Another, timely, review of the business was the CPA’s report, which I got last night. We just finished our taxes so the verdict is in. Drum roll . . . at the end of the first fiscal year we had a net loss of $84,650.  That sounds terrifying doesn’t it? But let me put it in perspective. The same PA owner who told me to double my expenses and halve my income also said he didn’t make a penny of profit until his third year. It would be truly incredible to make a profit the first year. The reason is, the upstart cost is through the roof while the income is very slowly to come it, at least at first. Honestly, our cash flow has only been regular starting at month 10 of operations. So we had upstart cost such as $9,000 to have our signage up to code (for our building) $4,000 for legal incorporation fees. We spent almost $20,000 on fees to credential with insurance companies.  Then of course there’s malpractice, business insurance, city, state and federal taxes that must be paid and that doesn’t even touch on hardware such as furniture. So roughly, I’ve brought in this first year about $300,000 (on my efforts alone) but the cost of running the business month to month, plus the $90,000 upstart costs has been about $385,000. But the good news is that all six people on the payroll have been paid on time, all our vendors are paid up and we have a steady flow of cash.  So, there will be no profit until the debt is paid, which will take a couple more years. Those PAs who think that this should be a no-brainer and the money will roll in, really don’t understand what they are getting into.  The key for us, as far as keeping a good cash flow, is being anal about the schedule. While we have been booked out for weeks, no-shows, appointment errors and etc. was leaving about 20% of our time each day unscheduled. Now, we have a “minute man” waiting list. As soon as a patient calls in to say they can’t make it, we immediately fill the schedule for that day.  Now, including work-ins, we keep the schedule about 125% full. I had my personal physical with my PCP yesterday.  He asked me out it was going. He gives me 10 .5 MG Atihttp://www.acousticalsolutions.com/audioseal-absorber-blanketvan a year . . . this past year I had to call and ask for an early refill.  He asked me if I need to increase the amount to 20/year. “Nope,” I said. “I think that life is getting back to normal . . . after one of the most stressful ones of my life.”

The ice is thawing after a long winter thus far, and I don’t mean literal ice.  It is the great financial drought is starting to see some relief. We made payroll without any help from anyone on Monday and I would have said that was impossible a few weeks ago. I had $2,000 come in yesterday so now I can pay rent. Our productivity increased by 81% in February over January . . . which is almost double. But, it takes weeks to see, financially, the fruits of your labor.  Our patient base is spreading to cover an area of 100 miles by 100 miles. Word is getting out. The demand for our services is growing. I can start to fantasize about hiring more help. Yesterday we got our first mail delivery to our door after 10 months of being in business. It sounds very “third-world” but we had to fight with the post office during this whole time to see this succeed. Now our payments will be less hindered. Now, if I can start paying off some debts I would feel much better. The stress of the week has been getting a total of 4 termination letters from insurance companies since Saturday.  This is very frustrating, especially considering that we’ve paid almost $20,000 to a professional credentialing company to prevent this. I did fire the company, but then they had the insurance companies call me and tell me that the terminations were due to computer errors inside the insurance company. They just simply have no accountability. Each time I get one of those letters, I think of the 100 or so patients who would be devastated if they couldn’t see us. Speaking of letters, I got a glowing letter of support from the # 1 headache clinic in the state, the one at the University of Washington. They made it clear that we are the only high-level providers of headache medicine in our region. We can use this letter to fight with other insurance companies. But for now, all seems well on the horizon.  I awaken early this morning with the news that my son and daughter in law were in the hospital to deliver their second child.  That’s why I’ve been up since 4:30. That’s why I have time to write.

It was so tight that I thought I would need a jar of Vaseline to make payroll on Monday.  I needed $500 more . . . got $1200 in today. A good night’s sleep is due.

