Thinking of a location to practice medicine or open a... There are a number of considerations that any pediatrician will... Launching Your Career in Pediatrics: Getting Started
Launching Your Career in Pediatrics: Getting Started Thinking of a location to practice medicine or open a practice is an important decision. There are a number of considerations that any pediatrician will need to examine before making a final decision. Pediatricians often choose their jobs based on several factors—family needs, spousal considerations, recreational and cultural opportunities, friends, size of the community, lifestyle, income guarantees, and benefit plans. This section will look at the most important things to consider when joining or opening a practice. • • • • • • Personal and Family Needs Financial Considerations Assessing the Community Practice Types Current Trends in Malpractice Professional Relationships and Opportunities Personal and Family Needs Family needs and wants are often at the top of the list when considering where to practice. Many pediatricians who have young children often choose to move closer to family and relatives for support. The location of where a spouse can work is an important factor when determining a location, as well. Also important are the availability of educational, cultural, and recreational activities. If you love outdoor activities, you may wish to move to regions that offer those advantages. As more women enter the field of pediatrics, there has been an increase in demand for careers that offer a work/life balance. This demand has prompted many pediatricians to seek careers that offer job sharing and part-time and flexible work schedules. The American Academy of Pediatrics (AAP) Women in Pediatrics Web site has more information about issues facing women in pediatrics. The same dynamics hold true for those on the opposite end of the spectrum—retiring pediatricians (Shrier DK, Shrier LA, Rich M, Greenberg L. Pediatricians leading the way: integrating a career and a family/personal life over the life cycle. Pediatrics. 2006; 117:519–522) To make a decision about where to practice, it is important to assess your goals. Clarify your career objectives. • Do you want to practice a specific style or philosophy of pediatrics? • Are you a team player or someone who likes to go it alone? • What type of location would you like to be in—rural, suburban, or urban? • What kinds of patients do you want to serve? -1- • What are your future goals? • Do you enjoy working shifts? • Do you prefer inpatient or outpatient care? Do you like the idea of hospital or academic practice, a clinic practice, or a private office? • How many hours do you want to work? • Do you mind working a lot of evenings and weekends? • How often do you want to be on call? • Is the practice committed to being a medical home for its families? What kind of lifestyle do you want outside the office? • Exposure to urban life opportunities • Outside adventures Financial Considerations Salary The region of the country where you practice will likely determine your lifestyle and practice income. Surveys of pediatric salaries show that incomes are highest in the Midwest and Southeast, with the lowest salaries in the Northeast and on the West Coast. The following chart from the US Department of Labor Bureau of Labor Statistics provides the annual mean and median wages for pediatricians practicing in all states based on 2007 data. The annual mean wage also varies by years in practice. For general pediatricians—annual mean wage: $145,210; annual median wage: $140, 690. STATE/COMMONWEALTH ANNUAL MEAN WAGE ANNUAL MEDIAN WAGE Alabama $145,950 $139,610 Alaska $140,140 $135,070 Arizona $149,440 a -2- Arkansas $135,100 $106,030 California $155,230 a Colorado $165,820 a Connecticut $135,860 $132,360 Delaware $141,580 $132,530 $74,830 $73,230 Florida $146,970 a Georgia $109, 280 $110,430 Hawaii $150,070 $136,180 Idaho $131,010 $139,430 Illinois $122,870 $117,130 Indiana b Iowa $151,250 a Kansas $141,300 $134,890 Kentucky $189,280 a Louisiana $170,280 a Maine $153,810 a Maryland $116,950 $115,050 District of Columbia $142,580 -3- $135,470 Massachusetts $147,310 $145,240 Michigan $140,810 $133,470 Minnesota $163,540 a Mississippi $152,270 a Missouri $136,790 $144,540 Montana $97,090 $99,300 Nebraska $171,340 a Nevada $181440 a New Hampshire $150,360 a New Jersey $146,450 $135, 270 New Mexico $156,660 a New York $141,960 $134,110 North Carolina $159,390 a North Dakota $129,450 Ohio $147,410 $139,690 Oklahoma $182,000 a Oregon $159,130 a Pennsylvania $139,440 $127,550 Puerto Rico $83,650 $64,390 -4- 126,980 Rhode Island $144,220 $140,410 South Carolina $132,460 $137,900 South Dakota $177,620 a Tennessee $156,560 a Texas $151,820 a Utah $159,170 a Vermont $117,460 $110,220 Virginia $133,220 $126,910 Washington $135,160 $130,230 West Virginia $162,500 a Wisconsin $161,430 a Annual wages have been calculated by multiplying the hourly mean wage by 2,080 hours; where an hourly mean wage is not published, the annual wage has been directly calculated from the reported survey data. a This wage is equal to or greater than $70 per hour or $145,600 per year. Data extracted on May 20, 2008. According to the Medical Group Management Association (MGMA) Physician Compensation and Production Survey. 2007 Report Based on 2006 Data, for salaries of physicians who are new to practice (1–2 years), the median income for general pediatricians is $130,633 and $192,664 for neonatologists. -5- References and Additional Resources The 2002 AAP Periodic Survey provides an overview of pediatrician’s characteristics. “Pediatricians Leading the Way: Integrating A Career and a Family/Personal Life Over the Life Cycle,” February 2006 “Pediatrician Workforce Statement,” Pediatrics, July 2005 “The Pediatrician Workforce: Current Status and Future Prospects,” Pediatrics, July 2005 Physician Compensation and Production Survey. 2007 Report Based on 2006 Data, MGMA Physician Placement Starting Salary Survey Report. 2006 Report Based on 2005 Data, MGMA Recent Graduate As the cost of higher education continues to rise, so does the amount of loan debt. Many members of the AAP emerge from medical school or pediatric residency with a balance of more than $125,000 in student loans. It is important to obtain qualified advice before entering into any loan repayment or employment agreement. There are many government programs that offer repayment programs. It is essential to learn about the commitments and expectations before entering into any formal agreement. Examine the source of funding and the fine print, and consult mentors on your faculty and in your student affairs office before entering into any commitments (Pediatrics 101: A Resource Guide from the American Academy of Pediatrics) The following links provide general information as a starting point for research. Consult with your college financial aid officer and other qualified advisors before committing to any financial arrangement. Resources Association of American Medical Colleges (MD)2: Monetary Decisions for Medical Doctors A database of state and other loan repayment/forgiveness scholarship programs with an interactive guide to information from state health departments, medical schools, federal programs, and military agencies -6- A chart showing tuition and student fees for first-year medical students, 2004 to 2005 (log-in required) National Institutes of Health Pediatric Research Loan Repayment Program—in return for a 2-year commitment to your research career, the National Institutes of Health will repay up to $35,000 per year of your qualified repayable education debt plus an additional 39% of the repayments to cover your federal taxes, and may reimburse state taxes that may result from these payments. Student Loan Consolidation—information on loan consolidation programs. Indian Health Service Loan Repayment Program Service Center Applicants sign a 2-year agreement and provide full-time clinical practice at the Indian Health Service facilities or approved Indian health programs. In exchange, a portion to all of their educational loans will be repaid. National Health Service Corps Applicants will serve on an interdisciplinary team to focus on community health. In exchange, applicants will receive job placement assistance, a competitive loan repayment program, an opportunity to join the National Health Service Corps Ready Responders as a US Public Health Service commissioned officer, and preceptorship and mentoring. Assessing the Community Whether you are considering opening a practice, joining a practice, or relocating, there are a number of things to consider before making the final decision. In real estate, the 3 most important considerations when buying a house are location, location, and location! The same is true of a pediatric practice. Many of the decisions about practices and lifestyles will be determined by your preferences about where you would like to live and work. Following are some tips on selecting a community in which to practice: • The most basic approach to assess the requirements for pediatricians is to determine the employment opportunities and competition for patients. • Consider trends in the local obstetrician demographics. • Contact the local chamber of commerce to find migration trends and the opening of schools, homes, and hospitals. This is often a good predictor of whether the location will be viable. -7- • It is important to know if the community in which you plan to practice is a younger community with new families emerging or an aging retirement community. • Identify where patients live. The rule of thumb is that patients will drive 20 minutes to see a doctor. Any farther, patients will look for a doctor closer to where they live. However, this rule may not apply to rural physicians. • Consider the number of retail-based clinics (RBCs) in your area. If there are no RBCs, this is a good time to establish your pediatric office in a central location near a major retail location to get ahead of the competition in the future. If RBCs do exist, make sure the practice you are starting or joining is providing competitive hours and values customer service. Families are using RBCs mainly out of convenience. If your practice can compete by providing the same or better level of convenience, your expertise as a pediatrician will far outweigh the services provided at an RBC. It’s a win-win situation for you and your patients. More resources on RBCs can be found on the AAP Practice Management Online Web site. • Consider the number of pediatric care professionals in the area.\ Urban Versus Rural Locations There are many differences between practicing in a rural versus an urban location. Those who choose to practice in a rural area usually prefer to do so in an effort to use all skills learned during residency. It is common for practicing pediatricians in rural areas to perform resuscitations, intubations, and lumbar punctures. It is often their responsibility to stabilize and care for children who are chronically ill. See Table 1 in “Trends in the Rural-Urban Distribution of General Pediatricians” (Pediatrics. 2001;107:e18) for more information. Practicing in an Urban or Rural Population Urban Rural More technology Less technology More networking opportunities Independent practitioner with less networking opportunities Less on-call and weekend hours Need to be available more (on call, after hours, and weekends) -8- More commuting time Larger salaries More physicians = more competition Greater need = less competition Access to subspecialists and children’s hospitals Often will need to contract with subspecialists Where Children and Their Families Go for Health Care The American Academy of Pediatrics (AAP) partnered with Dartmouth Medical School, Center for the Evaluative Clinical Sciences, to develop Mapping Health Care Delivery for America's Children. This Web site provides the status of current available national, state, and city data on the following: • Children younger than 18 years per clinically active pediatrician Percent of clinically active pediatricians who are female • Median household income • Percent of Hispanic children younger than 18 years • Percent of children 5 to 17 years old in linguistically isolated households It is important to note that while some areas in the United States appear to have a large number of pediatricians, these pediatricians are still employed and working. Practice Types There are a variety of practice options and structures available to pediatricians. Following is an overview of the various structures. Solo Versus Group Practice Solo Practice Group Practice More individual freedom Less individual practice freedom Longer work hours— clinical and business Shorter work hours Academic Health Center Hospital Owned Federally Qualified Health Center Not as much physician autonomy Not as much physician autonomy Not as much physician autonomy Work on a schedule Work on a schedule Work on a schedule -9- Complete responsibility for the business Less need to be involved in business aspects High public/patient visibility Less personal visibility with public and patients Subject to employee constraints Subject to employee constraints Subject to employee constraints Marketing department Marketing department Marketing department Extremes of financial return Built-in on-call coverage Centralized patient record keeping Business risk Lower Low to no medicolegal/business legal/business risk risk Less opportunity for More opportunity for Required informal professional informal professional referral consultations consultations patterns More limited working capital Total involvement in business concerns High-tech practice will depend on expenses Set growth pattern Centralized patient record keeping Low to no legal/business risk Required referral patterns Centralized patient record keeping Low to no legal/business risk Cost allocation to physicians Limitations due to federal fund ing regulations Access to larger amounts of working capital. Possible administrative limitations Less opportunity for involvement in business Greater chances to be involved in high-tech practice Systemdetermined decisions Better access to equipment and better equipment Systemdetermined decisions Better access to equipment and better equipment Systemdetermined decisions Better access to equipment and better equipment More limits on rapid income growth Steady flow of income Steady flow of income Steady flow of income Established benefit structure Established benefit structure Access to larger amounts of working capital Determine benefit structure Established benefit structure Required referral patterns Established benefit structure Source: American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Management of Pediatric Practice. 