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.
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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.
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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.
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I thought it would be meaningful for me to bring back this blog from the dead, if only for another post or two. For one, I’m at headache conference at a resort in Scottsdale and have a moment to write and think for once. The major development since I posted last has to do with my continuing shake up of the business end of the practice. If you knew me, you would how badly I crave a business place of peace and smooth sailing. I really hate drama. I want my focus to always be on patients. So, I may not have the perfect personality type for running a business, but that doesn’t change things. Beside not being your Type A, executive persona, I am also quite candid. I am candid about my fears and my mistakes. I’ve watched many others scream of their great successes . . . all the way to complete collapse and failure of their ventures. Donald Trump is the opposite of myself. Why some see him as the ideal businessman, I see him as a very insecure little man. My big mistake was in billing. It wasn’t a naive mistake. I knew from the start that billing was huge for a practice. I devoted months trying to find the best solution to my billing needs. I never took it lightly. At one point I outsourced to a highly reputable biller. Before our doors were even open, I started getting calls from my vendors that this biller was pissing them off. She had a very “negative” influence on people. So right or wrong, I decided to can her. Because of that, we were in a bind. Our doors were opening in about two weeks and I didn’t have a biller. I looked at many different options. Most of the outsource billers are quite expensive. Some require thousands upfront and then as much as 10% of your collections. About that time my office manager recommended a lady who had been a biller for years, but then stopped for her family. I met her, I interviewed her, I checked her references. She seemed very confident that she could do a great job. Then came the firestorm of opening the practice. I had patients pouring in from all directions (and still am). I was working 80 hours a week trying to keep all the plates spinning. I didn’t neglect the billing situation as I was looking over her shoulder every day. Things didn’t add up to me (see most of my old post) and I would have been much more concerned earlier, however my PA-Owner mentor and my SP both kept saying, forget about the money for the first three months. So I did. Then, when the fourth month rolled around, and money still was only trickling in, I launched a big audit of our billing from two sources. Both indicated something serious was wrong, but we couldn’t tell where. Finally I figured out my biller was making big mistakes. I gave her a warning and some bars to hurdle. She failed those goals miserably . . . so I had to fire her. I felt terrible about that at first. But then my old biller (who I had worked with for 8 years and have a deep respect for) came in to help fix things. As we unraveled the onion back, layer by layer, it was shocking. Not only did my biller not know at thing about billing, she covered her tracks. She did bizarre things like submitting the same claim about 5 different ways, hoping that one would be paid. It could even look like fraud to the insurance company. Four weeks into the clean up, my new biller is about 25% through the mess. Money is starting to flow. I’m not getting rich but each payroll is getting a bit easier. There should be a large chunk coming in soon . . . enough to give us a bit of cushion for once. So, it is disappointing. You want to trust people but yet you can’t trust anyone. You want to devote your energy to your patients, but if you don’t take care of the business end, you can’t help patients. I look back and think what I could have done differently. I’m not sure if I did anything wrong. It is part of business that you can check references and still get burnt badly by any employee. So, we move on. I feel that we are coming out of the woods now. Most of the dragons have been slayed. One, Group Health Insurance, was one battle we lost . . . but we won the others. So, this week, for the first time in months, I’m relaxing, learning a few new things about headache, rubbing shoulders with several old SPs and friends, spending some time with my new SP (whom I brought to the conference). My wife is with me to relax and soak up some SW sun. So I may be back if there are any new lessons to share.
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Here is where we met today, fourth floor conference room inside the bowels of Group Health Cooperative. My sp and I rode down to Seattle together. My office manager joined us. We had lunch and reviewed our strategy. I had done a lot of research and passed out graphs and supporting documents. We took deep breaths, left our coffee shop and walked over to the front desk of the headquarters building. We signed in. There was our names printed on the agenda of the day. We waited for about thirty minutes until the VP appeared. We did introductions.
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Well, today was interesting and a wonderful learning experience. I shadowed with a PA that specializes in Pulmonary treatment. When I arrived at 9am, we went over the appointment list, seeing who was coming in- at this point, the patient’s name is all we know. After the nurse rooms the patient, we got their chart. Reviewing their reason for seeing us today, we looked up their record in the amazing EMR. The EMR (Electronic Medical Record) is an amazing tool.. with the touch of a button, we could see X-Rays, Lab Results, Past Medical History, and more! We saw the patient, answered any questions the patient had, reviewed their medication, and listened to their chest. I heard the worst (hands-down) set of lungs I’ve ever heard. The patient was presenting with COPD (Chronic Obstructive Pulmonary Disease). The patients lungs, when auscultated with the stethoscope, sounded as if we were taking sandpaper across pavement with every breath. The patient said they dropped from four packs of cigarretes, to only three.. but wanted to know why there were still problems with breathing. This is definitely an interest of mine and I am excited to return Monday to finish my shadowing. I will be shadowing, over the next couple of weeks, PAs in Family Medicine, Dermatology, In-Patient Psychiatry, and Oncology. Shadowing has really opened my eyes to the profession and I am glad that this is my future profession.
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