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Kevin D. Plancher, M.D., M.S. Associate Clinical Professor Albert Einstein College of Medicine What is the Future of Orthopedics: Hospital Employed vs.

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Presentation on theme: "Kevin D. Plancher, M.D., M.S. Associate Clinical Professor Albert Einstein College of Medicine What is the Future of Orthopedics: Hospital Employed vs."— Presentation transcript:

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2 Kevin D. Plancher, M.D., M.S. Associate Clinical Professor Albert Einstein College of Medicine What is the Future of Orthopedics: Hospital Employed vs Private Practice AAOS Fall Meeting October 10, 2012 Philadelphia, Pa © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC

3 Disclosures Updated Sept 2012 The following relationships exist: Item 1 Royalties from a company or supplier: No Conflict Reported Item 2 Speakers bureau/paid presentations for a company or supplier: Linvatec Item 3A Paid employee for a company or supplier: No Conflict Reported Item 3B Paid consultant for a company or supplier: No Conflict Reported Item 3C Unpaid consultant for a company or supplier: Merck Item 4 Stock or stock options in a company or supplier: No Conflict Reported Item 5 Research support from a company or supplier as a PI: No Conflict Reported Item 6 Other financial or material support from a company or supplier: No Conflict Reported Item 7 Royalties, financial or material support from publishers: Saunders/Mosby-Elsevier; Thieme Item 8 Medical/Orthopaedic publications editorial/governing board: American Journal of Orthopedics,Techniques in Sports Medicine Item 9 Board member/committee appointments for a society: AAOS; American Orthopaedic Society for Sports Medicine; American Shoulder and Elbow Surgeons; Arthroscopy Association of North America; International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine

4 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Personal Disclosure Career Highlights Medical School Georgetown Residency Harvard Combined Program Henry Mankin/Clement Sledge/John Hall Fellowships Hand-Indiana Hand Center Jim Strickland Shoulder /Knee Sports Medicine Richard Hawkins/Richard Steadman Full Time Faculty 1994-1999- Montefiore Medical Center/Albert Einstein College of Medicine Private Practice 1999-2012 Academic Model 4 Partners 2 ACGME Sport Medicine Fellows 6 Station Cadaver Lab- Located 1 Floor Above Clinical Office Not For Profit- 501 C 3

5 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice vs Hospital Employed Topics Covered Common Ground Malpractice Staying Solo Emotional Advantages Hospital Employed Emotional Disadvantages For You Financial Pro/Cons Advantages From the Hospital Perspective Switching Practices Hospital Traps Negotating Contracts/ Did You Know? Coding Starting A Private Practice In-Network/Out of Network

6 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice Vs Hospital Employment First Job-The Facebook Era Ask The Correct Question!!!! Which Job will Give Me the Right Mentor Knowledge is Good Experience is Limited Judgement is Still Young The First Time For Doing an Operation Something New Everyday The Correct Program Watches You Grow Pro Hospital Good Chairman Con Hospital Make quotas for Set Salary Pro Private Practice Great Senior Partners Con Private Practice Pressure to Compete and Be Accepted Ask The Correct Question!!!!

7 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice Vs Hospital Employment 15 Years Into Practice Ask The Correct Question!!!! Which Job will Continue to Let Me Grow Knowledge is Good Experience is Good Judgement is Good The Kids Are in School Is Medicine Safe For Me I Dont Like to Take Risks The Younger Partners They Dont Have the Same Work Ethic They Dont Want to Take Any Call The Older Partners They Arent Around As Much Pro Hospital Seems Easy- Just Show Up and Go Home Con Hospital What Do I do with All My Patients Will They Follow My Practice Pro Private Practice No Change- I Know the Drill Con Private Practice Pressure to Compete Working Longer Hours and Less Pay

8 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice Vs Hospital Employment 10 Years From Retirement Ask The Correct Question!!!! Which Job will to Let Me Retire Knowledge is Excellent Experience is Excellent Judgement is Excellent The Kids Are Out of School I Want to Travel More / I Put in My Dues Downsizing the House/ Less Costs The Younger Partners They Dont Have Experience Liability with All Their Complications The Older Partners I am it!!/ I Want My Buy Out! Pro Hospital Seems Like Easy Money Do Clinic and Just Show Up Great Vacation Time Con Hospital None/ I am Done in a Few Years/ Why Not? Pro Private Practice I am the Boss Finally Con Private Practice Costs are way up My Take home is So Much Less