2nd ed. Elk Grove Villlage, IL: American Academy of Pediatrics; 1991 and American Academy of Pediatrics. A Guide to Starting a Medical Office. Elk Grove Village, IL: American Academy of Pediatrics; 1997 Solo Practice Solo practices are for pediatricians who want to own and manage their own practice. This physician is responsible for all aspects of the practice, including establishing policies and - 10 - guidelines, staffing, office hours, finances, and legal. Expense Sharing This type of practice may be as simple as 2 pediatricians sharing office space and staff but operating as independent practices. This provides some relief from the financial burden of overhead and office operations and provides some relief from finding night-call coverage. Patients should be made well aware that the 2 physicians have separate practices. If there is no written agreement and patients assume that the physicians are partners, both physicians may be implicated in malpractice litigation. Partnership A partnership is an association of 2 or more persons for the purpose of carrying on as coowners of a business for profit. The partners in this arrangement invest together to make a profit. In this structure, each partner has equal rights and management and also shares the risks and responsibilities. New partners are usually brought in after acquiring the consent of all existing partners. Like marriages, there needs to be compatibility in medical practice and management philosophies among partners. Partners can also expect to receive a formal accounting of all partnership affairs. On the other hand, all partners may be liable for each individual partner’s wrong acts or acts of commission or omission assumed by the partnership as a whole, inviting individual liability for any legal action against the partnership. Also, in much the same way partnership gains are shared equally, so may losses be expected to be shared. Multi-specialty (Large and Small) Single-specialty groups pool the resources of several pediatricians. The legal arrangement becomes important and is essential to define the roles and responsibilities of the partners. Multi-specialty groups provide a pool of other medical and management skills, but with significantly less personal autonomy. Corporate Practice Working for a large corporate health care provider is another option. Corporate practice reduces the personal and financial risk to the individual physician, while also providing opportunities to shelter income through a qualified retirement program. A large health maintenance organization (HMO) office allows pediatricians to practice without business or administrative concerns. This provides a great deal of security in terms of salary and benefits and eliminates the need to be concerned about administrative and business aspects of practice. Government and federal health care facilities provide another practice outlet. Academic practices provide many of the same benefits. Lastly, niche practices such as emergency department or delivery room coverage, working with specific disease entities like obesity, or substance abuse centers provide yet another practice outlet. Advantages include limited liability to the individual practitioner; centralized - 11 - management; continuity of life beyond the career trajectories of existing physicians; pension and profit-sharing plans that may be superior to solo practice or partnerships; tax incentives; and presence of other benefits that are more cost-efficient because of scale (eg, health benefit, life insurance, disability, malpractice discount). Disadvantages include need for an extensive organization to manage personnel, legal paperwork, tax, and accounting; need for higher start-up costs; and potential tax consequences (eg, corporate versus income tax). Corporate practices may exist in several forms—HMO groups, government or federal health care centers, hospital-based practices (eg, academic groups, hospitalist groups, emergency department physicians), and boutique practices (eg, substance abuse, surgical centers). These may all be structured very differently depending on local standards, community and state laws, and preferences of organizing groups. Each may have various arrangements for a physician’s role and responsibility within the group, including profit sharing, vesting time, amount of call, and academic partnerships. Academic and Hospital-Based Practices With the growing demands of outpatient practices, hospital-based practices are growing in almost every community. They may develop as an initiative of local physicians, or hospitals may choose to contract with them. They may offer around-the-clock care that primary physicians find difficult to provide. Having hospitalists has been shown to improve quality measures—including length of stay, mortality, and 30-day readmission rate—in several common inpatient diagnoses. Evidence also shows that hospitalists reduce costs and length of stay while achieving the same or better patient outcomes achieved by non-hospitalists. Hospitalists often practice in group-type structures; they may be simple informal arrangements among a group of physicians within a community who share hospital calls with or without teaching responsibilities, or they may be more elaborate corporate organizations that employ individual physicians. Some may even be organized on a national scale, with local “franchises” that operate within a community but are answerable to corporate headquarters. They may cover one or multiple hospitals depending on the demand and the particular relationships that exist between the group and hospital administration. In much the same way corporations offer benefits of scale in terms of sharing expenses, employee benefits, and tax advantage, groups that are more organized offer the advantage of monitoring the quality of care provided by their physicians. These groups may have methods in place to assess outcomes, lengths of stay, patient satisfaction, and reimbursement values. Physicians who practice within such a setting report the following advantages: • Satisfaction of working within a team • Satisfaction of contributing to the improvement of inpatient care or hospital processes • Flexibility of work hours (i.e., not necessarily 9:00 am–5:00 pm) • Opportunities for various educational interactions (eg, with other specialists, - 12 - • • • residents, medical students) Opportunity to have nonmedical responsibilities (eg, administration, quality assurance) as much or as little as one wants Large variety of clinical cases, which are often acute and whose successful outcomes provide enormous satisfaction Being kept on one’s toes Most physicians who work in this setting will report difficulty and even boredom with the daily grind of an office practice, which often seems to involve the same medical problems over and over. These physicians also perceive the business side of keeping a practice afloat not to their liking. They express a high comfort level with a hospital setting and the pace that such work involves. On the other hand, depending on the level of specialty required, length of training time, and challenge of working in a high-pressure field that may be dominated by males, some women may not find this to be a suitable practice alternative. Furthermore, practice turnover may turn the work hours from an advantage to a disadvantage, since regardless of the number of covering physicians, the group will still be committed to providing 24/7 care. Physicians in practice transitioning to or new graduates contemplating a hospitalist position should ask themselves a number of questions. What is the nature of the organization? Is it a corporation, a partnership among physicians, or a hospital-based group? Will a physician be an employee of the corporation or of the hospital? What is the basis of the corporation’s relationship to the hospital? What is the organizational structure? Who will serve as my direct supervisor(s) and what are his or her responsibilities? What is the group’s composition? Are they all general pediatricians? Are there family or nurse practitioners? Who are the actual physicians participating in the call rotation? What are the responsibilities of each physician who takes calls? What is the call rotation schedule? Are there outpatient responsibilities or emergency department coverage apart from inpatient calls? Where will these be conducted? Which hospitals does the group cover? If more than one, are there different responsibilities or expectations with each hospital setting? Are the patient load and population different with each hospital? If one is relocating, what is the approximate distance between each hospital and one’s residence? Is there a central office location for the group? What are other physician responsibilities apart from direct patient care? Are there administrative duties or teaching responsibilities? Are these expected, required, or optional? If one were to supervise or teach, does this involve nurse practitioners, physician assistants, other nursing personnel, residents, or medical students? - 13 - Does the group have subspecialty or surgical support? If so, who and where? Does it require transferring patients from a primary hospital to a tertiary one? What is the rate of physician reimbursement? What is the basis of this scale (eg, seniority, productivity, patient load, call load)? How is one’s productivity calculated and what factors go into this calculation? How does one’s productivity affect compensation and future raises? What benefits are offered to physicians? Do these include health coverage, malpractice liability, other insurance coverage, and retirement funds? If transferring from another practice, will the group offer tail coverage? What constitutes terms of separation, termination, and contractual breach? Are there any restrictive covenants (eg, geographic practice restrictions)? What are the laws of the state governing all of this and what are the responsibilities and liabilities if one assumes this position? You may need to consult your state medical board or a local lawyer. Retail-Based Clinics While the AAP does not support the RBC model of care for children, families are using these types of clinics. Located in retail settings (eg, pharmacies, supermarkets), these clinics provide families with a convenient location and the ability to multitask. While this may seem like a benefit to the family, the care provided at an RBC is very limited and only fragments the medical home. Practices must educate their patients on the importance of the medical home, but also provide a practice setting that meets the needs of busy families today. Practices must acknowledge the changing health care market and respond to remain competitive. Providing a medical home for patients can be challenging financially and administratively, but it is the best model of care for children. More resources on RBCs can be found here. Current Trends in Malpractice Pediatricians are sued less than other specialties—approximately 33% of pediatricians are sued in their career. However, the indemnities are 25% higher. (Donn SM. Is there really a relationship between medical liability, risk management and quality improvement? Pediatricians and the Law. AAP News. 2007;2:1 1) Malpractice coverage is necessary. There are 2 main options to choose from when deciding on malpractice coverage claims-made or occurrence-made policies. It is very important to understand the differences. Claims-made policies will only cover you during the time you hold the insurance policy; thus, once you leave the policy you will not be covered for any claims. For instance, if - 14 - you were in practice from January 2008 and left your job and policy in January 2009, after January 2009 you will not be covered for any claim made, even if it is regarding an incident that occurred between January 2008 and January 2009. However, you maybe able to purchase a tail, which can cover any claims filed about incidents during the time you had claims-made policy. Occurrence-made policy, on the other hand, covers all claims regardless of when the incident in dispute occurred. In other words, even after the policy expires, it still protects you from any claims filed for incidents that occurred while the policy was in force. This policy tends to be more expensive Resources “Malpractice Insurance,” American College of Physicians “Evaluating an Insurance Policy,” American Medical Association “Exclusive Survey—Malpractice Premiums: Starting to Level Off,” Medical Economics “Is There Really A Relationship Between Medical Liability, Risk Management and Quality Improvement?” AAP News. Professional Relationships and Opportunities Nearly 50% of physicians who practice in towns with a population of fewer than 2,500 grew up in a town with similar