Is the private podiatry office on the path to extinction? 

Flipping the pages of the October 2016 APMA News magazine, I pause in the Classified Adverts section. I count 60 Podiatry offices for sale. The advertising blurb sounds great, for all of them. It's such a good business, why is it for sale? Not always so easy to decipher.

In contrast there are 22 positions advertised, for the existing business. Roughly, then, for every post advertised, three Podiatrists are looking for an 'out'.

I have no idea what, if anything this 3:1 ratio means. I balance this information with the many posts, published on forums such as PMNews - from the disenfranchised, frustrated, burn-out, over-managed, and those suffocated by the burden of bureaucracy, rules, demands, under paid. I balance this information with the paucity of messages from doctors happy with their working lives & conditions.

I want to believe there are many happy, content doctors working in our communities - only we don't hear from those so much. Or are there ..... 

Addendum: it is not the purpose of this blog item to cast doom & gloom on our noble profession (it was pointed out to me, by a friend, some might think so). On the contrary, I believe this is a great profession. We are working in a difficult and challenging health care climate. This is true here (US) as much as elsewhere (UK). 

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  •  Hi everyone.

     

       I  have  built two private practices from the ground up Three podiatry related busineses. .  Here are  a few pieces of advice

      1. Meet  500 new patients each year.   Get out there.  and meet people in your community  be the smart ,, nice guy

      2. Dont be afraid to  ask patients for referrals. 

      3  Build yourself a niche.   ie  ESWT... Diabetic Foot Care.  Fungus Toe Nails  Anyone heard about the newest Clearanail  Smart Drill ?  Works and its cash

      4. Treatment of pain with Laser.  One of the best  treatmetns for  inflamatory conidtions. Achilles tendonitis.  etc

      5 Stop complaining and start working. If you dont  believe in your self  patients wont believe in  you 

       6.  I do believe that you should  joint  organiztation but that not how you will really  master podiatry and  make money 

    Find practices that are successful. you define success ? . Go visit  and  listen and learn and watch. Nothing like seeing success live. cant get that in a lecture

     

     This is my start shall I continue??/    David

  • Thank you Brandon for all your
    positive ideas.
  • www.aappm.org

    www.PodiatricExcellence.org is for IPED 


    Both have scheduled conferences over the winter.  Both are groups dedicated to helping practitioners of all ages and situations. They're unique in the world of medicine.  At the very least, get on their mailing lists

  • Don't let that scare you off.  There are challenges to be sure, some of them quite difficult and annoying (I should add infuriating and frustrating). The whole MIPS/MACRA thing has little to do with truly improving quality of care or much else other than to add regulatory burden.  BUT...since a lot of people will decide not to work at it and since the law states that the program is to be 'revenue neutral', it means that the bar for qualifying for avoiding penalties or even getting a bonus will be relatively low.  With every challenge comes an opportunity.  


    As I said above, the skills of running a business, especially a medical business, are not taught anywhere to those coming out of schools and residencies.  I've advised our local residents to visit my office or any office for just that purpose.  Only none of them ever do. There IS lots to learn and it can indeed be overwhelming to run a business with no training or experience.  Thats where AAPPM and IPED can be of great assistance.  In their programs they have learning tracks for the new practitioner, whether employed or running their own practice.  You can also visit offices if the're willing to let you observe their methods.


    I don't know if it was Steven Covey or Napoleon Hill, but one of them says "begin with the end in mind".  Picture what you want your practice to look like, then use every resource you can to figure out how you're going to get there.  That way the glass is always half full.

     

     


    Dr. Macy,

    Thank you for your words of encouragement. And your sage advice. I will check out the AAPPM / IPED facilities. And I have to agree with you about the deficit in education in the business aspect of podiatry. Although acutely aware of this requirement, as a recent residency graduate I have to add, the time pressure, schedule & burden imposed by the residency program can present a profound obstacle. Some residencies can, perhaps, provide better opportunities than others. All, I believe, have at least an ethical responsibility to make available this input, in addition to providing the clinical training. I have visited many offices in my job search, but few (if any) will offer to share their business acumen. Perhaps some believe there's a potential predatory conflict in doing so in their locale. 

  • Quote:

    Dr. Garfield,

    Seemingly you are, in fact, the best person to ask. Thank you for taking the time to do so. Especially for outlining the imminent obstacles, and the best choices to consider.

    (feeling a little queasy ... ) 


    Don't let that scare you off.  There are challenges to be sure, some of them quite difficult and annoying (I should add infuriating and frustrating). The whole MIPS/MACRA thing has little to do with truly improving quality of care or much else other than to add regulatory burden.  BUT...since a lot of people will decide not to work at it and since the law states that the program is to be 'revenue neutral', it means that the bar for qualifying for avoiding penalties or even getting a bonus will be relatively low.  With every challenge comes an opportunity.  


