What Price Would You Put on Freedom?

[jmj11]

So here I am at my sixth month point of opening my clinic. It has been stressful to say the least. It has been financially challenging at best. I'm still paying myself at the 10th percentile (from the bottom) for working 70-80 hours per week. So then, this past week I get this job offer. Over 100k for 40 hours a week (or less). I thought about it four about . . . 20 seconds. First of all, I still have debts with my new clinic that I want to pay off. But the real issue is freedom. I have total freedom for the first time in my career. I decide when to open, when to close, what patients to see and etc. No more calls at 9 PM, when I'm NOT on call, from my SP telling me I HAVE to go to ICU to see a patient because, although he is on call, he has out of town guest and can't go.

 

I'm going to a meeting this week in Az and I don't have to ask anyone's permission. I don't have beg to get my expenses paid. I am staying at the 5 star resort and everything is being paid for (by myself but by my company). There is no turning back now. As bad as it is some days (and I spent the week-end putting out fights between my office manager and my new biller) I could not work for someone else again. So, I know it varies from person to person, but how much value would you put on freedom? I must be putting about 50-100 K a year on it. I think I'm ruined . . . for the better.:wink:

[EMEDPA]

When I went from my first to second job for a better scope of practice I took an eight dollar/hr pay cut and lost time and 1/2 for overtime. that probably cost me 20k/yr.

when I went from my 2nd to third job I again took a pay cut which works out to around 50k/yr for a better schedule, better scope of practice, and the ability to work with docs who respect me more than any previous full time job. I wouldn't have it any other way. I still make good money for an em pa but I no longer make top 5 % income.

[ventana]

still chugging along working for others - - still working on a business plan to open my own clinic

 

 

honestly I would rate the ability to control your own future at atleast 50k and likely approaching 100k per year

 

BUT I think this mostly depends on the basic personality that you have - I know a great many PA and NP who are content to make 80-100k per year with a 45 hour work week and just keep workin away....

 

If you are one of these it would not be worth it to open a business as you would not see the benefit

 

BUT if you are one of (2) other types then a controling you own fate is worth a LOT

the two types -

1. the person that wants to not answer to anyone and will be willing to take equal pay for more work to be able to control their own day - my wife is this and owns here own PT/OT clinic and is not getting rich, but loves the control

2. the person who likely has less of the above trait(but still some) but is tired of other people making a living off their efforts and at the same time a little head strong and confident(?) that they could do it better then what they are seeing - i.e. why is the whole practice running 30-90 minutes behind schedule - does this not discount our patients valuable time? or that the person is tired of generating 200K+ for their employer with out getting the benefit - in this case I would value it at about $60-75k

[brianprepa]

I am not a PA but I have worked in every non-provider position within the neurology physician practice setting. Office manager, billing manager, transcription, credentialing and insurance negotiations, EMR implementation, sleep/EEG/NCS/EP tech--have done it all. In my various positions I have seen so much time and money wasted by physicians because of not knowing at least the basics of these positions and not finding people they can trust. I watched my last boss spend 25k on an EMR system. There is an open source system that is just as good and certified. I have seen terrible billers who do not do follow up-after six months when the cash flow starts to really dry up then the physicians take notice but its too late then. This year in my clinical duties as a tech my tests have generating 600k+ in revenue. Thats ok because I don't have any of the malpractice risk with the patients. I am a tech.

 

If I were a PA with confidence in my ability to work autonomously I would take some time to learn about the business of medicine so that I will not be fooled or make mistakes, I would bring on people I trust and pay them well to keep them happy and so that they stay, I would only purchase necessary items and use open source whenever possible. As a PA you share the risk so you should share a greater part of the reward. As a tech and a manager I can make about 65k. Some of the starting PAs make that----that is crazy.

 

Here's some resources:

Free EMR www.oemr.org

Don't buy Office, use openoffice.org

Learn billing, etc from the medicare learning network (CMS website should be your friend)

If you need to learn about something, Google is awesome

PM if you have specifics, I can't remember some things right now

 

If I were a PA and wanted to start a practice I could do it for less than 25k with full functionality. First year revenue in neurology would be 500k net minimum. That is definitely worth doing. But it does take the right kind of personality. If all you want to do is practice medicine, it probably won't work. If your interests are diversified and you are organized, then its not that complicated.

 

Cheers.

