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  • EntrepreneurMD
    replied
    In my experience dealing with insurers, it seems most do want acute patients to be seen within 2-3 days and, routine checks in 2-4 weeks. I believe they prefer this whether they are new or established.

    We try to do same or next day for acute, and within 1-2 week for general check-ups. Otherwise they end up at an urgent care - how long can you wait for a UTI or a respiratory infection? 6 months is a long time for new patients, we often get new patients that are hospital follow-ups so per guidelines 1-2 weeks is preferred if non-acute. To do that your employer needs to provide adequate resources (ie support staff) because you are a team, it's better from a patient care standpoint and for capturing new patients rather than them go elsewhere.

    I think most PCP's i talk to, myself included allow roughly 4-10 new patients a day. If you have a younger/healthier demographic, probably toward the upper number but less for a more complicated demographic. Sometimes the visits are not complicated so if you you streamline the intake (our patients download new patient paperwork online so they can complete before coming in) and as long as your staff can enter their information into the EMR efficiently, you should be able to see more without much intrusion to your schedule.

    Our demographic is mostly commercial and about 30% Medicare, no Medicaid, 5% cash pay.

    Leave a comment:


  • Antares
    replied




    Interesting perspectives. I was pleasantly surprised that it focused upon managing volume rather than marketing for additional revenue.

    Antares seems the most restrictive and rather exclusive. The vetting process must be stressful. (TIC).
    Click to expand...


    Yes, but on the other hand I’m 60 and in the last years of practice. It’s somewhat akin to going part time, as my need for income isn’t as great as it once was. Exclusivity is a privilege of age in my case...

    Leave a comment:


  • Tim
    replied
    Interesting perspectives. I was pleasantly surprised that it focused upon managing volume rather than marketing for additional revenue.

    Antares seems the most restrictive and rather exclusive. The vetting process must be stressful. (TIC).

    Leave a comment:


  • Physician Finance Basics
    replied
    You are a conscientious doctor, your patients are lucky to have you! You would be great if you decided to hang your own shingle, too. Maybe you'd even do better than 45% overhead?

    Love your signature

    Leave a comment:


  • Lordosis
    replied
    Good place to be!

    Leave a comment:


  • Antares
    replied
    As a psychiatrist, I’d respond, but the answer would be ridiculous and not helpful. At this point I think my existing practice will be plenty for the rest of my career, and new patients are where potential major stress lies. I want to see three letters of reference for any potential new patient, and preferably review psychological testing results before doing an evaluation ?

    Leave a comment:


  • Lordosis
    replied
    I have a lot if freedom in some things but limited in others. We have some rule that if a patient on the list to be seen has an acute issue they need to be seen in 3 days. It is so dumb. So basically anyone can come in for a new patient appointment if they have an acute issue. I have argued this several times but supposedly it come from the insurers.

    I have no say what insurance I take. I have a good mix. Maybe a little heavy on Medicare. I don't have a ton of Medicaid but they come in the most.
    One of the few decent things about NY is that the reimbursement is not terrible.

    I am happy with my model for now. Basically I keep 55% and that let's me earn a very good wage seeing a reasonable amount of patients. We also get to keep incentives from the insurances. I also do work with our nursery and get separate money for that.

    I was a Jew before I was a doc so whenever I see AK I always think of this.
    https://jel.jewish-languages.org/words/15

    I agree with your assessment of APPs.
    Thanks for the comments

    Leave a comment:


  • gap55u
    replied
    I'm in fam med too.  I had  to stop seeing new patients - I was getting pretty far on to burnout.  We definitely have a primary care shortage in our area too (a symptom of our system, where I can walk in and say "Yup, AK, 10 seconds of liquid nitrogen, done" and get paid more than HTN/DM/HLD/Depression/etc/etc/etc).   Our system lets APP's be PCP's but no one in my relatively affluent suburb wants that (they will go see APP's in a more under-resourced suburb in the hospital system).  At one point, I had a 7 month wait for new patients too.

