Building a successful solo practice

[newpodgrad]

Hi guys

What’s everyone’s take on how to successful build a profitable practice?

How are you all talking to patients about cash prices for services like orthotics or non covered RFC? How do you find patients take the news that yes, there is a out of pocket cost?

What else can be done in the office to build a good stream of revenue besides volume justifying office visits?

The previous threads have stated that surgeries aren’t paying well. What about in office surgery? I realize we aren’t doing fusions in the office, but what about hammertoes, cyst removal etc? Can these be done relatively easily in the office under local sedation? Any special regulations ? I figured just having everything sterile is good enough for this stuff.

Curious to hear people’s thoughts

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[Weirdy]

For non covered RFC:

"Hey Mr/Mrs xyz, unfortunately I don't think your nails will be covered under insurance. We do have a pricing menu for these types of things, I usually charge $__. Sometimes pedicure places will also trim your nails for you. Otherwise your feet look great."

*tries to justify class findings with xyz, my previous podiatrist did it, life story of how this is outrageous*

"I don't believe that's the case based on my exam. I don't want you to get hit with a bill and I also don't want to commit fraud."

Smile with your eyes. Reiterate cash pricing. Reiterate their current feet health in a positive manner. Empathetic body language.

Collect cash or PRN.

 

[DYK343]

I also don't want to commit fraud."

While this is true I have found using the term fraud makes patients very unhappy if they have had care with alternate DPM who "found a way" to get it covered.

The term fraud also makes them very unhappy when their PCP sent them to have their nails "only cut by a podiatrist because im a diabetic"

I typically say something like: "medicare is cracking down on podiatry. They dont like to pay for this service and they have certain rules that I legally have to follow. Your feet are healthy, I could get in a lot of trouble or lose my licence for performing care and billing to medicare. There are some DPMs that will do the care but that is a risk I am unable to take"

I typically say something along those lines. Ive had quite a few temper tantrums when I used the term fraud so I stopped using it. I had one patient call me "the worst doctor ever" after using the fraud term.

Bascially, Ive found it makes it easier if I put it that I am the one who can get in a lot of trouble instead of telling them their other DPM broke the law.

 

[newpodgrad]

What’s a reasonable amount to charge?

Not just for nails but things like orthotics etc? How do y’all figure out a pricing schedule

 

[heybrother]

Half-way down the front page is a thread entitled "How Procedures Get Reimbursed". Someone put a lot of time into writing it The vitality of this forum is somewhat increased by everyone's willingness to cover the same questions over and over again but it is nice to use resources/discussions that already exist to avoid starting from scratch.

 

[HardRoadPaved]

How do y’all figure out a pricing schedule

Call your competition and ask over the phone.

 

[Feli]

Solo private practice straight out of residency

Hello all, Long time lurker here, since the pre-pod school days. I'm going into PGY-3 and have been thinking about the real world post residency for about 6 months now. I've seen lots of good advice on here, and the majority of yall seem to think practice ownership is the best route to take, as...

forums.studentdoctor.net

Even if you are sure you want solo or buy-out practice, this question highlights one of the many weaknesses of doing it right out of residency: lack of billing, coding, office mgmt, etc skills ("practice management"). I believe the biggest strength of working for a well-run PP doc or group is the knowledge you gain even doing that for a year or two before you go solo (or maybe for a few years to get numbers for ABFAS cert if the job's not bad):
You will learn how to code, how to pick OTC products, develop your style with patients, get ideas of services to offer, get ideas for staffing and training them, see how your collections work, etc etc etc.

If you start solo, you will be learning basically everything trial-and-error. Sure, you will not be working "for the man," but you will probably be a pretty big putz and bumbling long hours to barely scrape by. Again, two ways to learn: your mistakes or someone else's... one's cheaper, one's quicker... and they're the same one. I wouldn't have started trading stocks or doing surgery or riding a motorcycle without learning with guidance and tips from exp ppl, so why do that with tackling running an office ON TOP OF trying to just take half decent care of patients coming out of training?

Unless your residency and/or personal background/interest is VERY strong, you will struggle mightily for awhile. Even if you get good at prac mgmt, you will still stuggle (I have multiple friends 5-15+yrs out of residency doing it right now with practices they started last year or this year). The only doc I saw do it pretty well was my very first boss, and he had moonlighted 2nd and 3rd year for the guy he bought out; even he admitted he that while he made money, he had worked a lot of 60-80+ hour weeks his first couple of years before I'd joined the office, though. Again, he sure wasn't asking for tips on a forum with a year until graduation. His situation was extremely unique with the moonlighting and knowing the office he bought very well (and getting sizable loan and line of credit pre-2007 crash). That is not the norm at all. IMO, it is well worth that bit of time to do an associate job and gain knowledge from a good practice for the vast majority of even entrepreneur-minded residency grads (and gain money, get on payers and hospitals if it's an area without non-compete, cases for ABFAS, etc). The choice is yours...