[jmj11]

brianprepa, all due respect, and I seriously mean that with all your variety of experiences, that I think that is a bit delusional. I had the same ideas (and ideals) which you allude to . . . small foot print, free sources, great people, pay them well, etc. Yes, I've used all the free software that I can. I do my own typing of notes and I have my SP do the same. I am even my own janitor. But my experience of starting a practice as been the same of the other five PAs and NPs I used as mentors. First of all, you can not start a brand new practice for just 25K. Besides all your upstart monies, you do have completely support your practice for at least the first two months while you are waiting on income to start rolling in. With that plus the basic furniture and equipment, you are quickly up to $60K. That doesn't even start to address the expenses for marketing and many other things.

 

I've worked in neurology for almost 30 years and have always seen the books. I've never seen a neurologist, let alone a neurology PA, collect $500,000 per year. Maybe they could do it if they EMGs 10 hours a day every day. I've seen the most productive neurologists collect $400,000. In headache work (because you are not doing EMGs, reading EEGs etc) the collections are lower. I've worked my butt off and collected about $300,000 for our practice at my previous job. I could have collected a bit more if I only saw good payers. But, it is hard to work in a rural area and not see some governmental payers in the mix.

 

I only post this because I don't want PAs who are thinking of starting their own practices to be idealistic and get burned. As one well-seasoned mentor told me, "Double your anticipated expenses and halve your expected income."

[brianprepa]

I work in a neurology practice with two physicians who also practice sleep. We are 7 years old now. Our expenses are typically about 30k per month and revenues are 125k. We do EEG, EMG/NCS, and PSG which is what primarily drives revenue (technical and professional). We didn't reach the $1 million revenue mark until the second year. Of course, being urban based we do not accept medicaid but our rates are typically 100-110% Medicare. Our first year was less busy but by the second year we were doing 20 EEGs per week and about one EMG per day. Now we do about the same number of EEGs and EMGs but also do about 50 PSGs per month and a couple of 48 hour video EEGs. So the two docs clear about $1.1 million per year (they're married).

 

I am glad you posted because I did not mean to give the impression that anyone can start a practice for nothing. However, why would you support a practice for two months? Credentialing should all be handled prior to opening. At the end of your first day you submit claims electronically, paid in 3 weeks. You can do the billing, claims filing, etc yourself fairly easily with such a low volume. Get the family to help with scheduling, or billing, etc. Marketing is important but is not expensive. Make a brochure and have it printed in the desired quanitity. Have your friends, family, wife, someone who is professional (or even you) spend a couple of days visiting the primary docs in the general area. Neurology is underserved, especially in rural areas, and the referrals will come. Spending some time on your website prior to opening will help. As for furnishing the office, our practice recently opened a second clinic and we found second-hand (but beautiful) furniture for the entire office for $2500. We spent about 1000 per room (exams and sleep 5 rooms). Computers and EEG/sleep EMG equipment can all be leased or rented. It really is doable but everyone is stuck in the 'it cant be done' mode. Insurance is the most expensive part.

 

Takes sacrifice but in the end all patients really want is great medical care and you need to be able to have a reliable operation, not necessarily fancy or expensive. So my estimation was based on actual experience, not delusion, but was only an amount needed to open the doors and get started. As the months go on you will end up with more expenses, but you will also have income. Only a few could do it that way, but it definitely is possible. It all depends on your business aptitude, tolerance for menial work, and willingness to see it through. Most would rather do what they feel is their calling, practice medicine, and that is also a beautiful thing.

[jmj11]

brian, I'm simply not going to continue this discussion here. My experience in starting and running a new clinic is typical of the five other PAs and NPs who have done it and who were my mentors. I'm just concerned that your idealized suggestions are going to be taken to heart by a PA here and they get burnt badly. I hear "expert practice starters" here and on another forum talking about how easy it is, yet us who have done it just have to sit back and smile and shake our heads. Unless you have done it, alone, yourself, you have no clue about how to start it.

 

I will just mention the one ideal about the start up of running the practice for two months. What you talk about is the text-book idealize start up. No practice, especially one own and started by a PA has such a rose colored experience. We are not stupid people who have done this. We all have done our home work. We are not business neanderthals. But I'm just saying that unless you are a PA and you have done this, I take what you say with a grain of salt and I'm just concerned that others will get the notion that this is easy. It is not.

