Open for Business

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I worked the late shift today.

I started out at 8:30 this morning and saw about 22 patients over the course of the day – until my schedule ended at 4:30.  I had a few new patients, a few well-checks, and overall had a steady, if not slow, day.  From 5:30 to 7 PM we have a walk-in clinic for our patients every weekday (and one on Saturday from 9 AM – Noon).  I covered it today and saw 13 patients – many with sore throats or urinary symptoms.

So in 8 hours, I saw 22 patients. which equals 2.75 patients/hour.  I usually see more in the order of 25-28 patients per day, but for some reason it was slower today.  In the evening clinic, I saw 13 patients in 1.5 hours, which amounts to 8.7 patients/hour.  It was steady, but not overwhelming and I finished at 7 sharp.  Here are some other facts to consider:

  • Our patients are absolutely delighted that we offer this clinic.  We also offer a walk-in clinic in the morning from 7:30 AM-9:00 AM.  
  • We are fairly strict at not letting anything but simple problems come to clinic.  If they are really sick, they go to the ER.  If they are not sick, we make them schedule an appointment.  The rule of thumb is that it must be a 5 minute visit.
  • We actually earn more per visit during after-hours clinic because we can charge an after-hours charge for all (except for Medicare and Medicaid).
  • For our one capitated contract, we get paid an over-and-above for these visits.  In other words, we just get the copay if they come during the day, but get paid per visit (at a fairly good rate) for after-hours visits.
  • We earn roughly 1/4 of our income in these clinics – they are extremely busy during the winter months, with some days getting over 30 patients in the evening clinic.   This is revenue we would have otherwise lost.
  • We run a disproportionate number of strep tests and urinalysis tests during these clinics, which ads to the revenue.

This is one of the main ways our practice is able to be so profitable.  Our EMR allows us to document very quickly and thoroughly.  At 7 PM, I had finished charting all of my clinic visits.

Why am I saying all of this?  You have to look at medicine as a business.  In this case, we make our patients very happy, build loyalty, and increase revenue with very little increase in expense.  The only negative of this is that three people have to stay late to do it.  Most doctors won\’t do this.

It mystifies me why more doctors don\’t follow suit.  I guess they don\’t want to run their practice like a business.  I am the last one out of the building tonight, but I have a lot to show for it.

29 thoughts on “Open for Business”

  1. How many docs in your practice? How do you share the evening work, and what happens when someone is on vacation or gets sick? We’re a practice of 3 pediatricians, and I know our patients would love it, but how do you manage day-to-day? What about the support staff? We’re pretty barebones, and would have to hire people to work the evenings, or pay overtime. Do you have some part-timers?And how do you keep really sick people out? Who triages and makes them go to the ER? How do you get the recurrent abdominal pain/ chronic daily headachers to come in during the day when they want to come in after work/school/ football practice? 30 minutes later…

  2. How many docs in your practice? How do you share the evening work, and what happens when someone is on vacation or gets sick? We’re a practice of 3 pediatricians, and I know our patients would love it, but how do you manage day-to-day? What about the support staff? We’re pretty barebones, and would have to hire people to work the evenings, or pay overtime. Do you have some part-timers?And how do you keep really sick people out? Who triages and makes them go to the ER? How do you get the recurrent abdominal pain/ chronic daily headachers to come in during the day when they want to come in after work/school/ football practice? 30 minutes later…

  3. We have four physicians and one mid-level. This works with four providers. One provider takes Mon-Thurs PM clinic and then the person on the weekend does Friday and Sat AM. We have one nurse and one front desk person who stays late. We give extra time off or extra pay for staying late. When people take time off, we just pitch in and do evenings.
    The key for us was to start using hospitalists. This has allowed us to work longer in-office hours. Plus, we have taken a full day off per physician – this makes staying late easier as well.

    The nurse triages the patients and if there is a question, they ask us. If a chronic patient gets back, the nurse hears about it. The physicians take the initiative to tell the patients that “this is not a clinic appointment.” But the way I say it is: “Your problem is too important for me to take care of it in just five minutes. Can I put you on my schedule so I can give you the time you need?”