statistics. Studies show that there is a strong correlation between where a pediatrician went to post-training studies and where he or she chooses to practice. You will also want to consider the professional relationships and networking opportunities that you have had. Often, your mentors and professors can serve as references and resources as you locate a place to practice. Your State AAP and Medical Society Contacts AAP chapters are organized groups of pediatricians and other health care professionals working to achieve AAP goals in their communities. There are 59 chapters in the United States and 7 chapters in Canada. The US chapters generally are drawn along state lines, but 2 states with large populations (New York and California) constitute more than 1 chapter. In addition, 2 chapters serve pediatricians in the uniformed services (east and west, divided by the Mississippi River), and Puerto Rico and the District of Columbia are also separate chapters. - 15 - I Already Belong to the National AAP; Why Should I Become a Member of My Chapter? Advocacy • Increase your knowledge of and participation in legislative and advocacy activities at a local level. • Increase involvement in the legislative arena to positively influence the quality of pediatric practice and the welfare of children in your state. • Build coalitions with other organizations working toward improving children’s health and well-being. • Promote the interests of pediatricians in the AAP. Leadership • Participate in chapter committees in areas of interest. • Serve as part of the chapter leadership team in an official officer capacity. Networking • Network with other pediatricians with similar interests. • Improve chapter membership participation on national AAP affairs. Education • Receive regular chapter newsletter and other informative mailings. • Attend local continuing medical education meetings and chapter annual meetings to further necessary educational requirements. To learn more about your state chapter, visit www.aap.org/member/chapters/chapfacts.htm. Launching Your Career in Pediatrics: Finding the Job For many, choosing a location to open or join a practice is the first step in searching for a job. Once a location has been determined, the job search begins. This next section will provide tips on the following: Searching for a job Researching the practice and community Recent graduates Identifying goals Timeline summary Working with recruiters Preparing a curriculum vitae and cover letter The interview - 16 - Negotiating an agreement Searching for a Job There are many ways to look for a job, from headhunters to posting your résumé on the Web to looking in journals, but one very important way is through networking. A personal recommendation and interaction go a long way. Some of the key people to network with include • • • • • • • • • Residency director and faculty. Contact the residency or training director and faculty at the institution where you trained. Many local pediatricians provide residency directors with job openings. Local agencies. Contact the local medical society or American Academy of Pediatrics (AAP) chapter. Many times these groups are aware of pediatricians looking for new associates. PedJobs. Visit and register with PedJobs at www.pedjobs.org. Hospital. Many hospitals will assist with practice setup if they have a need for a new pediatrician in the community. Additionally, many hospitals, local health centers, and urgent care centers are building primary care networks and are looking for physicians to staff them. You may want to consider contacting a hospital that delivers newborns because there may be opportunities to cover the nursery and delivery room. Additionally, some hospitals hire hospitalists to care for newborns, inpatients, and patients in the emergency department. Local pediatricians. Once you have decided on a location, get a list of the pediatricians in that area. Contact them expressing interest in working for them. If they are not hiring, they may be aware of other colleagues who might be looking for an associate. Events. By attending events, you can meet other physicians in the area. Colleagues. Your former and present colleagues are a great resource. They are the ones who have worked alongside you and know you well. Colleagues can be helpful if an opening becomes available at their practice or if they hear of another opportunity. Colleagues can include people you have interacted with in high school, college, and medical school. Ask. The best advice is “Ask, ask, ask!” If people are not aware of jobs, many times, they will refer you to someone who is aware. Recruiters. The use of recruiters can be very beneficial to a new job seeker. The recruiter’s primary goal is to fill a position for the clients they represent, whether hospitals, health systems, or clinics. Following is additional information on working with recruiters. Remember to tell everyone you know that you are looking for a job because you never - 17 - know what opportunities may arise. Having a curriculum vitae (CV) or résumé ready to distribute can help make the most of a time-sensitive opportunity. Resources Medical Economics: “Finding a Job: Step 1: What Do You Want?” Medical Economics: “Finding a Job: Step 2: Start Looking” Researching the Practice and Community When you have narrowed down the search to a few practices, it is important to research the practice and staff working at that location to determine if it would be a good fit for you. The following are guidelines to assist in this process: • • • • • Talk with other pediatricians about the reputation of the group that you are considering. Are they respected as good doctors? Look at the CVs of the partners in the practice as well. Do they have a Web site and what can you learn about them from it? Who is the local competition? Talk with the medical society about local medical issues. Call the chamber of commerce and learn what the community has to offer. Is the hospital open to new physicians or closed? Who would be your collaborator and competition? Recent Graduates The obstacles facing recent graduates and current residents looking for a position in pediatrics are different from those who have previously undertaken this process. Recent graduates are often individuals who have pursued a career path without any experience in job searches. These individuals transitioned from one level of training to another since high school. With this perspective, the foundational skills of a job search need to be reviewed. Specifically, recent graduates are often at a loss as to when to look for a job and how to design a CV and cover letter. Identifying Goals In the first year of residency, residents should identify their career goals and attempt to tailor their training appropriately. If this entails further subspecialty training, activities that strengthen the resident’s interest such as research and appropriate mentorship should be started. However, for those interested in general pediatrics, exploring different practice types while under the umbrella of training can offer much insight. Look to shadow and work in various practice locations. Residents should explore an academic practice, a rural practice, an urban practice, and all the variations in between. Discussions with program directors about career goals can be very fruitful during the later aspects of the intern year. - 18 - For those looking for general practice, the second and third years give residents time to hone in on the location and types of practice that they are suited for. This is important because various locations may have different requirements for licensing and skill sets. For instance, an academic position may not require in-hospital coverage and thus documentation for procedural skills and staff privileges within a hospital may not be as important. Those looking in a different state may also need to start working on how to obtain a medical license and credentialing in that state. For those interested in further subspecialty training, the second and third years involve further research and applying to the specialty of choice. Currently, pediatric subspecialty match involves the National Resident Matching Program on a subspecialty-bysubspecialty basis. There has been a recent move to involve all subspecialties in the match program, but some continue outside of the match. As the specialty of choice is identified, the application process must be identified early to avoid missing the appropriate application cycle. Timeline Summary Postgraduate year (PGY)-1 • Focus on surviving the intern year. • Assess fit with possible careers during various rotations. • Explore career goals by establishing a mentoring relationship. PGY-2 • Pursue electives to explore career opportunities. • Decide between general versus subspecialty practice. • Initiate research as needed to strengthen career choices. • Create CV and identify programs for fellowship. • Identify timing for various subspecialty fellowship applications. • Match for fellowship programs. PGY-3 • Identify suitable primary care positions and send out cover letters and CV during the early part of the year. • Interview during the middle portion of the year for primary care positions. • Solidify primary care positions and negotiate contracts and benefits during the second half of the year. • Match for fellowship programs. - 19 - Fellowship Application Schedule as of Spring 2008 Specialty Admission Cardiology Spring to summer PGY-2 Gastroenterology Spring to summer PGY-2 Rheumatology Spring to summer PGY-2 Allergy and Spring to summer PGY-2 immunology Nephrology Winter to summer PGY-2 Pulmonary Rolling PGY-2 Endocrinology Rolling PGY-2 Neonatology Winter to summer PGY-2 Hematology/oncology Spring to summer PGY-2 Critical care Fall PGY-3 Emergency medicine Fall PGY-3 Sports medicine Winter PGY-3 Participates in Match Yes Yes Yes Yes No No No No Yes Yes Yes Yes Resources Association of American Medical Colleges Electronic Residency Application Service National Institutes of Health: “Preparing the Curriculum Vitae” National Resident Matching Program New England Journal of Medicine: “Writing Compelling Physician Cover Letters” New England Journal of Medicine: “Working With In-House Physician Recruiters” University of Chicago: Department of Pediatrics Career Planning Working With Recruiters In transitioning from training into the workforce, residents commonly receive solicitation from physician recruiters. In approaching recruiters, the job seeker needs to understand the market that the recruiter serves. Although there are national recruiters, frequently recruiting firms operate in a specific geographic area. In addition, keep in mind that the recruiter’s primary goal is to find physicians for their clients. Thus, the job seeker should always be mindful that the recruiter is an extension of the position and approach interactions carefully and professionally. The use of recruiters can be very helpful to streamline the search process but does not eliminate all of the hard work. The networking that may result from this relationship can be very beneficial to a new job seeker. The following are some helpful guides in working with recruiters: - 20 - • Know thyself. Because opportunities can be endless, it is important to have a specific picture in mind of your ideal practice before working with a recruiter. Is it in a city or suburban town? Is it a partnership or salaried employee position? Will there be hospital-based work or clinics only? By focusing your goals, the recruiter can better work with you to identify the practices that would be a good fit for you. • Recruiters work for the companies for which they recruit. More importantly, they do not work for you. Recruiters’ job is to find suitable candidates to fill the positions for which they are hiring. In a November 5, 2004, Medical Economics article, “Finding a Job: Step 2: Start Looking,” Gail Weiss states that the use of recruiters may limit your bargaining power because the cost of using the recruiting firm may curb the employer’s appetite for working with you on compensation such as moving expenses. • Know who you are working with. You should be comfortable with recruiters’ style and approach. Before starting a relationship, you should check out credentials such as the history of the business, duration of stay for previous placements, companies that they have worked with, and their areas of specialty geographically and medically. • Confidentiality. Finally, one of the common mistakes in working with recruiters involves not protecting your confidentiality. The key is to work with a couple of recruiters (some have suggested 2-3) and work with them closely in identifying opportunities. Prior to starting any relationship, you should insist that you maintain control as to where your CV goes. If you lose control of the relationship and fail to establish confidentiality, your CV may get out to the same employer many times over from different recruiters and thus give the employer the impression that you may be desperate to find a job. As residents and new job seekers, your time is limited and the use of a recruiter allows for additional networking opportunities. However, knowing what you want ahead of time, understanding the recruiter relationship, trusting the recruiter, and protecting your confidentiality will make sure that this is a positive experience for all parties. Preparing a Curriculum Vitae and Cover Letter Writing a CV sounds easier than it may be despite its importance to applying to general pediatrician positions and subspecialty fellowships. Although the Electronic Residency Application Service of the Association of American Medical Colleges has composed a CV for all medical students applying for residency, the components of a job-specific