    As I said above, the skills of running a business, especially a medical business, are not taught anywhere to those coming out of schools and residencies.  I've advised our local residents to visit my office or any office for just that purpose.  Only none of them ever do. There IS lots to learn and it can indeed be overwhelming to run a business with no training or experience.  Thats where AAPPM and IPED can be of great assistance.  In their programs they have learning tracks for the new practitioner, whether employed or running their own practice.  You can also visit offices if the're willing to let you observe their methods.


    I don't know if it was Steven Covey or Napoleon Hill, but one of them says "begin with the end in mind".  Picture what you want your practice to look like, then use every resource you can to figure out how you're going to get there.  That way the glass is always half full.

     

     

  • Dr. Garfield,

    Seemingly you are, in fact, the best person to ask. Thank you for taking the time to do so. Especially for outlining the imminent obstacles, and the best choices to consider.

    (feeling a little queasy ... ) 

  • As for the DM shoes.  It may depend on your DMERC carrier and your state.  I was doing fairly well with them, then hit a wall and it was no longer worthwhile as stated above.

    Advice? Don't ask someone who gave up on private practice for advice. But here goes anyway: Join a mutispec group, hospital or look into federal employment. If you want to stay solo and you are not familiar with the abbreviations above, learn them all.  But most importantly find out who is running the ACO in your area and join.  Then, review the ever developing regulation under MACRA.  it it will determine how you get paid Jan 1 2018/19.  it was supposed to kick in Jan 1, 2017, but they realized it may cause a major disruption in healthcare and wanted to distance it from the election.  So you have a 1 year grace period to get  up to speed.

    You will need to determine how much you want to spend on staff and software to be compliant with the regulations or if you can afford to take the penalties and spend little or nothing on having an electronic office and satisfying the requirements. 

    If you are in an area where cash business is a viable option than pursue those routes.

    Here is one of many guides to MACRA https://ehrintelligence.com/features/what-is-macra-and-what-it-means-to-providers-ehr-technology.

    Keep in mind MU stage 1 audit failure is about 23%.  I passed, but I only reported for the first stage.  Later stages require you to use and maintain patient portals.  Which sounds great, but you have to pay for it and use it and properly document and report using it so that if you are audited, not only can you show that you have the capability, you will need to show that you are using it (your emr should have a way of measuring and reporting use).  I will also say that there is allot of scrutiny over how you conduct your own HIPAA audit.  You need to document what you do to protect patient information, how often, and how you took action.  The HIPAA audit is the most vague requirement and some reports have indicated that it was the most common reason for failing the audit.  When you fail they will take thousands to tens of thousands of dollars back, depending upon how many years you are being audited for.  The audits are pass/ fail :100% or 0% compliance. One mistake and they take everything back.

    You will need to understand how to report PQRS codes which will be changing and updating if you do not report you may not be paid at all by Medicare.

    If the ACO and or MACRA reporting options are not affordable for you.  You may have to consider practicing non-par with Medicare or simply not taking Medicare patients.  If that is the case , then you will want to focus your marketing on younger demographics and /or find out what insurance local industry/ large employers are offering and focus on those. 

    These are short term recommendations.  Trump has made no comment on MACRA or made any indication that he even knows what it is or that it is a problem.  Some medical news reports attempting to pin down his position on MACRA have indicated that he favors pay for performance and therefore assumed that he will leave MACRA untouched.  If it goes as many pundits anticipate, other specialties will be dropping Medicare in such large numbers that it will have to be re-examined.  If it hits like Y2K or ICD10, you will be stuck with it.

    So long term planning is unknown.

    I would consider an exit strategy from podiatry.  I am not saying that you should quit and give up.  I am just saying that the unknowns may make things too difficult to make a decent living and you might want to put a small amount of effort into deciding what you would do if you could not practice anymore. 

    Trump has changed his position on  many issues, he was a long time supporter of universal health care, now he is in the process of overturning the ACA without dropping anyone and keeping the popular provisions (Which is an oxymoron and an uncertain sign of things to come).  If things do not go well, the democrats have expressed great interest in a "public option".  This could be good to have a 100% insured population and simplified billing protocol, it could be MACRA with more headaches, and it may never happen.  So overall the future is very uncertain. 

