Yesterday I went to the post office.  In the mail I had another $550, which will keep us in the black for payroll tomorrow. My heart was encouraged. Then . . . there was a funny little card that I had to take to the front window. It was a certified envelope. I opened it. It was a letter from another one of our insurance companies saying that they will not do business with us anymore. Words can’t describe how frustrating this is.  This will launch me on another long, hard battle. It will probably cost me then thousand dollars by the time I’m done with it and many sleepless nights. It is so frustrating because you can’t just sit down with someone and explore it. Insurance companies are bullies. They hid their cards close their chest.  We fought with Group Health all the way to the top. At the top was only smoke and mirrors . . . no answers. One has to assume that it has something to do with me being a PA, a specialist and a clinic owner. I just wish they could come clean and we could have a reasonable discussion about it. But no.  They may never tell me. So tomorrow I throw down the gauntlet. I will fight this to the bitter end . . . alone.

I think I was seven years old the first time I visited Rock City, in Chattanooga, Tennessee. One of the most famous of their trails takes you though a narrow place, they named “Fat Man’s Squeeze.” Tomorrow is my “Fat Man’s Squeeze.”  I alluded to on my last post that a perfect storm of factors had created another financial crisis . . . out of a brief financial surplus. The good news is that just on the other side there is a lot of daylight.  The demand of our services is going through the roof right now. We stopped scheduling new patients (from requests coming in from referring providers) because I embarrassed to tell people that our next opening wasn’t for two months. We have a lot going for in other ways as well. We have a better payor mix.  We’ve worked out many bugs in our billing and etc. So this is how it stands. I have $5100 in the bank.  On Monday, I must make payroll. To make Payroll, I need $7400. Tomorrow is when we get our largest checks in. I don’t know what to expect. It could be like last Thursday . . . $50.  Or it could be like our normal Thursdays, $2500. Our doors have been back open for three weeks now so the drought should be drawing to a close. But will the checks start to come tomorrow?  Or will it be a week from now?  If I don’t have the money by Monday, what will I do?  I have no clue. I will get back on the other side. 

You know the image, the guy (or gal) keeping 20 or more plates spinning at the same time. That’s what owning a business is like. So Monday started my long-anticipated vacation.  On that day, I spent 6 hours in the office catching up and working on problems. Then Tuesday, I spent 5. Then yesterday I spent 4 hours in the office. Today I will spend 3 (or so I hope). Still, my office voice mail box had 10 at last count. I’m going to ignore them starting tomorrow. I’m leaving for Florida to visit my family. Sure, I will have hell to pay when I get back. But sometimes you have to put up some space for rest. I’ve been working seven days a week for almost a year now. Demi Moore was admitted for exhaustion? It seems like a lot of stars are admitted for exhaustion. Is there such a hospital? If so, what do they do for you there? I had a neurologist very willing to be my alternate supervision physician.  Unfortunately, his malpractice insurer is horrified by the thought. After all, PAs do hurt a lot of patients don’t they?  Hmm, they don’t?  They studies say no?  I’ve seen over 100,000 patients in my career and have never made a major error or mis-diagnoses.  There is a PA-paranoia out there, unfounded by the facts, but creates so much more complicating factors for a PA-owned practice. So, here is a toast to a few days of bliss, where I will try and pretend I don’t own a medical practice.

