Hello everyone, and thank you for joining me for the Medical Practice Operations Business Fundamentals 101 series brought to you by the American Osteopathic Association. My name is Jeff Gorky, and I will be ushering you through seven practice management, actually it ends up being I think nine practice management modules to give you some fundamentals and some background with regard to the nuts and bolts of practice management. Cruising through the disclaimer and the fact that I have nothing to disclose, a little bit about me and WIPFLY. WIPFLY is basically an accounting firm based in the Midwest. We have offices all over the United States, specializing in a bunch of different business verticals. We do accounting work in those verticals, and we also do consulting in a variety of different spaces. A little bit about me, I've been in healthcare for 30 plus years. I used to run private practices and was involved in a venture capital funded startup in the mid-90s, and have been doing consulting and advisory work for health systems of varying sizes and shapes for the last 16 or so years. My clinic practice platform, if you will, the delivery practice platform, varies from academic medical centers to private practices to rural health clinics to FQs to critical access hospitals. I do private practice work and I have done tribal work. I am what I call an operator. I've done a lot of the work in the weeds and a lot of turnaround related work, but I've also done a lot of strategic management work. I am what I call specialty agnostic, meaning that I basically live and breathe in any specialty or subspecialty in the healthcare environment today. And I'm grateful for having the opportunity with the American Osteopathic Association to present these WebExes over the course of the next, well, we'll be recording these over the course of about two weeks. Each one of these modules in this educational series will run between a half an hour and 45 minutes. And as you can see, effectively, there are nine modules with the finance and the revenue cycle modules being broken down into two different parts because they're so voluminous. And then module eight will be a Q&A session on May 10th, 2023, tentatively scheduled to begin at 7 p.m. Eastern time, six central, and it will run an hour to an hour and a half where we will basically field questions. Those best I know right now, and I will defer to the leadership of AOA, but these will be taped and we will go through a series of questions dealing with these modules and any questions you have based on your listening to an understanding of what I've presented in the modules, but also really shooting at any questions that you wanted to throw out on that date that we could go over and cover to help get a better understanding of maybe your current situation or the, again, questions and answers relative to the modules as they've been presented. I will put this caveat out there, and I do have a disclaimer on every one of these presentations. I am not an attorney. I'm not giving you legal advice. I'm not telling you how to set your compensation plan. I'm not telling you how to make your practice employment decision instead. I am giving you my counsel based on 30 plus years in the business with an understanding of all of these different varieties and aspects of practice management. This more than anything has been designed to give you a very facile topical understanding of some of the drivers in the healthcare scenario as it is as of this date in 2023. And so what we've done is broken down module number one into various different employment opportunities as a subsection to my caveat. This does not paint you a picture of every single employment opportunity that is out there for a clinician. Instead, it gives you a sense of those opportunities and some of the pluses and minuses inherent therein. So without further ado, we'll kick off into module number one, employment opportunities. The goal with and learning objectives for this module are give you a sense of the avenues and models of employment, discuss the differences between some of these employment models vis-a-vis private practice, hospital and health system, academic med center, and some other opportunities that are out there. There are opportunities for clinicians who are entrepreneurs who want to go create their own way and chart their own course, if you will, to begin startups on their own in healthcare technology and things of this nature. So again, this is more of an 80-20 approach to this to give you a sense of the 80% opportunities that are really fairly well defined and kind of split out how they're different. I am not advocating for any model. I'm simply pointing out some of the generalizations and insights into the different care delivery models from employment of clinicians and reminding you that this is neither binary nor one size fits all approach. And for instance, I have a physician associate friend who no longer treats patients. He is in the healthcare tech startup realm. He was in the military for several years, did several tours in the military, and performed a lot of in the trenches, really triage in both Iraq and Afghanistan, came back to the U.S. And after he retired, he started a career with a very large healthcare consulting firm and then decided that's just not where he wanted to be. He wanted to take his background and history in healthcare, his medical training, and deploy that in healthcare technology. So the avenues are endless. It just really depends on where you want to be and what you want to do. This is my healthcare clinic ecosystem. You will see this in probably just about every presentation that I do. This really, for all intents and purposes, is fairly generic. And what I mean by that is while this has nomenclature on it that talks about really many things related to