I am often asked, “Are you glad you did it?” I’ll get to my answer in just a minute. A year ago at this time, I was fighting with the bank for a loan. It was painful. They were telling me that any day I would hear . . . then they would never call. I was also trying to get malpractice insurance and there were delays after delays. But enough of that . . . all water under the bridge now. But it is a year later now. Here is how I answer the question. Imagine you were a man you fell in love with a strange, yet beautiful woman. She is this hybrid of genius and  lunacy, of tenderness and uncontrolled mania. She wrecks your life, crashes your car, takes your money, destroys your nerves, but loves you intensely while she eats your heart like a carnivore. She soothes your pain but smears your face with total chaos. When its all over, a friend asks you, “Don’t you regret ever meeting her?”  Then you just stare off into space . . . speechless.  That’s what’s been like. It has been a year of more continuous stress than any time I can remember.  In the last 365 nights, I’ve had trouble sleeping at least 300 of them.  I’ve been on the edge of bankruptcy several times and yet, here I am ten months after opening my doors, at that point again. So people ask, “Don’t you wish you had never done this?” I just stare out the window in silence. It is a crazy world, this world of medical business. Up one minute, crashing the second.  Just a few week ago I was trying to decide what I should do with my extra money. Pay my loan off early? Give myself a raise?  Hire that third provider? The winds of February blew in a perfect storm my way that sucked the financial blood out of me and my bank account. Right now I’m back at that point of counting tens of dollars to see if the money is there to pay the next bill.  I can’t cash my own paycheck right now and for the foreseeable future. We had to shop and shop to find the cheapest toner cartridge we could today. So what happened?  The first wind of the perfect storm came in the form of my supervising physician being out of the country for two weeks. The state required us to close.  Not a big deal. We do need a vacation sometimes, pus I spent one of those weeks in the office doing non patient seeing activities.  But it also meant two weeks of no revenue generation at all. The second great wind gave in the form of a HITECH (Obama Care EHR money) incentive gone a muck.  It is a long story, but we had spent over a hundred hours working on receiving a grant from the HITECH bill. They assured us that the second week of February, about the time our two week hiatus was ending, we would get a check for $18,000 . . . which was more than enough to make up for the loss revenue. We got back from our trip and there was no check. We had worked with the HITECH people for several days, then they finally figured out that because the PA (I think that means me) saw more Medicare patients than the SP, that they couldn’t give us 18K after all. No, we would be getting about $800 dollars instead . . . an it won’t come until March. The next whammy also involves the Feds. Because Congress is so incompetent, the national budget has had delayed and delayed. So, Medicare is technically broke. All Medicare money is being frozen right now. That hurts. Lastly, several insurance companies have decided that they would immediately stop sending checks to PO Boxes.  I’ve fought tooth and nail with the Post Office and our landlords for almost a year to get mail delivered to our office. To make a long story short, tomorrow our mailbox arrives, and we should be getting mail at our office by next week. But you would think that we were living in the Third World. So, I require $900 per day income to stay afloat. In the last four weeks we have suddenly averaged about $200 per day.  The cushion is gone . . . being replace by cold stone of reality. Are we going to make it?  I’m so confident that it will, that I had a phone conference early this morning with the custodians of my retirement fund. I am poised to liquidate.  So here is the great irony.  With my fears about the coming loss of money, I did some strategic things to increase our marketing.  It was like throwing a rock on the side of a mountain . . . creating a huge avalanche.  We are completely overwhelmed with patients right now. It is as nutty as the day the latest Air Jordans shoes were released.  There is a riot at our door wanting to get in.  We are %120 booked through the third week of March and the demand is growing. I think we have hit critical mass. So, don’t I regret walking into this valley of constant terror and turmoil? Don’t I wish this was a year ago before I made a commitment? I sit and I stare out the window of my office.  I sigh. I look at my clock and it is 7 PM once again . . . and I want to go home.  But I sit in silence. I look out over the acres of sailboats moored just outside my door. The lights flicker in a few of their portholes. I sigh as the question is asked again as if I hadn’t heard, “Man if only this were a year ago . . . if only.  If it were . . . yes, I WOULD do the whole thing all over again.” What’s wrong with me!?  Why do I like to tango with the torturous?  

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.