Related:

Buying into a practice

Hi, I am looking for any advice I can get on this topic. I will try to be short and to the point. I have been working at a private practice for 3.5 years now with an old pod that wasn't doing much surgery. He was basically chip and clip. Over the last 3.5 years, I have helped build up the...

forums.studentdoctor.net

 

[newpodgrad]

So I’m shadowing at another practice today.

Seems pretty busy.

Guy has been in practice close to 30 years. Has had associates on and off but no one at the moment.

Says he’s pretty content w solo. But one thing that’s quite alarming…he doesn’t take any tome off. No real vacations. Maybe a random Friday or Monday or something .
Says vacations are a waste because production stops and he’s rather just work.
This can’t be the private practice mentality?! I mean I’m not afraid to work long and hard, but I do want to enjoy my family at some point. Would love to take the kids to Disney or take a cruise or whatever.
What do you guys say on here? Is PP that grueling that basic life enjoyments get consumed with greed of always seeing patients?
I can’t really fathom that and if that’s truly the case I might need to look for something that can allow me to enjoy a little flexibility


Sincerely
Confused as hell pod

 

[Utvolsdpm]

So I’m shadowing at another practice today.

Seems pretty busy.

Guy has been in practice close to 30 years. Has had associates on and off but no one at the moment.

Says he’s pretty content w solo. But one thing that’s quite alarming…he doesn’t take any tome off. No real vacations. Maybe a random Friday or Monday or something .
Says vacations are a waste because production stops and he’s rather just work.
This can’t be the private practice mentality?! I mean I’m not afraid to work long and hard, but I do want to enjoy my family at some point. Would love to take the kids to Disney or take a cruise or whatever.
What do you guys say on here? Is PP that grueling that basic life enjoyments get consumed with greed of always seeing patients?
I can’t really fathom that and if that’s truly the case I might need to look for something that can allow me to enjoy a little flexibility


Sincerely
Confused as hell pod

That’s the one thing about PP that gets me. If you have your own solo practice when you take vacation time you’re not only not making money, you’re actually losing money because you have to pay all your overhead/staff, etc.

 

[air bud]

So I’m shadowing at another practice today.

Seems pretty busy.

Guy has been in practice close to 30 years. Has had associates on and off but no one at the moment.

Says he’s pretty content w solo. But one thing that’s quite alarming…he doesn’t take any tome off. No real vacations. Maybe a random Friday or Monday or something .
Says vacations are a waste because production stops and he’s rather just work.
This can’t be the private practice mentality?! I mean I’m not afraid to work long and hard, but I do want to enjoy my family at some point. Would love to take the kids to Disney or take a cruise or whatever.
What do you guys say on here? Is PP that grueling that basic life enjoyments get consumed with greed of always seeing patients?
I can’t really fathom that and if that’s truly the case I might need to look for something that can allow me to enjoy a little flexibility


Sincerely
Confused as hell pod

Yup. I have been in a couple msgs where I had paid time off 4 to 6 weeks. Always had that salary as a base but honestly I never bonused so I didn't really care at all and maxed out my time off. But yes if you're not in the office making money it's costing you money. This is part of the appeal of the VA is pure salary tons of time off enjoy life. Now that I am in private practice, it is 100% true and I don't take off as much time as I would like even though I could take as much as I want. And then when you are gone you're thinking about how you could be in the office seeing patients and making money. It is not a healthy mindset. At least where I am at, in theory I am not losing money because people just have to wait to see me since there isn't anybody else to see for a few hours. Whereas somebody in a larger City a new patient may just say screw it I'm going to go to the guy down the street and get on his schedule tomorrow and then that is completely lost to you.

 

[619]

Says he’s pretty content w solo. But one thing that’s quite alarming…he doesn’t take any tome off. No real vacations. Maybe a random Friday or Monday or something .

This is the absolute truth. And this situation is not unique to podiatry practice but the same for any solo business be it a restaurant owner, dentist, lawyer, accountant, even a lemonade stand. Taking a random Friday or Monday off (or both days) to go on a trip is what I did however when I returned, the rest of my schedule is packed for the week which I don't really like. It's just the nature of being solo. Not everything is roses.

Funny how I never noticed any significant drop in that month collections when I took Monday and Friday off. Taking a week or 2 weeks off then obviously that month collections will take a dip but should not be an issue the next month as schedule is back to normal. I am still recently new in solo practice but in years to come, will definitely be closing the office for a week or so to go on vacation and I am sure I will be fine. Only problem is a packed a schedule the following week upon return. It is humbling how most patients will wait for you to get back just to see you rather than see another doc, even new patients who heard great things about you (from family, friends or co-workers) will wait till you return from vacation.

 

[icebreaker32]

Definitely true. If no coverage from another podiatrist on staff you are friendly with or if you are not busy enough for an associate it will always be that way until you retire in PP.

 

[Feli]

... I am not losing money because people just have to wait to see me since there isn't anybody else to see for a few hours. Whereas somebody in a larger City a new patient may just say screw it I'm going to go to the guy down the street and get on his schedule tomorrow and then that is completely lost to you.

...It is humbling how most patients will wait for you to get back just to see you rather than see another doc, even new patients who heard great things about you (from family, friends or co-workers) will wait till you return from vacation.

