So, my wife wants to start her own medical practice....

[HardDrive]

As the title suggests, my wife wants to start her own medical practice. She's a pediatric anesthesiologist that specializes in pain management. Currently the director of the chronic pain service at her institution. She is well known in her field.

She's burned out and wants to return to WA state (Seattle) and start her own practice when her contract runs out. Her thinking is to start an independent practice that does pain management and 'alternative' therapies. She's a licensed acupuncturist as well.

I've done some research, but would love input on the following areas.

1) If she is working independently, but wants to perform interventional procedures like nerve blocks, she's going to need to admitting privileges at a hospital. How does that work from an malpractice insurance perspective?

2) She does not want to take insurance. She's adamant about it. The Seattle area is affluent to say the least, but is working outside the insurance system viable for someone who could potentially be doing very $$$ procedures on patients? Is asking patients to submit their own claims realistic?

3) I want BOMB PROOF insurance coverage. The practice would be an LLC. Any legal or insurance pitfalls I should be aware of?

4) Any thoughts on using online electronics records management? We would be willing to pay a premium to not have to invest in an EMR system.

This last question might require a crystal ball....

5) Are we going to lose our ass setting up this practice so my wife can make peanuts doing acupuncture treatments for the hippy families of Seattle?

[stomachmonkey]

Originally Posted by HardDrive

As the title suggests, my wife wants to start her own medical practice. She's a pediatric anesthesiologist that specializes in pain management. Currently the director of the chronic pain service at her institution. She is well known in her field.

She's burned out and wants to return to WA state (Seattle) and start her own practice when her contract runs out. Her thinking is to start an independent practice that does pain management and 'alternative' therapies. She's a licensed acupuncturist as well.

I've done some research, but would love input on the following areas.

1) If she is working independently, but wants to perform interventional procedures like nerve blocks, she's going to need to admitting privileges at a hospital. How does that work from an malpractice insurance perspective?

2) She does not want to take insurance. She's adamant about it. The Seattle area is affluent to say the least, but is working outside the insurance system viable for someone who could potentially be doing very $$$ procedures on patients? Is asking patients to submit their own claims realistic?

3) I want BOMB PROOF insurance coverage. The practice would be an LLC. Any legal or insurance pitfalls I should be aware of?

4) Any thoughts on using online electronics records management? We would be willing to pay a premium to not have to invest in an EMR system.

This last question might require a crystal ball....

5) Are we going to lose our ass setting up this practice so my wife can make peanuts doing acupuncture treatments for the hippy families of Seattle?

I know jack **** about any of that so my input / value here is pretty much useless.

My gut says question 5 is the one that you want to answer first.

Just seems to me that it's a specialty few would seek out independent of a referral from a Primary Care provider?

Put another way, is it a viable specialty for a private practice? Is there a market?

I have no idea.

[wdfifteen]

If your goal is to do acupuncture for hippies, the rest of it is moot.
I would not want to go into any medical profession today. To much control from insurance companies and other bureaucracies. But with her background, I think she might have a future in a cash-only pain management, weight management, tattoo removal, and acupuncture business.

BTW the pediatric anesthesiologist/pain management doctor was an angel when my grandson was suffering with cancer. God Bless people like your wife. I cannot imagine witnessing what they see everyday.

[Rtrorkt]

call on Virginia Mason to see what they would offer in the terms of alternative medicine. This is a pretty progressive organization. Next would be Swedish and then Group Health. Frankly if she can find a niche where personal pay rather than insurance is the vehicle, then she should do well. Go to Seattle and get some down and dirty advice. Ask your five questions. If you think you want to do it, i do have a couple of contacts that might make sense for you and your wife.

[Nickshu]

I'm in dentistry and own a relatively large fee-for-service periodontics specialty practice with two offices. I know medicine is a different animal to some degree but FWIW I use consultants for all those major decisions. Yes they are expensive but they always pay for themselves by keeping me from making various costly mistakes. She's an expert in doctoring, not in business. Get a consultant and a good business manager for the practice to do the heavy lifting. There's gotta be medical business consultants that do nothing other than handle practice startups like your wife's. I use one for dentistry called Cain-Watters out of Dallas. If you contact them maybe they can point you in a direction. I know they have a few MD clients, but I think they are mostly Ophthalmologists and Dermatologists (similar practice model to dentistry).

There are Concierge-MD networks she can buy into. One of them that is in our area is MD-VIP. Maybe worth looking into.

