waves

"you can't stop the waves from coming at you but you can learn how to surf"

Words to me from the wisest and most loving person I know.

My absence from blogging these past few months can't really be explained well.
Writer's block, maybe?
Lots of thoughts swirling in my head, but not able to put pen to paper.

And then there were the waves...

Unexpected illness of my Mom.
Tropical Storm damage to our home.
Financial uncertainty.
Progressive erosion of our country's culture.
Further decline of our healthcare system.

But then I popped up.
And balanced my stance on that board feeling the wave beneath me.
Experiencing its strength as I was propelled forward in the surf.
Salt air, ocean, warmth, freedom, purity...

Find your wave.
And hold on to it.

way over yonder

The delivery of healthcare in rural areas is in crisis with hundreds of hospitals closing.

According to researchers at Navigant, 10 states are at the highest risk of rural hospital closures. These include: Kentucky, Iowa, Oklahoma, Michigan, Arkansas, Minnesota, Alabama, Georgia, Kansas, and Mississippi.

Emergency and maternity services are most affected by this reality. More than half of all rural counties lack a hospital offering obstetrical care which increases the risk of pregnancy-related complications and poor birth outcomes. The increasing Obstetrician shortage is a significant contributor to this unfortunate issue.

When I opened my own Gynecology-only private practice 6 years ago, I never dreamed I would be delivering babies again. At that time, my plan was to provide "comprehensive high quality evidence-based office and surgical gynecologic care in a warm and relaxing environment". Which I did. But as the practice evolved, I realized the projected revenues were significantly less than anticipated (in part, due to my purposeful decision to spend more time with my patients accompanied by declining reimbursements). I began looking for extra work ("physician side gigs") as well as making the decision to return to school (more school?!) to learn the "business side" of Medicine.

For 18 months, I was a student in a hybrid (distance learning plus in-residence sessions) Masters Program for mid-career healthcare professionals. One of many "think tanks" where solutions to our complex healthcare system's problems are brainstormed. It offered me an incredible learning experience as well as the opportunity to work with national healthcare leaders.

I met two healthcare leaders from rural Kansas who through innovative strategies were successfully growing their hospital's Obstetrics service line as well as improving patient outcomes. This inspired me to obtain my Kansas medical license which led to my first rural locum tenens Obstetrics assignment.

Over the next two years, I've been fortunate to help hospitals in rural Kansas, Texas, and New Mexico. What started as a "physician side gig" has evolved into a renewed passion of practicing full-scope Obstetrics and Gynecology again. And helping others.

I encourage my physician colleagues as well as mid-level providers, nurses and ancillary support personnel to help our rural hospitals stay open. There are many locum tenens opportunities available throughout the United States with the flexibility of working a long weekend every few months to several weeks at a time.

"Way over yonder
Is a place that I know
Where I can find shelter
From a hunger and cold
And the sweet tastin' good life
Is so easily found
A way over yonder, that's where I'm bound..."

Carole King

flying solo

Given the complexity of our current healthcare system, is it possible to be successful in solo private practice?

Yes.
With careful and well thought out planning as well as patience, it can be done.

The rewards of professional autonomy cannot be emphasized enough.
Here are just a few:
The ability to take care of patients in an unhurried manner.
The freedom to set one's hours.
The opportunity to select your staff and empower them to work at the top of their licensure.

Keep things simple in the beginning, you can always scale up later if desired.
Think leanly in terms of start-up costs.
Negotiate, negotiate, negotiate.

(1) Develop a simple business plan
How many patients do you envision seeing each week?
How many hospital procedures, surgeries, deliveries can you do per month?
What gross income would you eventually like to earn?
How many days of vacation each year would you like to take?
Talk to your accountant about your plan.

(2) Contract with payers
Every physician has a unique NPI# which can be used to contract with insurance companies as an individual provider.
Calculate what your average revenue per patient encounter will be.
This will determine your projected gross revenue per month.

(3) Financial
Plan for a 6 month launch.
No income for 6 months so secure a nest egg of savings.
Set up PA or LLC with your state.
Bank account.
Business credit card.
Obtain small business loan.
Get liability coverage.

(4) Negotiate with EHR companies
Select one that can provide both documentation, e-prescribing and revenue cycle management.
Get several quotes from various vendors.