the revenue cycle ecosystem, the revenue cycle and the care delivery model in the ambulatory space work hand in glove. And we'll dig into that more when we get into the rev cycle piece and how revenue is generated. However, I would argue that 80 to 90% of what goes on in the ambulatory space has this type of flow to it, where you have patient eligibility work that's done on the front end, and then you have your staff that is doing scheduling and check-in, however that looks. Then there will be the patient workup. There will be the visit with the clinician, coding documentation, the cleaning, scrubbing, air resolution of the claims, then submission. And then on the care delivery side of the equation, there will be follow-up, scheduling of a recheck, etc., and then payment posting and all the good things that go with the rev cycle. The bottom line for me is this paints for you a picture of what the care delivery model looks like, whether you're an academic medical center, whether you're in a private practice, whether you're in a FQ or a rural clinic. This is essentially what the delivery model looks like. And I use this model because it helps me. I'm a real visual guy. It helps me to paint the picture and then talk through the aspects of care delivery in the outpatient setting. And many of the modules we will discuss in the Practice Management 101 series touch on these different avenues. So without further ado, we can talk a little bit about the private practice. For the first time in the AMA's analysis of private practice makeup or physician employment makeup, this came out, I think, 2017. They found that more physicians are in employed models than in private practice settings. And that is the first time that has happened or been tracked in their history. So the dynamic of employment is changing. That's not to say that physicians aren't working in private practices, and we'll talk more about that as we move forward in this. But in the private practice setting, what you have basically is physician-led governance, ownership. The physicians run the practice. They make decisions at the executive level, sometimes guided by input from external resources, which we'll get into. But generally, what happens is you have physician leadership. The good and the bad of that can be if you have physicians who understand the business of healthcare, and as I like to say, they get it. And by that, I mean, I'll give you an example. I've got a friend who runs 175 physician private practice on the East Coast. Their physician president has been in that role, I think, for about 10 years now. He's a clinician in his mid-40s, got an MBA, which doesn't necessarily mean that you can do the job, but it also does help with a little bit of business understanding. And that physician leader knows the business of medicine. He understands work RVUs. He understands the dynamic of patient scheduling and optimization. So he gets it. It's not purely going in, seeing patients, and then attending executive committee meeting. The downside is if you get physician leaders who don't understand, who just like to sit on the board or be in the exec committee, but don't spend the time to understand the dynamism of revenue cycle, how you're supposed to be staffed appropriately to deliver optimized care. Those practices struggle. They lack symbiosis many times, and they can be fairly toxic. A lot of the private practices are run two to 20 docs, but you do get much larger groups. Again, I have two friends in the business who have 150 plus physician private practices, and they are thriving and growing. So that is out there. There are also situations where you can get into two, three, four, five, six doc private practice, if that's the way you want to go. Smaller practices obviously mean more call. So if you're in a six doc private practice, you might do every sixth and then every sixth weekend, you have to decide what that looks like for you. Also single specialty versus multi-specialty. And for me, when I say single specialty, I mean orthopedics, but orthopedics with multiple subspecialties of ortho. When I say multi-specialty, I look at a primary care group that also has say nephrology or urology or gastro or cardiology. So I'm making that differentiation for me. Cardiologists is a single specialty group. If you've got electrophysiology or you've got interventional cardiology or non-interventional invasive, I look at that as a single specialty group myself. So there are obviously nuances there, and those will play into the role you play within the practice. Private practices are generally cash-based accounting, and I'll show you a graphic to explain what I mean by that. And then a private practice is really small business management, but in healthcare delivery. And what I mean by that is you are running, in many cases, a multi-million dollar small business that deals with rent, it deals with salaries, it deals with equipment. The differentiating factor is you've got this overarching umbrella of medical care. And so by that fact, you have to deal with medical malpractice. You have HIPAA you have to contend with and other medical nuance that doesn't enter into Joe Blow rental car business where you deal with salaries and rental of space and your fair market value of cars and renting cars. You have a little bit of nuance that comes into play and we'll talk about that a little bit later. And then in private practice, you have the opportunity to generate outside income. If you're doing a clinically integrated network, you might work with or your practice might work with a hospital system where you have service line leadership. So in other words, let's say you join a cardiology group and the hospital down the road needs a cardiologist service, cardiology service line leader, they can pay you a fair market stipend to help lead