For sure. It all depends how much competition is around and how strong your referral base is. In a metro, you can lose (or gain) years of work very fast by being available or unavailable. A lot of new patients will call to get an appointment, and if it's more than a couple weeks out, they just go down the list on Google. In the suburbs or rural, not so much. The trifecta of marketing and physician referrals and community/patient rep are all important.

The issue of being over/double/triple booked when you get back from vaca happens in any situation (PP/hospital/solo), so that's just something that you have to deal with as best you can. I try to help the schedulers know that the routine care can be moved but the new and post/pre ops have to be prioritized in that week I get back. It can also help to plan your vacations 2-3+ months out and add an hour per day of clinic the week you come back. It's lame.

That’s the one thing about PP that gets me. If you have your own solo practice when you take vacation time you’re not only not making money, you’re actually losing money because you have to pay all your overhead/staff, etc.

Yes, this is one of the biggest downsides to solo. Solo's a fine place to start, but unless real rural, goal should usually be finding associate/partner and making an efficient group asap. That's what I was saying in this kid's other thread on this: the $ inefficiency hemorrhage or workaholic tendency of solo practice is almost unavoidable in any medical specialty besides maybe something like FP or psych since their overhead is rock bottom.
In basically any specialty and urban/suburban setup, if you can create a group (or even find one good partner/associate), the office is still generating some money during owner vaca and staffing $$ doesn't go to waste (or worse, good staff leave if they can't get reliable hours).

icebreaker is right. The solo docs will take little vacation. The hospital employ (with no bonus) or associates who feel they can't hit bonus will take as much vaca as possible without getting fired. The main majority of DPMs who are hospital FTE with wRVU bonus or PP associate/partner with attainable bonus will usually take a medium amount of vaca. That's certainly what I do: have some fun, comfortable base... but I want to hit bonus most months too.

 

[DYK343]

Not at first but eventually youre gonna want a partner. As Feli said it keeps income going when youre not there. Also when you are gone its hard not to have someone to cover. Dtrack and I went back and forth with our opinions in another thread. So two sides of the coin there. But going true solo would be hard. Personally, I wouldnt do it. I would have to have a partner in private practice.

Ugh that first week back from vacation is BRUTAL

 

[dtrack22]

I went on vacation. My clinic schedule didn’t change. It just pushed some people out further than they otherwise would have. But if you have a scheduling template and stick to it there is no reason that you need to be extra busy.

I think a lot of us think we are more important or necessary than we really are. That matrixectomy doesn’t need to come back in 2 weeks exactly. The sutures can wait another week to come out. That new patient diabetic foot eval can wait a week or two to come in. The infected wound can go to the ED. If the physician in the ED feels they need to be admitted any other surgeon on call can manage it. The fracture can wait a week and let’s be honest, if you’re solo and in PP the ED isn’t sending you a lot of that any ways because it’s going to ortho.

It’s a mindset thing and PP will suck you in due to lost income (someone still answers phones while you’re gone usually), which makes sense. But you don’t HAVE to be busier as long as you have control over your schedule and do just a tiny bit of planning ahead. Go relax, have fun, live life, take some time off work. It’s going to cost you some money no matter what practice setting you’re in but your clinic schedule shouldn’t prevent you from taking vacation

eta: if you don’t believe me then I’d like to introduce you to my consulting practice, where for the low price of $10,000 I come to your office and show you exactly how to schedule around vacation and how to get out of the call you’re taking for free for the week. Without a partner or associate even! PM me for payment details.

 

[icebreaker32]

If you do not do any diabetic wound care or amputations your chance for an ER or Hospital consult are much, much lower, but not zero. A patient of yours can still go to the ER and be admitted when you are on vacation....Murphy's Law. Realistically even in this situation you still need coverage.

It only takes once and you might have something on your permanent record for patient abandonment. At one hospital the committees might be nice and give you a stern warning, but at another one they might not.

If you do lots of diabetic foot you definitely need to have a solid plan for coverage.

Someone on the internet might have great advice and ideas that work for them, but every situation and area is unique. From a patient care perspective you never get a vacation and need someone who covers for you. On the pros/cons list for solo PP, this is a con.

 

[Pronation]

If you do not do any diabetic wound care or amputations your chance for an ER or Hospital consult are much, much lower, but not zero. A patient of yours can still go to the ER and be admitted when you are on vacation....Murphy's Law. Realistically even in this situation you still need coverage.

It only takes once and you might have something on your permanent record for patient abandonment. At one hospital the committees might be nice and give you a stern warning, but at another one they might not.

If you do lots of diabetic foot you definitely need to have a solid plan for coverage.

Someone on the internet might have great advice and ideas that work for them, but every situation and area is unique. From a patient care perspective you never get a vacation and need someone who covers for you. On the pros/cons list for solo PP, this is a con.

Huh? I do tons of wounds and amputations. If the ER calls me I tell them that I’m not on call. Simple as that. If it’s a post op patient or a patient requests me, I let the ER/Hospitalist know that I can see them when I am next available but if urgent, call whoever is on call. Or if they call me and I’m out of town I let them know and also let them know I’m not on call.