Today I entered a long anticipated rest.  My SP is on bike in Asia. My agreement with the state required me to close my doors.  I did, just the other day, sign a alternate supervising physician.  However, I choose not to use him. We need the rest. So what did I do on my first day of vacation?  I went to the office.  I made phone calls to executives at insurance companies and at Allergan. The insurance and I have finally come an agreement, I think. It is not Group Health, but a very minor player who was threatening to drop us.  The Allergan executive promised to list me on their “Chronic Migraine” website.  They have been boycotting me. But, they’ve told me that they had fixed it before . . . and then disappeared off the face of the earth. Our schedule looks good.  Because our doors will be closed for two weeks, when I get back, I’m booked out for four so I don’t have an opening for six weeks. We will of course will have hell to pay come March. There will be a financial window of drought corresponding, roughly, to four weeks after we were closed.  We will loose $12,000 during our closure.  Can we make it?  I hope so.  If we do, then the sailing should be smooth for the foreseeable future. I came into this with the same (naive I might add) attitude that I’ve heard from other PA-Clinic Owner Wannabes (I’ll shortening it to PACOWs).  When I was a PACOW, I thought I could do things better than those around me. I would work harder. I would hire excellent people and reward them well for good work. I would have an extremely efficient office.  Pardon me while I add, yada . . . yada . . . yada.  As Donald Rumsfeld said so eloquently, “There are the unknown-unknowns.”  I wanted to share a couple of those. Myth 1: Pick good employees and pay them well and it will be bliss.  Well, I’ve been open about 9 months and have had to fire one employee (and it was ugly) fire a vendor or two and then last week come close to firing another employee.  I selected all of those very, very carefully. I did background checks.  I thought we were on the same page.  But no human is perfect. It wasn’t like I was seeking perfection. But there are tolerable imperfections (which we all have) and then there the intolerable ones. It is sad when you realize you are dealing with an intolerable one.  I treated my employees better than fair. But still there are different agendas in people’s vision of what they want to do. This last round of almost firing was painful.  I lost a lot of sleep over it and my peaceful office had some moments of heavy drama.  I hope we are on a smooth path now. But one can only hope. Myth 2: Do your homework and there be no surprises. Okay, this next one is complex and represents only an example of what it is like to do business in this crazy world. Going Postal I picked the most beautiful office building on our island for our clinic. It was a no-brainer to me.  We moved in and I was trilled to send out my address to all the (100 or so) entities that needed it.  Then to my horror, our malpractice insurance was cancelled because they had been sending me notices of payment and I never got them. As a matter of fact, I never got my business license, a ton of credentialing stuff, my DEA renewal and my professional license. The problem was, even though I could throw a baseball and hit the side of the Post Office down the street, the Post Master made a decision that “his boys” weren’t going to deliver mail in my building. I met with the Post Master several times over this. He is a crotchety old man.  His reason for not delivering mail in our building was “never have so we never will.”  He told me that I had to get a PO Box. I did buy a PO Box.  I went the long process of changing our address with our 100 or so entities.  Then I was started to be notified that entities (such as the state’s Medical Quality Assurance Commission) will not do business (or allow to exist) a PA who uses a PO Box as his mailing address.  Then the companies that send me samples told me, “If a PO Box is used as a mailing address there will be no more samples.” The next (and worse) layer of complexity is our bread and butter, the insurance companies started to deny claims because they “don’t send checks to PO Boxes.”  This I think is part of their complex strategy to find excuses not to pay. In the meantime, I’m going back to fight with the Post Office (remember this is when you are working 12 hour days seeing patients and getting behind).  Finally I spoke to more rational assistant Post Master. He told me that it is a law that if I am in the city limits, I have to have the potential of mail delivery. Yeah! I thought.  We’ve fixed this. So then I ask for mail delivery at my building in accordance with the law.  So, I had to meet with the crotchety Post Master, who wasn’t happy.  He came down and brought his mail carrier (who drove right past our building every day) and they picked a site on the side walk for the mail box. Next I had to meet with the city engineer to figure out what kind of mail box was allowed.  We jumped that hurdle the next month. Then I had to get the building owner (my landlord) to approve.  He, unfortunately was even more crotchety  (if you have ever seen the show on Discovery, Gold Rush Alaska, then you should think of Dakota Fred).  He was mad as hell that I would attempt to drill holes into his side walk. He asked me, “What don’t you just get a damn PO Box like the rest of us!”  I wanted to push the man into the sound with concrete boots on. So finally we worked out a compromise where we found some dirt to put a box in (now in the  meantime we are getting thousands of dollars in rejected money because of using a PO Box).  So then the post office comes back and says “Hell no. My boys aren’t getting out of their trucks and they ain’t turning into your parking lot to get to your mailbox.”  So the only place to put it was beside the road. How does this influence patient care?  I could give you a hundred examples. One is a lady I will call Ann. Ann has been to several headache clinics with level 8/10 headache every single day.  I’ve worked with her for a couple of years. Finally we stumbled on to Lyrica, which renders her almost headache free.  I fought with her insurance company for a month and they refuse to pay for it. So, the company (Pfizer) agreed to give me extra samples.  