Climbing Mountains

It's the start of week 7 for me, and I've seen 12 patients so far in my fledgling practice. This week is a little different in that I kind of don't want patients to call for appointments this week. That's because I'm a chaperone for my daughter's Outdoor Science School. It is an annual trip for the 5th graders at her school, one that usually provokes a lot of excitement for the kids because, for many of them, it's the first time they've ever spent so much time away from home without a parent or relative. And for the same reason, it provokes a lot of anxiety for the parents.

It is in the local mountains, about 45 minutes from home, with no cell phone access. But I did change my answering machine greeting to include the phone number for the Ranch, just in case anyone needs to reach me. I was thinking that I could always go back down the mountain if a patient wanted to schedule an appointment. We'll see if anyone will.

In a way, it'd be a disappointment if NOBODY calls especially because I spent 4 1/2 hours last Friday at the local Senior Center checking blood pressures, and handing out business cards and brochures.

I'm still learning about medical insurance plans and how they worked. I saw a elderly gentleman last week because his wife thought he should have a complete physical. He had Medicare, which I can't take yet, and Blue Cross, which I thought I could. It turns out he is part of a Blue Cross Medicare HMO, which will not pay for him to see a unapproved provider, such as myself. By the time I figured that out, it was too late to call him back and tell him not to come. So I figured that I'd do a physical exam on him, and see how long it would take. As for payment, I figured I'd take whatever he was willing to pay.

I ended up spending an hour and fifteen minutes with him taking a complete history and physical exam. But I could've spent even more time talking with him. He and his wife were very pleased that I took all this time, of course. I ended up charging him $100 for the visit, with a "prompt pay" discount which brought my total charge to $80. He will get his blood test results from his recent physical at the VA, and bring them to me for interpretation. But now I know that I have to find out exactly which health plan a patient has, and whether or not I can get reimbursed for it. And even though I didn't charge him my full amount, I figured that at $80 for a one hour physical, I'm still getting paid more than I do when I work part-time shifts at Kaiser, which pays $60/hr.

Speaking of Kaiser, I saw one of my former patients last week. Even though he still has Kaiser insurance, he thinks I'm such a great doctor that he is willing to pay out of pocket to see me. He started going on and on about how I should get a bunch of people without insurance to pay me a small amount every month, rather than a large payment at the time of service. I explained to him that, while it is a good idea, this was already being done as part of prepaid health insurance plans, and that I didn't want to have to chase people down if they don't pay their monthly premiums.

He said that he knows a lot of people without insurance, and appreciates what I am doing as a way to help people without insurance. He took a lot of my brochures and business cards and said he will send me a lot of new patients. Which could get interesting because he is the manager of a strip club.

I guess I'll climb that mountain when I get to it. This week, I've got real mountains to climb.

I've a feeling we're not in Kansas anymore

I feel like Dorothy in the Wizard of Oz.

Dorothy: Oh, will you help me? Can you help me?
Glinda: You don't need to be helped any longer. You've always had the power to go back to Kansas.

OK, I don't want to go to Kansas, but all this time I've been under the belief that I could not accept patients with insurance unless they paid me upfront. At least not until I was approved as a provider for their respective medical insurance plan, which can take 3-4 months. I've turned away a few people who expressed interest in scheduling an appointment only to have me explain that I didn't accept insurance yet, so why don't they wait until 3 months from now when I hope to be a participating provider?

This past week I figured out that I had the "power" to see patients with insurance as an out of network provider. Many health insurance plans allow visits to an out of network provider, but will reimburse less of the total charges, or require a higher deductible. I realized this when I read some of the plan descriptions in detail.

So 3 nights ago, I saw a little boy who was visiting his grandmother from out of town. His parents had Blue Shield PPO which had a $45 copayment for an office visit, and which his parents readily paid. This surprised me, because up until then, my typical fee for a 15 minute visit was $40 ($50 minus a 20 percent "prompt pay" discount).

Another family who has been waiting to see me has Blue Cross and they are used to paying a $10 copayment for office visits. But their plan won't pay for any out of network visits until after they meet a $1000 deductible. Yikes! I told them that I would be willing to see them and just take the copayment. To me, that's $10 more than I'm getting now, plus it's a way of building goodwill and loyalty. Plus, I might be able to hold on to the claim and submit it a few months from now AFTER I've been approved as a network provider.

Tomorrow I'm doing blood pressure checks at our local Senior Center Health Fair. Hopefully it'll generate some visits for me, but since I'm not yet a Medicare provider, I'm not counting on a lot of hits.

Our daughters' piano teacher has been doing some advertising for me, giving out my business cards and brochures to some of the other families who are part of her piano studio, and she told me she was surprised at how much interest there was in my practice. So much so that she has asked for 20 more brochures to hand out next week.

