Leaving a Hospital Job to Start a Solo Practice

Dr. Lois Freisleben-Cook is a pediatrician that started her practice after completing a two year contract with the local hospital.

These days, you don’t hear about too many docs leaving hospital jobs to open up solo practices, so I wanted to learn amount what many consider to be a rare, dying breed of doctors.

I reached out to Dr. Freisleben-Cook and asked her if I could ask some questions regarding her experience as a solo rural doc. She was gracious enough to allow me to post her responses.

The post is a little long. Certainly longer than usual for PediatriInc; but Dr. Freisleben-Cook provided SO much information that I couldn’t pass it up.

Enjoy!

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Tell me about your experience making the transition from clinic practice at a local hospital to a solo doc.

I left a clinic practice at a local hospital after my two year contract was up and over 2500 patients came with me.  By the fourth year I was up to 4000 and now over 6500.  The population of this town is expected to triple by the end of this year and do it again in another year. I have been the solo pediatrician here for the past twelve years with the nearest pediatric care over 120 miles away to the east and over 500 miles to the west and south.  Canada is to the north and there is nothing between us and Canada.

Holy Cow. That is a lot of patients

I can’t stop taking new patients because the rest of the community docs are also full.  I am especially obligated to take all the CSHCN as they have no one else to see for over 120 miles.

Before you started, what resources did you use to gather information about starting a practice?

Before starting I used what I had learned over the years managing developmental clinics for the Department of Defense. I had no experience with the financioal side of things and foolishly thought I could learn as I went on. The clinic had a huge cash buffer provided by my husband and myself so we were able to make a lot of mistakes and survive financially.

Now I would suggest the AAP practice management resources. It is excellent for setting up the logistics of a new practice.  I did not use them ‘till I was five years into practice thinking I already knew it all.  Boy was I wrong.

Life would have been a lot simpler if I had used those wheels instead of trying to invent my own.   Another source of good and practical advice offered with no strings attached is the PCC site.

There is a lot of information out there and much of it can be confusing and wrong.  You can’t go wrong if you start out with just these two sources.

Since there is so much information out there, where should one begin in terms of  preparation?

Learn all you can about coding and documentation as that drives your revenue stream. The biggest mistake most new docs  make is to under code and undervalue their services. Although it was forced on me, I took a coding class in California that more than paid for itself.

Anything else you would add to a doc that is preparing to open up their own office?

Remember everything you do that requires thought and knowledge is valuable.  Even things that are obvious to you are important to patients and are valid billable services.  If your see a newborn and spend time counseling about breastfeeding to solve a feeding concern document it and charge for the time.

I have learned that there are ways to be compensated for my time even if providing an “uncovered service”.

Some of our insurers, for example, do not cover asthma education.  I simply document the elements we discussed and code for time spent in the chart.

As Herschel will say, do not give away the talents and information you have earned.  Remember you are valuable and do not let insurance company or anyone else say otherwise.

Editorial Note: Dr. Herschel Lessin is a regular contribution to Survivor Pediatrics and a very passionate member of the pediatric community. Dr. Lessin has posted on PediatricInc before

What else?

Learn the Medical Home standards and start off with the structure you will need to meet them using the ample free on and off site support available too you from the AAP and a number of other medical home agencies.

Speaking of uncovered services, many docs find out very quickly that what you learn in a coding class in terms of appropriate ways of billing, doesn’t always fall in alignment with how insurance companies pay for services. What do you think about that?

Follow CPT guidelines and bill even if the insurance company says it will not cover.  For example an insco may say it does not cover after hours codes. Document and bill them anyway and track the refusal to pay so you can later take it higher.

If something is in the CPT as a billable service, don’t leave it out because they never pay.  That is a reason to keep it in.

Make sure your payment data is in a format that is conducive to searching who pays for what and what refusal codes they use and what services they illegally bundle.  In a few years you will want to analyze and act on that data.  Encourage families to update their insurance policies to take advantage of the ACA. If a policy is grandfathered, have them consider making a small change that will put it into the newer eligible for ACA category.

Those are great tips on the billing side, what about staying up to date on the clinical side?