 

I could write a book describing the difficulty. But getting back to the income the first two months. I did a huge amount of research and hire one of the best credentialing companies in the country. They started in April for an opening day on June first. My clinic was the most difficult they had every processed for several reasons. One, it is PA owned. Two, it is a sub-specialty and I could add a few more points. Their work alone cost about 20K, because they were the best and we needed the best. For your information, I have worked my *** off for a year. I didn't have all this free time you are talking about to do things myself. I left an eight year practice and was swamped with last minute demands for my services. I opened the doors of my new clinic and have been completely booked out for weeks from our opening day. We worked in patients early, worked through lunch and stayed after work to see patients almost through the whole summer. Yet, and consistent with every PA and NP I've talked to, did not see real money coming until towards the end of august. I had to make payroll during this time.

 

So, I'm ending this discussion. When you, as a PA, go out and start your own practice from scratch, then come back and we will have this discussion. But I'm warning PAs out there who are thinking of starting their own clinics, to take what you say with a grain of salt. I too was idealistic to some degree. I thought I could do things better. But there are so many barriers and things that they just don't teach in Harvard's business school. Only listen to those of us who have done it.

 

I will add one more bit of warning for the listener. You speak of how your neurologists bring home $600,000 each per year. I will put everyone here in touch with reality. The national average income for a neurologist is about 185K a year. The extreme top end is about $380/ year. So your neurologists are $600,000 year, and according to you, that was an easy obtainable salary . . . something isn't right here.

[Contrarian]

It can be opened for $25k... but that's just it... the doors will simply be opened.

 

I stopped reading at the assertion of getting paid by third-party payer within 3 weeks of opening..

 

Also account for the local medical/nursing community "PA Haters" that WILL mount a obstructionistic campaign against your practice. I'm dealing with that now.

 

signed... "a Clinic Owner"

[paporzelt]

I'm curious....how do open you'r own clinic, how do you get around the physician supervision especially with billing. are certain specialties better for this type of situation?

 

-totally clueless anything having to do with this, but curious.

[brianprepa]

My point in writing was to actually applaud the PA's who have gone out on their own or who are thinking of doing so. I was encouraging putting all your effort in and taking the time to be able to set yourself up for success, without huge debts and the stress that ensues. You are correct, I have not set up a clinic as a provider, I can only imagine that is difficult. Nor do I think providers have free time. That was why I said it would take a certain type of person who was able to make the time for it. Obviously hiring a firm to do the credentialing, etc is a large expense and does not fall into the scenario of what I was describing. That is why I mentioned that a PA would have to really do their homework so as to avoid paying a company for such services, who in my experience, are not usually worth the cost anyway. I described having to do all the work yourself or with the help of family. However, I have set up four clinics from scratch for my employers in the role of an office manager. I had to go through the entire process four times. So I do know all thats involved. In every case, I watched providers spend money on unnecessary items that they believed were essential because other providers told them those items were required, and they knew since 'they have been through it themselves.'

 

I understand you being leary of people coming on forums making claims, which is usually to get business for themselves. Believe me, I don't want anyone's business. I am happy with the money I make in my job and with my other business interests, so I am not wanting to do practice management in addition. Besides, I was telling people to do it for themselves.

 

In actuality, for a June opening the ball should have started getting rolling the previous October with planning and credentialing, etc beginning in earnest January 1. Everything could have been ready opening day. Lack of knowledge and/or preparation is usually what causes problems. Your management company should have advised you to wait an additional 2-4 months before opening, but they were looking to get paid. Had everything been started in the right timeframe, with all the details worked out and even some claim mapping done prior to assure accuracy, three weeks for reimbursement would have been expected.

 

I agree with you however, very few could do the scenario I described, and not at all if you hire any part of it out for the first two months. Please take jmj11's advice and follow whatever course he suggests, it probably fits into the way a majority of people would work.

 

As for your claims about our income it breaks down this way (but we are epilepsy-based):

 

EEG 4 per day = 20 per week @ $325 * 48 weeks= 312k

NCS/EMG 1 per day =5 p/week @ 550=132 k

PSGs = 50 per month * 12 @1200 = 720k

48 Hour video EEG = 2 p/month @ 2000 p/24 hours = 8k p/month *12 months = 96k

Consults = 30 pts p/day * avg $150 p/pt *48 weeks = 216k

Total $1,476,000-360,000= $1,116,000 revenue for 2 physicians

 

I didnt mean to argue nor do I want to give people false hopes. Like I said I applaud you. As a tech, I hate performing an entire 8 hour sleep study, scoring it, generating the report and then the doc takes 2 minutes to review, sign off, and make most of the money. But thats his practice and his risk so its ok. If I could practice, well lets just say, I wouldnt share that much revenue if I also share the risk. So i was actually trying to help and encourage you guys to go out on your own if you are so inclined. I also said people could ask me questions. I may not be a PA but I have been in the business management of healthcare for 15 years and i know how to assure a practice makes money, as the above revenues prove. I am sorry if I offended. I wish you success.