[stomachmonkey]

Originally Posted by Nickshu

I'm in dentistry and own a relatively large fee-for-service specialty practice with two offices. I know medicine is a different animal to some degree but FWIW I use consultants for all those major decisions. Yes they are expensive but they always pay for themselves by keeping me from making various costly mistakes. She's an expert in doctoring, not in business. Get a consultant and a good business manager for the practice to do the heavy lifting. There's gotta be medical business consultants that do nothing other than handle practice startups like your wife's. I use one for dentistry called Cain-Watters out of Dallas. If you contact them maybe they can point you in a direction. I know they have a few MD clients, but I think they are mostly Ophthalmologists and Dermatologists (similar practice model to dentistry).

There are Concierge-MD networks she can buy into. One of them that is in our area is MD-VIP. Maybe worth looking into.

This.

[HardDrive]

Good advice Nickshu, thank you.

I should mention that we spent 10+ years in Seattle, and moved to OH 2 years ago. My wife still has a healthy network there.

[Cajundaddy]

I am not a MD but have owned small businesses all my life. She should decide if she really wants to practice medicine or wants to run a business. Not many do both very well and often the cutthroat business aspects tend to harden a good Doctor's heart. One of my friends is also an anesthesiologist and he recently unraveled a medical practice partnership because of the business headaches. He wants to practice medicine so he generated relationships with MDs, hospitals, and clinics and now does a mobile service. All the overhead is handled by others and he charges a simple fee for service. Lots of scheduling flexibility now and he took his life back from the rat race.

Worth considering this option. It is probably what I would do in this uncertain medical coverage climate.

[island911]

Why couldn't she work on a contract basis? I'm fairly certain that Swedish uses nothing but contract anesthesiologists.

[wdfifteen]

Originally Posted by Cajundaddy

She should decide if she really wants to practice medicine or wants to run a business.

+1000
One of the best questions asked of me (by a business consultant), "Do you want to be a businessman or a man running a business?" There is a huge difference.

[HardDrive]

Originally Posted by island911

Why couldn't she work on a contract basis? I'm fairly certain that Swedish uses nothing but contract anesthesiologists.

She might supplement her income with contract (locums tenens) work.

BTW, if this all works out, your Piper Cub kit will be making its second move across country......safely in the box.

[Noah930]

Every state is different, so YMMV.

1. If doing nerve blocks, then she's working as an MD (or DO). If she does them in a licensed surgery center (like an epidural or stellate ganglion block--as opposed t a mere trigger point injection, then she'll need to have some sort of hospital privileges. Even if she never plans on setting foot in the hospital. Usually malpractice policies cover a doc for the scope of practice--not necessarily where it's done. You just have to make sure what you're doing is in a place where it is supposed to be done.

2) In a concierge practice, it is reasonable to expect your patients/customers to submit their own billing to their insurance companies. That's part of the deal. And it's entirely possibly to make money by having patients pay out of pocket. Look at cosmetic plastic surgeons. There are also medical credit companies (i.e. Care Credit) that almost work like credit card companies do--but geared towards medical expenses. Let someone else take on the risk of a patient not paying the bill.

3) Don't know. Talk to an attorney in your state re: what works best.

4) The only need for EMR is if you're dealing with Medicare. They're the ones effectively mandating it. But in a concierge practice, no need to comply if you don't want to.

5) Don't know. But there are certainly people in seattle who earn a living as Licensed Acupuncturists. But is it the income level you're looking for?

Good luck!

[LeeH]

#5. That's the one that would keep me up at night. Couple of random thoughts:

I did the books for an independent nurse practitioner. She was cash only. Eventually, she felt it was in her best interest to accept insurance.

As someone who does accounting/consulting for small businesses, my first thought it that she should start by finding a job in the area doing the sort of work she'd like to do in her business. This would allow her to check out the market and possibly build a patient base before putting out a bunch of capital.

[LEAKYSEALS951]

Random thoughts:
The fee-for-service practices (or practitioners) that I've seen usually start off as regular practices, building a clientele . If that clientele hits a critical mass large enough where there are enough patients who can pay out of pocket, then the Doctor can ween their way out of insurance, or start their own practice and take the clients with them. Starting from scratch may be plausible, but I haven't heard of it as much as people who put in the sweat equity first. Also- getting patients willing to submit their own insurance is a lot easier when they know they value of what they are getting. For example- my wife's MD just went to a non insurance model, but because my wife had been a patient for so long, she was willing to follow. Again, the MD had done her sweat equity in a regular model of practice building which built the relationship between herself and her patients. Would my wife be willing to jump through those hoops for a stranger without that previous relationship? I don't know.
Starting from scratch, I would assume your wife would need an alternative "real" job, as she built a clientele large enough to support her dream practice to the point where she could stay busy full time. Her new clinic might only start off with enough patients for one or two days a week.
I could be totally wrong with her profession, but that's what I have seen.