the cardiology section of the hospital. And you don't have to be an employee of the hospital, but you do have to have a fair market value contract in place. We'll talk about FMV related work and other legal pitfalls in healthcare in another presentation. But you can generate revenue that way. Private practices are generally not large enough in terms of revenue or clinician size to have in-house counsel or an in-house accountant. And I would suggest to you that if you are joining a medical practice, a private practice, one of the things you should look at and ask questions about is where they are relative to their accountants, their consultants and their outside attorneys. I always counsel my clinician associates that you need to deal with people in those spaces who are well-versed in the subsection or in the vertical of healthcare. So in other words, if you're dealing in healthcare, you want a healthcare attorney who understands healthcare law. I did some work recently with a physician who was acquiring a medical practice, and I handed him off to an attorney who deals in M&A work and deals in works in deal structure, because there is nuance that your run-of-the-mill business-related attorney may or may not be up to speed with. Likewise with accountants, accountants who are well-versed in healthcare understand the nuance in healthcare and the P&L. They understand and can provide some more counsel on pluses and minuses with regard to care delivery, what the numbers say. Likewise with consultants, you don't want your brother Jim, who's a consultant in the widget factory, to tell you how to see patients. That normally doesn't end well. And it's not because cousin Joe or brother Joe isn't intelligent. It's because healthcare has a lot of landmines that you need to navigate very carefully. So for instance, I heard of a clinic where they wanted to financially reward clinicians for every EKG they ordered. That is against the law. People outside of healthcare maybe don't understand that that is a nuance to healthcare management that you need to be privy to. So the bottom line is in all of that, any outside counsel should be well-versed in healthcare, specifically in the healthcare aspect you're looking at, like acquiring a practice or hiring a new physician or things of that nature. The competitive and stance and structure of a private practice are very important. When you're joining one, the question is, again, we talk about specialty. And then with regard to the demographic, do they quote unquote own the market? Are they the biggest player in Charlotte, North Carolina in the cardiology space? Or are they the biggest player in Lenore, North Carolina in the cardiology space? That matters because it speaks to how they can negotiate contracts. It speaks to what kind of comp you can demand or expect out of a group like that. Also the leverage, large groups who have a big footprint, you may see some of these mega ortho groups who have statewide dominance in a particular state. When that's the case, that gives them better leverage to negotiate better contracts with insurance companies, not Medicare, mind you, but with the commercial payers like Blue Cross Blue Shield, United, Aetna, Cigna, et cetera. We talked about single specialty versus multi-specialty. If you join a three doc internal medicine group in New York City, you probably have about zero leverage in negotiating your fee schedule rates with the commercial payers. If you're in a $150, that changes pretty dynamically. And then the opportunity to participate in different businesses. A lot of private practices own buildings that they rent. So in other words, I'm going to rephrase that, a lot of private practices will have real estate holdings in a separate company, usually a limited liability corporation, where they rent the space from their own LLC. So I'll have my practice in my building and I will pay rent to that real estate holdings corporation. Likewise, a lot of medical practices own surgery centers or have joint ventures on surgery centers. That is something that you would want to inquire about if you're joining a surgery group or even an internal medicine group. A lot of them have their own buildings and the question becomes, you know, A, will I be able to join partnership down the road? What does that look like? What's my out-of-pocket, etc.? And then the second piece of that, is there another LLC where I could maybe have equity ownership down the road? These certainly aren't, you don't want to come in like a bull in a china shop in negotiations, but you want to understand that dynamic when you're joining a private practice. So let's get into cash accounting. Like I told you, I am very simple in my math models because it makes it very digestible. Also, using graphics paints a pretty simple picture of what I'm trying to explain. So cash accounting, what that means basically, is dollar in the door means you have a dollar to spend. So in the private practice, here is my revenue, my receipts. This is, we'll call this January. I generated $100 in total revenue in January. So I billed probably in November and December and collected those revenues in January of this year. $70 or 70% came from my commercial payers, Blue Cresple Shield, United, Aetna, Cigna. 