Running a solo subspecialty practice

[wamcp]

Anyone have pointers for a “definitive guide” to running a solo outpatient practice (not procedural, it’s not onc/pulm/gi/cards)?

My spouse is very interested in leaving her employed job and striking out for freedom by either taking over a retiring doc’s practice or starting her own…we don’t know where to start thinking about the day to day operations of this stuff

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[bochaw]

i think providing the name of the specialty will get you more responses

 

[wamcp]

Update, we met with a solo practice doc. Doesn’t use EMR, runs super lean on costs. Doesn’t use midlevels.
Overhead 43% instead of the median at 65%!

Takes in 800K for income, although is working 40 hour week instead of the traditional 32 hours.
So if you normalize it, would be taking less than 640K if this doc chose to do 32 hour work week (as overhead will likely increase in percent).

Compare to my wife current hospital system employee position, she is taking in 340K for 32 hour weeks.

Seems like if you are business savvy and the right location, solo practice in her subspecialty is super worth it. For the $$$.

However of course, inherent to all solo practice in general, you will be on call 24/7 and difficult to find vacation time during the year

 

[chessknt]

Update, we met with a solo practice doc. Doesn’t use EMR, runs super lean on costs. Doesn’t use midlevels.
Overhead 43% instead of the median at 65%!

Takes in 800K for income, although is working 40 hour week instead of the traditional 32 hours.
So if you normalize it, would be taking less than 640K if this doc chose to do 32 hour work week (as overhead will likely increase in percent).

Compare to my wife current hospital system employee position, she is taking in 340K for 32 hour weeks.

Seems like if you are business savvy and the right location, solo practice in her subspecialty is super worth it. For the $$$.

However of course, inherent to all solo practice in general, you will be on call 24/7 and difficult to find vacation time during the year

How much of that is ancillary income instead of straight E/M billing? Any of that from an infusion center and vulnerable to the new CMS changes? Same subspec as you? Not using an EHR confers a compensation penalty to all CMS fees, is this physician not seeing medicare patients (or only a small fraction of medicare patients)?

 

[IM2GI]

Not using an EMR in 2022 seems ridiculous. Not sure Id be modeling myself after this person.

 

[bronx43]

Update, we met with a solo practice doc. Doesn’t use EMR, runs super lean on costs. Doesn’t use midlevels.
Overhead 43% instead of the median at 65%!

Takes in 800K for income, although is working 40 hour week instead of the traditional 32 hours.
So if you normalize it, would be taking less than 640K if this doc chose to do 32 hour work week (as overhead will likely increase in percent).

Compare to my wife current hospital system employee position, she is taking in 340K for 32 hour weeks.

Seems like if you are business savvy and the right location, solo practice in her subspecialty is super worth it. For the $$$.

However of course, inherent to all solo practice in general, you will be on call 24/7 and difficult to find vacation time during the year

What specialty? These numbers are hard to interpret without knowing this.

 

[wamcp]

What specialty? These numbers are hard to interpret without knowing this.

How much of that is ancillary income instead of straight E/M billing? Any of that from an infusion center and vulnerable to the new CMS changes? Same subspec as you? Not using an EHR confers a compensation penalty to all CMS fees, is this physician not seeing medicare patients (or only a small fraction of medicare patients)?

Allergist. Big shot volume and built up steady referral base with plenty of news daily

 

[chessknt]

Allergist. Big shot volume and built up steady referral base with plenty of news daily

Well that is the thing then--ancillary income from shots + mostly private patients with insurance. It is difficult to understate how crucial payor mix is in reimbursement and that is highly specialty dependent. It means you can do 1/2-1/3 the amount of work for the same pay as someone who is getting reimbursed by CMS. Allergists are almost the exact opposite of geriatrics in their patient makeup, very little government insurance.

 

[sloh]

Allergist. Big shot volume and built up steady referral base with plenty of news daily

When you say big shot volume, how many patients per day? How many patients per week?

 

[wamcp]

Well that is the thing then--ancillary income from shots + mostly private patients with insurance. It is difficult to understate how crucial payor mix is in reimbursement and that is highly specialty dependent. It means you can do 1/2-1/3 the amount of work for the same pay as someone who is getting reimbursed by CMS. Allergists are almost the exact opposite of geriatrics in their patient makeup, very little government insurance.