 

[air bud]

Huh? I do tons of wounds and amputations. If the ER calls me I tell them that I’m not on call. Simple as that. If it’s a post op patient or a patient requests me, I let the ER/Hospitalist know that I can see them when I am next available but if urgent, call whoever is on call. Or if they call me and I’m out of town I let them know and also let them know I’m not on call.

agree. Each situation is different. Before I got here, they sent everything 3 hours away anyways. So they are used to it. Now I don't take official call most of the time, but I do encourage people to still call me and I will help guide treatment even if I can't actually see the patient. But that is not often so it is not a burden to me. If you had a running cenus of like 6 or 7 patients I would say yeah no way. But we are talking about maybe 4-6 inpatients a month for me.

 

[dtrack22]

A patient of yours can still go to the ER and be admitted when you are on vacation....Murphy's Law. Realistically even in this situation you still need coverage.

Post the section of your hospitals bylaws where it states you must be available for ED or inpatient consults on patients you have personally treated in the past, 24/7. I’ll wait.

It only takes once and you might have something on your permanent record for patient abandonment.

Nothing you posted meets the definition of patient abandonment.

How about this, who here has taken a new consult (while on call) for a diabetic foot infection on a patient that you had never seen before AND was being treated by another doctor in town? Everyone who has taken call would be raising there hand right now. So why wasn’t that other doctor forced to come in and see his/her patient?

Any patient who presents to the hospital has the chance that the doc who has treated them in the past isn’t available and they might get the “on call” doctor. If you aren’t the one on call then you have no legal or ethical obligation to come treat that patient. You are free to do so out of the kindness of your heart but you are also free to be on vacation. If the hospital doesn’t have anyone capable of treating the patient (and they do because they have 24/7 ortho and Gen surg coverage and don’t NEED you at all) then they can transfer the patient to a facility that does.

My consulting service is all inclusive and looks like it would still be worth it for a significant number of podiatrists around the country. I highly encourage you to reach out, we do offer payment plans. We throw in some cool freebies like Formula 3 and UV light shoe sanitizers that you can sell to patients. The consulting fee basically pays for itself.

 

[Weirdy]

My consulting service is all inclusive and looks like it would still be worth it for a significant number of podiatrists around the country. I highly encourage you to reach out, we do offer payment plans. We throw in some cool freebies like Formula 3 and UV light shoe sanitizers that you can sell to patients. The consulting fee basically pays for itself.

....you have any job openings?

 

[icebreaker32]

You are responsible for you own patients. The other stuff you can usually get out of without a problem for unassigned patients.

If they call you from the ER you do not necessarily need to see your own patient in the ER, but you must at least return their phone call. If you out of the country with no cellphone coverage and no coverage it can burn you.
If your own patient is in the hospital and another doctor refuses to see them for you, you can get in trouble.

I am not making this stuff up.

You usually only get in trouble when another doctor complains. There obviously has to be something in the bylaws you violated.

The specific situation I was involved with was a hospital where podiatry was not required to take ER call and podiatry did not agree to take ER call when asked.....needed a 100 percent vote to do this and not all agreed.

Which then led to a written bylaw, certified letter etc that you responsible for you own patients 24/7, 365 days a year but not unassigned patients. If you are not available you must have coverage.

 

[DYK343]

Youre not going to get charged with abandonment for going on vacation.

But murpheys law will enact itself right before you want to leave. That big case you just did with hardware will start showing signs of osteo or something catastrophic right before vacation. It will happen because thats when it happens.

On the flip side. How many times have we had the patient who states "But doctor im going to europe next week"
...No youre not. Sorry.
I feel like ive ruined so many peoples vacations lol

It would be a lot easier to just have a partner to cover call. And again. every situation is different. Mine not so great. I dont really have anyone to cover anything for me and I manage a lot of inpatients at any given time (Typically 3-5 in house any given time). Turning away ER consults for a week before vacation and the time on vacation would be my only way to not have inpatients when I leave. Thats a lot of lost revenue for a practice. It just makes sense to have a partner. Maybe not right away but eventually yes - especially if busy with ER/diabetic stuff (again everyone situation is different...)

 

[Feli]

Post the section of your hospitals bylaws where it states you must be available for ED or inpatient consults on patients you have personally treated in the past, 24/7. I’ll wait...

You never need to be available 24/7 (or even at all after you finish clinic), but nearly every private (non-gov) hospital I've ever signed up for asks for the name of at least 1-3 docs who can cover your inpatients, new consults, etc if you are not available. It is not penalty-of-death stuff, but you won't finish the apps and get on staff without it. I usually pick other DPMs in my group, but I've had to get creative and call former co-residents nearby, other area guys I knew, etc when I was the first DPM in a multi-specialty just to meet those reqs. As far as I know, they were probably never called since I just did the consults myself and didn't get many, but you will always need references, backup call, coverage, etc at the majority of facilities.

That is why I said in this kid's other thread that there is no true "solo practice"... nobody is completely on an island.