30% came from Medicare and Medicaid. And understanding those percentages also plays a role, which we'll get into down the road, in understanding what your patient demographic looks like. So this might be an internal medicine group in Washington, DC, where they've got a fair amount of commercial pay, maybe even self pay, and very little Medicare, Medicaid. When you start getting into cardiology, this dynamic changes. In any event, story for another time. So you've generated $100 in revenue, and you've collected that. So now your expenses down below are equipment, salaries, rent, MedMal, drugs, right? And I've made that overly simplistic, but it paints the picture. I collected $100, I paid out $50 in expenses, I've got $50 in profitability. And generally, the physician employees will be what I call above the line. So they will fall in the salaries and benefits, and you might have a subcategory for them up there. Some private practices pay them below the line. But the bottom line is, when you're beginning an employment agreement, you will be paid, generally, a fixed salary, and you may have some upside in that, in some sort of bonus structure, which is another dynamic altogether. And we are doing a module on physician comp, where I'll get into that. In this model, $100 in revenue, $50 in expenses, $50 in profit. Generally speaking, that $50 in profit gets paid out to the shareholders. So if you look at it this way, any dollar that doesn't get spent on expenses goes out to the shareholders. So in this model, if I had one owner, he would make $50. Now think about that times 100 or 1000. And you get a better picture of what this can look like. And remember, I said earlier, private practices are multimillion dollar businesses. If you are in a one physician, or you're joining a one physician, private practice, internal medicine, that is going to be at least, if it's functioning at least nominally, well, that'll be a 750 to one and a half million dollar business. So think of it in those terms, where one FTE physician, especially in a specialty setting, a one FTE clinician in specialty medicine will be somewhere between $750,000 and a million and a half dollars in revenue. Some of the questions you want to understand very clearly. Call, you're joining a two doctor, two doctor private practice. So am I on every other day, every other weekend, that becomes fairly onerous. Comp, is comp while I'm employed, fixed compensation, do I have some bonus, the bonus may be based on my personal expenses minus a share of, or excuse me, my revenue collected minus my share of expenses. And I might get a sliver of that. And we can talk about that in the comp module. But base, do I get base and bonus? What are the math calculations behind the bonus? Because if you understand what those calculations look like, you can figure out what your year one income is going to be. So for instance, if I get an employment contract, first thing I do is boil that down into an Excel spreadsheet really simply, so that I can take the narrative, and I can look at what that means mathematically. Medical malpractice, are you joining a practice that's got a history of bad outcomes, or a history of being sued? That matters. Because if you're in market, which means you're buying standard rate health, medical malpractice insurance, you might have a fairly decent premium. If you're what we call out of market, where your practices had a lot of claims against them, you're shopping at a very elevated rate. And that can go from, you know, a practice with a good history, paying $2,500 per physician per year, to paying $15,000 to $20,000 per physician per year. And that is an expense to the practice. So where you saw above the line, that med mal falls in here, that crushes profitability. So what you want to understand is, how are we doing with our malpractice? Do we have exposure? And ask those questions, understand that, and don't do it aggressively. But I think it also shows that you're trying to get an understanding of the history of the practice, and what goes on within the practice. Management structure is another important thing in private practice. What's the tenure of management? If the practice manager or administrator, so the leading non clinical executive, has been there two years or less, and he or she is the third one in five years, that's a problem. Either they hire poorly, or the physicians are horrible to work for. But it's one of those two things, and it's not good. Understand the rev cycle, ask them questions about, you know, how efficient the rev cycle is. The owner physicians should understand how many days in AR they are. They don't have to talk the talk and walk the walk on all the nuance. And you'll see what I mean by that in another module. But they should understand the key measures of how the revenue cycle is doing, because that directly impacts how the revenue flows into the practice. Do they have policies and procedures in place? Good policies and procedures on the operations of the practice, both clinically and operationally, impact medical malpractice, right? Am I doing informed consent on people that I'm going to do surgeries on? I surely better. Those types of things, or how staff functions and operates, matters to the overall efficiency and operationalization of the clinic. How many physicians in the practice? How many are on a path to buy-in? That matters, because it goes hand in glove with what the equity piece will look like. What's the infrastructure look like? How is our EMR? How old is it? How's our practice management system? Are we doing any disease management, population health, or value-based care engagements presently? Are we in an ACO, understanding accountable care in those types of situations? And these on their whole don't, on individually don't matter. But taken on the whole, they paint a picture for you of what that practice looks like. So let's see, my goal is to keep these 45 minutes or so long. So I'm going to move forward. We talked about the policies and procedures, physician leadership rotation. Do they have a term and tenure to the executive team? It can be dangerous to have one physician leader who has been in the saddle as the de facto leader for 20 years. That could be something that's worth questioning. Do they have a strategic plan? I would suggest to you a five-year strategic plan generally has de minimis value as you get past