Guess what. First thing this morning I get a letter from Pfizer saying that all future samples will be cancelled because we have a PO Box in our address (I also have a street address for them because they ship via UPS).  I asked them, simply put a line through the PO box and send it. It will be delivered by UPS anyway directly to our door. Pfizer’s response: “Well, it is illegal for us to tamper with an official address.” Me: “I’m giving you permission to.” Pfizer: “You don’t have that right.” Me: “What do you mean I don’t that right. It’s my address.” Pfizer: “Uh . . . no it’s not. It is the address on your DEA. Therefore, we can not strike out the PO Box unless you go to the DEA and strike it out.” Me: “But the problem is, the DEA sends out their renewals and etc by U.S. mail. My DEA expired last time because they sent it to the street address and the Post Office returned it.” I won’t belabor this any longer.  But you get my point.  So, hours have been spent on this silly problem. Who suffers?  The patient who can’t get their samples. The business that could fold if we can’t get their checks from the insurance companies.  And my taxes pay for the Post Master’s salary?  My rent pays for the landlord’s income? The easy solution, you may think, is finding a new place for my clinic. That would be a nightmare for several reasons. For one, which makes no sense . . . but still a part of this maddening world we live in . . .       is that part of our business loan was for me to sign a paper saying that we will stay at the same address for the duration of the 7 year loan.  They reasoned that a business that moves from place to place has less of a chance of succeeding.  If I moved locations, they could demand the full payment of the loan (now about 52K). I don’t have that cash anywhere. I could actually loose my house over this. So welcome to the world of business.  It is a bit like being in Wonderland, or at the Mad Hatter’s tea party, where nothing makes any sense.  But I hope to put of the mailbox, in the middle of the night if I have to, and see what happens. In Conclusion: I have no apologies of saying I’m a type B when it comes to personality.  I think I’m successful as a PA because I am empathetic and feel things deeply. It was hard for me to fire my one employee and was horrible to think about firing my next.  But this morning, I listened to myself as I made a phone call to an insurance executive. He answers and I say, “Why in the hell didn’t you call me back? I’ve left you fifteen messages over the past three weeks! There is no excuse for such behavior. I don’t need your damn business but I have about one hundred of your subscribers who are going to have hell to pay because you being delinquent!”   Now, I wasn’t in a state of rage. This is what it is like to do business. It is totally out of character for me. But I’m adapting.

So this morning I biked in the frigid morning cold, into the village to have coffee with my son. From there I went to our PO Box.  From a distance, through the glass, all I could see was paper.  I put my key in and opened it. It was so stuffed that I almost needed a crowbar to pry them them out. They were all checks, several thousand dollars in total. I had shut down this blog a while ago, because I thought my story of starting a new clinic had come to a close. Maybe it has. But this morning I couldn’t help but reflect back on those hard days of sweating bullets to see if we could make payroll.  Our corporate bank account has gotten down below $100 twice in the Fall. No, we are not rich.  I had unexpected bills last week of over $1,000. Our complex phone system got into a dispute with our computer server (fighting over IP addresses) and it took both a computer tech guy and a phone system guy a whole morning to solve. Each billed about $500. On top of that, we still have our old debt.  But, It felt so good to have turned the corner this financial drought. We are booked out almost five weeks now and the momentum is growing.  We have a new professional web site that we are still tweaking Another reason is that I brought this blog back to life briefly is that I’ve been in three conversations recently about PAs/NPs starting their own clinics. In one case it was a practicing PA telling how easy it is to do it and make big $$$. Then there was an NP boasting how easy it is to start a clinic and make $$$. Lastly was a pre-PA student making the same claims.  All three had these things in common; 1) They had never actually done it, 2) They knew they could be very successful because they knew more about business than us who have done it, 3) They had no interest in listening to us who have done it and 4) they had projections of success based on the complete negation of Murphy’s law.  I could write a book on the unforeseen complexities that I’ve run into . . . and I had done my homework. My other reassurance, that I do know what I’m talking about, is that every PA and NP who I’ve talked to, who HAS done it, are on the same page as me. One of the most successful PA clinic owners told me that he did not report a penny of profit until his third year.  One of the best NP-owned headache clinics in the country, which was in a very affluent suburb of Washington DC and, like me, whose schedule was full from day one, had to forfeit her own salary three months during her first year. However, ironically when she did start making money her neurologist supervisor became angry with her over her income. So, the supervisor pulled out. NPs can’t make over $100,000/ year so she argued.  This was the days before NPs could work independently.  So a wonderful, cost-effective and successful clinic had to close due to political reasons with the nearby neurologists. So, I wanted to bring back this blog to celebrate good news and to be a voice of reason for those considering this. You will notice that I’ve deleted my old posts. The reason for that is that when the PA Forum made this blog so visible, my patients started reading it.  If they took some of the posts out of context they could get the idea that this whole venture was about getting money. It is not. So I deleted them. My last battle has been the notice that another major insurer (UnitedHealthCare)was going to drop us . . . they could only list us as Family Practice (PAs can’t be specialist) and we didn’t meet the FP criteria because we had not admitted any FP patients to the local hospital this past year.  Another round peg in a square hole issue. I may be back if anything interesting pops up.