[andersenpa]

I'm curious....how do open you'r own clinic, how do you get around the physician supervision especially with billing. are certain specialties better for this type of situation?

 

-totally clueless anything having to do with this, but curious.

 

I'll let the clinic owners chime in for details, but you never get around physician supervision. It's state practice law. You arrange it such that you fulfill the state requirements to the minimum extent which allows you the most freedom/autonomy.

 

OK, Mike/C, fill in the details if I am off base....

[Contrarian]

Thanks for the clarification...

 

But as a non-PA... there are problems you aren't realizing.

 

If he has a June opening... and as you say... should have started in October... then he would have had to sign the lease and start paying rent in Oct/Nov. to secure the location or else it would have been occupied by another business. This is rent without income because he isn't going to open until June.

 

He could increase his loan to pay/cover this... but then that just makes it harder to secure a larger loan. To secure the loan... he would need to show that he was credentialed and the potential income he would generate.

The location (clinic space) is required for credentialing, and licensing, and practice plan, etc... which is required to secure the loan.

FYI ... they don't grant loans to PAs/NPs like... as easy as they do to Physicians.

 

Yes... its circular...

 

And yes... I opened mine for ~$25k... but ts in a different real estate market/location and I don't accept insurance of any sort and only open 3 days a week.

 

Thanks

[Contrarian]

Andersen is spot on...

 

I'm curious....how do open you'r own clinic

 

Like any business. Planning, savings, loans, etc.

 

 

how do you get around the physician supervision especially with billing.

 

You don't...!!!

You move and practice somewhere ... where the PA practice laws allow minimal "supervision" and you arrange you practice style to meet that minimum.

 

re certain specialties better for this type of situation?

 

Yes... basically non-procedural-"cerebral" specialties that don't require a gaggle of specialized equipment.

[paporzelt]

i obviously didn't mean "without supervision" literally; I didn't sleep through my Law class, but here in NY its a bit stricter than other states. ...what I'm asking is how does one meet the supervision requirements without having an MD on staff? Hence it being your own practice.

 

so these type of PA owned clinics are really best for neuro is what you're saying?

[EMEDPA]

you pay a doc 1000/mo to carry a cell phone and sign the min required # of charts/mo.

the doc is "on staff" but either never sees pts or only the min required by law. some states say md on site 4 hrs/week, etc

in NC for example a doc needs to talk to a pa about their practice twice a yr to meet the supervisory requirement.

[EMEDPA]

primary care is probably the "easiest type" of pa owned practice to open. I know several pa's personally who have done this successfully.

following jmj's struggles I would say neuro IS NOT an easy field for a pa to own their own clinic in.

I believe his is the first subspecialty pa owned h/a practice in the country.

very few pa's open specialty clinics. most are primary care, occ. med, or urgent care.

I know of one who runs a bunch of wt loss centers.

you need to think long and hard about opening your own practice. it's not as easy as it sounds.

[brianprepa]

Thanks for the clarification...

 

But as a non-PA... there are problems you aren't realizing.

 

If he has a June opening... and as you say... should have started in October... then he would have had to sign the lease and start paying rent in Oct/Nov. to secure the location or else it would have been occupied by another business. This is rent without income because he isn't going to open until June.

 

Actually this is not a PA issue but a business planning issue, with multiple options for resolution. First, is the general area that you want to practice in foreign to you? Most likely you are choosing an area that you are familiar with and have relationships with other providers. Use those connections. If you have very good relationships with certain providers, or you know some who are struggling, or ones like yourself who only use an office a certain number of days per week, approach them about renting space. There are other businesses where such a space-sharing arrangement would be appropriate, such as executive offices that are very inexpensive and are a month-to-month arrangement. Use a PO box for your correspondence/billing address to use for the insurance companies. Changing that address causes many problems but a PO box is transferable to any practice location. Changing your practice location with the insurances is typically not that much of a problem as long as you aren't changing your mailing address. If you have a great relationship with your current employer where they are perhaps your friend and understand your motivation for leaving, perhaps they would allow you to list their office as the practice location, which would be accurate at the moment, while still utilizing a PO Box for your mailing address.