The "Relay for Life" organizer also recommended that I consider joining the Kiwanis Club as a way to network with other business and local community leaders.

My latest marketing idea is to arrange for Mark Crilley, author of the popular Akiko series books, to come and give a presentation to either my childrens' elementary school or local public library. How does it help my practice? OK, it's not exactly health-related, but it does promote uh...literacy. And reading, which is healthier than say, watching TV.

OK, OK, the truth? My kids really LOVE the Akiko books. As much as I do. Plus it allows me to bring this blog entry round full circle back to where I started since the Akiko series has been described as "a light, illustrated adventure novel in the topsy-turvy tradition of The Wizard of Oz".

There's no place like home.

A Slow Week

No patients this week. Even though I wasn't seeing patients, I did accomplish some things.

Because I had plenty of time, I finally filled out applications to become a participating provider for Aetna, Blue Shield and Pacificare this week. I had filled one out for Blue Cross, but since it was from over one year ago (did I mention that I'd been planning on going solo for a while?), I thought I should request a new application form and use the latest contract. Who knows? It might have changed since last year.

I still have to send off the Medicare application, too. Unfortunately, I recently read about delays, some as long as 4 months, in approving Medicare enrollment for physicians. So it may take me a while.

I went to a "networking" reception one evening this past week, sponsored by our local education foundation which raises money to supplement our public school system. The idea is that local businesses help donate services and money to the schools/fundraising activities, and in return the education foundation helps promote local businesses. I did meet several new business people, including one who is the business manager of an established rehab medicine clinic. His wife works at Kaiser and said good things about me to her husband, so he suggested we meet for lunch some time and discuss how we can help each other.

I tried calling back some of the patients I had seen the week before to ask them how they were doing, but I only reached their answering machines. Still, I left messages because I think it's a good idea to follow up by phone and let them know you care about them. I sent an elderly patient information about personal medical alarms, in case she "falls and can't get up". (Nostalgic video here.)

I've also been wondering what else I can do to bring more patients into my practice. The weekly newspaper ads have not generated business, although I know people are seeing them because they tell me.

Like all physicians, I get a lot of "throwaway journals", journals that I don't have time or interest in reading. One of them used to be Medical Economics. But I have to say that since I became interested in going solo, I've found it to be a valuable resource. Every issue seems to have at least one horror story, like this one. Brrr! That one gave me the willies!

This article from Medical Economics discusses some marketing ideas, as well as some cautions against bad ideas:

Novelty is one thing, but you don't want to step over the line that separates a professional business from the mundane. So think twice before including an ad for your practice in a coupon pack, amid notices for discount pizza, dry cleaning, and lawn services. "That can be detrimental to your image," says Santa Rosa, CA, management consultant Keith Borglum—who also cringes when he sees doctors' faces on supermarket shopping carts.

Consultant Betsy Nicoletti, in Springfield, VT, recalls another example of inappropriate advertising: A primary care physician was trying to lure patients away from a walk-in clinic in Vermont's ski area. "He ran a series of ads," says Nicoletti. "The first one featured a picture of his mother and the caption, 'Hi, I'm Dr. Smith's mother. Go to him because he's a great guy.' Then he ran pictures of his father, his father-in-law—even his dog—all with the plea, 'Go to Dr. Smith because he's a great guy.'

"If you want to be noticed, that certainly does it, but you have to be careful about the message. This one just says, 'I'm desperate.'

I hope I'm never that desperate.

The best suggestion I've heard was from other physicians who have gone solo, too. One suggested I could see patients who have insurance, and hold on to their bill until I get approved, and then send it for reimbursement. Or I could take their regular copayment, and write off whatever the insurer would have paid me. The upside is that I could start building up my practice now. A downside is that I don't get as much money now, plus later when I can bill their insurer I would have to use the lower paying "established patient" codes rather than the "new patient" codes. Since I am not making any money now seeing zero patients, any income that I can generate seems like a positive to me.

I did come up with a marketing idea, sort of. We are having an upcoming local "Relay for Life" to raise money for cancer research, which seems like a natural tie-in for a family doctor. I left a message for one of the organizers, offering to help, although I'm not sure exactly how. Free cancer screening? Discounts on lipid profiles? $10 discounts for relay participants? Just donating money (which I am running out of)? Run/walk the Relay myself? Free Brains in a Dish? (Or is that one of those "bad marketing ideas"? Yeah, I thought so.)

Is There a Doctor in the House?

8 patients so far, and 1 house call. The house call was to the home of a 92 year old woman who had seen me once, and we agreed it'd be easier for her to just have me visit her at home for a follow up. The first thing she said when I arrived was that her granddaughter knew me. It turns out her great-grandchildren share the same piano teacher as my daughters, and that we'd seen each other before at piano recitals. What a small world!

