other people. However, I see some of the EMG/NCS reports that he reads/interprets and they are complete garbage. Sure, if I am just looking for a quick way to make a buck and dont care about the quality of the product/service I give, then I could do as you say. However, I already have a good reputation in the community because of the good product that I put out. But, to be honest, my heart doesnt belong in medicine, and in the long run I need to creat an alternative lane that will take me to a better place.

Can you describe what a day looks like for you? What do you bill for and how?

In my example it was skilled nusring homes so every patient in a room (some long term , some post stroke , some knee replacement rehab and so on) had a "provider" but it was actually more than one provider (doctors and/or nurse practitioners) assigned to one company or practice.

So the nurses would call with lab results , sudden changes in condition etc. Doctors / np's would come through for rounds etc.

So the value being paid for was someone with prescription priveleges to hand out pills and in the case of physical rehab , rubber stamp a physical therapists treatment plan (for billing) , and occasionally send some guy on coumadin with a wonky INR who fell and hit his head to the hospital (not a fun call , but I digress...)

So what value specifically so you provide that allows you to bill and get paid for its service being renders and can you get the "you spensing time every day in some building" part of getting paid out of the equation?

Ego aside here. Lets be real. You spent what , 13 , 15 years in school? And like you said how many years building a "reputation"? , thats dandy but if you want out of wage slavery then you have to stop trading time for money, end of story.

You'd have the final hire / fire decision and all the quality control over vetting your underlings if you started youre own business right? , so don't hire incompetent nitwits that you wouldn't want making medical decisions for you and move on with it.

If something about the type of medicine you practice precludes any outsourcing then the obvious next step from where I'm sitting would be to hustle up some cash and start or invest in a completely different venture. A little moonlighting with an MD after your name should certaintly give you a little cash flow to play with some of the other ideas on this site.

 

[Amogh Sahai]

Welcome aboard.

You're missing the point of my books. It isn't to move to Silicon Valley and found a start-up.

You don't need to own a big "startup" to free yourself through business.

It can be a small company with 1, maybe 2 employees and be totally under the radar.

The word "startup" is loaded, and misleading.

I think you are right. The media sometimes distorts the reality of what running a business really is. You could have a great gig, but still be operating under the radar. It might be even better that way.

 

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[Amogh Sahai]

Can you describe what a day looks like for you? What do you bill for and how?

In my example it was skilled nusring homes so every patient in a room (some long term , some post stroke , some knee replacement rehab and so on) had a "provider" but it was actually more than one provider (doctors and/or nurse practitioners) assigned to one company or practice.

So the nurses would call with lab results , sudden changes in condition etc. Doctors / np's would come through for rounds etc.

So the value being paid for was someone with prescription priveleges to hand out pills and in the case of physical rehab , rubber stamp a physical therapists treatment plan (for billing) , and occasionally send some guy on coumadin with a wonky INR who fell and hit his head to the hospital (not a fun call , but I digress...)

So what value specifically so you provide that allows you to bill and get paid for its service being renders and can you get the "you spensing time every day in some building" part of getting paid out of the equation?

Ego aside here. Lets be real. You spent what , 13 , 15 years in school? And like you said how many years building a "reputation"? , thats dandy but if you want out of wage slavery then you have to stop trading time for money, end of story.

You'd have the final hire / fire decision and all the quality control over vetting your underlings if you started youre own business right? , so don't hire incompetent nitwits that you wouldn't want making medical decisions for you and move on with it.

If something about the type of medicine you practice precludes any outsourcing then the obvious next step from where I'm sitting would be to hustle up some cash and start or invest in a completely different venture. A little moonlighting with an MD after your name should certaintly give you a little cash flow to play with some of the other ideas on this site.

Sure, wont get into a lot of details since I have to hit the sack soon.

I usually have 4 days of clinical duties. These are usually 7-8 hours long, and my focus is primarily MSK medicine. So I evaluate patient with orthopedic problems such as knee osteoarthritis, frozen shoulder, achilles tendinitis, plantar fascitis, Carpal tunnel syndrome, etc. I decide what workup they will need: xrays, emg, labs, etc. Then I formulate a tx plan that could entail medications, us guided injections, fluroscopically guided transforaminal shots, physical therapy, etc. If patient dont get better after all the w/u and tx plan, then I proceed to getting MRI's and referring out to the surgical specialties for more invasive tx. Of course, this is grossly oversimplified, and there are a lot of many other things entailed.

I forgot to mentions that I also spend an additional day doing EMG/NCS studies, and I am also affiilated to a local hospital in which I also go to evaluate patients 1-2 x per week.

 

[MHP368]

Sure, wont get into a lot of details since I have to hit the sack soon.

I usually have 4 days of clinical duties. These are usually 7-8 hours long, and my focus is primarily MSK medicine. So I evaluate patient with orthopedic problems such as knee osteoarthritis, frozen shoulder, achilles tendinitis, plantar fascitis, Carpal tunnel syndrome, etc. I decide what workup they will need: xrays, emg, labs, etc. Then I formulate a tx plan that could entail medications, us guided injections, fluroscopically guided transforaminal shots, physical therapy, etc. If patient dont get better after all the w/u and tx plan, then I proceed to getting MRI's and referring out to the surgical specialties for more invasive tx. Of course, this is grossly oversimplified, and there are a lot of many other things entailed.

I forgot to mentions that I also spend an additional day doing EMG/NCS studies, and I am also affiilated to a local hospital in which I also go to evaluate patients 1-2 x per week.

Ok, so to have a PA do what you do you'd have to provide the on the job training, to have an NP do it you'd have to (apparently) look for ones who graduated from duke university (The only orthopedic NP program in the world) and then give them on the job training. Lets walk through it anyway for some back of the napkin feasibility, you would have to A.) forma company that would employ these folks, B.) sell the idea to the clinic and the hospital (and actually a few more orthopedic clinics and hospitals needing the equivalent) and C.) figure out how much you could charge

You pay PA /NP X, you charge x+10 or 20% and pocket that extra bit , presumably as long as the providers are credentialed you shouldn't have a legal problem with this model.

Can you think of perhaps a different model with a similar theme (you paying others to do the grunt work and taking a cut) that would work with your background? , partner with physical therapists? , provide sports medicine consultation to teams?

Seperate track, what if you do consult work for lawyers suing companies for bad knee implants and things? , or the government working on workers comp claims?

What if we get you away from fee for service toward value or risk based payment?https://www.aaos.org/uploadedFiles/...volving Health Care System White Paper(1).pdf

What if you and a number of others in your specialty band together to form a group / network (leave the PA's and NP's aside) , now you can control the supply better (and control over your payer contracting)