9 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice vs Hospital Employment What is Common –Success is Easy Availablity Yes –Always! Non-Displaced Radial Head Fracture ­Never Send to the Office ­Grandmas Pubic Ramus Affability Difficult These Days Administrators Nurse Managers Colleagues Playing in the Sandbox Ability Cutting Edge Knowledge Community Guy ­Popular-Knowles Pins You Know Better-A Problem

10 Orthopedic Surgeon Practice Setting: 9,400 Returned Practice Surveys Type of Practice 2004 2008 % Change Priv. Practice-Solo 25.8% 20.9% 19% Priv. Practice-Group 50.6% 44.3% 8.3% Total Private Practice Groups & Solo = 65.2% Priv. Pract.-Multi sp. 7.3% 8.3% 12.3% Academic Practice 8.4% 8.5% 1.2%Academic Practice 8.4% 8.5% 1.2% Hospital Employed 3.8% 6.7%Hospital Employed 3.8% 6.7% 76% AAOS NOW, December, 2009

11 Recent Trends in Practice Setting Source AAOS Survey 2011 Practice Setting2004200620082010 % Change Solo-Private25.8%24%20.9%18.5%28.2% Group-Private50.6%48%46.4%45.3%10.5% Multi Specialty7.0% 8.3%9.0%28.6% Academic1%2%6.7%3.6%>200% Hospital Employment 2% 6.7%8.1%>300% AAOS,Health Systems Committee:, 2011 AAOS,Health Systems Committee:, 2011

12 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice vs Hospital Employed Where to Start/ All Jobs-Patients Hospital Based-Patients Con-Minimal Relationships Pro-Minimal Relationships Expectations Low PA/ Resident Middle of the Night Private Practice-Patients Pro- Strong Relationships Con- High Expectations Always Available Call Schedule Doesnt matter Cant Drink at a restaurant

13 Private Practice vs Hospital Employed Malpractice Pro-Hospital Based Dont have to worry about it Paid for but…… Con-Hospital Based If you leave…? Tail Do Have to worry about Type Occurrence vs Claims Made Pro-Private Practice Select the Type You Want Decision About Lawyers Your Decision Con-Private Practice Cost is high Games-New York State Berkshire Hathaway

14 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice vs Hospital Employed Advantages of Staying Solo You are Your Own Boss.. PRICELESS! Spend all Those Years to Become an MD Hospital Based Automomy Lost Hire and Fire Whomever You Want Without Asking Anybody!! Come and Go As You Like!!

15 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice vs Hospital Employed Disadvantages of Staying Solo You Can Come and Go As You Like……… As Long As You Have Back-UP!!!!!!! Thats the Catch!

16 © Copyright 2012 Plancher Orthopaedics & Sports Medicine PLLC Private Practice vs Hospital Employed Advantages of Hospital Employed Employee or Business issues No Concerns No Overhead Expenses Stable Income For the Time Being –Steady Paycheck Based Upon the Local Private Practitioners Incomes MGMA National Data. Automatic Referral Patterns Forced by CEO Artificially Busy Large Patient Base Not Yours Ability to Encourage Hospital to Develop a Subspecialty Orthopedic Department ACO Automatically Included

17 Private Practice vs Hospital Employed Advantages of Hospital Employed Employee benefits 401K 401K Pension Pension Holidays Holidays Time Off Time Off Reimbursement Contracts with Payors No Worries Malpractice No Costs To You No Costs To You Indirectly Effects Paycheck Indirectly Effects Paycheck

18 Private Practice vs Hospital Employed Disadvantages Hospital Employed Employee benefits No Say When or If They Change Large Patient Base Payor Mix Medicaid Limited Salary Potential Ancillary Revenue No Ability to Share No Ability to Share Non-Compete Enforceable 50 Mile Radius Control of Employees None Your Reputation AAOS NOW, 5/2012

19 Private Practice vs Hospital Employed Potential Disadvantages Hospital Employed Decision Making Bureaucracy Meeting Time-Lengthy Termination Without Cause Forced Retirement Age Contract Length Short 3-5Years on Average Call Schedule Indentured Servant Never Graduating Rigid CallSchedule Kaiser Orthopedics Administration Does Not Understand How Orthopedics Differs From Other Specialties AAOS NOW, 5/2012 AAOS NOW, 5/2012

