I'm a rural family doctor and opened my own clinic April 30, 2010. This goes against the trend of employed doctors. Here's my business update.
Two days ago it was just starting to snow as I drove to work. My son left for school before me, driving. The IT called me to ask if school was really in session. The website assured us it was. She called me 45 minutes later and said that the bus never came. By then we had a good two inches of snow. We rarely get snow here, but this is supposed to be a hard winter.
Patients arrived anyhow. We called the 80 plus year old because she lives more than two towns away. But her daughter was bringing her and they made it. Their battery died so they had to find another way home. All of our patients showed up. Everyone scheduled on Tuesday called and moved appointments.
With no one coming in, Tuesday was a snow day. I did keep the monthly meeting with the accountant/small business adviser. I have to meet with the bank in December to discuss converting the line of credit into a loan. I like my banker very much. But I don't know the language well and needed to know what reports to take to her.
We've done version four and five of the projections for next year. We have a budget and are trying to project what we will actually collect for patient visits, which has nothing to do with what we bill. And then there are all of the weird billing rules about how to charge for a level of visit.
My estimates were, of course, all wrong in the initial business plan. I thought medicare would pay less than it does, so that was good, but my estimate of how fast people would come in to the clinic was too high. We've been tracking that. The first month we averaged 1.1 per day. 1.8 in month two. 2.1 in month three. It is linear. Our medicare is approved, so we're working on billing for the last six months. All others pay cash, so our proportion of medicare patients kept rising. It was 82% in October, so version 4 of the projections had us increasing patient visits by one every other day each month, and assumed we'd be 100% medicare.
But November is not looking like that. Our proportion of medicare patients is down to 70%, to our surprise. I fill a special niche. Our advertising says "Takes time to listen, takes time to explain," which is really what I like to do. Low on procedures, good at sorting out complex pictures. I'm really comfortable with the 80+ year old who has 8 chronic diseases: diabetes, heart failure, a previous 5 vessel bypass, colon cancer six years ago, some skin cancer, moderate renal failure, atrial fibrillation and is on some old antipsychotic medicine that they've been on for 30 years and I have to look up. We are getting healthy medicare patients too. Non-medicare? Most of them are insured and most of them are VERY complicated. We are hearing over and over from patients that the hospital clinic doctors aren't allowed to spend much time with them. We are even getting people who have insurance that won't pay anything for an "out-of-network" doctor.
Two recent rare diagnoses: loin pain hematuria syndrome, which I had never heard of, and eosinophilic esophagitis. I seem to be having a special on peripheral vascular disease too, damn those cigarettes.
Version 5 of the build up estimates lowered the increase in patients per month, doesn't look quite as linear as we'd hoped. But then, November and December usually are a bit slower in clinic and then all heck breaks loose in January and February.
The accountant looked rather fierce after looking at next year's budget because we are still losing money, even at the end. He said, "Have you looked at the end result, will you be earning money to make this worth your while?"
I handed him 6 estimates, hand written. Let's see, if I work four days a week and we have all medicare patients and we subtract vacation, continuing medical education, sick leave and holidays, what would the business generate at 12 patients per day, 14 and 16? And then, if we take the projected amount earned per patient visit based on the last month, 25% non-medicare, it's higher, run those numbers. Even at the lowest estimate, once we're running at capacity, it works.
Oh, he said. He said that he sees people with business plans that he tries to talk them out of. He fails sometimes and he has business owners that running at full capacity, the owner is taking home 20K. Or nothing. Or has a loss. For the third visit in a row, he complimented us and said that he sees few few business startups that are doing the math for what full capacity looks like and is the goal reachable and will it be worth it?
I don't know the language, but I bloody well understand the math. I blinked at him and said that I had trouble imagining running things with an "I hope it'll work" attitude. It's still all estimates, because the amount of money collected per patient is a nightmare in itself, because there are all different levels of visit and then medicare keeps changing it's rules and it's payments and what they paid for this year is different from what they will pay for next year. Confusion rules.
I am tired out currently, even seeing 4-5 patients a day, when I averaged 16 for years. It's not because I have the added jobs of business owner and nurse, really. It is other, extraordinary stressors. I am tired all the time and am trying hard not to get sick. I can't estimate whether the number will be 12 or 14 or 16, because things are out of whack.
We thanked him and left, my office manager and I. Encouraged. Depending on which estimate we use, we'll be at full capacity in 2 years or a bit more.
I walked to the dentist's office in the snow and sun, 29 degrees. The IT was declared fine and we got cookies and orange juice at the store as a treat. We walked home down Lawrence Street and past the Kai Tai Lagoon, enjoying the rare snow.