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All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH.
No statement or presentation made is to be regarded as dedicated to the public domain.
IC25-L: Managing Burnout/Moral Injury
Moderator(s): Melissa Arief, MD
Faculty: Orrin I. Franko, MD, Noah M. Raizman, MD, MFA, Mark E. Baratz, MD and Simon G. Talbot, MD
Session Handouts
76th Annual Meeting of the ASSH
September 30 – October 2, 2021
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
9/24/2021
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Picking and Starting a Practice
Orrin Franko, MD
2-person Private Practice
East Bay Hand Medical Center
San Leandro, CA (SF Bay Area)
Disclosures
• I love my practice
• I want you to pursue private practice (if it’s right for you)
Fundamentals of Practices
• What sets Practices Apart?
• Finances of Practice
• Challenges & Opportunities
• Finding the right job…
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My practice…
What is “Private Practice” ?
• Doctors own the practice• LLC or S Corp Partners• Income beyond salaries becomes “distribution”
• Control over…• Office personnel / management• Clinical patients / demographics• Personal life / days / hours of work
• No restrictions over other opportunities• Research / Ancillaries / Call / Locums• Ownership of intellectual property• Real Estate ownership
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I NEVER hear the phrase…
“…you people….!”
Practice Models
Solo Practitioner Single Specialty Group Multi Specialty Group
Office-Sharing Fixed / Variable Equally Divided
Size/Type
Overhead
None Some / Shared Complex / Shared
Ancillaries
My PracticeEmployed
Income Streams
Practice Income
50%
Hospital Call Stipend
20-30%
Ancillaries
15-25%
Other*
Volume: Marketing, Referrals, OutreachContracts, Efficiency, Coding & Billing
Overhead, Overhead, OverheadRejected claims
Regional competitionContracts
Insurance Legislation
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Income Streams
Practice Income + Hospital Call
50%
Hospital Call Stipend
30%
Ancillaries
15%
Ancillaries: ASC + Therapy
50%
Volume: Marketing, Referrals, OutreachContracts, Efficiency, Coding & Billing
Overhead, Overhead, OverheadRejected claims
Regional competitionContracts
Insurance Legislation
Income Streams
Practice Income + Hospital Call = 30%
Hospital Call Stipend
30%
Ancillaries
15%
Ancillaries:ASC, Imaging, Therapy, Real Estate
70%
Volume: Marketing, Referrals, OutreachContracts, Efficiency, Coding & Billing
Overhead, Overhead, OverheadRejected claims
Regional competitionContracts
Insurance Legislation
Income Streams
Salary + Production Incentives = 90%
Work more Competition from partnersCall = 10%
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Overhead Income
60% overhead…
How Employed Overhead Works…
40% income…
25% increase in collections =
25% increase in income
Months
Overhead Income
Months
FIXED overhead…
How Private Overhead Works…
VARIABLE income…
25% increase in collections =
50% increase in income
$40,071
$42,720 net
$39,419
$56,669 net
$32,916
$87,724 net
16% ↑ Collection33% ↑ Income
45% ↑ Collection105% ↑ Income
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Lifestyle
• Level 2 Trauma Center
• General Ortho Call ~4 days/mo
• Hand “Activation” call ~10 days/mo
• 9am – 4pm with 1 hr for lunch ~25 patients/day
• Thursday afternoons off
• 3-4 vacations, 3-4 conferences, 4-6 long weekends
Practice Mix & Volume
• New Patients = 30 min, F/U Patients = 15 min, + emergencies
• About 25-35 patients/day in office (3-3.5 days/week)
• Surgery 1-1.5 days/week
• Average 8-10 elective cases/week (low-average for hand)
• Combination of routine vs. complex cases
• Hospital call / Hand call
• Average 4 consults / week - often at convenient times
Private Practice 401K
• 11-13% invested annually surpasses Kaiser pension value
• Plus the benefits of….• You OWN the entire portfolio (your heirs inherit residual value)
• You have FREEDOM to use it• Early withdrawal if necessary
• Alternative investments
• Control over investment choices
• You have EQUITY in the practice / ASC / Ancillaries
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Retirement FundsFor more info: www.whitecoatinvestor.com
• There is no “pension” like some employed positions (Kaiser)• Kaiser pension is worth ~12-15% of your annual salary• Ex: $440k at Kaiser = $500k private practice
• Let’s do the math…Kaiser pension: 2% per year x first 20 yrs, then 1% per year.Assumption: Start at 35 yrs old, salary of $440k, work until 65 yrs old…Pension = 2% x 20 + 1% x 10 = 50% salary x $440k = $220k / yr
Payments start at 60-65 yrs, increase 8% each year deferred Payments until death or death of spouse (I think) Lump sum payment for amount above IRS limit $1.5m (est) Still have options for 401k contributions
How about if you make $500k? 4% withdrawal rate =
$219,595 / yr
AND…..
You still have $5m in the bank!
Challenges & Opportunities
• Managing Employees
• Controlling Overhead
• Strategic Decisions
• Insurance Contracts
• Income inconsistency
• Self Promotion / Marketing
• This can be mitigated with • Great office managers
• Consultants ($$)
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Office Set up
• “Low Overhead” means no extra staff• Room your own patients
• Perform your own flouro exams
• Remove / wrap your own casts
• Dictate your own notes (template + Dragon)
• Code your visits
• Patients LOVE it
*Efficiency tips discussed in other lectures
Where to FIND a JOB?
• There is no “job board” for areas in need…
• Example from my area:
2 general orthos retiring within 5 years with busy hip/knee/shoulder practices
Aging (and shrinking) call pool for general ortho and trauma at Level 2 hospital
Three surrounding ASCs that are all profitable
If you called asking for a “hand-only job” Sorry, we can’t support you
If you called for a general ortho job with call EASILY make $1M+ within 2-3 years
This is my Summary Slide
• There are GREAT jobs out there
• The BEST jobs are not “posted” anywhere
• Get in the room with the right people
• Cold call practices
• Be open to change and new opportunitiesTaking call, work comp clinics, med-legal
• Talk to friends, colleagues, acquaintances, and attendings
• When you start practice – be AWESOME and build your reputation
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Midlife InflectionMark Baratz
University of Pittsburgh Medical CenterPittsburgh, PA
Disclosures• Integra: Royalties. Speaker’s Bureau• JBJS, JSESAm & British, JHS, Hand: Editorial
Boards• Board AFSH
None relevant to the content of this talk
Interviews
• 6 surgeons: 8-19 years in practice• 3 men/3 women
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Three Questions
• Challenges of Practice• Challenges at home• How you see the future
Common themes
• Practice booming• Kids getting older and more active • Less time with partner
Challenges of practice
• Harder to get home• Harder to get away• Pressure live up to rep built on being
available and affable
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• Current behavior not sustainable• Is there a ceiling at my institution
Unique to current events
• Covid fatique• Frustration with antivaxers• Longing for return to normality
Family
• Struggle to be present for everything• The only mom to miss school events
• Missing stuff on call• Enough quality time with partner
• Will we survive this?
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How I see the Future
• Generally optimistic…if can make changes• Get practice partner• Protected time
• To coach kids• Be more available for kid functions• Time with partner
• Should I limit my practice• New community• New institution.
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