20 Private Practice vs Hospital Employed Advantages to the Hospital for Orthopedist Employment Revenue Generator-HUGE Ancillary Service Revenue Generator-Huge Estimated Between $2.3 to 2.4 Million/MD In Rural Exception Hospital System In Rural Exception Hospital System Even Larger than HugeEven Larger than Huge Control the Orthopedic Marketplace Within the Community Complete Loss of Autonomy

21 Private Practice vs Hospital Employed Advantages to the Hospital for Orthopedist Employment Virtually, NO DOWNSIDE to Hospital Administration Generating 4 to 6 Times Your Salary But Tremendous Negotiating Ability Productivity bonuses Add Ancillary StaffAdd Ancillary Staff Help You Generate More Income Help You Generate More Income PA-C, NPs, Administrative etc. Vacation time PA-Cs Run Clinics for You Salary Adjustment Demand Productivity Based Not RVU

22 Private Practice vs Hospital Employed Willingness to switch? Ironically,,Among Those Currently Employed, 58% said they would consider making the move to private practice Yet, 58% in Private Practice Said They Would Consider Moving to Being Employed Full-time! Shapiro, AAOS Now, 11/2008

23 Schizophrenia Private Practice Stress Stress Employed Physician

24 Private Practice vs Hospital Employed Reasons for Leaving Private Practice Decrease In Reimbursements Difficulty in Practice Management Ancillaries Physical Therapy, MRI etc. Difficulty in Marketing Match competition From Hospitals Increase In Malpractice Insurance Premiums 120K at 10 Years Claim Made Private Practionner NYC Unwillingness to Provide Uncompensated Care Unwillingness to Provide Uncompensated Care Indentured Slavery Lifestyle Issues Lifestyle Issues Work/Home Balance Work/Home Balance

25 Private Practice vs Hospital Employed Being Flexible Why Be Flexible He Thinks He Has a Problem Often We as Physicians Think We Have a Problem With Our Job Think Twice Does He Have a Problem –NO Do You Have a Problem??????

26 Private Practice vs Hospital Employed Hospital Traps-Contracts Beware of Non Competes Carve Out Practices to Stay in Town When Terminated 50 mile radius Avoid Claw Back Clauses Salary That Is Returned When Productivity RVU Goals Are Not Maintained Remember The Hospital Does The Collections No Incentive to collect or appeal Need A Health Care Attorney Language is Too Complicated Production Formullas

27 Private Practice vs Hospital Employed Hospital Negotiations-Contracts Revenue-Know Your Worth Know How Much You Earn The HMO /Hospital Use As leverage: Higher Salary More Clinic Staff Surgery Obtain 2 OR Rooms Once or Twice/ week Ancillary Help 1 or 2 PAs In Clinic Improve Your Efficiency Quality of Life Obtain an Administrative Assistant PA-Cs -1 st call

28 Private Practice vs Hospital Employed Hospital Traps-Olympic Time Demand a Long Term Contract 10 Year Minimum Termination Without Cause Remove From Contract If Making Too Much Money Must be Paid on a Productivity Basis Learn How to Say No!!!!!!! To Administrators To Lawyers To Nurses Politely To Patients Earn Respect You Sacrificed All Your Years of Training Wall Street Boys Start at Age 23 You Start in your Mid 30s Stop Worrying!!!!!!!

29 Private Practice vs Hospital Employed Hospital Contracts: Define Outside Activities Exclude From Hospital Ownership IMEs Depositions Medical Record Reviews Paid Quality Assurance Roles Insurers Any Paid Agreements Implant companies, Clinical advisor fees Consultant Fees Speaking Fees Royalties

30 Private Practice vs Hospital Employed Private Practice Traps Formula Must Favor Productivity No Equal Split No 25% or 50% Split The Higher of Which Always Favors The Lower Producer. Termination Without Cause As You Age / Not Liked- The Group Wants to Get Rid of You Require 100% Partner Agreement Length to Partnership Buy in For Ancillary Services Easy in- Easy out Minimal Buy In and Minimal Buy Out to an Exiting Partner Avoid Owing Alot of Money to an Older Partner On Retirement