 

If you absolutely must (and I doubt that) sign a long-term lease and begin paying rent immediately, then see what other options there are for generating revenue. In specialties you can contract with a testing provider who could utilize the space. That would be building a patient base prior to your start date. Or perhaps there are other professionals in complementary fields that are looking for flexibility also, such as another PA or a doctor that wants an office one day per week. Or perhaps a psychiatrist or counselor, etc. There are as many legitimate, ethical options as you can conceive. It takes time and planning, but is an approach that mitigates risk of failure and reduces debt.

 

 

He could increase his loan to pay/cover this... but then that just makes it harder to secure a larger loan. To secure the loan... he would need to show that he was credentialed and the potential income he would generate.

The location (clinic space) is required for credentialing, and licensing, and practice plan, etc... which is required to secure the loan.

 

If a loan is required it is much easier to obtain when you have insurance contracts in place, or perhaps if you are already doing ancillary testing, then you are already generating revenue. Besides, if you take the previously discussed high costs of a facility out of the equation, the loan amount is significantly reduced and may not be necessary. If the loan is only for equipment, then that can be fairly easily obtained because there is collateral on that.

 

 

FYI ... they don't grant loans to PAs/NPs like... as easy as they do to Physicians.

 

True, but as I wrote, it may not be necessary. Banks care about your ability to repay. If you have already put things in place with contracts, location, and perhaps already generating revenue its much easier.

 

Yes... its circular...

 

Perhaps it doesn't have to be.

 

And yes... I opened mine for ~$25k... but ts in a different real estate market/location and I don't accept insurance of any sort and only open 3 days a week.

 

Thanks

 

You proved it can be done, although I am sure this is not the norm. If you are a general/family practice I guess not taking insurance makes sense. In specialty, the high costs of testing I think would make you lose out on a lot of revenue.

[brianprepa]

primary care is probably the "easiest type" of pa owned practice to open. I know several pa's personally who have done this successfully.

following jmj's struggles I would say neuro IS NOT an easy field for a pa to own their own clinic in.

I believe his is the first subspecialty pa owned h/a practice in the country.

very few pa's open specialty clinics. most are primary care, occ. med, or urgent care.

I know of one who runs a bunch of wt loss centers.

you need to think long and hard about opening your own practice. it's not as easy as it sounds.

 

I actually think that with such a demand for neuro services that such a practice would have a much higher likelihood for success and higher profits than other models, especially at first because you can contract with testing providers to immediately generate revenue.

 

However, I absolutely agree with the clinic owners here, it would be a huge undertaking. I don't think I ever implied it was easy. I did say it was not complicated. With planning, organization, attention to detail, willingness to sacrifice and do menial tasks, it is possible, even uncomplicated. But I wouldnt describe that as 'easy.' In fact it sounds very difficult.

[EMEDPA]

the issue is getting a state medeical board to approve a subspecialty practice with a pa owner/practitioner. jmj had a lot of problems with that. they are much more likely to approve a primary care practice.

issues specific to opening a practice as a pa(jmj & c., correct me if I'm wrong here):

finding a doc to collaborate with

board approval

loan approval(may be able to circumvent by mortgaging house , etc)

malpractice issues(will they even give you a policy?)

insurance companies willing to pay a pa

local physician groups blackballing your practice only because you are a pa

drug companies not wanting to sell specialty drugs to pa's without a doc involved(jmj had an issue with this- one of his drugs is for "rx by neurologist only")

 

it's very different than hanging out your shingle as an md.

[brianprepa]

the issue is getting a state medeical board to approve a subspecialty practice with a pa owner/practitioner. jmj had a lot of problems with that. they are much more likely to approve a primary care practice.

issues specific to opening a practice as a pa(jmj & c., correct me if I'm wrong here):

finding a doc to collaborate with

board approval

loan approval(may be able to circumvent by mortgaging house , etc)

malpractice issues(will they even give you a policy?)

insurance companies willing to pay a pa

local physician groups blackballing your practice only because you are a pa

drug companies not wanting to sell specialty drugs to pa's without a doc involved(jmj had an issue with this- one of his drugs is for "rx by neurologist only")

 

it's very different than hanging out your shingle as an md.