CV differ. There are many online resources available for help in writing a CV, but what is frequently most helpful is to look at a mentor’s CV and use that as a guide in creating your own. The PedJobs CV Builder is available to assist in constructing a CV. - 21 - Once a CV is created, cover letters are needed to submit applications for positions. In general, the cover letter expresses the interest in a position, summarizes the qualifications of an applicant, and ties those skill sets to the needs of an employer. All this is accomplished in a direct, well-written letter. Finally, cover letters should always be targeted to a specific position and employer. (Example cover letters are included.) The CV and cover letter are often the deciding factors on whether you will be called for an interview. The person hiring for the job will look at these documents to gain an understanding of your training, experience, volunteerism, and most importantly, what you can bring to the position. Therefore, it is important that these documents look professional and accurately relay the pertinent information about yourself to the reader. Following are some tips on creating a CV and cover letter: • • • • • • Be sure that the CV and cover letter provide an accurate description of the work that you have done over the course of your training. Include titles, names, and dates for each job that you have had since school. List all job duties for each position or training experience. The positions should be listed in chronologic order. The cover letter should specify why you are a good fit with the practice and position. Check all grammar and punctuation. Be sure that your contact information is included and up to date. - 22 - Sample Cover Letter 1 DATE NAME, TITLE STREET ADDRESS CITY, STATE ZIP Dear Ms Smith: I am writing in response to your recent classified ad for a full-time pediatrician. I am in my final year of pediatric residency and will be graduating in June 2008. I will be boardeligible and intend to sit for the pediatric board examination later this fall. I am interested in starting with a practice this summer. During my pediatric residency, careful listening, vigilance, compassion, and enthusiasm enabled me to excel during my outpatient and inpatient rotations. Although it is a challenge to provide treatment for children who are more acutely ill or sometimes chronically ill, the true reward is in watching them heal and improve. Working as a primary care pediatrician will allow me the chance to continue to play a major role in this process. I also look forward to teaching and supervising students and residents if the opportunity arises. I am organized and hardworking, and work excellently as a team player. I hope to join a practice where I can use my current skills and continue to grow and develop new ones as I gain experience. My pediatric training at <name of pediatric hospital> has given me diverse exposure to primary, secondary, and tertiary care pediatric medicine. Because this is a large children’s hospital, I have become comfortable with working in an environment where one may have to see 20 to 30 patients a day. I have an interest in asthma management as it pertains to primary care pediatrics. I also love the continuity and the preventive care aspects of this field. I am fluent in German and can speak conversational Spanish as it pertains to medical history taking. I am excited about joining a practice and feel that I would a great addition to your team. Enclosed you will find my CV. Please call me at 888/333-3333 or e-mail me at [email protected] if you are interested in talking to me further. Thank you for considering me. - 23 - Sincerely, NAME, Resident Sample Cover Letter 2 DATE NAME, TITLE STREET ADDRESS CITY, STATE ZIP Dear Mr Smith: I am writing to express my sincere interest in a job opportunity that your practice recently posted on www.PedJobs.org. I am currently a board-certified pediatrician at a large private practice clinic in southern Washington. I have 4 years of experience in private practice. I am looking to relocate to your area so that I can be closer to my family. My primary goal is to join a group practice that will provide me with the opportunity to practice the best standard of care in pediatrics. I am interested in a practice that will allow me to focus on outpatient pediatric care, especially preventive medicine. I have experience in inpatient primary care pediatrics as well and look forward to continuing those skills if the opportunity allows. As a former chief resident, I have a passion for teaching and would welcome the chance to interact with medical students and residents as well. I feel it is essential to be a strong advocate for my patients and an active participant in their care. I have served in various leadership roles at my current practice and hospital and would like to continue to do so in my career. I feel that by becoming a part of the decision-making process in my practice and hospital, I can make a difference in my local medical community. I currently work 4 days per week and 1 weekend per month, seeing an average of 25 patients per day. I have an on-call schedule of 1 in 7. Our calls typically include emergency department consultations, phone triage, admitting patients into the hospital, and attending high-risk and cesarian deliveries. I am fluent in English and skilled in conversational Spanish. I strongly believe that your practice has the potential to enable me to achieve all of my - 24 - goals. I would welcome the opportunity to speak with you directly. Please contact me if you are interested in setting up an interview. I have attached a copy of my CV. Please call me at 888/555-5555 or e-mail me at [email protected]. I look forward to hearing from you. Thank you in advance for your time and consideration. Sincerely, NAME, MD, FAAP The Interview Once you have identified a practice opportunity, you will start the interviewing process. It is important to know that the interview is for the person hiring for the position and the person seeking the position. The interviewer will use this meeting as a way to determine if you are a good fit with the practice’s mission, staff, and position. The interview is also an opportunity for you to examine the practice to determine if it is a good fit for you. Therefore, it is important to prepare for the interview beforehand and come with questions about the practice and community that can help you make this decision. Five Steps of the Interview 1. Get acquainted. Are you compatible? 2. Find out about the practice goals, philosophy, lifestyle, and working relationships. 3. Ask questions about the practice. • Number of patients seen (per year, per day) • Staffing ratios • Income and financial stability • Partnership opportunities and procedure • Marketing techniques to gain patients • Comfort with technology • Payer mix • Others 4. Assess practice and candidate attributes. 5. Negotiate a deal. Depending on your location and the location of the interview, the first encounter will be by phone, by e-mail, or in person. When arranging an interview, determine who you will be interviewing with, if your expenses for travel will be covered, and what the expectation is from you. - 25 - Tips for the Interview • Dress professionally for this interview. Business attire is most appropriate, even in a casual practice. • Bring your CV along as well as any other information about yourself which you feel would be helpful. • Make eye contact with your interviewer and listen carefully to the questions. Be sure that you answer all of the questions completely. • Talk with the partners and also the staff. If possible, speak with some of the patients about what they like about the practice. • As you begin your questions, do not start by discussing salary. It is better to understand the practice structure and responsibilities before getting into financial questions. • If the interview will occur by phone, be sure you schedule this at a time when there are no disturbances. Be sure that there is no background noise. Following are some questions that you may wish to ask the interviewer about the position or practice. Interview Questions Following is a useful checklist to take when going in for an interview with a prospective practice. Keep in mind that most interviews proceed from the informal (eg, getting to know each other, seeing if the new physician is a good fit) to the more formal (eg, contract negotiations). Keep the checklist in the back of your mind, but avoid coming across as too forward or pushy. Remember that the group may have a set of criteria by which you are being evaluated as well. • How is the practice organized? Is it a partnership or corporation, or are the physicians all employed? • Who makes up the group? Are they all general pediatricians? Are there family or nurse practitioners? Is everyone working full time? Who are the actual physicians participating in the call rotation? What are the responsibilities of each physician who takes calls? What is the call rotation schedule? • Are there hospital responsibilities? Do these involve nursery calls or inpatient admissions? Does the group use area hospitalists? • What kind of nursing support does each physician have? Will each doctor have a medical assistant, licensed practical nurse, or registered nurse, or do they share a pool of nurses? • How does the office flow? Will each physician have a set of examination rooms or does everyone use a common set of rooms? How are patients checked in and out? • What is a typical workday for each physician? How do they schedule well and follow-up visits versus acute visits? - 26 - • • • • • • • • • • • • • • • • • • • • • • • • Who triages patient phone calls? What is expected of physicians with regard to returning patient calls? What laboratory or radiology support does the group have? If laboratory tests or radiographs are done within the facility, how does the practice bill for these? What kind of medical record system does the practice have (electronic versus paper)? Are there plans to convert to an electronic medical record if paper is still being used? How user-friendly is the system? What is the physician payment rate? What is the basis of this scale (eg, salary, seniority, productivity, patient load, call load, combination)? What benefits are offered to physicians? Do these include health coverage, malpractice liability, other insurance coverage, and retirement funds? If transferring from another practice, will the group offer tail coverage? What constitutes terms of separation, termination, and contractual breach? Are there any restrictive covenants (eg, geographic practice restrictions)? Does the practice have any relationship with area hospitals or universities? Will you be responsible for any administrative or management responsibilities? What will be your clinical duties (eg, calls, coverage)? What will your office schedule be? Hospital rounding? Will you need to attend deliveries? Cover the emergency department? Will your schedule include weekends, evenings, or holiday coverage? Is there a phone triage or answering service at night? What office space is available? Staff-provider ratios? What expenses are covered by the practice and what are your personal expenses (eg, licenses, phones or pagers, subscriptions, automobile)? What is the policy on vacations and sick leave? What is the policy on personal days and pregnancy or paternity leave? Is there a retirement plan? When can you participate? What is the arrangement for continuing medical education (CME)? Time? Expenses? What is the philosophy of the practice? What is the length of the contract? Are there renewal options? What privileges or affiliations are required? Board certification? Hospital privileges? Licenses? Will the practice pay for these? How will patients be assigned to you? Do you share patients with other providers or do you have your own patients? Will the practice assist with moving expenses? Additional Tips on Interviewing (http://practice.aap.org/content.aspx?aid=2237) Behavior-based interviews have become popular recently, replacing loosely structured, - 27 - traditional interviews. This type of interview allows employers to ask candidates questions about how they have handled previous situations in an effort to predict future behavior. Behavioral interviewing is used to assist employers in finding a good match, lower turnover rates, and increase job satisfaction and performance. Behavioral interviewing focuses on asking about a situation in the past, the action taken to address the situation, and the outcome. Tips for Preparing for an Interview • Be prepared. Questions will be based on your past experience. Therefore, have specific examples and situations prepared to share. If this job will be based on seeing patients, be prepared to answer questions such as, “Tell me about a time when you encountered a difficult patient who was unhappy with his or her service.” • Beware of questions that ask for your mistakes or personal failings. Don’t answer them in a way that will make the employer doubt your abilities. You can discuss something that was difficult, but end on a positive note by relating how you managed it. • Allow time to think of an appropriate answer, even if it requires a few moments of silence. • Answer each question concisely, with one example. Let interviewers ask if they want elaboration or another example. • Rehearse answers to potential questions ahead of time. Here are some examples of interview questions using the behavioral interviewing model. • • • • • • • Tell me about a project or an idea that was successful mostly because of your efforts. Think of a time when you had to make an important decision without enough information. Explain your decision-making process. Tell me about a time when you encountered a difficult patient who was unhappy with his or her service. Tell me about a time when something unexpected happened that changed the way you planned your day. Tell me about a situation in which you had to overcome or manage an obstacle to accomplish your objectives. Give me an example of a situation in which you found a new or an improved way of doing something significant. Tell me about a time when you had to work with a colleague who has a different work style or ethic. How did you handle a situation in which you disagreed with that colleague? - 28 - After the interview, it is important to send a personal note of thanks for the time the practice spent with you. Also, follow up with appropriate questions and requests for further information in a timely manner. If the practice offers you a job, you are ready to move to the next level—reviewing the contract. Negotiating an Agreement Once a position has been offered to you, it is time to negotiate an agreement. Following are points to consider when negotiating an agreement: 1. Status a. Will you be a salaried physician or full partner? b. If you will not be a full partner, will the opportunity be offered to you at a future date? If so, at what cost? c. How will expenses, profits, and losses be divided or managed? Know what your limits will be concerning openness relating to financial accounting of the firm, even if you are not a partner or an owner. 