31 Private Practice vs Hospital Employed Contracts Private Practice or Groups New Laws-Practice Without Walls Band Together Join Other Soloists or Small Groups Form a Larger Group Use the Umbrella Merger Concept Attractive Local Hospital System ACOs Will Be In Need of Orthopedic Coverage Avoid Fragmented System May Entice the Hospital Hire Their Own Department

32 Private Practice vs Hospital Employed Coding Private Practice Its Essential-Coding Learn it in your Residency or Fellowship Its a Game Its Business No Emotion Consider Pro bono Work Hospital Based Keep Track of Your Billings Lost Control of Appeals Ways to Get Rid of a Doctor Encourage Monthly Reports Go to National Courses Learn How to Code

33 Private Practice vs Hospital Employment Treading Lightly The Other Side of the Classroom Treat Others Well Operating Room Environmental Service Receptionists Boston vs. Indiana vs New York Take a Deep Breath Two Ears, One Mouth Even When You Are Right Senior Partners Team Player Even when Equipment is Outdated Taking A Stand Be Ready for No Be Ready to stand strong and walk out Wall Street Style Athletic Trainers Be Aware They Run the Show

34 Private Practice vs Hospital Employment Advice-Never Tread Lightly Patient Advocate Its You Against the World It Will Secure Your Practice For Life Sit Down in an Exam Room Dictate in the Room Never the Hallway They hear you !!!!! Physicians are Fickle Send Referral Letters Hospital Based Forced to Refer to You Private Practice Referrals to Good Guys Not necessarily Best Trained Focus on Patient to Patient

35 ? () Any Conclusions? (Too Early-Hold On)

36 Caught Your Attention? Have I Convinced You to Think Twice About Hospital Employment? Lets Look at Private Practice

37 Establishing a Sound Business Classic Medical Model Where to Start-Private Practice Know Your Neighborhood Worry Is There a Market For Your Services? Who Will Be Your Patients? Who Are the Payors? Specific Insurances In-Network Medicare Medicaid Is My Overhead to High

38 Establishing a Sound Business Medical Model Resources Question: How Do I Know What I Need to Get Started? Ask Your Colleagues and Your Mentors Use Available Resources AAOS ( http://www3.aaos.org/member/prac_manag/prac_manage.cfm ) AMA ( http://www.ama-assn.org/ama/pub/physician- resources/solutions-managing-your-practice.shtml ) http://www.ama-assn.org/ama/pub/physician-

39 Establishing a Sound Business True Business Model Where to Start Decide Where You Want to Live Ignore Everything Else Be Ready to Listen to Your Patients – Customers Nordstroms vs. K-Mart Dictate in Front of Patients Seat Height Out-Of-Network Insurance Never Look at Someone Elses OR Schedule-Worry About Yourself Rarely If Ever Have Someone Cover For You Participate in >1 Hospital ER Never Be Held Hostage-BI North Never Send to My Office Ill Be Right In Consider Being Both Academic and Private Practice Accepting New Patients

40 Establishing a Sound Business True Business Model Where to Start Realize There is Always Room for Another Great Surgeon Available Affable Appropriate Available 24 hours/day 7 Days a Week Be prepared to Miss School Functions Be Prepared to Miss Family Birthdays Be Prepared to Miss Parties You Are a Physician!!!!!!!!! Not a Stock Broker They Play for a Living You Practice for a Living! Personal Sacrifice Dont Want it –Thats okay Hide in an HMO- 9-5 pm

41 Establishing a Sound Business Model Private Practice The Numbers Budget-Design It Indirect Expenses Variable Expenses Direct Expenses Obtain a Loan Understand Your Cash Inflow Office Visits Surgical Procedures Are You an Orthopaedic Surgeon or an Orthopaedist? Ancillary Services-Beware of Stark Laws

42 Establishing a Sound Business Model Private Practice In-Network vs. Out-of-Network Out-of-Network 4 Times the Reimbursement More Pro Bono Work Common Myths Cant Do It In My Neighborhood Bronx NewYork My Chairman Wont Let Me Separate Tax ID Number It is Doctor Driven Hospital Anesthesia Emergency Room Visits-Love to Go By Law- Distal Radius $1500 vs. $200 Paid By The Insurance Companies Never Hurt the Patient