In any metro or suburbs setup, I've found that if you (or someone in your group) can't respond for consults, ER calls, and even your own PKTY post-ops or wounds from office... then you tend to lose a lot of them. Good/bad medicine or ok/bad ethics aside, let's get real: that f*cks with your money to lose patients and it really screws you to lose referral streams, esp for good payer sets. It helps to talk to the competing DPM groups, put a face to a name, and have a basic mutual respect to avoid "stealing" pts... but some ppl will say one thing and do another.

I sure don't like going to ER for my partner's pt with bandage too tight, having to figure out Rx refill or change on a weekend, or going in early/late to do a wound consult on the floor... but if it keeps the ER f/u fx pts sent to my office or keeps the PCP group happy and feeding me bunions and fasciitis, then it is obviously worth it. That is a hard part of solo to compete for that stuff (not as necessary in rural, but still helpful anywhere to optimize rep and referrals and $$$). That is why you almost always see young docs taking call/consults awhile to build their name and their pt base, and then established practitioners get by on name/rep (or send associate to do call/consults).

 

[icebreaker32]

I am not trying to scare anyone away from PP. The pros typically do outweigh the cons of being an associate unless there is a fair buy in to become a partner after a couple years.
Care for your patients when you are out of town is something to take into consideration.

 

[Jummy Biffett]

Care for your patients when you are out of town is something to take into consideration.

This is always something you need to take into consideration, no matter your situation (except maybe VA or hospital-based with multiple DPMs etc). Yes, it is easier to do if there are other pods in your group practice, but on the flip side of that you'll be expected to cover for them when they are out too. ER's and Urgent Cares exist for a reason, we are not so important that we can't enjoy some time off without the world ending.

 

[air bud]

That is why I said in this kid's other thread that there is no true "solo practice"... nobody is completely on an island.

Ahem

 

[HardRoadPaved]

The pros typically do outweigh the cons of being an associate unless there is a fair buy in to become a partner after a couple years.

nobody is completely on an island.

This opinion is being completely on an island. I would say jet through some past threads how bad associateship really is. Learn on their dime for a year or two and move on to your own shop.

 

[icebreaker32]

This opinion is being completely on an island. I would say jet through some past threads how bad associateship really is. Learn on their dime for a year or two and move on to your own shop.

Which to be honest is one of the major problems with podiatry. PP has its pros and cons, but is better than being an associate more often than not in podiatry. The trend in medicine is to be an employee and make your 200-400K with benefits. There will always be more upside potential in PP. Some experienced podiatrists chose this route for this reason. Most in podiatry chose PP not because of this, but be because being an associate is so bad. There are not enough good jobs for all.

Most end up doing well enough eventually to be grateful all things considered for the lifestyle podiatry provides. Does that mean all would do it again? No, but the same can be said for marriage and many other large decisions.

 

[PeaJay]

You never need to be available 24/7 (or even at all after you finish clinic), but nearly every private (non-gov) hospital I've ever signed up for asks for the name of at least 1-3 docs who can cover your inpatients, new consults, etc if you are not available. It is not penalty-of-death stuff, but you won't finish the apps and get on staff without it. I usually pick other DPMs in my group, but I've had to get creative and call former co-residents nearby, other area guys I knew, etc when I was the first DPM in a multi-specialty just to meet those reqs. As far as I know, they were probably never called since I just did the consults myself and didn't get many, but you will always need references, backup call, coverage, etc at the majority of facilities.

The first line is true in rural.

I am available to my patients during office hours. All calls received during office hours will be addressed that day. If my patient has an emergency that cannot wait till next office hours then they call a staffed nurse line and go to the ER/Urgent care. Unless you are paid to be on call by the hospital or are required to do it for free by some archaic feudal system you have no obligation to go in. The hospital has emergency room providers, general surgeons, and orthopedic surgeons who are paid to handle emergencies. Why should I go in for free? I will take over during business hours. That being said I offer to provide guidance by phone if the other paid specialists are at a loss.

Pain specialists, FP/IM/PT wound providers, and many others perform procedures, place implants, VACs, ect and feel no need to follow the emergent needs after hours following their procedures.Why should we?

 

[dtrack22]

Pain specialists, FP/IM/PT wound providers, and many others perform procedures, place implants, VACs, ect and feel no need to follow the emergent needs after hours following their procedures.Why should we?

Well yeah that’s because the on call surgeon is responsible, regardless of who the patient has seen in the past. Still waiting to see the actual bylaws requiring 24/7 coverage of any patient you’ve treated in the past who comes into the ED. Even general surgeons don’t do that. Doesn’t matter who the patient has seen before, the on call doctor takes over when admission/operative criteria have been met.

Could you imagine Gen surg or ortho calling some other doc and being like, “Hey bro, I know I’m on call but you saw this patient in clinic last week and I’m gonna need you to come in and take care of them…yeah, I know you’re in Belize but it’s YOUR personal patient…right, I’m getting paid to take call tonight but I’ve never seen this patient before…I know I treat patients I’ve never seen before all the time but…yeah hospital says it’s your patient therefore you need to not be in Belize right now…sorry bro. Thanks.”