    Lordosis - if you can't "turn off" new patients, you can certainly effectively do that by adjusting your template. If you have 100% control of your template (enjoy it while you do!) - just change to 1 new per week or 1 new per month or whatever to keep your workload manageable.  I once worked with an awesome practice manager who dynamically adjusted templates - he did stuff like cluster physicals in the slow summer months, have more acutes in winter, have fewer physicals and more acute/routines around the times of when you went on vacation, block some slots until 1/2 way through your vacation, so you could get people plugged in who needed you right when you got back, etc.   An evening clinic of school/sports physicals when there would be demand.  He kept a pretty close eye on panel size and 3rd next available for different slot types. Alas, I don't have that in my practice now.

    As for a collections model, you now have a lot of incentive to see more private pay than medicare than medicaid than self-pay.  We put informal caps on different insurance types.  Worth keeping an eye on, if someone can run those numbers for you.  OTOH, I used to volunteer in free clinics, now I don't.  So I don't sweat it too much if I see a few more, or if I fudge down and pretty much never bill a 99214 to a self-pay patient.   I did find out I have a ridiculous % of medicare patients, so successfully lobbied to have no new medicare, though I do still accept my own patients who age in.    Your collections only model may also change -we moved to a $/wrvu model, which is fairer.  We all know a medicaid 99214 is harder than a BCBS 99214, but the collections for medicaid suck.  I get the sense you know what you're doing, but learning to code and learning what pays well and what doesn't will definitely do you well.

    As for APPs, I completely  agree that it's all in the experience, training, and fit between supervising physician and APP.  Most PA's I've worked with have been good, most older NP's (experienced nurses before brick and mortar NP programs) are good.  I've got good relationships and trust now with the 2 I supervise.  It's the college -RN - straight to online program NP that scares me, as  they oftentimes don't know what they don't know, and don't have "sick / not sick" judgement.   I saw a patient who was just out of nursing school, 6 months experience on wards, already doing an online program, and getting her clinical hours with another APP who had done the same kind of track, with less than 2 years experience as an APP.  No thank you to hiring her on.

    and, enough rambling.

    Leave a comment:


  • nephron
    replied
    We probably have some 50% no show rate, and avg some 10% no shows in follow ups.   We give the primary care physicians office a time for new patients to be seen when they are referred, a lot just decide not to come or don't know to come? I imagine.    We never "fire" any patients from our clinic, the patients who do not make their appointments, take their medications, etc are usually the ones that are much more likely to need dialysis and actually need our services.   We have a real shortage of primary care physicians in my area as well, even my patients with private insurance tell me that they cannot find anyone accepting new patients locally.

    Leave a comment:


  • SLC OB
    replied


    Wow a 7 day a week clinic.  I would never sign up to work that but it is good for the patients.
    Click to expand...


    I live in a ski community, so working Sat/Sun when the ski resorts are super busy and being off on Tuesday/Wednesday/Thursday (our docs work 4 days a week) is actually nice for those without kiddos.


    I know this is an issue with my staff and I am trying to figure out a way to address it.
    Click to expand...


    Is the Urgent Care part of your system? If not, then maybe management can help by rewarding the MAs and Front office staff when they help you with this extra work. Maybe they get their names put in a hat for a monthly massage drawing, Starbucks card, etc. I know it goes a long way for me to just say "Wow, you guys really hustled today, not only do I appreciate it but the patient really appreciate it, thank you!"

    On occasion, I am the only doc in the office and get completely hammered (20+ patients in a half day). I have had our management buy bouquets of flowers, place a sign in lobby saying "Dr. XXX is the only one in the office today. Due to the demand of our community, she is completely overbooked. We apologize in advance if you have to wait. Please have your questions ready so that she can answer them for you.  Please take a flower as our token of appreciation for your understanding."  At the end of the day (which usually is amazing because the patients understand and are efficient in the visit!) I have my office staff take home the rest of the flowers as appreciation. Just another thought...

    Leave a comment:


  • Lordosis
    replied




    I have a 6 week wait list but my partners can see new patients the same day. It is too bad for my surgical case volume, as those that need surgery often can’t wait. I have been established in the community for 15 years, so people will wait. If they have an urgent need, have seen me before or a doctor is calling specifically for me, I will squeeze them in. I also squeeze the acute/urgent patients in same day (like UTI, yeast, etc.).