43 Establishing a Sound Business Model Private Practice In-Network vs. Out-of-Network In-Network EGO-Driven Doctor I Do 800 Cases a Year Are You Busy? No- Actually I make 4x the Reimbusement and Play Golf, Volunteer and See My Family. I Do 250 Cases a year and 25 Patients a Day Instead of 50 in the Morning. Are You Worth a 10 Dollar -25 Dollar Co-Pay? Drop Plans When Financially Possible 9 Years Periodic Evaluation Pare Out Slowly Get a New Tax ID Number Its a Game –Be READY to PLAY Everything is Negotionable

44 Establishing a Sound Business Model Marketing-Private Practice Your Relationship With Your Patients IS Your Business – Pay Attention to Them Establish a Relationship With the Community Participate Little League Coach etc. School Functions Meet Your Colleagues Be Kind Market Yourself Dont Offend Your Colleagues What is Your Niche?

45 Establishing a Sound Business Model Marketing-Private Practice Your Relationship With Your Patients IS Your Business – Pay Attention to Them Announce Your Arrival Referrals Will Get You Started-Insurance Books 1 Year-To Be Included Dont Expect Another Pediatrician or Internist to Refer to You Arthroscopic Rotator Cuff vs.Open Repair

46 Establishing a Sound Business Model Marketing Advertise Individuals Internet Show Your Face In Offices/Hospital Hospitals Local Newspaper Regional Newspaper Branding HSS-New York Times Hospital Newsletters

47 Establishing a Sound Business Model Staff/Associates Surround Yourself With Quality People Office Manager/Assistant Billing Staff-Ethical Always Dictate Your Own Operative Report Accountant Insurance Agent(s) Banker I.T. Spend a Lot More to Get Quality Help Know the Laws! Never Break Them!

48 Establishing a Sound Business Model Keys to Success Be Humble Put Away Your Pride Dont Be Afraid to Work Pound the Pavement Lectures to Senior Citizen Groups Athletic Trainers Physical Therapy Groups Hospital Grand Rounds Publish Papers Be an Authority Private Practice Experience Always Say YES Be Available Avoid Being Cheap Most Doctors Are!

49 Establishing a Sound Business Model Classic Medical Model Earn Before You Spend!

50 Private Practice vs Hospital Employment How Much Do You Get Arthroscopy Shoulder Labral Repair In Out Rotator Cuff Repair In Out Arthroscopy Knee ACL In Out Total Joint Total Knee Replacement In Out Hospital Trauma ORIF Radius-Gallezzi Surgeon Hospital

51 Private Practice vs Hospital Employment How Much Do You Get Arthroscopy Shoulder Labral Repair In -$850 Out-$8,500 Rotator Cuff Repair In-$1200 Out-$9500 Arthroscopy Knee ACL In-$1,081 Out-$8,000 Total Joint Total Knee Replacement In-1,600 Out-10,000 Hospital 65K Trauma ORIF Radius-Gallezzi Surgeon-$750.00 Hospital-39K

52 Private Practice vs Hospital Employment How Much Do You Get Dont Ever Apologize! The Enemy The Insurance Company For Profit Stock Must Go up The Hospital Re-imbursed almost double for same procedure as a surgery Center Lobbies Get Mad-Make a Difference The public Surverys of Educated College grads- New York Times-Doctors are underpaid

53 Establishing a Sound Business Model Classic Business Model Spend and Invest In Your Future Wisely! Stop Worrying! Focus on Your Patients!

54 © Copyright 2011 Plancher Orthopaedics & Sports Medicine PLLC

55 Thank You If You Build It They Will Come!!!!

56 Did You Know! Being a hospital employee allows for involvement in the capitation or ACO processBeing a hospital employee allows for involvement in the capitation or ACO process You are the one bringing patient volumeYou are the one bringing patient volume Orthopedics is the most lucrative surgical subspecialty next to CV surgery reimbursementsOrthopedics is the most lucrative surgical subspecialty next to CV surgery reimbursements You bring in anywhere between 4 to 6 times your salary net to the hospitalYou bring in anywhere between 4 to 6 times your salary net to the hospital Dont ever forget to remind them of this fact !Dont ever forget to remind them of this fact ! Dont Apologize when NegotiatingDont Apologize when Negotiating


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