2. Involvement a. Will you have a voice in the administration and management of the practice? If so, to what extent, and with what limitations (eg, staffing, purchases, additional of new physicians, policy changes, site changes)? 3. Insurance a. Does the practice cover your malpractice insurance? What type of policy? Are health, life, and disability insurance included? Who will pay for these? What is the amount? b. Will tail insurance for malpractice be provided? 4. Duties and assignments a. What will your duties be? b. What will your on-call, referral, coverage, and house call schedules be? c. What will your office schedule be? d. How are weekends, evenings, and holidays rotated? e. How many hours per week and per year will you be required to work? f. Is there additional compensation for hours worked beyond the required amount? g. Will you be required to take emergency department or hospital calls? h. Will you be attending deliveries? i. How will hospital rounds be rotated? - 29 - 5. Office space a. Will you have your own office space? b. Will staff be shared within the offices or will specific staff be assigned to you? c. Will you be required to furnish your own office space? 6. Business-related expenses a. What expenses will you be personally responsible for? b. What expenses will you be expected to pay and in what proportion? c. Who pays for licenses, dues, pagers, journal subscriptions, and automobile expenses? 7. Office supplies, marketing, and advertising a. Will the group pay for the expenses of adding you to the practice such as announcement cards, business cards, door plaques, stationary, advertising, and changing of indoor or outdoor signage? 8. Leaves, vacations, and paid time off a. What are the vacation and sick leave plans? b. Are personal days allowed? In what quantity? Are these paid? c. Is there pregnancy leave or paternity leave, and is this time paid? d. Will the number of days off or vacation weeks increase after the first year of the contract? 9. Retirement/death planning a. Is there a retirement plan and how does it function? b. Is there a contingency plan in the event of your death or the death or incapacity of a member of this group? c. Is there a 401(k) plan, and how soon can you participate? 10. Continuing education a. Are time or funds allotted for CME? b. Will travel expenses be paid? c. Can time be taken off without penalty for CME or to be involved in speaking? d. Is involvement in professional organizations encouraged? 11. Practice philosophy a. What are the philosophies of the existing group about medical care, employee relations, expenses, and the like? b. Are you in agreement with these philosophies? - 30 - 12. Salary and compensation calculations and payment a. How are salaries computed and when are they paid? b. Is there a percentage of the fees that you will be paid over and above a certain amount? c. Are there bonuses given, and under what circumstances are they given? d. Do you receive a share of income from income-producing assets (eg, laboratory)? If compensation is based on productivity, what is the formula used, and are there minimum (base) guarantees and maximum ceilings? e. If you are required to submit reports to justify the payment due you, what information must you submit? Who must have access to this information? f. If a hospital is subsidizing your first year of practice or your practice setup, is repayment expected, and if so, on what schedule and at what percent interest? 13. Termination/withdrawal a. What is the termination or withdrawal policy? How much notice must be given once you decide to leave? Can you be fired or dismissed from the group, and under what circumstances? What rights do you have to dispute your termination or rectify the situation? 14. Restrictive covenants a. What is the noncompetition policy of the group (restrictive covenant) should you decided to leave? Would there be a certain radius from the office within which you could not practice and for what period? What would the penalties be for a breach of contract? Look for these 4 parts: geographic area, time restriction, monetary penalty, and schedule of penalty payments. 15. Moonlighting and other outside activities a. What is the policy addressing moonlighting and other outside activities? b. Are you permitted to keep funds received from outside sources? 16. Length of contract and renewal clauses a. What is the length of the contract? b. What are the renewal stipulations? 17. Privileges, affiliations, and certifications a. What privileges or affiliations will be required? b. Is board certification required within a certain period after beginning work? - 31 - c. Are there any obligations, implied or specified, to admit to certain hospitals or use certain medical facilities? d. Will you need to have licensure in more than one state? 18. Practice location a. At what site will you be required to work (if there are satellite offices)? b. Does the group do contract work at a well-child clinic, hospital nursery coverage, or group home coverage? 19. Disability a. What is the policy should you become ill or disabled and unable to practice for a length of time? 20. Moving expenses a. How much, if any, of your moving or relocation expenses will be paid, for what specific expenses, and how will these expenses be paid (prepaid or by a specific date)? 21. Accounts receivable and patients a. Who retains ownership (property) or fees that are charged or collected by the practice—you, the practice, or your employer? b. Who will be doing the billing—an outside party, the practice, or perhaps the hospital? 22. Patient base a. How will patients be assigned to you (ie, how will you get your fair share of patients)? Are patients considered your patients or patients of the practice? b. Where will referrals come from? Note: It is very important for a lawyer to review any contract before signing. Resources AAP News: “Pediatricians and the Law: Careful Review of Employment Contract Sets Graduates Off on Right Foot” Employment Contracts: A Practice Management FAQ Sample Employment Contract - 32 - Launching Your Career in Pediatrics: Opening a New Practice Opening a new practice involves many steps including business decisions, community networking, credentialing, obtaining proper insurance, working with various consultants, and deciding on an implementation of a computer system for practice management and electronic records. This next section will provide tips on the following: Making Business Decisions Writing a Business Plan Getting a Loan Credentialing Working With Consultants and Advisors Obtaining Insurance Coverage Setting Up a Computer System Tips From the Experienced Template/Timeline for Opening a New Office MAKING BUSINESS DECISIONS Health Insurance Plans/Payer Mix Questions You Need to Ask and Answer What payer mix might you expect in the community? If the area has a high percentage of children on Medicaid, are the state’s rates reasonable and profitable? Similarly, are the State Children’s Health Insurance Program (SCHIP) payments acceptable? What are the major private insurers, and how well do they pay? Ask other pediatricians if they have had particular difficulties dealing with certain programs or insurers. The American Academy of Pediatrics (AAP) Section on Administration and Practice Management (SOAPM) and Practice Management Online (PMO) can be superb sources for information and feedback. If you are considering a cash-only or concierge practice, are there enough families to support your venture? Are there many military families in the community, and will there be any issues contracting with Tricare? (Tricare will usually not allow private pediatricians to be primary care physicians if there is a military base nearby.) Contact your state medical society for information on payer mix and the business climate within your area. Working With a Hospital System If you will be contracting with a local hospital for financial assistance, how much control will they have in the decision of where to locate your office? How much input do they require on your practice style or hospital admissions? What kind of reputation does the hospital have in the community—will patients avoid your practice if you are associated with that hospital? Are there local pediatricians who do not have privileges at the hospital—and if so, why? If the community is served by more than one hospital, do the other hospitals have expansion plans of their own? Do the hospitals have different payer - 33 - mixes and birth rates that might affect your growth and patient demographics? Will the hospital’s emergency department be a source of desirable referrals? Do contractual or distance issues preclude you from obtaining privileges at another hospital? Will you be willing or required to take unassigned patient calls, inpatient coverage, or delivery or newborn coverage? Working Near State Borders Communities near borders with other states deserve special consideration. You will need to research Medicaid, SCHIP, and private insurers for the nearby states; in addition, some state Medicaid programs may not cross state lines, and you may not be able to participate. Will you need or want privileges in another state’s hospital? Will you need another state license and state-controlled substance privileges? WRITING A BUSINESS PLAN Writing a business plan is a useful exercise for several reasons. For your practice to succeed, you need to know where you’re going and how you’ll get there. Creating a business plan forces you to set goals, determine the resources you will need to carry out your goals, and foresee problems that might otherwise broadside you. If your business plan is not being used to solicit financing, you can create an informal plan that serves primarily as a planning tool and a device to keep you on track. An informal plan can also be used to show to potential partners when you are ready to recruit. There are several online resources and software that can help you formulate and write a business plan. The key elements usually include 1. Introduction: provides an outline of the business plan and an executive summary, which is a snapshot of the practice setup, philosophy, and viability. 2. Business description: provides your practice vision and includes who you are, what you will offer, what market needs you will address, and why your business idea is viable. 3. Market description: provides your interpretation and research of the existing trends and conditions in the area in which you plan to practice; this will form the basis of the succeeding marketing and financial plans you wish to propose. 4. Development and production: provides a description of the current state of your practice and your plan for continuing or completing its development (eg, hiring staff, buying equipment, leasing space). 5. Sales and marketing: provides a road map of the strategies and resources you will employ to generate practice growth. - 34 - 6. Management: describes the team you will gather to manage the practice, including specific strengths, qualifications, and responsibilities of each team member. 