 

Corporate ownership of medical entities is almost universally accepted. I feel this is the best approach for a PA, to incorporate, contract and market as a medical practice. Don't name the practice John Doe, PA-C. Call the practice Main Street Primary Care. When you file with the medical board, you are practicing at Main Street Primary Care. Get malpractice insurance in the name of the clinic. When you list providers, list yourself and your supervising physician. Of course that's more expensive but should be prorated based on 'part-time' status. The coverage would only apply to his work for the clinic anyway so there's no overlap with the MDs own insurance coverage. This allows you to mitigate the MDs risk to a certain extent and should make the arrangement more appealing to an MD. There are also a couple of malpractice insurance carriers that specfically cover self-employed PAs if you go that route instead.

 

As far as contracting and getting paid goes, insurance payors typically have no difficulty paying a corporate entity.

 

As far as the local physicians blackballing you, again the presentation should be as a corporation. If the doctors group asks who owns the practice you simply say its owned by a corporation. If they ask who the doctor is, say the name of your supervising physician. In time it might get out that you are the provider but it doesn't work in your favor to advertise that fact. Why tell them that you are the owner or the only provider? There is no advantage to advertising your ownership/autonomy. If you are able, situate your physical location near practices who would likely view you as a good referral source as opposed to being near many practices in your own specialty. What type of practice do you send most of your referrals to? Locate yourself near that type of a practice. That practice will definitely ally itself with you, especially if you refer to them almost exclusively and often. That group won't care that the primary doctor 5 miles down the road doesn't like you, because they want your referrals.

 

As an additional protection, consider allowing someone else to become part of the corporation, such as a family member or even another business person who can infuse capital. That way if the medical board questions your relationship to the supervising physician, you are able to say that there is a decision making process regarding business practices among the owners. You can also say to the doctors groups that the practice is owned by some local business people. I recommend consulting a very good attorney who has worked with either PA practice setup or corporate practice setup.

 

Regarding drugs, if there is a requirement that a physician be involved with specialty drugs, that should fall within the scope of the supervising physician's contracted duties. It might be a hassle but there is necessity to work within the framework of the current laws.

 

The AAPA used to have an entire section dedicated to PA practice ownership but you have to have a membership to see inside the website now so I don't know what's there currently.

[brianprepa]

If you followed the backstory that this PA has, you'd see how every step of the way he hit barriers that physician providers wouldn't have to deal with, from the banks to the pharmaceutical reps. That's why it sounds silly to hear the solutions provided by a physician's office manager. Banks fall all over themselves for doctors and dentists, and a lot of the groundwork is in place to cater to them.

 

You can say 'you are not a PA' or 'you're only a physician practice manager' with the same condescending tone that a physician has when he calls you a 'mid-level' or 'physician's assistant' or 'just a PA.' That is fine. I am not belittling the PAs who have gone out on their own, I admire them. All I have tried to say is that there is more than one way to accomplish something. I also tried to offer some help. If the going is truly as difficult as you state, then why not allow some other ideas that might make it easier. Being a physician practice manager is not all I have done. I am also specialty-trained, multiple-credentialed technologist that performs and interprets diagnostic testing of the brain and nervous systems. I see the value of my work but do not share in it financially beyond my paycheck. I also do not share risk. I flirted with the idea of opening medical practice/testing facility at one time, but (funny) I could not find a PA/NP who wanted to practice autonomously. The shortage of neurologists prevented me from finding a neurologist but I thought there would be greater availability in the PA/NP field, but no dice. So I am very familiar with PA/NP ownership as I did extensive research at the time. I have since moved on to other things but take the things I write for what they are. If you find them helpful, great. If not, well this is the internet.

[brianprepa]

If you infer a condescending tone from what I wrote, then it's your prerogative to read more into things than I intended. But you come off way more condescending when you gloss over the difficulty the op faces. It reads very "let them eat cake" esque. I mean, yeah... Incorporate... Sounds great. Problem is that the op wrangled with issues and hit snags in places where you keep telling him he should have smooth sailing.

