S o, I got up at 5: 30 hoping to bike into work, but my new Saint Bernard puppy ran interference and delayed me. He likes to steal all my clothes while I’m in the shower . . . underwear upstairs, left shoe in the basement, shirt in the kitchen, right shoe out on the deck. You get the picture. I did get to work by 6:30 via Jeep. I had a meaningful teleconference call with Steve Hansen and Michael Powe about our insurance issue with Group Health. I feel hopeful and am grateful for their interest. I worked on that some more as I prepared for my first patient. Most of our days are spent as if we were holding on with both hands to the back of a speeding firetruck. We rarely get 15 minutes for lunch and when we do, I feel a little sick about it . . . worried about lost revenues. Today, we had a new patient have to cancel at the last moment, opening up a 1 hour and 45 minute lunch. We couldn’t fill it from our waiting list. Our finances are in decent shape for once. The sun is out, the temps near 80 and . . . for the first time this season, I had my kayak on top of my Jeep and my paddling clothes in the trunk. Years ago I fantasied that if I could create the perfect PA job, it would be my own headache clinic, on an island’s beach in the Pacific Northwest . . . where I could jump in my kayak at lunch and go for paddle and then back into the clinic for the afternoon patients. Today, that fantasy was realized. I grabbed an ice tea, threw my kayak in the water (the launch is about 25 feet from the front door of my clinic). I donned my paddling clothes and paddled out to were I had a full view of Mount Baker . . . heavily snow-clad where the fiery peak is still doing battle with winter. It is peace, finally peace, after a year of hell. :> )
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I’ve alluded to these stories before but I want to tell one of them again, with an up date. These are things that you could never foresee when you plan a business. Everyone who has never done this would argue that somehow they are too smart or talented to allow these things to happen . . . but in reality, there is nothing they can do. We we chose our office space, I picked the newest and prettiest office building on our island. I think it was a smart choice. As part of our SBA loan, we had to sign an agreement that I would not leave this space for six years, the duration of the loan. We we first moved in, and had given out our address to all important entities, we noticed we weren’t getting any mail. Now the Post Office is just up the street and I’m sitting here typing and can see the top of the building easily. But, to my horrors, the Post Office told me that they did not deliver to this building. I spoke to the Post Master and he said they “never would and never will.” That was the only reason given. They had also sent back all of our mail as “no such address.” This caused a huge amount of nightmares including having our malpractice cancelled because we didn’t pay the premiums. It also caused a stir with many of our vendors, such as insurance companies. Finally we had to get a PO Box at the Post Office while we continued our fight. We had to give a “change of address” to the PO Box. This created a month delay in getting our payments and almost caused us to go bankrupt last summer. I was about to give up the fight in December, when Regence and a couple other insurance companies announced that they would no longer do business with practices who receive their mail via PO Box. One insurance company had already denied $3,000 in claims because of having a PO Box. I had to move forward more aggressively. The Post Office finally agreed to deliver mail but only of the mailman didn’t have to get out of his truck. There was only one spot where a mailbox could go. The landlords denied permission to put it there. I had to make the empty threat to move out (empty because if we moved out we would violate our contract with SBA and I would be force to pay them $65,000 immediately). So, finally the landlord approved the site. The post master took another month to give his approval. Then we put in our “change of address” to all entities. Oddly, every single insurance company, which refused to do business with us because we used a PO Box, only had PO Boxes. They are bullies and hypocrites! So, while we remain working our asses off, suddenly our income started to dry up again. Today, we finally had the chance to work on that. It turns out that if you do a “change of address,” in our case from a PO Box to a street address, it is counted as a “move.” So, if a practice moves, then the insurance companies denies payment until they credential you at a new site. This is so frustrating and they don’t care if this makes no sense. Any excuse to delay payments makes them richer. The last one, which had not paid us in a month, was medicare. We called them and said because we moved they would withhold all payments for 4 months. That was the last straw for me so I called my congressman this morning and we are working on fixing this. But who would have guessed that this would create such a nightmare for a small business.