    We have done it for a number of years now, so it rarely comes up any more.

    It works.

  4. We have four physicians and one mid-level. This works with four providers. One provider takes Mon-Thurs PM clinic and then the person on the weekend does Friday and Sat AM. We have one nurse and one front desk person who stays late. We give extra time off or extra pay for staying late. When people take time off, we just pitch in and do evenings.
    The key for us was to start using hospitalists. This has allowed us to work longer in-office hours. Plus, we have taken a full day off per physician – this makes staying late easier as well.

    The nurse triages the patients and if there is a question, they ask us. If a chronic patient gets back, the nurse hears about it. The physicians take the initiative to tell the patients that “this is not a clinic appointment.” But the way I say it is: “Your problem is too important for me to take care of it in just five minutes. Can I put you on my schedule so I can give you the time you need?”

    We have done it for a number of years now, so it rarely comes up any more.

    It works.

  5. My pcp’s office does something similar. They are owned by a large “nonprofit” hospital center, though.
    Good post, Dr. Rob. Helps patients see the business side.

  6. My pcp’s office does something similar. They are owned by a large “nonprofit” hospital center, though.
    Good post, Dr. Rob. Helps patients see the business side.

  7. Our doctor’s office also has early morning walkins. I think they’re great. Glad to know it helps the office also.

  8. Our doctor’s office also has early morning walkins. I think they’re great. Glad to know it helps the office also.

  9. More often than not i’ve just wished dr’s would take patients later at night or earlier in the morning so we don’t have to miss work. The clinic idea is good, especially for people who feel sick and can’t wait for an appointment.

  10. More often than not i’ve just wished dr’s would take patients later at night or earlier in the morning so we don’t have to miss work. The clinic idea is good, especially for people who feel sick and can’t wait for an appointment.

  11. “You have to look at medicine as a business.”
    I was thinking the very same thoughts today. Everyone else but docs in this business get it, and everyone but the docs are making money.

  12. “You have to look at medicine as a business.”
    I was thinking the very same thoughts today. Everyone else but docs in this business get it, and everyone but the docs are making money.

  13. Dr. Rob,
    Great blog….I couldn’t agree more with your underlying premise. Any doc who has a practice (or groups of docs), has a business, period. Helping doctors open up the entrepreneurial side of their brains (something I do as a physician coach) is not only good for their financial health but is a boon for their patient customers. Whether it’s thinking about how to extend and expand the venue of practice as you illustrate in this posting or coming up with other ways to support patients such as creating information products, there are so many creative and too often untapped ways that physicians can help people.

  14. Dr. Rob,
    Great blog….I couldn’t agree more with your underlying premise. Any doc who has a practice (or groups of docs), has a business, period. Helping doctors open up the entrepreneurial side of their brains (something I do as a physician coach) is not only good for their financial health but is a boon for their patient customers. Whether it’s thinking about how to extend and expand the venue of practice as you illustrate in this posting or coming up with other ways to support patients such as creating information products, there are so many creative and too often untapped ways that physicians can help people.

  15. I agree completely with your post. Older docs are the most resistant ones, having lived through the Wednesday off era and incomes 3 SD over the mean for American incomes.Now docs must find creative ways to accomodate demand if they are fortunate enough to have it.
    Nice job.

  16. I agree completely with your post. Older docs are the most resistant ones, having lived through the Wednesday off era and incomes 3 SD over the mean for American incomes.Now docs must find creative ways to accomodate demand if they are fortunate enough to have it.
    Nice job.

  17. I agree with Rebecca. I’ve often thought that if I was a physician, I’d make my set my office hours at something like 11-8 or Noon-9, so people wouldn’t have to take so much time off work – not only for their own appointments, but for the kiddos as well. That’s the way my body clock works, anyway, so it would be good all around – better hours for the patients, and a happier, more awake, more alert provider for them.
    Too bad I’m not disciplined enough and don’t want the debt. I’m just selfish like that.

