Private practice– your next adventure Tom Archer, MD, MBA UCSD Anesthesia What Do All of These Jobs Have in Common? We are all workers in service industries! Does This Fact Make You Uncomfortable? Competition Implies That the Customer is Free to Choose Between Competing Alternatives Competition • Aren’t we doctors above that? • Doesn’t competition lead to haste and errors? • Isn’t competition grubby? • Shouldn’t the public just trust us to do the right thing? Competition • A fact of life in private medicine. • You are competing with other anesthesia groups and with other anesthesiologists in your own group. • The challenge is to maintain a high level of service without compromising safety. • Whether you like it or not, personal relations are every bit as important as technical or “medical” skill. • The 3 “ables” of the anesthesiologist: Available, Affable, Able. Arrogance or Apathy– Not an Option • You will be expected to be a “team player.” • If you are apathetic or unresponsive… • Your customers will take their business elsewhere. The Patient as Customer • Patients are more demanding than 30 years ago. • Scrutiny of medical practice (by everyone) has intensified. • Physician is still a respected authority figure, but… • Physician must realize that she has to please customers and is part of a team. • The days of prima donnas are over. Are We In Business? Or Are We Practicing Medicine? • Isn’t business all about money? • Doesn’t business subordinate quality, ethics and patient care to the Almighty Dollar? Are we in business? Or practicing medicine? • Is there a conflict between business and medicine? • NO! • Good medicine implies good business, and vice versa. The business of medicine • Efficiency, quality and customer service never go out of style. The Business of Medicine • In a competitive health care environment, providers will give the best care they can at the lowest price. • Competition fosters improvement and innovation. • State health care monopolies foster slow, inefficient and bureaucratic care. • Academic medicine frequently lacks incentives for production (monopolistic mind-set). Good doctors and good business people: • Give the best customer service they can (technical care, bedside manner, punctuality, courtesy). • Don’t waste time or resources. • Know their customer’s needs and wants. • Know how to work in teams. Service and safety issues • Safety Issues are sacrosanct and must not be compromised. • Service issues (start times, cases on Saturday and Sunday, after midnight, etc.) are negotiable. • You need to clearly understand the difference. • Monopolies (us?) often camouflage a desire to avoid service as a safety issue. Customers and the Golden Rule • Modern business philosophy: patients, family, surgeons, nurses, administration, technicians– these people are all our CUSTOMERS. • This is really a restatement of the GOLDEN RULE: • Treat your customers– your fellow human beings-- with respect and with consideration for their aspirations, needs and fears . Private practice– what will it be like? • Possible contrasts with academic medical centers: – Faster pace (no one is in training). – Great emphasis on good interpersonal relations (being nice) and consistent, good results. No rewards for originality or extra frills. – Emphasis on collegiality rather than conflict (everyone’s earnings depend on everyone’s actions). – Pay is based on cases performed– not on salary. Anesthesia groups are not all the same! Anesthesia Groups • Look at more than just: – Types of cases and how much money you will earn. – Work hours, call schedule, vacations and CRNAs supervised. Your Job is to Get Behind the Window- Dressing and Find Out What the Group is Really Like. Anesthesia Group Culture • Some groups are healthy and promote the happiness and prosperity of their members. • Other groups are dysfunctional and full of psychopathology. What Does Your Gut Say? • Do people seem happy? • Do group members seem to like one another? Or do they gossip with a newcomer like you? • Do members appear over-worked, unhappy, and yet greedy for more cases? Are New Group Members Treated Barbarically? • They get poorly paying cases. • More nights and weekends. • Buy-ins are excessive. • Many new hires don’t make partner. They get booted out before they become eligible for partnership. How are the MDs compensated? • What is the incentive structure? • What behaviors are rewarded? • What behaviors are penalized? Straight Salary • You get paid the same whether you do a lot of cases or not. • More common in academic settings. • Does NOT reward production or efficiency. • Disadvantage: slackers can slack off. • Big advantage: allows time for teaching, research, innovation and careful, methodical care. “Eat What You Kill” (Type 1) • “Fee for Service” from individual patient. • You receive specific collections from patients whom you anesthetize. • If you have indigent patients, you earn ZERO! • If you have all insured patients, you earn mega-bucks. • FTC: Price-fixing via sham corporation? • Fraught with abuse potential– schedule manipulation, etc. “Eat What You Kill” (Type 2) • “Fee for Service” (Based on Group Average Unit). • Money is pooled for entire group. Your month’s income = Group’s Total Collections X (Your Units / Total Group’s Units) “Eat What You Kill” (Type 2) • In my opinion, EWYK Type 2 is the best system for private practice. • This system rewards work and efficiency and ignores payer mix. • Schedule manipulation and lies just stop. Do You Hear About Conflicts Over Anesthesia Service? • Do surgeons want more night and weekend coverage than group wants to provide? • Do the anesthesiologists have a “can-do” service orientation? • Does the group work with nursing and administration to provide service as a team? • Or does the group blame nursing or other hospital employees for inadequate service? Who runs the group? • A group of old cronies, in a murky and capricious manner? Or… • An elected Board of Directors? How does the medical community view the anesthesia group? • As money-grubbing technicians? Or… • As team players? Is the “group” really a group, with a clear business purpose? • Yes, the group takes care of all the patients in an efficient and compassionate manner. • No, the so-called group is a loveless marriage of convenience between competing individuals. A Good Anesthesia Group • Healthy, happy individuals, who enjoy caring for their patients. • Internally, the group functions as an anesthesia team, with a clear business purpose. • Minimal to no schedule manipulation, cheating and lying. A Good Anesthesia Group • Externally, the group works constructively with nursing and hospital administration to provide care as a hospital-based team. A Good Anesthesia Group • The compensation structure aligns individual incentives with business goals. • Best system is income pooling with individual compensation proportional to services provided. • Individuals who participate on Medical Staff and hospital committees are respected and rewarded. The New Member (You) • Well trained. • Knowledgeable. • Eager. Advice for the new member: • Be humble– there’s more than one way to skin a cat. • Ask lots of questions– and learn! • Try to understand why they do what they do– it MAY make sense! (Or it may not!) • Ask the established and respected practitioners how they would do things. One Final Note • Try really hard to be respectful, pleasant and courteous to EVERYONE. • I am VERY serious about this and this is VERY important. • Arrogance and being a jerk is our most common mistake. • This point has nothing to do with your “technical” care, but it has everything to do with your success in your new work environment. Good Luck!