7. Financials: documents the viability of your business idea and its soundness as an investment, using specific financial information and risk assessment. GETTING A LOAN How Much? The biggest factor in determining when you will break even is the amount of money you have to borrow to start up the practice. When determining a loan amount, it is important to consider the cost of equipment, rent, malpractice, and other insurances (eg, worker's compensation, liability). Also, during the first few months, you will be paid on what you borrow or have set aside, as you will have little to no income for 30 to 90 days, depending on how well you did your homework with the local managed care organizations (MCOs). You will need to borrow or use capital for your income over the first 90 to 180 days; if you borrow more, you will have to pay back more. In addition, check the sample supply and equipment checklist (http://practice.aap.org/content.aspx?aID=2395) to get an idea of how much money you will need to borrow to stock and furnish your practice. For information on obtaining loans, check with various bank Web sites. For additional information, visit the US Small Business Administration. CREDENTIALING The process of becoming credentialed to open a medical practice is time consuming and laborious, and involves lag time in terms of completion. When beginning, be aware of which processes take the longest and which are more rapid and straightforward, and prioritize accordingly. Although universal applications exist for some issues, they are rare, and there is little way around the busywork to be done. However, many applications ask for the same information, and keeping essential data handy and organized can save time. Be prepared to budget at least a few thousand dollars for the process. Some entities do not charge a fee; others do. Additionally, unanticipated expenses may be incurred, such as getting duplicates of appropriately sized diplomas. At times you may have to depend on organizations and individuals to send the necessary information. Check with your state medical society for state-specific information. American Board of Pediatrics The American Board of Pediatrics (ABP) offers certification in general pediatrics as well as pediatric specialties. This information will be needed when going through the credentialing process. The ABP also maintains Maintenance of Certification. Visit https://www.abp.org for more information. - 35 - Obtaining Hospital Privileges Hospital credentialing committees meet periodically, usually monthly. It can take several months to be approved, so start early. Fortunately, many hospitals accept that privileges are applied for and do not require the process to be complete before processing applications. Also, many hospitals will grant temporary privileges, if needed before the credentialing process is complete. Credentialing With Health Insurers Most large insurers and all MCOs will require credentialing for participation as a provider in their plans. It is necessary to start this credentialing process as soon as you have enough of the required information to do so; many insurers take 3 to 6 months, and at times, a preapplication step is required as well. Some hospitals offer credentialing services for a fee, which may save considerable time. These services often are able to negotiate contracts with insurers. For information on universal credentialing, visit http://practice.aap.org/content.aspx?aid=2196. Another solution is to access Council on Affordable Quality Healthcare online at www.CAQH.org, which provides a single application for many payers. Occupational Safety and Health Administration All practices must be in compliance with Occupational Safety and Health Administration standards. These encompass a large number of requirements including employee dress, waste disposal, and universal precautions. While meeting some of these requirements is straightforward and intuitive, some may entail a process that takes several weeks. Biohazard removal, for example, may require a scheduled educational session before the office can be set up to handle biomedical waste. Thus, it is worthwhile to address this at least several weeks before anticipated opening. For additional information, visit www.osha.gov. Employer Identification Number All businesses require an employer identification number, also known as a federal tax identification number. Your practice attorney or accountant can obtain one for you. It is also possible to obtain one online. Plan on a few weeks for this process. State Tax Identification Number Check with your state to see if a separate state tax identification number is required. A link to state agencies, as well as information on obtaining a federal tax identification number, can be found at www.irs.gov. State Medical License Whether you are starting your own practice or entering private practice as a physician employee, it is extremely important to start your license application early. States differ in - 36 - their approach, but it is not unheard of for a license to take a year or more to obtain. It is not unreasonable to begin the license application process before deciding on an ultimate location. Begin to gather information from all colleges and universities, as well as your medical school, residency, and places of employment on the forwarding of all of your records. Most will want copies of diplomas, residency certificates, and board certification. Be prepared to explain any breaks in the educational process and don’t forget courses taken elsewhere. When in doubt, it is best to be thorough, honest, and complete with any explanations. Some states have extra requirements, such as a special examination or letters of recommendation. Read the application early so none of these requirements is missed; notification from state boards on missing material is often slow and can waste valuable time. Most states have an online information system that informs you of the process, needed materials, and contact information specific to that state. Drug Enforcement Agency An application should be filed with the Drug Enforcement Agency (DEA) for a DEA number, which is required to prescribe any medication. This is usually a fairly rapid process. Individuals who already have a DEA number should keep the agency informed of any address changes. For more information, visit www.deadiversion.usdoj.gov. State Narcotics License Check with the state medical board to see if a separate state-controlled substance license or permit is required. It is usually less involved to obtain this than the medical license itself. National Physician Identifier In 2008, a requirement was initiated for all physicians to have a unique National Physician Identifier (NPI) number. Among other uses, it is the number recognized by most insurance payers and is necessary for payment for services. This is usually a fairly straightforward process. Apply at www.cms.hhs.gov/NationalProvidentstand. Business License In addition to federal and state licensing, be sure to check with your city and county about the possible need for obtaining a business license. If needed, this is usually an inexpensive, routine process and in most cases can be done after some of the more involved tasks are completed. Be aware of specific requirements—most will want a copy of your medical license, and many will want information about your location, including access and trash removal. - 37 - Laboratory License Decide if you would like to have an in-house laboratory and if so, what tests you will be performing. Any testing at all—even a rapid test for blood in the stool—requires an application with Clinical Laboratory Improvement Amendments (CLIA). This is a process that may take several months and is worth starting earlier rather than later. Some states charge additional fees and have an additional application process for in-house laboratories. A CLIA license is not required if all testing is to be sent out. WORKING WITH CONSULTANTS AND ADVISORS Why Hire Consultants? As one can see from this discussion, there are myriad processes the new practice must set up across a broad range of disciplines, including medical, legal, technologic, insurance, business, and management. While many physicians have tried to save money by doing all of this themselves, it may not be the best way to proceed. While doing it alone may be possible depending on the skill set of the physician(s) in the new practice, it is absolutely critical to establish all of these systems correctly the first time out. Given the increasing complexity of these matters and the total lack of physician training and experience with any of them, failure to do so can be very, very expensive to you and your practice in the long run. Herein lies the dilemma of consultants and advisors. Doctors are notoriously averse to paying others to do tasks that they somehow feel they ought to be able to do for themselves. After all, how hard could it be for the bright individuals who go into medicine? Unfortunately, it is considerably harder than it looks. Choosing the proper help is vital to a new practice. Such help includes a health care accountant (not only bookkeeper), a health care lawyer (not a general practitioner), and a practice management consultant. All of these consultants can entail significant expense in the short run. Doctors are again notorious for viewing such expenses as overpriced and unnecessary. However, when used properly, they will pay for themselves many times over. Legal Counsel The most expensive will generally be legal counsel. Some practices choose to have everything set up by their legal advisor. While this may be possible with an experienced health care attorney, their time is the most expensive of all consultants. They may be good at what is legal but may not appreciate the day-to-day dynamics of medical practice management and administration. A good legal mind to advise you on partnership agreements, corporate structure, leases, contract negotiations, and contracts is absolutely vital. Yet many of these tasks can be accomplished just as effectively with lower cost consultants, with only a final legal review at the end. - 38 - Health Care Accountant A good health care accountant is someone who does more than keep your books. This accountant will help you with budgeting, help you with contacts at local financial institutions, supply you with advice in financing business practices, and provide you with frequent reports based on benchmarking your performance against other practices in the field using national norms and local experience. Practice Management Consultant Lastly, hiring an experienced practice management consultant is a good idea. It is important to begin working with a consultant during your third year of residency. Lay and physician consultants are available. Consultants can provide the overview you need to coordinate and get the most out of your other consultants. They can review your practice’s processes from a functional end-user point of view and can assist you in assessing whether your plan will work in a real-world setting. Consultants are also available to assist you with coding and physician profit distribution, staffing, salaries, and marketing. Often, they can assist you with drafting documents for later legal review. Consultants are available to help you compare electronic health records (EHRs) and practice management software (PMS), negotiate with payers, and construct an office policy manual. Finally, consultants can even help run your practice until you are able to hire your own management team. Please realize that none of this advice comes cheap, but it is a worthy long-term investment to make sure your new practice is primed for success. OBTAINING INSURANCE COVERAGE When opening a practice, it is vital that you obtain insurance. If an employee slips on a wet floor and breaks a leg, you need insurance. If a burglar steals your computer equipment, you need insurance. If a hurricane destroys everything in your office and you’re out of practice for the next 6 weeks, you need insurance. But there are many kinds, and no one-size-fits-all exists. The first step is to find an insurance agent. Ask around, get recommendations, and make an appointment. Keep in mind that some agents work for specific companies, whereas others are independent and deal with a few different companies. Regardless, a good agent will be able to compare quotes, process paperwork, help you get the best coverage for the best cost, and generally make your life much easier. You will need the following coverage: Malpractice Insurance It’s best to shop around and ask peers about malpractice insurance. This is an activity to accomplish early because many other entities will want proof of coverage. Be ready to - 39 - forward information on previous insurers, if any, as well as any explanations of claims. Your state medical society can be an excellent source of information. Worker’s Compensation. This is mandatory in nearly all states and is needed to cover your employees in the event they get injured on the job. This coverage can be obtained, in most states, from private insurers. However, some state agencies or state funds offer this as well. As you set up a practice, a certified public accountant can help you through the maze of local, state, and federal tax and employment regulations and be an invaluable resource, especially if you consult with one early in the process. Commercial Property This is your standard general business insurance and covers property loss and business liability, as well as other business-related risks (eg, loss of income, employee theft, employee dishonesty, employees’ personal property, electronic data). Take the time to investigate the coverage limits and exclusions. Most businesses don’t fail directly from a material loss, but rather from the subsequent loss of operations and inability to recover. Make sure your policy covers the total value of your business property and will provide enough money to get you back on your feet. There may be specially delineated coverage for items such as computer equipment, papers and records, exterior signs, glass (which some landlords specifically require), and building damage; understand the limits and ensure they are adequate to cover all potential losses. Unique to pediatric offices, vaccines will need special additional coverage in case of power failures; some policies may contain a specific vaccine rider, while others may include these under “spoilage.” Again, make sure the policy limit is high enough to cover a total loss of inventory. Carefully review what situations might be excluded, and if you are at risk for these instances. Common examples are earthquake and flooding. If there is any confusion over the policy, talk to your agent to help clarify. You don’t want to learn of any gaps in your coverage after a disaster strikes. Liability Most general business insurance policies also offer coverage for slips and falls, defense costs, and judgments against the business owner and employees. Employment