year two, because the market changes, the dynamic changes, the staffing and the physicians come and go. So, but do they at least have a one to three year plan of a strategic plan in place to get an understanding of where they want to go? Because that will guide you and lead you. And it's, it's malleable and it lives and breathes, but you want them to at least have pontificated on where the practice is going to go. Coding and review and compliance. Do they perform coding audits? Do they perform coding education? That is important. Overcoding claim can get you into legal peril. And we'll talk about that in another module. Revenue cycle, we talked about staffing, contracting, we talked about, and again, we will dig into, gain a deeper understanding later on in these modules. Private practice pluses, generally speaking, nimble, think speedboat, you can move fairly quickly, and you can change course fairly quickly. Shareholder value, the owners own the business. Decision maker, maybe even as an employed physician, you can have a seat at the table, helping to make decisions or at least understanding the dynamic and being a fly on the wall to understand how the conversations go with regard to the operations. You are not beholden to a health system or a private equity company. So the decisions you make impact you and your peer group. The minuses, you do have complete autonomy and complete responsibility. So any decisions that are bad ones will come back to impact you. When you're the new guy or gal on the block, do you get a say? And that's important to understand going in. Will they value what you have to say? The flip side of that is, please don't go into a medical practice thinking you understand everything there is to know about healthcare management, because I can guarantee you, even after 30 years, I'm still learning something every day. You will be too. So go in with an understanding and hope that they will educate you, have someone who will mentor you, and help you in the ways of medical practice management in clinical operations and efficiency. Understanding the call. I have seen clinics, when they hire the new guy, and this has been some time ago, but the new guy ends up getting hammered with call. Understand the call rotation very clearly. I think a lot of groups have grown to understand, you don't want to abuse the new folks. That ends up being long term, a bad idea. And it's really a bad idea, just on a human level. If there is no profitability, if you're a shareholder, technically, there is no pay. And there is no bonuses. I have seen clinics, when they aren't profitable, they borrow from their line of credit. That could be a short-term fix. Long-term, that's bad, because all you're doing is getting into debt. Poor management and accounting, that's on you guys. No positive procedures means you're basically on a rudderless ship. Now, hospitals health systems. Underlying baseline. So really, the baseline in the private practice, you have autonomy, you are in a kind of quick-moving entity that's more intimate, really. Underlying baseline for health systems, you are an employee of a health system. Now, if you're in a small health system, maybe you have more of a say. If you're in a 1,500, 2,000 doc health system, I would suggest you probably, your input is maybe less valued than smaller systems. Accounting, we'll get into the difference here between private practice and health systems, but you will be on accrual accounting versus cash accounting. And you get profit and loss allocations versus direct attribution. And I'll discuss what that means a little later in one of my handy dandy examples. Compensation, you are an employee, you will be paid even if the system loses money. That is one of the benefits, I guess, for being employed in health system. You will be employed many times on, at least in part, in a work relative value unit measure. We'll talk a lot about that in the compensation planning stage or module. But I would ask you, if you don't know what a work RVU is, pay attention to that. You will see that more than likely for the rest of your days in health care. It plays a very large role in every delivery of care module. Whether you're in a academic med center or a private practice or you're in a private equity funded health entity, everyone pays a lot of attention to work RVUs for a lot of reasons. And we'll talk about why they do have value. You can argue their value, but we'll get into that a little later. Health systems generally, you will have a base. In many instances, there is upside compensation opportunity, and we'll dig into those nuances more. Again, competent assurances, you're not tied to system profitability, but your longevity within the health system certainly could be damaged if you're upside down, i.e. you're not producing more than you get paid. Many high-functioning health systems ask for physician input. I have been involved in working with many that don't. And I would suggest to you, those systems that do really well, just like the private practices do well, they have physician teams and leadership who understand the value of physician leadership. And that's not only, in my opinion, on the clinical aspects of leadership, whether you're doing care design, value-based care delivery of a, say, total hip or total knee. But in my opinion, it's also physician input on the optimization of the practice, how the practice functions day-to-day. So here's our accrual accounting. Health systems will look at your charges as your quote-unquote gross revenue. We'll talk about why charges don't matter, but they allocate those as gross revenue. Charges in the private practice do not count as revenue. The actual collected revenue in a cash-based system is your revenue. So this $70 would have been what you accrued in revenue in a cash-based system. The health