 

Ok if that's not how you meant it then please accept my apology. I went back and read much of the OP's prior posts on the subject and about the difficulty he had. My posts were not meant as a personal attack on the OP, just an observation that perhaps there's a different way to approach things. I actually admire him and wish there were more PAs like him, with his courage. In reading his story however I also read a post by Gregory Cain-PA. In Gregory Cain's case there was a different approach taken, with just as successful an outcome. In my opinion his claims were harder to believe than my suggestions: 'getting a supevising physician for 1000-1500 p/month, credentialed with Medicare in 23 days, bank loan was easy, did no marketing.' Yet he was encouraged to blog about it without any questioning at all by the OP. But when I posted something much more realistic, I was told I don't know what I'm talking about.

 

It probably should be noted that the state you're in matters. I am in Florida. Here the PA would have to have a license from the Medical Board to practice as a PA, like in every state. The supervising physician would add him as a subordinate practitioner to the MDs medical license file with the state. To receive Medicare, the practice can only be owned up to 99% by a PA so the PA would either have to incorporate with a family member or find another co-owner if they wanted to bill Medicare. Also, Florida has a law that if the corporation is not 100% owned by a provider and/or immediate family then it has to be licensed as an independent clinic. This is the best scenario because it legally establishes a separation of the clinic from the provider as an independent medical practice. What's more is that the state is making the distinction. In Florida this is the structure I would suggest. Other states have their own way to approach this, that is why you should see a great lawyer.

 

Like I said, I know a lot about this because I previously wanted to partner with a PA/NP to open a neuro clinic. I was going to do all the management, billing, etc and the diagnostic testing since I own my own equipment and am qualified. The PA would have seen the patients and obviously would have provided the medical care/direction. I would have gotten to do the business/testing side and the PA would have done the practice side. I even had a physician that I know who was willing to supervise. This was all in an underserved area but was just outside of Orlando so it was still in a desirable location. I just could not find any PA/NP that was willing. I realized later on that these types of business arrangements are usually built on trust after years of knowing someone and thats why I couldnt find anyone to partner with me. Additionally, even though I thought it would have been the best thing ever, it would have meant a ton of responsibility on the PA, as neuro cases can be extremely challenging and sometimes its not worth the headache. I was even given that reason for not wanting to partner with me, that 'I dont want that much autonomy.' So I do know quite a bit about PA practice rules, especially in Florida. But you are right, I have not done it for myself.

 

One more suggestion, if you will tolerate me. You know how taken advantage of many of you feel by the physicians. Others who offer value to a practice often feel similarly. Why not leverage those feelings for your benefit? I am sure there are awesome billers, managers, techs, nurses, etc. that you have gotten to know and have great relationships with that you also trust. Why not ask them to do some work for you? Ask them for advice. Most of the time they are eager to help. They often will do things without charge and you can pay them when you are on your feet. If a PA that I work with would come to me and ask me to help him with credentialing or billing, I would be happy, because I feel a kindred connection. That's leverage that you can use and they will feel that their opinion and work are valued. You can always bring them on as an employee later. Becoming autonomous from the physician does not mean you have to go it alone. But it should all be done with the thought of educating yourself about the issues so that you are prepared.

[Ocean]

I have been practicing dermatology in Texas for 10 years. My yearly income was 300,000. My annual receipts were 1.9 million a year. Not bill outs, Reciepts! It takes a lot of organization, now I own my own practice and my earnings would make you sick. But it can be done. Yes I do surgeries facial surgeries ears nose etc... I have my own lab. It can be done. Remember work like a dog for yourself and enjoy your efforts, or just work. The choice is yours.

[Guest JMPA]

When I went from my first to second job for a better scope of practice I took an eight dollar/hr pay cut and lost time and 1/2 for overtime. that probably cost me 20k/yr.

when I went from my 2nd to third job I again took a pay cut which works out to around 50k/yr for a better schedule, better scope of practice, and the ability to work with docs who respect me more than any previous full time job. I wouldn't have it any other way. I still make good money for an em pa but I no longer make top 5 % income.

I have left many positions, mainly out of boredom, and only have had an increase in salary. It's not what an employer can afford to pay you, it is what you feel you are worth. And yet now i feel so fortunate to be working with and for wonderful people whom i feel would not try to pay less then worth. Don't ever settle if you want happiness.

[EMEDPA]

I have left many positions, mainly out of boredom, and only have had an increase in salary. It's not what an employer can afford to pay you, it is what you feel you are worth. And yet now i feel so fortunate to be working with and for wonderful people whom i feel would not try to pay less then worth. Don't ever settle if you want happiness.

settling for a poor scope of practice makes me unhappier than settling for less pay.