Tuesday, January 16, 2007

Searching for Medical Office Space in NYC.....

Yes, New York City is where I live and practice, and as you may imagine, office space comes at a premium. Finding office space that is affordable is a challenge. Finding office space, period, is a challenge! But like I've said before, no matter where you're at, if you can purchase an office space you're steps ahead of the game. Just think about it, owning your own space means locking in mortgage payments that are predictable and will not increase for the next 15 years, unlike rent under a lease. Of course, you can start small and just rent a room in a space, but eventually you will need to grow. Yes, I know you could have a micropractice and limit your practice size to a certain number of patients. I'm all for that, but there's no replacement for being the master of your own domain, where you can add your personality, likes and tastes.

New York City is a jungle with many players and dealers. You have to develop a sense for real estate brokers that you can trust, and ones that you cannot. Now given that they're all invested in a commission they're making from the lease or sale, old-school me says take everything they say with a grain of salt. In fact, my experiences thus far have taught me to "trust, but verify" as my father used to say. You're never completely sure who you can trust. Personally, there's only a few people I trust -- my accountant and lawyer are up there, but definitely not my broker, as great as they may be. Such is the name of the game.

So through trial and error you go on the search. Myself, I trust my gut more than anything. If I'm not completely feeling a space, I won't commit. I've been looking for a space to move to for almost 2 years now. Moving a medical practice is a big deal. You have several considerations: 1) Location -- will my patients follow me, 2) Location -- is it convenient to the hospital (hopefully not -- I hate the hospital), 3) Size -- what size space do I need, 4) Size -- will I be alone or sublease to someone else (btw, the smart thing to do, especially for you pcp's and family doc's out there -- face it, we're not making enough money), and 5) Location -- how long will my commute be. These are all very important questions.

Next: 1) Is the space built out as medical? 2) Is the space zoned for medical use? (turns out a very important consideration in a zone-crazy city like Manhattan; if not, rezoning is a nightmare) 2) Is there water in the space? If not, you'll need to find the nearest pipes and figure out if they can be run into the space? 3) Do you need to knock down walls or build walls? 4) Is there a bathroom? Do you honestly want your patients running down the hall with a urine cup in their hand? 5) Does the layout allow you to build the right flow for your practice?

This is when you might hire an architect to take a casual look at the space. I advise against paying at this point. Just get them to give you an idea if the job is doable. Once the lease or sale is closed, you'll need to get a jump on this, as you may have to submit the plans to get a work-permit from the building department. New York City's has a special name -- "the Department of Aggravation." Since plans may take a while to get approved, then you may need to hire an "Expeditor." Sounds "Terminator-like," doesn't it? These people are highly skilled individuals specialized in the art of getting your plans through the building department and approved in a matter of days, instead of weeks. Amazing, huh? Isn't it great what bureaucracy has created?

Once you have a plan, you need a contractor. GOOD LUCK! Hahaha! Yes, this may be quite a difficult task. Remember what I told you in the beginning about trust and honesty. Don't trust these!!! They will promise you the sun and the moon, but in the end may only deliver a raisin. They may quote you 25K now, but by the end it's 50K. Always hidden surprises! Check their references! Then check them again! Ask to see samples of their previous work. The research invested before the job begins, will save you tons of aggravation later. Remember, the day your lease or sale closes is not the day you move in, unless you've have found that once in a blue-moon space that is in move-in condition. Not in NYC where space is scarce, and demand is high. If you live where I live, you'll probably have to do some work to the space. Maybe even a lot of work if the people who left it never made any improvements, unless you like working in a time-capsule.

Aahh, finally....... moving day! Everything is done! Right? Wrong, did you forget to tell each insurance plan you belong to about the impending move? It may take these wonderfully bureaucratic entities a month to enter your new address in the system -- God knows changing a few letters in a computer is a difficult task. Then, it will probably take them another month to start sending your mail there. Did you not tell them to change the mail-to address as well? Those checks are important, so either change to direct deposit before you move, or make sure to give the insurance plans plenty of notice. Tell all of your referring docs as well. Then forward your mail anyway.

And the Best Part! Throw an Opening Reception party! Invite all of your doctors friends and potential sources of referrals to gawk at how great your new space looks. All your hard work has paid off. It's time to celebrate and begin building your future!

Please remember -- don't make it another boring doctor's office. Hang up some artwork for God's sake!

Monday, January 01, 2007

Ring in 2007 with renewed vigor for Medicine!

Yes, I know it's hard. You feel like you work harder every year and make less money. Personally, I've only been in the solo game for 2 1/2 years now, so I've only felt a slight crunch, whereas those of you who have been practicing for more than 5 years have really felt the crunch. Unfortunately, I already started halfway down the reimbursement hill, but I do face the same struggles of keeping a practice afloat. Some of you got frustrated and left, and I don't blame you. After all, how does one keep going? Do I smell the ashes spelling B-U-R-N-O-U-T ? Well, at some point if you're a hamster on the healthcare treadmill, unless you're Lance Armstrong, you're going to get tired of it and jump off. It's no fun playing a game where you have no control over any of the rules.