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We will be approaching our anniversary date in a a few weeks and I wanted to do a series, maybe just two, posts about where we’ve been and where we are. A quick update: The demand for our services has never been stronger. Two of the five headache practices in the state are shutting down, so the demand should continue to grow. I’m quite confident that I could hire and support a new NP or PA in headache. The trouble would be the transition months. They would want a guaranteed salary. We would not have the funds to support them until their revenues started coming in . . . which would take about three months. I’m still trying to get my head around that idea. The bank has refused to help us. The revenues are steady. We are not getting rich as I have a large debt load. Much of load came from the perfect storm were we had to greatly under perform for about six weeks. It was the combination of the holidays, my office manager being out ill, snow storms and my SP being out of the country for two weeks forcing us to close our doors. But I’m paying off the Feb debt $5,000 at a time. At this rate it will take two more months. I think we have helped a lot of people. It is so rewarding having patients come from 100 miles away on a whim (having been followed by several other clinics) and then to find relief. As a couple of patients told me last week that this is the best they’ve done in 30 and 40 years respectively. That’s why we come to work everyday. I hate this idea of having to focus on money and worry about it. But if we don’t have the money to keep the doors open, then we can’t help the patients. In this posting I want to speak of one big lesson I’ve learned over this first year. I may share more later. A wise PA, who had started his own practice a few years ago, told me, “Mike, figure your budget the best you can. Then double your expenses and halve your income . . . then you will have an accurate number.” That didn’t seem right to me. I honestly felt like I could do things better. Be more efficient. Hire good people, yadda, yadda, yadda. But, he was right. I wanted to talk about why he was right. The Principle of Vendors: All companies need vendors to survive. These are the suppliers of materials and services that you need to run a business. The way that vendor companies usually work, is that they have a sales force that pulls you in. You have to keep in mind that the salesmen work on commission. By selling you products and services, they are able to pay their mortgage, buy their cars, put food in their babies’ bellies and buy their little princesses the latest Justin Bieber CD. So, they are highly motivated to make the sale. Once you have purchased their product, they disappear. Products and services are always over sold. They never perform to the level you were told and they ALWAYS cost more than you are told. What is worse than that, is that you then decide that you will not take the disappointment sitting down. So then you go to war with your vendors to get what you had paid for. You can only fight so many wars for so long and you become completely exhausted. So when a phone company says their system can do A-Z and cost $x, what they really mean is that their phone system can do A – E and cost $x+30%. If you later want F-Z, it will cost you $x+300%. That’s just one example of hidden cost. I will give another example. I pay $500/month for billing software. My biller doesn’t like the software. I started a dialog with several companies. It was like entering shark infested water coated in blood. The phones rang off the hook. We finally “test drove” a system that promised to cost us $300/month. After wasting hours on it, in the end (through bait and switch) we found out it could not do nearly what we wanted then, through hidden fees, realized it would cost us over $600/ month. But that was a lot of wasted energy and time. Positive Note: One of the things that was keeping me awake a year ago was my fear that there would not be enough patients to support practice. By hard work (connecting with our referral base) and giving our patients a good service, we have had plenty of demand. Patients don’t seem to care who owns the practice or who sees them, if that provider is knowledgeable and compassionate. I will be back as I have patients coming in the door and I must go. That is another issue, giving up virtually all your free time in order to keep the ship afloat.
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Before creating this clinic, I had a hand full of worries. What if the insurance companies don’t credential with us? What if the patients don’t come? What if . . . maybe a thousand other things? The money is trickling in . . . but enough to pay the bills. Much more is on the way. So what is the great stress? We are in the middle of an avalanche of demand. We have had a 120-120% full schedule for the past four weeks. Looking into the future, it is the same well into April. The problem? I have calls every day from providers asking me to do them a favor and work in their patient, before we open, after we are closed, during lunch . . .anytime! All our lunches are booked. We haven’t seen the benefit, financially of all the hard work as we just came out of our “being closed shadow.” But it looks good for the coming weeks. My mind is contemplating hiring help. But it is impossible do that without some financial reserve. It is just ironic how I laid in bed a night or two a year ago worrying . . . what if I build it . . . and no one comes? Guess what? They came.
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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.
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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.
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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.
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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.
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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?
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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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