I’m the only podiatrist with privileges at my hospital. Guess what? When a foot infection comes in and I’m not available any other surgeon who’s on call takes care of it and they’ll pass it off when I’m available/back in town. It literally makes zero difference wether or not I’ve ever treated the patient before. Hospital wants “back up” coverage? List “on call ortho” as your back up. They are getting paid every day to do exactly that. Leave it to Podiatrist to let hospital admin convince them that they need to be available 24/7, for free, while every other surgical specialty who does routine inpatient or emergent surgery gets paid to be on call.

 

[wakaflocka88]

The first line is true in rural.

I am available to my patients during office hours. All calls received during office hours will be addressed that day. If my patient has an emergency that cannot wait till next office hours then they call a staffed nurse line and go to the ER/Urgent care. Unless you are paid to be on call by the hospital or are required to do it for free by some archaic feudal system you have no obligation to go in. The hospital has emergency room providers, general surgeons, and orthopedic surgeons who are paid to handle emergencies. Why should I go in for free? I will take over during business hours. That being said I offer to provide guidance by phone if the other paid specialists are at a loss.

Pain specialists, FP/IM/PT wound providers, and many others perform procedures, place implants, VACs, ect and feel no need to follow the emergent needs after hours following their procedures.Why should we?

Example scenario: recently had a patient I saw in clinic with wet gangrene, clearly needs emergent OR. it’s 4pm and I send patient to ED for admission and OR. I don’t take call, but in this scenario, if I send patient there to get treated by the on call doc - am I cleared of any obligation?

 

[air bud]

Example scenario: recently had a patient I saw in clinic with wet gangrene, clearly needs emergent OR. it’s 4pm and I send patient to ED for admission and OR. I don’t take call, but in this scenario, if I send patient there to get treated by the on call doc - am I cleared of any obligation?

doesnt matter I want that cash. Level 5 office note, take to OR 28003, bill for progress note the next day, the next day to take to OR for repeat debridement rinse repeat.....

 

[Jummy Biffett]

Example scenario: recently had a patient I saw in clinic with wet gangrene, clearly needs emergent OR. it’s 4pm and I send patient to ED for admission and OR. I don’t take call, but in this scenario, if I send patient there to get treated by the on call doc - am I cleared of any obligation?

I don't think you'd be legally responsible for their care in that situation, but it could be viewed as unprofessional if you have surgical privileges at said hospital and choose to dump that onto the on-call.

Regarding the bylaws, I just looked up my hospital's out of curiosity and this is what it says:
"Any person presenting at the Emergency Department who has not been referred by or is not the patient of a specific Professional Staff Member, and who does not express a desire for the medical services of a particular member, shall be assigned to the hospitalist service or the appropriate Physician on call for Unassigned Patients." Seems like a bit of a gray area?

 

[DYK343]

I don't think you'd be legally responsible for their care in that situation, but it could be viewed as unprofessional if you have surgical privileges at said hospital and choose to dump that onto the on-call.

Regarding the bylaws, I just looked up my hospital's out of curiosity and this is what it says:
"Any person presenting at the Emergency Department who has not been referred by or is not the patient of a specific Professional Staff Member, and who does not express a desire for the medical services of a particular member, shall be assigned to the hospitalist service or the appropriate Physician on call for Unassigned Patients." Seems like a bit of a gray area?

I think we should all just agree that this whole thing is a gray area. No right or wrong. Multifactorial and case by case and provider/provider in how its handled in their particular situation.

 

[PeaJay]

Example scenario: recently had a patient I saw in clinic with wet gangrene, clearly needs emergent OR. it’s 4pm and I send patient to ED for admission and OR. I don’t take call, but in this scenario, if I send patient there to get treated by the on call doc - am I cleared of any obligation?

I would believe you to be legally clear in this situation. The situation was assessed, it was determined that the patient needed higher levels of care and the patient was referred. You attempted to call ambulance for transport, which as denied by the patient after consul of associated risks.

The hospital/on call provider may be upset, however at the end of the day the person on call has the responsibility to treat the emergent concern. Further cares would be deferred to established provider.

Edit- You cannot and should not be forever responsible for every train wreck that walks in the door of your office. They wandered into your door randomly and you should not be responsible for 24/7 care due to them finding you (unless you want to offer that service).

Post-op concerns should be few if there has been proper patient/procedure selection. Education and prophylactic management of possible concerns should be addressed. If properly done peri-operate care should be rather smooth and only rarely will require ER referral. If you recommend surgery to every breathing individual ill regard of medical comorbidity and social constructs then you best be available to go in the cover your back end, otherwise the ER can handle it (people wonder why they fail boards, it not your skills, it’s your ability to select that is often flawed).

There are exceptions like complex cases/procedures that need better triage. In this cases you need to either have a pod on call or take care of it yourself. This should not be the rule though.

 

[icebreaker32]

Since podiatry did not form a call group at the ER we had to return their calls 24/7, 365 for our own patients. It is not than many calls. It could be no calls for 3 weeks then 1 during the next week and 2 on the weekend etc.