[PorscheGAL]

My advice: Your wife needs to contact some successful pain physicians in the area and ask them some of those questions.

From what I know pain practices tend to do the best in high retirement areas.

Good Luck.

[HardDrive]

Thank you for the input all.

[Mark Henry]

Can't help, but in Ontario Canada my buddy who is also a pediatric anesthesiologist only bills one insurer, pays a insurance policy not much different than a auto policy and that's about it. Except for a broom closet at the hospital, where he can hide, he doesn't even have a office.
He pays his wife to do the books, she gets full time pay for a part time job.

He loves it, except for the job on hand he has close to zero stress.

[Moses]

Originally Posted by HardDrive

1) If she is working independently, but wants to perform interventional procedures like nerve blocks, she's going to need to admitting privileges at a hospital. How does that work from an malpractice insurance perspective?

No worries. Malpractice claims almost always always fall within coverage limits. Hospital done procedures provide liability insulation. Hospitals have deep pockets.

2) She does not want to take insurance. She's adamant about it. The Seattle area is affluent to say the least, but is working outside the insurance system viable for someone who could potentially be doing very $$$ procedures on patients? Is asking patients to submit their own claims realistic?

Low volume, boutique practice. Even in Seattle. Will she have a busy practice without accepting insurance assignment? Almost certainly not.

3) I want BOMB PROOF insurance coverage. The practice would be an LLC. Any legal or insurance pitfalls I should be aware of?

You should be fine with standard $1M/$3M coverage. If youre nervous, buy an umbrella policy.


4) Any thoughts on using online electronics records management? We would be willing to pay a premium to not have to invest in an EMR system.

Absolutely no need for an EMR with a boutique cash practice.


This last question might require a crystal ball....

5) Are we going to lose our ass setting up this practice so my wife can make peanuts doing acupuncture treatments for the hippy families of Seattle?


Almost certainly.

Hope this helps.

[bpu699]

Originally Posted by HardDrive

As the title suggests, my wife wants to start her own medical practice. She's a pediatric anesthesiologist that specializes in pain management. Currently the director of the chronic pain service at her institution. She is well known in her field.

She's burned out and wants to return to WA state (Seattle) and start her own practice when her contract runs out. Her thinking is to start an independent practice that does pain management and 'alternative' therapies. She's a licensed acupuncturist as well.

I've done some research, but would love input on the following areas.

1) If she is working independently, but wants to perform interventional procedures like nerve blocks, she's going to need to admitting privileges at a hospital. How does that work from an malpractice insurance perspective?

2) She does not want to take insurance. She's adamant about it. The Seattle area is affluent to say the least, but is working outside the insurance system viable for someone who could potentially be doing very $$$ procedures on patients? Is asking patients to submit their own claims realistic?

3) I want BOMB PROOF insurance coverage. The practice would be an LLC. Any legal or insurance pitfalls I should be aware of?

4) Any thoughts on using online electronics records management? We would be willing to pay a premium to not have to invest in an EMR system.

This last question might require a crystal ball....

5) Are we going to lose our ass setting up this practice so my wife can make peanuts doing acupuncture treatments for the hippy families of Seattle?

I practice and also do hospital administration...

Private practice is nearly impossible to do, with all of the govenment intrusion. Perhaps in primary care you can do a cash-business, and charge $100-200 a visit. With procedures costing thousands, thats unlikely, even if you live in an affluent area. Most of my patients that are wealthy, are the MOST averse to paying out of pocket.

Also, there is no such thing as "fool proof insurance." The lawsuit is against the physician, not the LLC. Your comfort level is as good as your malpractice coverage...

If you get sued, lose, and the judgement is over your limits, your assets are at risk...

Hospital admitting priveledges require malpractice/liscensing/credentials/etc. Nothing new. The patients will certainly need medical insurance as the hospital portion of the bills will usually be high, and typically isn't paid in cash by patients. Your wife may wish to simply do outpt procedures in her clinic.

Finding a patient who has medical insurance, and at the same time volunteers to pay your wife cash for expensive procedures, is looking for a unicorn. Why wouldn't they just take a doc who accepts their insurance?

Perhaps your wife wishes to pursue a tract as an instructor, or locum?

Bo

[bpu699]

Originally Posted by Moses

Hope this helps.

1 million/3 million in coverage got mentioned....

I wouldn't dream of practicing with that little coverage, unless every asset I had was protected in some trust and under my wife's name.

When you get sued, and as a doc you will (I have), you learn a lot. Lawyers rarely ask for reasonable amount, regardless of fault or diagnosis. You will be shocked when the plaintiff mentions they are suing for $5-10mm dollars for something assinine. Will they win? Usually not. But, sometimes they do.