(5) Pick out an office space
How many exam rooms will you need?
Provide ample work space for front office staff and nursing staff.
Recommend two bathrooms: one for patients, one for staff.
Aesthetically pleasing waiting room.
Adequate parking.
Wheelchair accessibility.
Close proximity to ancillary services: imaging center, hospital, laboratory services.
Easy to find.

(6) Build out office
Negotiate cost of build out with landlord.
Sign longer lease to get reduced rent.
Furnish with second-hand exam tables, medical equipment.
Enlist help of office staff with selection of furnishings.
Phone system, fax, computers, printer, shredder.

(7) Hire staff
Two well-trained, devoted employees is all you need!
Recommend one employee as your Office Manager and the other as your Patient Care Coordinator.
Cross-train your two employees so they can cover for each other.
Meet regularly and enlist their opinions in setting up your practice.

(8) Develop marketing strategy
Inexpensive basic business cards.
Simple website.
Facebook page.
Reach out to existing patients.
Ad in monthly community newsletter.
Network with potential referring physicians.
Meet with hospital marketing representative.

(8) Schedule patients!
Dry run with mock patients prior to opening day.
Schedule lightly the first few weeks.
Send thank you notes to those who refer patients to you.

(9) Opening day
Fresh flowers.
Refreshments.

Begin celebrating the professional life you have imagined!

negotiation

"Everything is negotiable. Whether or not the negotiation is easy is another thing." Carrie Fisher

This is an important concept to remember when transitioning from residency training to your first clinical job or as you segue from one clinical job to the next.

My youngest daughter begins her first year of medical school this week. I've glanced at her curriculum which includes Anatomy, Cell Biology, and Development of Clinical Skills. Notably absent are courses on Operations Management, Finance, Strategy, Healthcare Economics, and Negotiation.

Because the delivery of healthcare is a business in the United States, I feel the basic tenets of business education should be introduced to future physicians beginning early in their training. So that they may be better equipped to work as part of the team of people taking care of patients. So that they may be better prepared to negotiate employment contracts, payer contracts, etc... So that they may better understand how their "work product" affects the company bottom line.

Specifically, understanding the concept of BATNA can aid future physicians in positioning themselves in the best financial situation. Thereby avoiding further accrual of debt, avoiding burnout, avoiding being taken advantage of. Leading to less stress, better productivity and yes, better outcomes for patients.

Learn how to negotiate. Remember, there is no healthcare without the fundamental physician-patient relationship.

You are in the driver's seat.

navigation in choppy seas

The cost of healthcare is rising. Patients are having difficulty affording out-of-pocket costs for recommended drugs and treatments. Retirement savings are being tapped into for the purpose of paying for healthcare costs.

How did we get here?

What can patients do?

90 years ago, the first employer-sponsored hospitalization insurance plan was created by teachers in Dallas, Texas. President Lyndon B. Johnson signed the Medicare and Medicaid programs into law in 1965. Over the next 50+ years, the health insurance industry has become increasingly more expensive, more complex and more difficult for patients to navigate.

Rising monthly premiums, more prior authorization requirements,  increasing medication, procedure and ancillary service denials, and unaffordable out-of-pocket costs are all contributors to this complexity. This creates confusion for patients as they navigate the healthcare system.

Some pointers:

      Understand your healthcare insurance policy as it is a contract between you and the health insurance company. Take the time to learn and understand the following terms: individual deductible, family deductible, co-pay, co-insurance, annual maximum allowable. Remember, your healthcare provider does not know the intricacies of every health insurance policy.

      Understand what is and isn’t covered under your plan.

      If your plan is employer-based, take the time to meet with a Human Resources representative from your company in order to better understand your policy.

      Establish an HSA (health savings account) with deposits from your pre-tax income that can be used to pay out-of-pocket healthcare expenses. The unused balance may be rolled over annually. Understand which out-of-pocket expenses may be paid from an HSA.

      Shop around! There is considerable price variability between imaging centers, medical practices, labs, pharmacies, urgent care centers and hospitals for healthcare services--even within the same zip code. Price transparency exists for almost all consumer goods except healthcare. Ask about prices. If you can’t get an answer, then keep shopping…

      Ask about “care credit” whereby large medical expenses may be paid using a monthly installment linked to your credit/debit card, HSA or bank account.