We spent some time talking about her family, and other things. I focused most of my questions on gathering a medical history, but naturally the conversation wandered into areas such as safety of various medications, osteoporosis prevention, and personal alert button in case she falls and can't reach the phone. In all, I spent about an hour there, and we had such a pleasant conversation I'm sure I could have easily spent another hour there, except that I had made an appointment with another patient (for which I was now late). So when it came time to pay, I told her I would only charge her for a 30 minute house call, since I felt guilty about charging her for an hour. The old "undervaluing my time" complex again. In all, I charged $125 for the house call, but because I offered a 20% discount for prompt pay, it worked out to $100.

This article discusses some nuts and bolts about how to do house calls.

There are some practices that do house calls only. Housecall Family Practice is one. This is a nationwide referral list of the American Academy of Home Care Physicians, but it looks like it only lists its own members (naturally). This site talks up house calls as an alternative practice style for physicians.

Want to feel like a Doctor again?

Our physicians, seeing just 7 patients a day, can earn $130,000 to $170,000+ annually. They're rarely on call, and no one ever tells them how to practice medicine.

Sounds too good to be true.

But there is something about house calls that does make me feel "more" like a doctor than just an average office visit. I think because I feel like I'm doing something above and beyond what an ordinary doctor would do. I also feel this way when I feel like I've made a great diagnosis that I think few others would have made.

While at Kaiser, I made a few house calls. It is certainly not a routine service that I did, but there were times when it seemed appropriate. Like the time a patient's daughter called because her mother fell out of her chair and couldn't get back up because she weighed over 400 lbs. She called the advice nurse first and they told her a home health nurse wouldn't be able to get out to them until tomorrow. I thought this was inhumane and ridiculous that she'd have to spend the night on the floor, so I walked down the hallway and recruited another family physician, and we drove to her apartment. With the help of a neighbor, we managed to get her into bed. Since then, she's lost over 100 lbs through bariatric surgery and I've seen her at the clinic.

Another housecall was to a little old man who had been bedridden for over a year because of a compression fracture in his spine. He was having trouble breathing and coughing a lot. When I listened to his lungs, he had rales halfway up. I had a long discussion with his wife and (by phone) son concerning what might be the best way to manage this probable pneumonia. In the end, the wife and patient elected not to go to the hospital, so I prescribed Zithromax but before his family could pick it up the next day, he passed away.

There was a little old lady who called me because she wanted to know what she should take for cold symptoms. I told her, but because she didn't drive, couldn't get any medicines until she could find someone to drive her to the pharmacy. Instead, I told her, we would just deliver them to her house. So after work, I bought a $5 bottle of Robitussin DM, and drove it to her house myself. Naturally, I didn't ask her to pay me back.

None of these home visits were compensated financially, but as a family physician, that's not the main impetus for doing this. However, as a solo family physician, I now am keenly interested in financial compensation because otherwise I can't keep on being a solo family physician.

I remember checking out this site several months ago when I first considered doing house calls. It was one of the few I could find that actually listed its fees. Basically, $79-224 per visit depending on complexity and length, plus $35-95 "transportation fee". By comparison, I'm a bargain!

And yet, no massive influx of patients or calls for home visits. That's either because a) there isn't a demand for these services or b) they just don't know about me yet. I'm hoping it's b.

More patients!

After a slow start, business has been picking up. Since my first patient 1 week ago, I've seen 5 others since, ranging in age from 8 to 92. My first visit was at 8PM, another was on a Sunday afternoon, and 3 saw me today. I was surprised to get 3 calls requesting appointments on my home phone today from people we know. I'm going to have to start monitoring the home phone number, too, it seems. The common denominator to all these is accessibility. I was able to accomodate people who wanted to be seen after hours, on weekends, that same day. Most of the patients I saw already had a doctor, but found seeing me more convenient, even though I told them I wasn't able to accept insurance yet.

When I thought about it, I realized that this is the way it will be most of the time. People calling that same day for an appointment. I should get used to it, never knowing what to expect from the day. Each patient has expressed how much they appreciate what I'm doing, how "nice" it is to be able to call up and see a doctor in town, that same day. I've given everybody a copy of a newspaper article about Drs. Gordon Moore and Linda Lee describing their solo practice models. I feel like I want to promote this concept of a hassle-free doctor as much as I want to promote my own practice.

I've yet to feel totally comfortable with my office protocol, though. I have office forms borrowed from other physicians, but I don't need all the information these forms ask for. I'll have to sit down and fine tune them to suit my own needs. I have learned the hard way that I have to make sure I ask patients to fill out the forms BEFORE I start talking about their problems. I guess that's what receptionists normally do.