    Our system had a long wait list for PCP but modified the number of physicians and increase to 7 day availability and now we can accommodate much much better. Our ED visits are dropping, as the simple stuff is now going to the 7 day a week clinic instead.
    Click to expand...


    Wow a 7 day a week clinic.  I would never sign up to work that but it is good for the patients.

    My office staff does not like how accommodating I am to squeeze in acutes.  I feel it someone calls in with a URI/UTI/stubbed toe/ etc those should be easy visits that can be worked in rather quickly.  The patient is happy because they can see their doc for the problem.  I am happy because I can tell them it is a cold and Urgent care does not put them on a zpak.  I am also happy because I get paid rather then losing the revenue to urgent care or the ER.  I have room built into the schedule for acutes but some days you get more and others you get less.  It is hard to predict.    The office staff only gets the added work and nothing else.  This has been a struggle.  Especially since the other docs in the office are more apt to send extras off to urgent care.

    I know this is an issue with my staff and I am trying to figure out a way to address it.

    Leave a comment:


  • Lordosis
    replied




    As an APP I’m going to objectively say that YMMV when it comes to APPs. Honestly as a new grad working rurally at an FQHC with only one other physician, I wished the clinic had been more selective in assigning patients based on complexity. I made it work because I studied all the time and was paranoid about making a mistake. My SP and I were both early birds and in the clinic by 6a for an 8a start, and I would review all my patients for the day, and ask questions as necessary. I was single and had the extra time but not everyone has that luxury. He loved to teach and we got along well, so it was a good fit. I can easily see how that situation could have been very different for the patients.

    After 7 years of chronic disease management I don’t think I’m properly being utilized in my current clinic. There is an NP who has been there longer but has less experience. They see mostly chronic patients and I’m mostly the acutes and well visits, but from a care quality (and the NP’s sanity because they struggle) the roles really should be reversed. New grads should not be seeing moderately complex patients every 15 mins and really need to be in an environment conducive to developing the training which is hard to swing for a lot of clinics.

    New grad APPs can easily handle the easy acutes (UTIs, URTIs, cellulitis, etc) and preventative visits, but if I were a physician I’d probably appreciate a few of those sprinkled in my schedule for a mental break. I can’t imagine seeing only the most complicated patients all day would be fun unless you had unlimited time with them. An experienced APP could really work well for a practice though for the routine chronic care, more complex acute visits, and as a catchall for the physicians they work with, but ideally as a physician I’d need to be very confident in how they practiced, their attention to detail, their drive to improve their knowledge, and how well they knew their limitations, especially since there is liability attached. I wish administrators cut physicians more slack in terms of being able to have the flexibility to develop that relationship with an APP without financial penalty/lost productivity. It would really optimize quality and access to patient care with some financial benefit to the practice. I wish I had the financial smarts to come up with the numbers to find the magic formula to support the best mixture of APPs/physicians.
    Click to expand...


    Just like there are good and bad physicians I am sure there are good and bad APPs.  Maybe good and bad is not the right way to put it.  Well trained and less so.

    You seem to be of the well trained variety.  I am lucky to also have a well trained NP in my office.  However the way it is run here the NP has his own patient load.  All of his patients are assigned to one of the MDs but there are enough that follow just with him that it gives him his own panel of sorts.  I do not really care for this model but it was here when I got here and inertia has kept it.

    The next system over does things differently.  The APPs only see the overflow.  When not busy they are handling the prior auths and MDs inboxes.

     

    I do like the sprinkle of acutes in my day.  It is nice to help people when they are sick. I can adjust BP and DM meds like a pro but it does get monotonous.   Usually though it is extra work because they are put between follow ups.  But I get paid for the extra work so it does not matter if it is reasonable.

    Leave a comment:


  • SLC OB
    replied
    I have a 6 week wait list but my partners can see new patients the same day. It is too bad for my surgical case volume, as those that need surgery often can't wait. I have been established in the community for 15 years, so people will wait. If they have an urgent need, have seen me before or a doctor is calling specifically for me, I will squeeze them in. I also squeeze the acute/urgent patients in same day (like UTI, yeast, etc.).

    Our system had a long wait list for PCP but modified the number of physicians and increase to 7 day availability and now we can accommodate much much better. Our ED visits are dropping, as the simple stuff is now going to the 7 day a week clinic instead.