    But, if you follow SERMO, Kevin MD, Modern Healthcare, and other health industry journalism, private practice is considered to be on a path to extinction.  The only organizations refuting that are selling you software or management services sucking the last bit of lifeblood out of you.  The stats bear out that physician owned practice will wind down to a very rare thing.  Articles indicating that the bottom is not falling out are all citing 2012 studies before the main hits from meaningful use and ACA took effect.  below are a few I googled, but was vaguely familiar with. I get alot of articles on my facebook feed.  Not sure how much effort it takes to search them down right now.  If you want more let me know.  Larger organizations can pay people to monitor the compliance with the newer regulations, keep up with the changes and make changes to minimize the time of the 6 figure doctor on paperwork and maximize the revenue.  Every patient you bill, will be like filing a small tax returns with all the ancillary information you will need to submit in order to be considered for payment.  None of this, thus far has been shown to benefit patient care and certainly not practice flow. Small practices will have to increase staff while accepting decreasing reimbursements and thus take home less money than in the past.  Pick your poison.  There is no one representing your interest to own a private practice. The APMA and other medicl societies have all failed or avoided the confrontations over MU/ MACRA and focused on the shiny carrots their members might receive if they just all play nice.  No one wants to stand up and demand to not be paid based on "performance".  Explaining how these measures dont help quality is a dizzying lecture that cannot be understood by those not in the arena.   The optics are just bad, so we have lost the battle of medical politics.

    Biggest piece of advice is to be conservative in your investment in your practice.  Not a good time to expand or take out 100K lease and buy digital x ray, expensive EMR, lasers or other conference marketed toys.  Being over leveraged may make shifts difficult in the future.  Minimize debt like never before so that if an opportunity arises to move to a safer harbor you can afford to do so. If you can stockpile cash, do it and dont spend on anything you don't need.

    Other recs: Develop a solid plan for collecting balances from high deductible patients.  (Get a collections attorney!! or agency), collect as much as is allowed up front. Or don't accept those plans if that is a viable option for you.

    Learn how to bill, so you can better audit what your biller is doing or so you can do it yourself, if the need arises.

    Determine how you want to handle co-insurance payments (These are often small amounts of patient responsibility, that can cost more in postage than you make in collections, but they add up on your accounts receivable (AR) report rapidly) Consider devoting staff time to phone collections or if your system can bill by email, use that.  Or Just collect when you can on follow up appointments and plan to write off the rest as a loss.

    Determine if your state or insurance participation contracts allow you to take a patients credit card and bill balances to it.  Consider if this will fly with your patients or if you will loose more patients than it is worth. I would never agree to this, but I guess some people do it.

    If MACRA gets repealed or watered down, and payment gets simplified to 2010(or just pre MU) levels, I would recommend moving forward to invest in your practice.

    http://www.healthcareitnews.com/news/why-trump-wont-change-macra-much

    http://blog.sermo.com/2015/05/25/macra-bill-will-destroy-private-practice/

    https://www.merritthawkins.com/Clients/BlogPostDetail.aspx?PostId=39406

    http://www.healthcarefinancenews.com/news/recruiting-firm-says-solo-physician-practice-dead

    http://www.medscape.com/viewarticle/835138

    http://www.kevinmd.com/blog/2015/05/is-starting-a-private-practice-a-dying-art.html

  • Thank you, Dr. Macy, for this helpful information.

  • Dieter:


    While there are many resources, there are companies such as Safestep where they have information and paperwork forms on their website.  If you choose their services, they have a system where you can be walked through the process.


    If you've ever heard a lecture by Dr. Moore, he of the Moore Balance Brace, his lectures contain this information.  


    The company Amerx, makers of Amerigel and other wound care products, oftne have memory keys at their booth at conferences which have everything you need for documentation for DME--shoes, braces, wound care products.


    If you have the form templates, you're most of the way there.  Develop a checklist to make sure you have all your bases covered.  Most of it is just the nuisance of documentation, but since they want certain items in certain terms, then you just have to learn to think along those lines and eventually it will come more naturally.


    Brandon

  • Quote:

    Diabetic shoes and DME, including orthotics is a winning proposition.  Too many fret about the propect of pre or post payment audits, but if you develop a protocol or system of doing the paperwork the right way, you have little to worry about.  Even with an audit, they'll tell you just what you are missing and you may well be able to produce the answers which will get you paid.  It pays far better than surgery and with fewer headaches if you do it right.

     

    As with many other fields, medicine (including podiatry) is evolving.  You have to evolve with it.  There are plenty of ways and resources to help you along--if you are willing to keep an open and optimistic mind.


    Brandon

    Dr Macy,

    Are you able to elaborate, to understand better the system / protocol?

    ps apologies for the crazy formatting of fonts  IT glitch

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