If ER calls and says your patient has osteo of the toe and needs to be admitted. I guess you could say I am on vacation and Dr. X at another hospital 25 miles away is covering for me transfer there or admit to or consult someone else. If we say we have no one take call or don't return the call at all because we are somewhere with no cell coverage we will get in trouble. For an unassigned patient we have no obligation from the ER.

I think podiatry as a specialty has underestimated this requirement as we have so many solo physicians and many rarely go the hospital.

The culture of your medical community and your bylaws may vary.

The botton line is when you are out of town you should technically have someone in the area who covers for you. Some may not do this and never have a problem. Almost every application for hospital and insurance plans ask this. It is one of the cons to solo PP in my opinion.

 

[HardRoadPaved]

we have so many solo physicians and many rarely go the hospital.

I'm glad not to go. Let someone else be up at 2am dealing with pus foot. None of the hospitals around me care about podiatry. If they did they would pay for call. I am not sitting around for free waiting for an uninsured/poorly insured trainwreck diabetic. Let the associate in some conglomerate PP go in for that call out of residency not knowing their boss is making money off them.

the next day to take to OR for repeat debridement rinse repeat.....

For sake of argument. That 28003 now with no global is $275 and this is more rare since you need to I&D multiple areas compared to a 28002 which is a more common I&D ($150). I'll stick around the office for an ingrown or pretty much any pathology than go back the next day for a "debridement" aka 11043 ($160).

Reimbursement, clipboard nurses, endless paperwork kills the hospital joy for me. Thus I adapted my practice and lifestyle. Good riddance.

 

[air bud]

I'm glad not to go. Let someone else be up at 2am dealing with pus foot. None of the hospitals around me care about podiatry. If they did they would pay for call. I am not sitting around for free waiting for an uninsured/poorly insured trainwreck diabetic. Let the associate in some conglomerate PP go in for that call out of residency not knowing their boss is making money off them.

For sake of argument. That 28003 now with no global is $275 and this is more rare since you need to I&D multiple areas compared to a 28002 which is a more common I&D ($150). I'll stick around the office for an ingrown or pretty much any pathology than go back the next day for a "debridement" aka 11043 ($160).

Reimbursement, clipboard nurses, endless paperwork kills the hospital joy for me. Thus I adapted my practice and lifestyle. Good riddance.

true, i forget about decreased reimbursement....and it is literally 28003 everytime review your anatomy not hard to find "mulitiple" compartments...but yes I think one day I will rebrand myself as the ingrown nail king. billboards across the city.
Also many of my 28003s pay 2.5x medicare thanks to some contracts...YMMV

 

[icebreaker32]

I agree hospital podiatry is rarely worth it for the uninsured, underinsured, noncompliants patients for solo PP. Wound care can sometimes be very profitable, but that in turn leads to more inpatient work.

Unless you have a partner or are truly rural with different expectations, the diabetic foot can be a challege as a solo physician in PP. There are definitely easier ways to make money. With some of those easier ways you might be at increased risk of audit/payback or stark violations. Podiatry is not unique in this regard, but I think solo PP tends to have a higher risk tolerance.

Every op report for general surgery for a wound I have ever seen wether a foot or but is wound debridement to wound level of bone to up their fee or wRVU. They don't even take bone cultures most times. Their op reports are also much shorter than podiatry most times.

 

[HardRoadPaved]

Also many of my 28003s pay 2.5x medicare thanks to some contracts...YMMV

I think its that with the global change most payer contracts havent been updated so they are paying you the original value of what the case was worth. I'm sure they'll find some sucker to take the lower reimbursement if you drop them.

rebrand myself as the ingrown nail king.

Worked for that chiropodist in Canada that hacks people up on TV called Toe Bro or that JAWS guy from FL all over Youtube.

I think solo PP tends to have a higher risk tolerance.

100%. If you want to feel 'safe' then you work for someone and let them take the liability. However dont complain when you see your paycheck and come on SDN to rant.

I love the autonomy as a solo provider and wouldnt trade it away to be harassed by a CEO or clipboard nurse (or worse a PP DPM owner)

 

[PeaJay]

I like how the term clipboard nurse has caught on.

 

[josebiwasabi]

SDNs contributions to the podiatric lexicon:

Clipboard nurse
Mustache pod

Any others?

 

[SouthPod7]

SDNs contributions to the podiatric lexicon:

Clipboard nurse
Mustache pod

Any others?

Nail jail

 

[Pronation]

Well yeah that’s because the on call surgeon is responsible, regardless of who the patient has seen in the past. Still waiting to see the actual bylaws requiring 24/7 coverage of any patient you’ve treated in the past who comes into the ED. Even general surgeons don’t do that. Doesn’t matter who the patient has seen before, the on call doctor takes over when admission/operative criteria have been met.

Could you imagine Gen surg or ortho calling some other doc and being like, “Hey bro, I know I’m on call but you saw this patient in clinic last week and I’m gonna need you to come in and take care of them…yeah, I know you’re in Belize but it’s YOUR personal patient…right, I’m getting paid to take call tonight but I’ve never seen this patient before…I know I treat patients I’ve never seen before all the time but…yeah hospital says it’s your patient therefore you need to not be in Belize right now…sorry bro. Thanks.”