Real-World Assessment of Asthma Specialist Visits Among U.S. Patients with Severe Asthma - PubMed

Specialist care was observed in fewer than half of U.S. patients with severe asthma and was least frequent among older adult patients and those with more nonrespiratory comorbidities. Increased specialist involvement in managing severe asthma may help improve care and patient outcomes.

pubmed.ncbi.nlm.nih.gov

Allergist visits for asthma:
Median patient age is 36
Percent medicaid/medicare: 8.7%

Pulmonologist visits for asthma:
Median patient age is 49
Percent medicaid/medicare: 14.6%

That’s a stark contrast.
I am sure the gap in payor mix is even more in favor of allergy over pulmonary when all visit types are considered instead of just asthma as the visit type.

 

[collegestud2013]

Update, we met with a solo practice doc. Doesn’t use EMR, runs super lean on costs. Doesn’t use midlevels.
Overhead 43% instead of the median at 65%!

Takes in 800K for income, although is working 40 hour week instead of the traditional 32 hours.
So if you normalize it, would be taking less than 640K if this doc chose to do 32 hour work week (as overhead will likely increase in percent).

Compare to my wife current hospital system employee position, she is taking in 340K for 32 hour weeks.

Seems like if you are business savvy and the right location, solo practice in her subspecialty is super worth it. For the $$$.

However of course, inherent to all solo practice in general, you will be on call 24/7 and difficult to find vacation time during the year

How is he/she making $800k in a non-procedural specialty? I doubt it's with only E&M alone (even if this practice had 100% private insurance patients, to make $800k from just E&M would require seeing an immense volume that can't be reasonably accomplished in 40 hrs per week); there must be ancillary services with good profit margin.

Also I doubt this person only works 40 hrs per week total. That might just be the clinical time per week, but running a solo practice requires a SIGNIFICANT amount of administrative/business work on top of that. And scaling down to 32 hrs per week would like result in much less than $640k since running a solo practice has fixed costs that don't really change with the volume of patients you see. And as a new practice you're not going to net anywhere near that much until you build up your patient base which can take a few years (and she is a currently a hospital system employee in a mostly outpatient specialty, she likely has a non-compete in her contract to make it much harder to just take her patients with her).

Any if you are solo, you're technically on call 24/7 for your patients, will be very difficult to find coverage for emergencies/sickness/vacations, and your overhead costs will run high.

Running super lean on costs can be hard to do without also slowing yourself down (eg not having EMR or hiring minimal support staff would just mean more work falls onto yourself).

Probably much more cost efficient to partner up and start a practice with at least 2-3 physicians. That way costs and resources can be easily shared, as well as coverage for time off.

 

[HemeOncHopeful19]

Not using an EMR in 2022 seems ridiculous. Not sure Id be modeling myself after this person.

I agree it’s unusual but I respect any doc that wants to fight back and stay on paper. I don’t think we should be forced to switch by financial penalties, instead the EMR should make us more efficient to the point that it’s a no-brainer to switch.

It wouldn’t shock me at all to find out this is not true for smaller practices.

 

[NewYorkDoctors]

I agree it’s unusual but I respect any doc that wants to fight back and stay on paper. I don’t think we should be forced to switch by financial penalties, instead the EMR should make us more efficient to the point that it’s a no-brainer to switch.

It wouldn’t shock me at all to find out this is not true for smaller practices.

Meh EMR makes life so much easier with the copy forward ability and the ability to “normal “ all ROs and Physical exam findings . Of course one should unclick what was not asked and not done and update the assessment and plan . But with all the minute details of the HPI and patient care required , I can’t possibly remember all the details without copy forward

If anything the EMR helps me document carefully so I can CYA very clearly and carefully with time stamps

Sure beats some chicken scratched PEERLA EOMI ATNC NAD CTAB NO RRW S1S2 RRRNOMRG SOFT NTNDBS+ No c/c/e
C/w all meds . Refer to specialty

Plus how do you share notes with other doctors ? Unless you’re one of those who refers out with NOTHING to give the specialist to work with and hope the specialist just “figures it out .” Lol. Too many of those dinosaurs still roaming around . The Yucatán asteroid is coming for your generation

 