So, how do you make it work for you?

Personally, I've decided the New Year will mean a rethinking of how I structure my practice. Of course, I should have done this from the beginning, but I was younger and not necessarily led in the right direction by well-intentioned physician colleagues. You see, the Healthcare Monster has created this perception that you need this and that to operate your practice, whereas perhaps you don't. These colleagues have been entrained to think this way. A biller, an extra medical assistant, someone to answer the phones, someone to call about referrals, and insurance plans having buildings full of ominous employees working to reject claims -- how is this supposed to control rising healthcare costs? It's like the Cold War all over. One side builds up its arms, and the other side is forced to build up its own in order to survive any act of aggression by the other. It makes no sense to me. Managed care actually lowered the quality of care, created more bureaucracy, and added to the toil of medical care. Somehow this was supposed to make healthcare more affordable? Well, of course it did, at the cost of quality.

Quality of life has been affected as well for both patient and physician. This year I plan to take back more of my quality of life. No, I probably won't work less hours, but those hours will be more fulfilling and have a higher yield curve as my overhead is slashed by a better-planned operation. After all, what do businesses do when they need to enhance their profits and tighten up their operations: sell off losing businesses and fire employees. What led me to the decision to downsize? Three things did: 1) the unjustifiably high cost of overhead, 2) the availability of technology that can automate many tasks that previously required that excess staff, and 3) reading this article about physician micropractices.

Even though my practice already has fulfilled many of the things I wanted to gain from being in solo practice, namely:
1) Autonomy,
2) Creating meaningful relationships with my patients,
3) Being able to give quality, compassionate care to my patients,
4) and Practicing medicine the way I felt it was meant to be practiced,
it still has a high operating expense because of the way I structured it.

Initially, I thought I needed all the bells and whistles, because a fellow physician that I share office space with convinced me so. Having no prior experience running a medical practice, and finding the referral/billing/ insurance bureaucracy overwhelming, I thought this was the way to go. Overnight, I found myself starting a fledgling practice while trying to pay an overhead I thought would be eventually justified when I got busy. I see no need for that anymore. I made a mistake, and I admit it. The lessons learned in the last 2 1/2 years are what are going to give birth to my new practice model.

The Micropractice:
1) Downsizing is good! That's right, even as small as one employee and myself. It will require multitasking, but it will also create a better patient experience as messages will not be lost, interactions will be more personal, and I won't be under the pressure of higher volume to maintain an out of control overhead.

2) Lower real estate cost. With downsizing comes less need for excess office space. Moving to a smaller office helps control costs. The article doesn't talk about this, but why be someone else's lease subsidy? Rather than sharing with another physician that is the lease owner, I will become the lease owner, and perhaps find another doctor to subsidize my lease. This makes more sense. No one ever talks about this.

Downsize the practice, too! That's right, lower overhead means less need to rush through patients, more time with new patients, and the ability to really get to know the issues troubling your established patients. These things cannot possibly be garnered in a 10-15 minute visit. Patients will be better taken care of, and your life will be less hectic and more liveable. I might even consider capping my practice, which I haven't done yet.

The Electronic Medical Record: automate, automate, automate! That is the name of the game. Make everything automatic, including billing. Why pay for a biller when a well-designed PM system can help you do it yourself. Modern technology has made is easier to achieve an ideal practice environment without excess staff. This year I will be adopting an EMR as part of my practice redesign.

Same-day Appointments are here again! Over and over, I hear patients calling other doctors complaining of a sore throat, only to be told the next available appointment is 3 weeks from now. Now how is this realistic? Patients need to be seen today for urgent problems, not 3 weeks from now when a simple cold could have turned into a pneumonia. Same-day appointments is the key feature of the micropractice that increases the quality of care for your patients. I have been able to do this already, but will use this as a key publicity point for my practice.

Filling a nitch. All of the above fulfill the need of patients to be heard, understood, and taken seriously. Patients want and deserve that regard. This is a return to how medicine should be practiced, not how They think we should practice medicine because of the need to power the out-of-control money-guzzling bureaucratic healthcare machine. The micropractice is a return to the traditional practice of medicine that patients have been longing for but didn't know how to ask for. Goodbye to the medical-industrial complex!

Offering an interactive website. This could be done through the EMR system. Offer online appointments and prescription refill requests. Create more informative content for your patients. This will attract patients to you, and will show your patients that you are devoted to and interested in what you do.

In 2007, I'm going to take back the practice of medicine. How about you?

Imagine what could happen to healthcare if doctors across the country created a network of low-overhead, high quality micropractices that banded together to purchase medical supplies in bulk, for example, at reduced rates. Wouldn't that control healthcare costs, I wonder? Topic for another blog entry.

and btw, Happy New Year to all!
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