Private practice management issues

[imFellow]

I want to check with the SDN brain trust on issues I am seeing at a private practice where I am employed. First year out of fellowship employed in a large (10+) private practice. The group was private practice with their own infusion before but now it is mostly PSA with a large health system. Clinic attached to hospital. Overhead is very small. I am employed with a salary first year and will be fully production driven 2nd year onwards.

1. The partners who are working for 15+ years have very few slots for new patients. So most new patient slots come to me and I havent been able to build meaningful RVU's for last 6 months. Looks like the practice is hiring new physicians to handle new patients and I dont think this is sustainable long term. Are new patients divided equally in other practices. Can somebody give some examples on how different practices handle this?

2. Each physician is provided a mid-level and the patient load between mid-level's are not equal. Some mid levels are overworked whereas others have light schedules. How do other practices ensure midlevel are utilized efficiently?

3. How do practices handle when a physician is not full-time. Is there an expected baseline on patient encounters per week. We have quite a few physicians (5+) who are full time in name only and also don't have any administrative tasks. Are common practice expenses (payroll taxes, malpractice, benefits, overhead) still equally divided? I understand they are all production driven but should a practice set minimum production levels.

Thoughts?

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[Mehena]

I don't have meaningful input to provide here but if you fail to find satisfying answer here, please consider posting at WCI (practice management) subforum, they seem to have people well versed in private practice management, structure minutiae etc. Good luck

 

[HemeOncHopeful19]

Are you taking all the new patients to build up your practice? In a year or two will you be full of follow-ups after churning through all these new people?

 

[Scope guy]

it is common practice for new partners to take bulk of the new patients and thats how you are going to build your panel. I am not sure why you are complaining about it. after 1-2 years, you ll have less space for new and half your schedule will be follow ups. Plus new ones pay more than follow ups, so perfect in ur first year

 

[gutonc]

it is common practice for new partners to take bulk of the new patients and thats how you are going to build your panel. I am not sure why you are complaining about it. after 1-2 years, you ll have less space for new and half your schedule will be follow ups. Plus new ones pay more than follow ups, so perfect in ur first year

Yes...but.

I can see 4 level 5 follow ups in an hour and make 8.4 wRVU from it. In an hour I can see 1-2 new patients which pays max of 6.34 wRVUs. So it's actually a disadvantage on that end to fill up your schedule with new patients.

That said, a new grad isn't usually seeing more than 2-3 patients of any kind an hour so it all more or less shakes out until you get your feet under you.

 

[gutonc]

I want to check with the SDN brain trust on issues I am seeing at a private practice where I am employed. First year out of fellowship employed in a large (10+) private practice. The group was private practice with their own infusion before but now it is mostly PSA with a large health system. Clinic attached to hospital. Overhead is very small. I am employed with a salary first year and will be fully production driven 2nd year onwards.

I will preface everything I say below by noting that I am hospital employed and in administration. I direct a 14 physician academ-ish community oncology group that is owned by the local AMC but operates on community hospital campuses, in partnership with those hospitals (actual profit/loss sharing agreement). I also manage 2 small groups (one in a different state, otherwise they would be part of the primary group, and one rural group at a Critical Access Hospital) who are under PSAs. So my advice may not be directly relevant to your situation, but I still think it might be valuable.

1. The partners who are working for 15+ years have very few slots for new patients. So most new patient slots come to me and I havent been able to build meaningful RVU's for last 6 months. Looks like the practice is hiring new physicians to handle new patients and I dont think this is sustainable long term. Are new patients divided equally in other practices. Can somebody give some examples on how different practices handle this?

This is how medicine works. As the new guy, your schedule is probably pretty empty, and the "old guys" are full up with follow ups so probably only have 1-2 slots a day for new patients. Our group divides new patients by whoever has room on their schedule, except if they were specifically referred to one of us. If you're new, the referring docs don't know who you are yet, so you're probably getting a lot of the anemias, Stage 1 ER+ breast and anticoag consults...at least, that's how my practice started. As I got my face seen and my interests known, and as I worked well with referring docs, I started to get more "good" referrals and the seeds and stems went to the next guy hired, and so on, and so on.... That's how community/PP practices work in general.

2. Each physician is provided a mid-level and the patient load between mid-level's are not equal. Some mid levels are overworked whereas others have light schedules. How do other practices ensure midlevel are utilized efficiently?

Mostly pretty poorly. And I include myself and my group in this. There are a number of models for this including:
1. Fully shared visits, where the NP/PA does all the work and the MD/DO goes in, gives a high-five, co-signs the note and then bills. I do this for new patients who are likely to get chemo so the patient gets to meet the NP/PA early on and won't be surprised if they see them for on-treatment visits or "urgent care" stuff. CMS is f***ing with how they pay for this right now so I'm not sure how this model will change over time.
2. Survivorship/long-term follow up. Basically, early stage breast cancer. These patients can be emotionally exhausting and demanding so this model is fraught with problems unless the person doing it is good at managing anxiety.
3. Same day and on-treatment visits.
4. All of the above (which is how we do it, with varying levels of success).

If you have your own NP/PA, and the folks in the group who have been there for 10-30 years have theirs as well, yours is likely to be less busy than the rest. There's also the question of how the billing and payment works, both for you and for them. If you're not doing shared visits that you can bill, or the NP/PAs aren't there to allow you to maximize your own productivity, you'll be less likely to utilize them. If you're turfing all the 99213s to them so you can see the 99215s, then you're going to do that.

3. How do practices handle when a physician is not full-time. Is there an expected baseline on patient encounters per week. We have quite a few physicians (5+) who are full time in name only and also don't have any administrative tasks. Are common practice expenses (payroll taxes, malpractice, benefits, overhead) still equally divided? I understand they are all production driven but should a practice set minimum production levels.

I can only answer this from an employed model so this is probably not useful to you. The short answer is that, in a production driven system, expenses should be "equally" shared and income should be individualized. It costs the same to keep the lights on and the nurses in the infusion room whether Dr. Smith is working or golfing. So if Dr. Smith is "full time" but chooses to only see patients 2.5 days a week, Dr. Smith should pay the same as everyone else working FT and take his income based on actual productivity. If, OTOH, Dr. Smith has negotiated a PT position with the group, expenses should be adjusted accordingly.

In an employed model, benefits (health insurance, vacation time, retirement match, CME reimbursement) are typically normalized to FTE but the rest of the overhead is "equally shared" (AKA...covered by the employer).