[dozitgetchahi]

Meh EMR makes life so much easier with the copy forward ability and the ability to “normal “ all ROs and Physical exam findings . Of course one should unclick what was not asked and not done and update the assessment and plan . But with all the minute details of the HPI and patient care required , I can’t possibly remember all the details without copy forward

If anything the EMR helps me document carefully so I can CYA very clearly and carefully with time stamps

Sure beats some chicken scratched PEERLA EOMI ATNC NAD CTAB NO RRW S1S2 RRRNOMRG SOFT NTNDBS+ No c/c/e
C/w all meds . Refer to specialty

Plus how do you share notes with other doctors ? Unless you’re one of those who refers out with NOTHING to give the specialist to work with and hope the specialist just “figures it out .” Lol. Too many of those dinosaurs still roaming around . The Yucatán asteroid is coming for your generation

Totally agree. I for one never understood the “paper notes are so much easier and better” argument. For one, most paper notes I’ve seen are complete garbage in terms of detail and portability. Parsing indecipherable handwritten notes is a big waste of time for everyone else involved in patient care. All this is not to say that EMRs can’t be made better, but paper charts really suck in a lot of ways and I’m happy to finally see them go the way of the dodo bird.

 

[NewYorkDoctors]

I wonder how I would react to holographic computers in the future... I would like to think I would adapt to the new technology since it all builds off of the same kind of computer user interface. But I would probably go senile in my older age and yell at the clouds and say "in my day we used touchscreen tablets!"

 

[HemeOncHopeful19]

I wonder how I would react to holographic computers in the future... I would like to think I would adapt to the new technology since it all builds off of the same kind of computer user interface. But I would probably go senile in my older age and yell at the clouds and say "in my day we used touchscreen tablets!"

I always like to think I am great with technology until I have to use a fax machine at work and for some reason “this is how my parents feel when they try to use a computer.”

 

[Sushirolls]

Read my thread, it will be quite informative. There is even a post buried in there with a check list of play by play practice formation.

Luminello, an EMR geared more towards psych, might even be applicable for allergy specialty, too.

Some of the comments on here from people not doing their own solo private practice, should be taken with Salt Lick size 'grain of salt'

There is nothing wrong with using paper charts, and there are ways to be efficient in work flow/charting, billing, and communicating with other specialists, too. Paper in small lean practices isn't an enemy. There can even be hybrids of paper notes that can scanned to a hard drive, so ultimately there are no paper records. No long term storage issues. So many options

 

[NewYorkDoctors]

I always like to think I am great with technology until I have to use a fax machine at work and for some reason “this is how my parents feel when they try to use a computer.”

I use Doximity efax and also EFAX.com
Works like email.

My handwriting is terrible so I would not use paper records for that reason alone. Moreover, I can type accurately up to 180WPM without typographical errors. Therefore, it is far more efficient for me to type things out. But other individuals can handwrite more neatly and cannot type as quickly. Those individuals should use paper charts as they see fit.

 

[dgdg]

My wife and I have had a solo primary care practice since we left residency.
The negatives are lower commercial reimbursement rates, unless you are part of an Independent Practice Association (IPA) in your area. Not sure if they do that for specialists or just primary care. IPA gives better contracted rate, but will involve data mining and using an EHR/PMS. We stayed independent for the quality of life and flexibility being our own bosses (to an extent LOL). So many threads I see people seeking the highest income, but balance that with how happy you are. The two aren't always the same.
Definitely get a cheap EHR, PMS, and decent billing clearing house contract. If you are planning on the income stated above, it's foolish to do paper charts instead of an EHR. You save a little money for big headaches. Paper charts are fine if you are a 70 yo PCP and just wanting to work a little longer.
If you do your own billing, you'll save ~7% off the top right there. It's not hard to learn.
You have to really want it, its certainly doable, but you're going to be wearing all the hats (HIPPA, OSHA, IT, Billing, Inventory & Purchasing, Payroll, HR), and training all your staff. Billing is something you have to be very involved with, sending claims, reviewing rejections, and billing the balances after insurance payments. You can't leave that to 'a biller' that is your employee and assume it will work well. Either you will have a lot of unpaid claims or, worse. If you have any physical servers in house, then you are also IT, so probably recommend using a cloud based service.