practices liability insurance provides limited coverage for claims resulting from employmentrelated wrongful termination, discrimination, sexual harassment, and other workplace torts (eg, retaliation, defamation, emotional distress, invasion of privacy, negligent evaluation, wrongful discipline, wrongful failure to employ or promote, wrongful demotion). Auto liability protects against vicarious liability in case an employee gets into an accident while running an errand at your request (eg, a trip to the bank or post office). - 40 - Specific Hazard If you are in a flood or earthquake zone, you can purchase coverage for these hazards separately within the context of your general business insurance. Flood coverage is available from the federal government. Earthquake insurance is usually either an additional endorsement or a separate policy from a private insurer. Keep in mind that these special policies usually cover physical losses only, not loss of business income or related recovery expenses. Immunizations are an expensive “stock item” for practices, unless you are in an all–Vaccines for Children state (universal purchase state), and can be a major source of loss in the case of power failure or theft. Be sure to have coverage clearly spelled out. The typical practice may have an inventory of $150,000 per physician or more. Umbrella Coverage An umbrella policy provides additional coverage above the usual commercial policy limits, in case of liability. As a doctor, you and your business have the potential to be an attractive target in a lawsuit, and an umbrella policy can offset that risk. Consider how much you will need to protect the value and earning potential of your practice. A standard policy might supply coverage up to $1 million. Expect to pay a premium of a few hundred dollars annually if you elect this coverage. Be absolutely sure the insurance contract spells out all coverage as well as noncoverage, and what your responsibilities are as the insured. Disability Insurance A disability insurance policy covers you in the event that you cannot perform the work you want to perform. Own-occupation coverage may cost significantly more but only requires that you can no longer function as a pediatrician (as opposed to being completely incapacitated from any work). Most plans offer different options for waiting and benefit periods. For example, a plan may not pay until after 30, 60, or 90 days of disability. Benefit periods may last for 1 year, 3 years, 5 years, or up to age 65 years. Make sure your disability plan offers the ability to increase coverage limits each year, to grow with your practice’s success and your ever-increasing income. Also, rates for this coverage are generally lower when you are healthier and younger. Life Insurance Life insurance should be purchased to cover any liabilities or debts of the practice, or to replace your income for your family. If married, consider a policy for your spouse to offset the loss of the numerous ways he or she helps you (eg, providing a second income, caring for children, helping manage the practice). - 41 - Health Insurance Don’t forget this for you and your family, and consider if and how to offer coverage to employees. The local chamber of commerce can be a valuable source of information in this regard. The AAP offers a discounted rate for group insurance plans covering term life, disability income, office overhead expense, dental, and long-term care. Visit www.aap.org/moc/memberservices/affinity.cfm or www.aapinsurance.com/index.html to learn more. Record Your Property Once you have obtained insurance, keep a copy of the policy (or policies) safe and away from the office. Take an inventory of the office, whether written, photographed, or videotaped. Keep purchase receipts to assist in determining the amounts of any potential loss. It is usually a good policy to have a second copy of all the inventory, photographs, or videotapes in the hands, or files, of your insurance agent. If so, make sure you update them regularly as you acquire equipment or materials. Using Your Policy In the unfortunate event that you have to use your policy, consider the cost of your deductible(s) against the amount of loss. Coverage and exclusions that seem straightforward may be subject to debate after the fact. As an example, after a hurricane, insurers may debate “wind versus water,” where water damage related to wind—such as a breached roof and subsequent rain damage—is covered, whereas water damage related to storm surge is excluded. Conflicts can arise in determining what portion of equipment or structures were damaged from which cause. The delineation may be even more important because straightforward property loss usually has a flat dollar-amount deductible, whereas wind or earthquake damage usually has a deductible based on a percentage of the value of the property. Loss of business income may be denied because of flood damage, but could instead be claimed from loss of power and infrastructure, or civil disturbance. If you are not satisfied with your insurer’s settlement offer, consider appealing to your state insurance department. It is always critical to involve your agent’s help from the outset. Check with your state medical society for additional information about insurance policies. Special thanks to Jeff Bogan of Jeff Bogan Insurance Agency, Naples, FL, for assistance with this article. - 42 - SETTING UP A COMPUTER SYSTEM As you set up your practice, an integral part of your business operations may involve purchasing and implementing a computer system. Even if you are not very comfortable with computer systems, many are easy enough to use with adequate training. Consider that more and more practices are adopting EHRs and with more regulations such as Health Insurance Portability and Accountability Act (HIPAA) and electronic prescribing, a computer system may be inevitable in the future of health care. There are several levels of how a computer system can be integrated into your practice. The cost is determined by what level of involvement you desire. If you are just setting up your practice, it may be easier to start with an EHR rather than trying to convert your practice at a later time. However, it is significantly more expensive and time consuming to implement an EHR system as you start your practice. Some hospital systems are helping practices by offsetting expenses with a system that is compatible with the hospital’s system. This would be worth investigating if it is true in your area. Steps for Choosing a Computer System 1. Determine to what extent you would like to use a computer in your practice. 2. Perform a financial analysis to see what is affordable and what your return on investment (ROI) would be. Investigate options such as hospital system financial support. Contact banks or lenders in your area if financing will be needed. 3. Research vendors and systems. 4. Meet with several vendors for product demonstrations. If possible, visit pediatric practices that are currently using the system. 5. Contact SOAPM and the AAP Council on Clinical Information Technology (COCIT), and review the publications and advisories on PMO and the COCIT review of available systems (additional information follows). 6. As you refine your search, make sure you understand the initial costs of acquisition and implementation, as well as any ongoing maintenance costs. 7. Once a decision is made, define an implementation and a transition strategy. Information is available through SOAPM, COCIT, and PMO to help you plan these processes (additional information follows). 8. Schedule installation of required wiring, networks, telephony, hardware, and software. This is especially important if you are constructing a new office and can install the necessary wiring during the building process. 9. Plan and carry out implementation of products with all necessary training and customization. - 43 - How Will the System Be Used? When looking to purchase a computer system for your practice, the first question that you must answer is, “For what will I be using the system?” The answer will determine the type of system you need, the investment that will be required, and the timeline for installation. The simplest use of computers in an office is like what you would do at home—word processing, spreadsheets, simple accounting, and possibly Internet access. The next step would be to use a computer system to run PMS. This software typically would allow you to use a computer for appointment scheduling, billing, and storing patient demographics. The final step for using a computer in a pediatric office is for EHRs. This is essentially patient charting completely on the computer. The cost of and time for installation increases as you proceed from stand-alone computer to full-scale PMS and EHR. Sample costs are listed in the Table. Electronic Cost Comparison Single-User Computer $500–$1,000 Software cost Hardware cost Implementation cost PMS PMS and EHR $1,000– $1,000– $5,000/FTE $50,000/FTE $2,000 desktop $1,000–$2,500 per desktop/laptop/tablet $2,000–$4,000 per server Additional for printers, scanners, modems, networking equipment $75–$150 per hour of training/implementation (usually some hours included in purchase price) Average 35 h for implementation for EHR 2 wk–1 mo 3 mo 3–6 mo Simple Moderate Complex Time frame Implementation difficulty $500–$1,000/FTE $1,000– Maintenance/support None–$100 $4,000/FTE (yearly) PMS, practice management software; EHR, electronic health record; FTE, full-time equivalent. - 44 - Financial Analysis Dependent on which system you buy, there is usually a significant up-front expense. However, it is extremely important to investigate what the recurrent expenses include. Hardware and software maintenance can be very costly and are a necessary burden to keep your business running. Additionally, hidden expenses for upgrades, support, and additional training should be outlined before you sign any contracts. Benefits of an Electronic Health Record Why go electronic if it costs so much? There are many benefits to being on a computer system. You gain accuracy, efficiency of charge capture and billing, legibility, and accessibility. Improvement of coding is more easily achievable with electronic capture. Increased legibility and better documentation result in improved patient care and decreased medical liability. Depending on your practice, you may see improved work flow. Locating and pulling charts are no longer an issue with EHRs. This results in more rapid processing of refills and forms. There are no longer concerns about lost charts. If you do internal billing, you can take advantage of electronic filing and posting, which can significantly reduce your accounts receivable. These are some of the most tangible benefits to being electronic. While not helpful for most pediatricians, there are also significant savings of transcription costs. With these benefits, it generally takes 2 to 3 years to get an ROI. The other important point is that it is far easier and less costly to start a practice with information technology (IT) in place than to implement at a later date. The AAP SOAPM e-mail list provides pros and cons from various members. Visit http://practice.aap.org/content.aspx?aID=1971 to view comments. Also see the article titled “Electronic Health Records: Should I Convert My Office to Paperless?” There are many resources to help you to calculate your ROI available from Physicians Practice and the Medical Group Management Association. Because you are just starting in practice, you may need to talk to other practitioners to get a better feel for work flow, time costs, and expenses. Evaluating Software Once you’ve determined the computer needs of your practice, the next step is to evaluate vendors of PMS and EHR software. One of the best ways to evaluate software is to ask around in your local community or the AAP to see what other pediatric practices are using. The Certification Commission for Healthcare Information Technology is an organization that certifies health care software that meets certain standards. The AAP COCIT Web site (www.aapcocit.org) also has many valuable resources. - 45 - The AAP offers answers to some frequently asked questions as well as reviews from fellow AAP members. • • • “Electronic Medical Record FAQ” (www.aapcocit.org/EHRfaqs.pdf) EHR reviews (www.aapcocit.org/EHR/readreviews.php) “Implementing an Electronic Health Record” (www.practice.aap.org/ehr.aspx) There are some features of the PMS and EHR that you should investigate that are unique to pediatrics. Practice Management Software • Is it capable of family billing using head of household? • How are siblings linked in the system? If you update one child’s address, will all the siblings be updated? • Can you put alerts on the account for special situations (eg, child with special needs requires extra time for appointments)? • Can you design appointment templates that can specify different types of appointments (eg, well-child appointments vs sick-child appointments)? • Can you easily move appointments from one physician’s schedule to another? • Is it capable of running queries so that you can do studies or single out patients within certain demographics (eg, to determine your payer mix or how you are being paid for certain procedure codes)? Electronic Health Records • Does it have growth charts? Does it have specialized growth charts (eg, preemie charts, Down syndrome charts)? • Can you create forms (eg, school)? • How well does it handle immunization records? Can you add new ones (as vaccines are developed)? How does it handle reminders if a child is due for vaccines? Can it communicate with statewide immunization registries? • How do you enter notes? Via templates? Can you type free text also? Can you customize