    Leave a comment:


  • mainah
    replied
    As an APP I'm going to objectively say that YMMV when it comes to APPs. Honestly as a new grad working rurally at an FQHC with only one other physician, I wished the clinic had been more selective in assigning patients based on complexity. I made it work because I studied all the time and was paranoid about making a mistake. My SP and I were both early birds and in the clinic by 6a for an 8a start, and I would review all my patients for the day, and ask questions as necessary. I was single and had the extra time but not everyone has that luxury. He loved to teach and we got along well, so it was a good fit. I can easily see how that situation could have been very different for the patients.

    After 7 years of chronic disease management I don't think I'm properly being utilized in my current clinic. There is an NP who has been there longer but has less experience. They see mostly chronic patients and I'm mostly the acutes and well visits, but from a care quality (and the NP's sanity because they struggle) the roles really should be reversed. New grads should not be seeing moderately complex patients every 15 mins and really need to be in an environment conducive to developing the training which is hard to swing for a lot of clinics.

    New grad APPs can easily handle the easy acutes (UTIs, URTIs, cellulitis, etc) and preventative visits, but if I were a physician I'd probably appreciate a few of those sprinkled in my schedule for a mental break. I can't imagine seeing only the most complicated patients all day would be fun unless you had unlimited time with them. An experienced APP could really work well for a practice though for the routine chronic care, more complex acute visits, and as a catchall for the physicians they work with, but ideally as a physician I'd need to be very confident in how they practiced, their attention to detail, their drive to improve their knowledge, and how well they knew their limitations, especially since there is liability attached. I wish administrators cut physicians more slack in terms of being able to have the flexibility to develop that relationship with an APP without financial penalty/lost productivity. It would really optimize quality and access to patient care with some financial benefit to the practice. I wish I had the financial smarts to come up with the numbers to find the magic formula to support the best mixture of APPs/physicians.












    Leave a comment:


  • Lordosis
    replied




    Lordosis–family practice PA. I’m the newest (to the clinic) of 2 physicians and 3 APPs, averaging 18-24 pts a day the past month, mostly acutes, new patients, and yearly physicals. That’s mostly because I have the smallest patient panel, not necessarily because that’s how the clinic utilizes APPs. Our physicians see 22-28/day. New patients can call for a same day appointment with me but I usually don’t get records ahead of time because they are trying to keep my scheduled filled. Our physicians see about 1 new pt per week but I don’t think there is any formula on how often they are scheduled. You can usually get an acute visit with our physicians specifically within 2-7 days, same day or next day with an APP. Hospital followups usually within the week with our physicians, and theoretically depending on the complexity of the patient, sooner with an APP. The office tries to avoid scheduling our most complicated patients for hospital followups with anyone but their primary because 15 mins isn’t enough time to review a history, do the med rec, etc, but our physicians have been okaying them being put in my schedule if they can’t get them in. Our physicians’ schedules are pretty full when the week starts, I’d say around 90% full, but 2-3 weeks out there are plenty of openings.

    I do most of the office’s well woman checks because we are male provider heavy, and get most of the newborns as well. I’d say my day is 40% new patient visits/well child checks/yearly physicals, 40% acute visits, and 20% routine f/us. My preference would be to do more chronic care because I do have some experience under my belt, but it’s been an asset to our clinic to have some breathing room for the acutes. We are at a sweet spot in having lots of same day flexibility but ending up with full schedules. However I am not a fan of not having records ahead of time (that includes hospital f/u in addition to new patients).

    When I see complicated patients whom I know need to be seeing a physician, I’ll spend extra time with them and do as much of the grunt work as I can, then touch base with their physician at the end of the day and review the case to make sure nothing extra needs to be done. Whatever I can do to make their lives easier with the patients that can really consume a lot of time. I usually make sure they have an appointment within the next 1-4 weeks with a physician.
    Click to expand...


    Even patients who wait six months to see me more often then not arrive before their records :P

    When ever I mention this issue at work everyone wants our NP to help establish the new patients.  I put my foot down here because I need that chance to get to know them and set things right from the start.  Also you never know how complex someone is before they show up.

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