I still feel awkward when they ask me how much they should pay. My "rate" has been $50 per 15 minutes with a 20 percent discount for prompt pay. So it's been working out to $40 for most people, not because everyone takes 15 minutes or less, but because I feel guilty about asking for more than that. I don't think I've spent less than 20 minutes with anyone, and most get more than 30 minutes of my time. At this point, it doesn't much matter since I don't have any other patients waiting. But my practice model was planned with an average reimbursement of $75 per 30 minute visit in order for me to reach my target. Hopefully this will change once I can accept insurance.

Speaking of which, it has taken me longer than I planned to apply. Mainly because I had difficulty figuring out how to get a copy of the fee schedules for each insurer. I didn't want to sign any contracts without knowing in advance what I was going to get paid. Pacificare's application packet already included a list of the 25 most common CPT codes and what Pacificare will pay for them. For Aetna, I had to fax a list of my most common CPT codes and they faxed their reimbursement rates back. So far, it seems like everybody pays LESS than what Medicare pays. Aetna's rates range from 78-106% for the E&M codes, while Pacificare ranges from 63-91%. I imagine Blue Cross and Blue Shield will be similar. At least, I hope they aren't much worse.

But quite a few patients are waiting for me to accept insurance before they will come see me. I don't blame them. I guess I'm surprised to have patients willing to pay me for my services at all.

I wonder if anyone will call tomorrow?

My 1st patient!

I saw my 1st patient on Monday evening. But he was almost my 2nd patient.

I had received a message on my answering machine Sunday night from an older gentleman who was looking for a new doctor. I called him back the next morning, but it was clear from talking with him that there was some serious Axis I issues going on with him. I briefly considered whether it would be worth it for me to try and help him, but after 15 minutes of listening to him ramble from one delusion to another, I decided that it would be a lost cause. So I told him that I was very sorry but I didn't think I could help him.

After I hung up, it occurred to me that this was one of the benefits of no longer working at Kaiser. If I saw someone like him at Kaiser, I'd be stuck with him as a patient unless he voluntarily switched to another physician, or he acted in a manner that would justify my discharging him as a patient. That only happened once that I could recall (me discharging a patient, that is).

It was an elderly woman with chronic complaints who somehow had gotten a hold of my private phone line, and would call throughout the day to complain about this or that. At that time, I guarded my private phone number like it was gold, and never gave it out for fear of getting inundated with messages from patients. We had a system whereby messages from patients would get filtered by a nurse, who could sometimes handle the call, or route it to the appropriate doctor. My reasoning was that, if patients called me on my line directly, I could easily spend hours handling phone calls, and not have enough time to see the patients in for office visits. But it was inefficient, too, because the messages would get to us 2 hours after the original call, and when we'd call back, the patient would no longer be at the callback number, and the game of phone tag would begin.

So when this patient first called, I was very surprised and asked her not to call my direct number, explaining that I didn't have her chart or information in front of me, and to please call the message line instead. But she refused, saying she would call me whenever she wanted to. Well, I got angry and asked the clinic administrator to transfer her to a different primary doctor, which she did. Strange how now, I'm giving out my cellphone number to patients on my business cards. In retrospect, I'd have to say that that lady probably had it right, that she should be able to contact her doctor whenever she needed to. But she should've respected my request to follow my policy for its use, too. It's a two way street.

Anyways, later on Monday, I got another call and the caller ID read "**** RESEARCH INC". Having received a LOT of telemarketing calls, this sounded suspicious to me so I elected not to answer it. However, after the beep, a voice started explaining how he wanted to see a doctor...

I quickly grabbed the phone and started talking. He wanted to be seen but worked until 7:30 PM. No problem, I said. How about 8 PM? Flexible appointment times is another benefit of having my own practice. And even though it was raining, he did show up at 7:45 PM. I had explained on the phone that I wasn't able to accept insurance yet, and he said that was okay since he didn't have any insurance. I had explained that I charged $50 per 15 minutes, but would reduce it to $40 if he paid at the time of service. I asked him how he heard about me, and he explained that his secretary had read an article in the newspaper about me (the one I wrote the press release for).

We spent probably 30 minutes talking but I charged him $40 because, well, it didn't seem worth $80 to me (my problem with valuing my own time). But he only had a $100 bill; did I have any change? Of course, I didn't, but I didn't want to send him a bill. We finally decided he would go down the street to the local grocery store and get change. He offered to leave something to show that he would return, but I told him that I trusted him, and I did. He returned with the $40 and I gave him a receipt. I still have the two twenties in my office. I'm wondering if I should frame them as my first earned income as a solo practitioner?
It turns out he owns his own company, and so I'm hoping he may steer some of his employees my way.

This business of finding patients seems to be a slow process. But as long as it grows, that's okay. This morning I spoke to another person who scheduled an appointment for his son next week. A patient a week. Good thing I'm still working part-time at Kaiser.