Learn and keep up with Bright Futures and use it as the model for preventive care.  Assign one of your staff to use that to design all well child visits and documentation and remember everything in the Bright Futures preventive model is covered under the ACA; so bill for the hearing and vision screens, developmental screens, the depression screens as separate and not bundled services.  Record the refusals to cover and the bundling.

What about billing staff, what should you instruct them to do as you get started?

Make sure your billing person gets current literature i.e. AAP coding bulletin etc and attends continuing education activities. The return will more than pay for the classes.

Make sure your clinical staff have opportunities to learn new skills and advance in their own careers.  They will eventually grow out of their jobs but will be sure you have what you need in new hires.

Managing employees is no easy task. Any words of wisdom? 

Value everyone who works for you and show that your value them.  Don’t set up a hierarchy but instead use the team model including the 180 degree evaluation process.

You seem to have a lot of great ideas. Can you think of one (maybe two) that isn’t as common to the rest of us that would help our practices?

Recruit a parent to be a consultant to the practice, reviewing how you do things and giving input on what would work better from the parent perspective. Include that person in staff meetings .

OH  YES  never forget to have regular staff meetings.  That was one of my biggest mistakes.  Ask the parent consultant to interview families leaving the practice. That will be more forthcoming with their reasons with the “parent consultant” than with a member of your staff.

Do satisfaction surveys early on and often to identify ways to better meet the needs if families. You will get enormous PR capital by taking the information in these surveys, sharing it with families, and having them help you brainstorm improvements.

Many pediatricians have a tendency to want to do everything. What do you say to those docs?

Do not be penny wise and pound foolish.  If you are spending time doing something you can train an employee to do then do it and give it up.  If you can hire someone to do it for ten dollars an hour that frees you up to make a lot more than her salary.

Can you give me an example?

Hiring a scribe is a really good investment.  You will be a better doc if you delegate things you do not need to be doing yourself. Remember to follow up on tasks you delegate.

You need time to think, have a life and sleep. Your family needs you to spend time with them when you are not exhausted.  Just like a marathon, you can start up with a slow pace and little work and build up to more and more as you find yourself able too handle the flow.

On the SOAPM listserve you’ve shared some pretty scary circumstances that have added stress to your private practice endeavor. I’m not going to get into those challenges, but would you speak a little bit about why you do what you do despite those challenges?

I love coming to work every day.  I love being able to employ and train and offer the services of care coordinators, parent advocates, clinical and administrative support to local activities such as Head Start, and practicing the way I want to.

I love being able to write off a bill now and then when someone really is in a bad spot financially. I love being able to handle 99 percent of the care from my office.

I love the fact that in twelve years we have NEVER had a bad outcome, not one of my patients has died and the only two deaths we have experienced were inevitable when we first saw the children (a drowning and an end stage neuroblastoma) .

I love that children and their parents feel at home in our clinic and readily bring their concerns and their family members, friends, neighbors to us.

More recently I have had the unimaginable pleasure of hearing parents stay they feel well cared for for the first time and are grateful they came here because their children with special needs are doing so much better than they did in the “big cities” they came from.

I guess what I am trying to say is that in spite of the horrendous medical climate and incessant bullying I experience, I would not go back and change my decision to stay here.  While I could have easily returned to Westwood and had a nice and stressless practice there, I would not have the wonderful sense of purpose and service I find fulfills me.

If you could go back in a time machine (like Marty McFly), what would older Lois say to younger Lois as younger Lois was ready to embark on this long scary journey of opening up a practice?

BE HUMBLE

BE HUMBLE

BE HUMBLE

Even as you value your services, do not overvalue yourself as a person as we are all in this world together and you could never survive without your cleaning lady.

Learn how to make the rest of the world disappear and be infinitely present to the moment when in a room with a family.  They will feel your attention and the time spent with you will feel like it is long enough even if it is only five minutes. Greet the child first when you enter a room and briefly interact with the child before addressing the parent.

Anything else you would say?

Ask questions.  There is no such thing as a stupid question and everyone her and at the AAP loves to answer questions and give advice. Start with SOAPM first.

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