the templates? • How does it handle documenting a sick visit in addition to a well check? • Does it have coding assistance? • Does it offer electronic prescribing? Does it have a weight-based prescribing system for calculating pediatric dosing? • Does it have laboratory report integration and ordering? Can you set pediatric norms for laboratories? Can you interface with local hospital laboratories and major laboratories? For how much? • Can you use images or photos (eg, drawing of lesions)? - 46 - • • • • • • Can you capture signatures (eg, for waivers)? Is there an online interface available where parents can request refills, schedule appointments, or preregister online? Are there pediatric-specific educational handouts? Can you integrate a spirometer, electrocardiogram machine, or vitals machine? Is it capable of sending charges electronically? Will it support patient self–check-in? General • What is your support turnaround (including after hours and weekends)? • How frequent do you have upgrades? Who does those upgrades? • Are upgrades included in the maintenance cost? • Who performs support for your system? Is there someone local who will come onsite? Or is it done remotely? • Is there a resource for users of the same specialty to network and share ideas for using the system? • How long has the company been in business? What is the company’s business plan? Does it give you a feeling of confidence in that it will be there for the duration of your practice? • How do you store backups for patient data? Is it done locally? Is there off-site storage? • What are the security features? HIPAA compliance features? Once you have chosen several vendors, schedule demonstrations. Make sure that the vendors demonstrate a pediatric scenario for you. For such an expensive capital purchase, it is wise to meet with at least 3 different vendors. When you have decided which ones you like the most, visit practices that are using these systems in real life. These practices can give you a much better feel for how the system works in everyday pediatric practice. It is also a good idea to get information about obstacles they encountered, how they would do things differently if they could, and whether they would purchase the system again knowing what they do now. The implementation of an EHR in an existing practice can be a very painful process. Depending on what stage they are in the implementation process, you could take their advice accordingly. In general, once you are 2 to 3 years into a system, you will find that the EHR was a good choice and that you wouldn’t go back. However, those first years can be very strenuous as you make the transition! Technical Support There are many ways to implement a computer system. The larger your practice and the more features you make electronic, the more likely you are to need technical support. This may take the form of a staff member who is technically savvy and a local engineer from - 47 - your vendor. It may be a local computer support business or your local “geek squad.” If your system is large enough, you may need to hire an IT specialist. Regardless of the system, you are likely to encounter needs for upgrades and maintenance (eg, backups), as well as troubleshooting problems. The problems will range from simple (eg, the mouse doesn’t work) to complex (the network is down for your satellite office). In general, it is wise to have someone you can call for help when these issues arise. Data Storage, Backups, Power Outages, and Disaster Plan Lastly, it is important to consider how you will protect your data. There are frequently news reports of patient data being stolen by employees. Once you are electronic this issue should be examined carefully. It is much more difficult to steal 1,000 paper charts than to steal a computer containing that same information. Investigate your vendor’s capacity for security and virus protection. EHRs must be compliant with specific HIPAA rules. Backup for your data can be done many ways depending on your system. Investigate options with your vendor. If your system is on site, certain precautions should be taken to have some form of off-site storage for your data. You should also have a disaster plan in place. This will be important in case of extreme disaster to your practice (eg, fire, water damage), but also in other cases when something as simple as the power goes out to your building. For power outage or when the system is down for some reason, a common plan is to go onto paper. The data is scanned into the computer when power is restored. Design a plan that works for you and your practice. For information on implementing an EHR, visit http://practice.aap.org/ehr.aspx. For additional information on PMO about EHRs, visit here. This section of PMO also provides articles provided by those practices who switched to EHRs. TIPS FROM THE EXPERIENCED Before opening your doors, here are some important points to keep in mind. 1. You must be credentialed with any and all MCOs and Medicaid before you open your doors. You are not credentialed until you hold a piece of paper in your hand saying you are, regardless of who tells you what. If you are not credentialed, you may not be paid at all, or your payments will be held until you are. Delays in payments over the first 6 months of opening a practice can be lethal. 2. Establish what your hours are going to be, and be there. If you have office hours on evenings or weekends when you are starting up to increase your revenue, you will also be creating an expectation among all your patients that - 48 - you will always be open during those times. When you are first open, you need to be available. SOAPM and PMO have excellent advisories in this area. 3. Keep in mind that hospital work provides income without adding to practice overhead, even at Medicaid rates. 4. Be sure that your payer mix is incorporated into your business plan. Also, decide ahead of time what percentage of Medicaid patients you are willing to accept. 5. It is important to create a financial policy and share it with your patients when they join the practice. Click here for a sample financial policy. Also, create a patient payment agreement and enforce it from day one. Establish your ground rules early and enforce them consistently. TEMPLATE/TIMELINE FOR OPENING A NEW OFFICE Task Details/Notes Obtain/submit the following: Open a bank account. State medical license DEA certificate Tax ID number Business license Malpractice insurance Medicare application UPIN/NPI number Health plan credentialing Hospital credentialing (allow 3 months) Insurance credentialing (allow 3 months) State payroll tax number Unemployment payroll tax number Determine a business plan. Create a budget. Meet with consultants (eg, legal, practice management). - 49 - Completed Locate space to lease or purchase. Choose a corporate structure (eg, partnerships, corporations, limited liability corporation). If leasing, review, negotiate, and sign contract. If building or modifying existing building, choose architectural firm. Negotiate and sign architectural agreement. Select carpeting, wall coverings, paint, tiles, cabinets, furniture. Choose a contractor. Complete construction contract. Consider parking, access, build-out costs, terms, and rent rates. Consider legal review. If leasing, contact landlord. Consider legal review. Consult with landlord first. Consider legal review. Also determine who will be responsible for fire extinguishers during construction. Plan for opening day Usual construction time is considering, staff hires, 12 weeks for 3,000 square holidays. feet. Create staff job descriptions Determine how you will and pay scales. Begin hiring screen new hires. process. Create staff training plan. Determine how medical record transfers will occur (eg, new registration, consents, privacy policy, medical records). DEA, Drug Enforcement Administration; ID, identification; UPIN, unique physician identifier number; NPI, National Physician Identifier. - 50 - 12 to 16 Weeks Prior to Opening Day Task Details/Notes Arrange for Web site. Design, address, content Recruit and hire practice Be aware of appropriate manager. interviewing questions. Train practice manager. Apply for business credit cards. Assess telephone and Arrange for installation 2 computer needs. Plan 2 weeks before opening day. lines and a private line for each of the first 3 MDs. Select vendors and obtain quotes. Confirm phone and fax numbers for advertising. Set up cost center. Set up accounts payable and payroll. Create a central purchasing Store in a place for staff to log. find. Order exterior signage. May need landlord approval. Order examination room furniture (eg, examination tables, cabinets, stools; consider one table capable of pelvic examinations). Order lobby and modular furniture for office space, break rooms, nursing areas. Begin recruitment process; set start date for reception staff 2 to 3 weeks prior. Nursing staff can start 1 to 2 weeks before opening day. Train employees (eg, scheduling, charge entry). Review cabling plan with - 51 - Completed contractor and vendor. Include examination rooms, MD offices, practice manager space, reception areas, nursing stations, laboratory, printer locations, and copier locations. - 52 - 10 to 12 Weeks Prior to Opening Day Task Details/Notes Completed Order furniture for MD offices. Set delivery date. Determine the laboratory If moderate complexity, procedures that will be request CLIA number. performed in the office. Order necessary forms to support laboratory functions. Determine fax and copier needs. Obtain quotes and place orders. Develop appointment templates. If using paper charts, order materials. Set up accounts with the following: Laboratories—order forms and drawing supplies Medical equipment and office suppliers Pharmaceutical companies Set up Internet access accounts for online ordering. VFC program Place VFC order as appropriate. CLIA, Clinical Laboratory Improvement Amendments; VFC, Vaccines for Children. - 53 - 8 to 10 Weeks Prior to Opening Day Task Details/Notes Completed Order interior signage. Restroom doors, examination room numbers, physician names, wording about co-payments expected at time of service. Plan advertising/marketing strategy. Post MD pictures in advertising and on Web site. Contact local yellow pages. Order letterhead, envelopes, script pads, tablet paper, and business cards. - 54 - 6 to 8 Weeks Prior to Opening Day Task Details/Notes Confirm malpractice coverage (nose or tail coverage?). Order medical record shelving. Determine equipment needs (eg, audiology, vision screening, otoscope, ophthalmoscope heads, transformers, blood pressure aneroid (wall or movable), nebulizer, pulse oximeter, thermometers, adult and infant scales). Order the following: Medical equipment Credit card machine Toys, books, magazines for lobby Appliances for office including laboratory and immunization refrigerator with separate freezer door, separate staff food refrigerator, microwave, and coffee pot. - 55 - Completed 4 to 6 Weeks Prior to Opening Day Task Details/Notes Order check endorsement with stamp and account number. Arrange for cleaning service. Arrange for medical waste pickup. Arrange for garbage collection, if not provided by the city or building. Determine list of medical supplies needed and price shop. Set up Web site. Include MD pictures, biographies, and driving directions. Make sure that the wall/door charts are part of the construction plan. Determine MD-RN communication system (eg, colored clips, flags). Order materials as needed. Determine which office forms and educational materials will be used. Order, if necessary. Order examination and restroom soap, paper towel dispensers, sharp containers, and gloves. - 56 - Completed 2 to 4 Weeks Prior to Opening Day Task Details/Notes Arrange for moving company, if needed. Mount room flags, chart pockets, brochure holders, calendars, bulletin boards, diplomas. Determine artwork selection. Prepare “Patients Rights and Responsibilities” posting at the front desk. Obtain governmentrequired employee notification posters. Plan OSHA-required training and documentation. Train nurses on stocking examination rooms. Contract with answering service. Obtain computer access for all employees, including network drives, e-mail, and Internet. Be sure HMOs have provided forms, network books, and referral access numbers to the new physicians. Have phone system installed after the new phone lines are in. Train staff on use and maintenance. Order the following: Medical supplies Office supplies Remembers shredder, coat hanger for lobby, 3-ply - 57 - Completed receipt paper, wastebaskets, and garbage bags. Patient registration forms, release of information, and other forms to be used OSHA, Occupational Safety and Health Administration; HMO, health maintenance organization. - 58 - Within Last 2 Weeks Prior to Opening Day Task Details/Notes Moderate/minimize patient loads during the first week to allow for a smooth start. Place pharmaceutical order. Start cell phone and pager service for MDs. Train MDs in coding and billing. Obtain cash for petty cash. Develop fire safety plan. Develop site security plan, install security system, and provide training. Establish procedures for check-in and co-payment collection. Pre-build patient folders. Train staff on completing time sheets appropriately. After Opening Day Task Have outside photo taken of location once sign is up. Have internal pictures taken as soon as site is complete with furniture and artwork. Take pictures of staff and MDs. Arrange open house, if desired. Update Web site with pictures. Details/Notes Completed Completed This document was adapted from forms provided by Tom Dunigan, MD, FAAP, and Tom Barela, MD, FAAP. - 59 -
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