I’m the only podiatrist with privileges at my hospital. Guess what? When a foot infection comes in and I’m not available any other surgeon who’s on call takes care of it and they’ll pass it off when I’m available/back in town. It literally makes zero difference wether or not I’ve ever treated the patient before. Hospital wants “back up” coverage? List “on call ortho” as your back up. They are getting paid every day to do exactly that. Leave it to Podiatrist to let hospital admin convince them that they need to be available 24/7, for free, while every other surgical specialty who does routine inpatient or emergent surgery gets paid to be on call.

I live in an area where I have multiple options for taking cases that are more appropriate for the hospital than the ASC. It's funny that you mention the above because I did go to a hospital where I applied for OR privileges and they demanded that I either take 24/7 "attached" call on my own patients or have another pod available at all times as a backup for these patients. I asked them how much they would pay me to take THEIR call. Answer: big fat zero. Told them to go pound sand and took my cases elsewhere.

 

[Jummy Biffett]

I live in an area where I have multiple options for taking cases that are more appropriate for the hospital than the ASC. It's funny that you mention the above because I did go to a hospital where I applied for OR privileges and they demanded that I either take 24/7 "attached" call on my own patients or have another pod available at all times as a backup for these patients. I asked them how much they would pay me to take THEIR call. Answer: big fat zero. Told them to go pound sand and took my cases elsewhere.

Seems to be yet another example of pods getting taken advantage of by hospitals. Seems like the preferred route is forgo the hospitals and just operate at surgery centers if you don't plan on having a busy inpatient/consult practice?

 

[DYK343]

Seems to be yet another example of pods getting taken advantage of by hospitals. Seems like the preferred route is forgo the hospitals and just operate at surgery centers if you don't plan on having a busy inpatient/consult practice?

In my practice about 60-70% of cases can be done at a surgery center. The rest need hospital due to cost, complexity, or overnight stay.

 

[Steveington]

I'm surprised as I read how some of these hospitals are treating their community podiatrists. Hospitals make a lot of money from surgery and if you are doing surgery on a consistent basis, they'd love to have you. If they are demanding some unreasonable call, it might take a little talking to someone who is looking at the financials, such as the CEO, CFO or even the OR manager, instead of the credentialing person, to get things fixed. Hopefully they can see that you bring more benefit to them than the other way around.

I also think that we should be reimbursed for call. All the other specialties are paid for their time, we should be as well. Originally I wasn't being paid for being on call. I talked to the CEO of the hospital about it, he considered it and he said "they couldn't justify doing it at this time." I graciously thanked him for his time, reminded him of my support of the hospital over the years and my surgeries and gave him a date in the future when I'd be removing myself from the call schedule. This would give them time to find any needed coverage or replacement. Good news, only a couple weeks later, I had a signed agreement to be paid for my time on call. Now I wasn't being paid as much as ortho or general surgery, but I wasn't expecting that, nor was I getting called in as frequently either.

 

[air bud]

I'm surprised as I read how some of these hospitals are treating their community podiatrists. Hospitals make a lot of money from surgery and if you are doing surgery on a consistent basis, they'd love to have you. If they are demanding some unreasonable call, it might take a little talking to someone who is looking at the financials, such as the CEO, CFO or even the OR manager, instead of the credentialing person, to get things fixed. Hopefully they can see that you bring more benefit to them than the other way around.

I also think that we should be reimbursed for call. All the other specialties are paid for their time, we should be as well. Originally I wasn't being paid for being on call. I talked to the CEO of the hospital about it, he considered it and he said "they couldn't justify doing it at this time." I graciously thanked him for his time, reminded him of my support of the hospital over the years and my surgeries and gave him a date in the future when I'd be removing myself from the call schedule. This would give them time to find any needed coverage or replacement. Good news, only a couple weeks later, I had a signed agreement to be paid for my time on call. Now I wasn't being paid as much as ortho or general surgery, but I wasn't expecting that, nor was I getting called in as frequently either.

Agree 💯 with all of this. And congrats on putting your foot down and standing up

 

[newpodgrad]

With so much variation in podiatry across the county, differences in ER call, differences in surgery vs non surgery, differences in abfas vs ABPM , the fact that we’re ALL still DPM’s, in my opinion this leads to a lot of confusion amongst the public, ERs hospitals etc. What do u guys think the future of solo practice is? I hear different things. A recent article from top practices indicated that the “golden age “ of solo practice is coming due to big hospitals and groups being booked out months and months in advance. But others say that more practitioners will be tempted to form super groups etc. But again with differences in training skills etc, it just seems like a mess. Let’s get a good discussion going on this. Always great to hear feedback and others thoughts

 

[Jummy Biffett]

There certainly seems to be a trend of corporate 'super groups' buying up small private practices unfortunately. I agree, it does give you an advantage if you can be more available for patients than big groups/hospitals...however, I fear that insurance contracts will continue to become less and less friendly for solo/small group practices under this trend. So you may need to be super high volume to make it work. Hope I'm wrong.