  18. I agree with Rebecca. I’ve often thought that if I was a physician, I’d make my set my office hours at something like 11-8 or Noon-9, so people wouldn’t have to take so much time off work – not only for their own appointments, but for the kiddos as well. That’s the way my body clock works, anyway, so it would be good all around – better hours for the patients, and a happier, more awake, more alert provider for them.
    Too bad I’m not disciplined enough and don’t want the debt. I’m just selfish like that.

  19. I agree with the underlying premise, but, subject to the business case making sense, (which was more than those typos I nearly did would have 😉 ) have you considered running evening surgery on a similar basis?One of my biggest complaints is that it’s almost impossible to get to see profesionals, or even tradesmen, outside of 9-5 Monday through Friday, even though I don’t lose pay when taking time off for medical appointments.

  20. I agree with the underlying premise, but, subject to the business case making sense, (which was more than those typos I nearly did would have 😉 ) have you considered running evening surgery on a similar basis?One of my biggest complaints is that it’s almost impossible to get to see profesionals, or even tradesmen, outside of 9-5 Monday through Friday, even though I don’t lose pay when taking time off for medical appointments.

  21. Our clinic had one of these, and recently closed it. Why? I’ve got no earlthy idea. My doctors get very frustrated with me coming in very sick. But I refuse to go to the ER for a UTI, or an URI … PERIOD. Granted, I’m on Imuran, Prednisone and Plaquenil, and by the time I start to not feel good on wednesday or thursday …and by Monday, I’m good and *REALLY* sick …but I’m still not going to spend 8 hours in an emergency room for a urinary tract infection or bronchitis … so that I can get exposed to who knows what else????
    It’s gotten me in some pretty tight physical spots, including needing IV antibiotics …but I’m sure that going to the ER would get me into tighter spots .. I KNOW it would …

    I do not understand why they closed the clinic. Our clinic has 19 clinics spread around town, there are plenty of docs who could take the calls for the weekend spots. Whenever I did go, there were anywhere from 10 to 15 patients in the waiting room (regardless of the time I went to the clinic) so you know it was being used, and therefore profitable …

    it makes no sense as to why they’d shut it.

    yes, this is a sore point for me. just a bit.

  22. Our clinic had one of these, and recently closed it. Why? I’ve got no earlthy idea. My doctors get very frustrated with me coming in very sick. But I refuse to go to the ER for a UTI, or an URI … PERIOD. Granted, I’m on Imuran, Prednisone and Plaquenil, and by the time I start to not feel good on wednesday or thursday …and by Monday, I’m good and *REALLY* sick …but I’m still not going to spend 8 hours in an emergency room for a urinary tract infection or bronchitis … so that I can get exposed to who knows what else????
    It’s gotten me in some pretty tight physical spots, including needing IV antibiotics …but I’m sure that going to the ER would get me into tighter spots .. I KNOW it would …

    I do not understand why they closed the clinic. Our clinic has 19 clinics spread around town, there are plenty of docs who could take the calls for the weekend spots. Whenever I did go, there were anywhere from 10 to 15 patients in the waiting room (regardless of the time I went to the clinic) so you know it was being used, and therefore profitable …

    it makes no sense as to why they’d shut it.

    yes, this is a sore point for me. just a bit.

  23. My partner and I are thinking about starting a medical practice. We are certain that we want to include after-hours (or, early morning hours as well) for the higher charge. Are there basic things that we would need to start this model?
    Also, what do you think of having an “urgent care” type of area in the office that one doc could staff while the other sees appointments during the regular day? Would we be able to charge differently for the scheduled appointments vs. the urgent appointments?

    Thanks

  24. My partner and I are thinking about starting a medical practice. We are certain that we want to include after-hours (or, early morning hours as well) for the higher charge. Are there basic things that we would need to start this model?
    Also, what do you think of having an “urgent care” type of area in the office that one doc could staff while the other sees appointments during the regular day? Would we be able to charge differently for the scheduled appointments vs. the urgent appointments?

    Thanks

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