      Ask about reduced prices for payment with cash rather than filing an insurance claim.

      For non-urgent care, I recommend doing your homework. Shopping for high quality, low cost medical care is worth it.

      And finally, take advantage of annual preventive services covered by your health insurance policy. Most preventive services are $0 co-pay. Be sure to mention any symptoms or concerns to your healthcare provider at the time of your annual exam.

Here’s to calmer seas…

show me the money

The delivery of healthcare is a business in the United States. Healthcare costs consume 18% of our GDP. This is projected to increase to 20% by 2026. Despite this, our health outcomes rank 37th in the world.

Hospital systems are either for profit, not-for-profit or funded by the government. For profit hospitals earn money for their investors, not-for-profit hospitals earn money which is funneled back into the operating expenses of the hospital, government funded hospitals rely on tax revenues for operating expenses. But the bottom line is the bottom line, regardless of the financial structure of the hospital. 

Why is healthcare so expensive in the United States? 

What can be done to improve this situation which is frankly not sustainable?

Simple answer to a complex question: all stakeholders in the healthcare system need to be less greedy.

Less greed on the part of insurance companies (the CEO of one insurance company earns a reported $15M+ annual total compensation). Less greed on the part of hospital systems (why are C-suite executives earning more than physicians who provide the services from which the hospital profits?). Less greed on the part of pharmaceutical companies (rising drug costs are leading patients to stop taking necessary medications and tap into retirement savings to pay for out-of-pocket treatments). Less greed on the part of physicians (should we really be offering non-evidence based treatments to our patients for cash?). And yes, less greed on the part of patients who insist that their physicians order expensive unnecessary tests.

Everyone needs to do their part.

Together, let’s redirect the focus away from the bottom line and towards improving health outcomes.

Isn’t that what healthcare should be all about?

We really should be #1 not 37th.

au-ton-o-my

Autonomy: from the Greek roots: autos = self and nomos = law. Oxford English Dictionary definition "freedom from external control or influence; independence".  In childhood, autonomy is when one understands oneself as a self-governing individual.

A world-wide epidemic of physician burnout exists according to an editorial published in The Lancet (Physician burnout: a global crisis, The Lancet, July 13, 2019). Doctors are retiring earlier than planned. Suicide rates for physicians are higher than for any other profession. Not only does burnout affect physicians' personal lives, but also affects patients' care and safety. Why is this happening? Rising educational debt, increasing administrative tasks, long hours, professional competition, demanding patients, erosion of physician autonomy...

There is a sentiment brewing that our country's healthcare crisis may be aided by establishing a system modeled after the NHS in the UK where physicians are employed by the government. According to The Lancet article, 80% of doctors in a British Medical Association 2019 survey were at high or very high risk of burnout. Is this really the only practice model that should exist for our physicians?

I have worked under almost every practice model available to a physician: multi specialty group practice, hospital employed, academic medicine, small group private practice, locum tenens, solo private practice, full time, part time and for two brief periods in my career, I didn't work at all! Each model has its strengths and weaknesses and I chose each model for a particular reason (work-life balance, financial, benefits...) at a specific time in my career. But none has afforded me as much autonomy as solo private practice.

I realize that not every physician desires to be a solo practitioner, but feel that preservation of physician autonomy is essential to combating burnout. By encouraging a variety of practice models to co-exist, physicians' professional longevity as well as patient care and safety will be improved.

epiphany

Isn’t life funny?

The “retrospectoscope” allows one to see things more clearly than when we’re in that moment of cloudiness.

Crying without reason.

Time pressure.

Misdirected anger at patients and colleagues.

Broken relationships.

Unhealthy choices.

Stress.

Fear.

Perseverance and survival mode thinking led me to cast many lines in the water.

Many nibbles.

Few bites.

Then one day the cloud was lifted.

Joy has returned to my professional life.

Balancing solo private practice with locum tenens work in rural underserved areas.

Oceans and mountains.

Financial security.

Feeling appreciated.

Ready to share my story.

I didn’t realize I was burned out until I wasn’t...