system here, in this instance, will say, we generated $100. That's accrual accounting. They will accrue $100. Then they will take write-offs and their contractual adjustment estimate for what they've contracted with payers for, and they will expect a net revenue of $70. So I have $100 in quote-unquote revenue, but our net dollars in the door, we expect to get right about 70 bucks. So here are our expenses. They're $50. I have generated $20 in profit to the health system. When you are an employed physician in a health system, you will be parsed out, your expense will be parsed out up here. You are a day-to-day expense. And when I talked about pro rata shares of expenses, when you're in a private practice, your rent is $8. You will pay $8. Let's say your IT infrastructure falls in equipment. You will pay whatever that is on a monthly basis. When you're in a big health system, many is the time when they will say, IT cost $100 for our whole health system. We have 10 practices, so each one eats $10 of that cost attributed to their P&L. So that's a pro rata share of that expense that hits you on your P&L. And what happens many times is health systems will buy private practices, and then sometimes in the integration or assimilation, they fail to explain how the P&L is going to be impacted. And what ends up happening is the health system will technically, on the P&L, get upside down when the practice in cash-based accounting is profitable. And there are a lot of reasons for that, and we will speak to those in a little more detail later, and we can also cover that on the Q&A or at a different time. So what you want to ask in a health system in the employment model certainly is, you're going to have similar questions, especially if you're looking at private practice versus a health system. But if you're looking at health system one in Charlotte, North Carolina, versus health system two in Charlotte, you want to be able to compare them apples to apples. So you want to understand, OK, I'm a cardiologist. Am I able, as the new guy or gal on the block, to offer input into the cardiology service line? Or do I get excluded altogether? Am I in a 2,000 doc health system in Atlanta where I don't have any say within my subspecialty? And in the subspecialty space on a large health system, you really need to understand what the health system looks like and what your subspecialty looks like. I will give you an example of a small health system that I worked with many, many moons ago. And I hope this never goes on elsewhere. It was a small health system with an OB-GYN service line. They had two OB-GYNs. One left for the reasons I can't even remember. And the system wanted to hire another OB-GYN. And they did not let the current employed physician interview the other physician. And as soon as the other physician was hired, it was oil and water. To the point where they split staff, they split the office. And obviously, well, I hope to my holy God that doesn't happen very often. But there is value in understanding who you work with and being able to work together. Are you gonna work together perfectly every day? No, you're not. I mean, that's just human existence. We don't cohabitate well all the time. But you want to understand how they practice. You wanna learn from them. You want them to learn from you. You wanna be as simpatico as possible because you're gonna be spending a lot of time together. The strategic plan, I would suggest the same thing, one to three years. If you're in a large health system with a multi-specialty, and by that, I mean cardiology, ortho, OB-GYN, IM, uro, nephro, you want to understand for the system, where do they wanna be? Are they gonna grow throughout the whole state of Georgia or Alabama or Arkansas? Are they going to grow my service line? And if they do, are they gonna ship me off to a new office 50 miles away three days a week? I certainly wanna get an understanding of what that looks like. The compensation, again, you wanna understand not only what you're gonna get paid on the whole, but how that is derived. And the health systems generally are getting to work a base, work our view plus base, maybe some efficiency aspects, and maybe some quality aspects. And then two, understand the quality programs. Those are becoming more and more prevalent. We even now have consulting companies that just specialize in building out value-based care, and we'll talk about that in another module. So the questions, are they involved in ACOs or clinically integrated networks? Revenue cycle, these are some of the same questions, but on a different scale that you will want to understand in a health system. So pluses and minuses. Relative safety. For lack of a better phrase, I would say you can hide out in a health system as long as you're doing your job, keep your head down, you'll be in good shape. Access to capital. If you're in a big health system, they have a lot better access to capital to do building projects, to expand the physical plant and footprint, to rehab rundown locations, to acquire practices, to build surgery centers. So that is really nice, because a lot of times when you're in private practice, you have to personally guarantee any loans that you take to do build outs or to put in EMRs or to build surgery centers, et cetera. Guaranteed comp plan. We talked about better payer contracts. I live in the greater Atlanta area. We have three very dominant healthcare payers, and I can guarantee their contracts with the commercial insurance companies are really good. So having the scale with provider numbers gives you the opportunity to negotiate better contracts. And in many instances that can translate into better pay. Maybe access to more internal specialists. If you're in an internal medicine group, you are shipping out a lot of care to nephro, cardio, whatever. If you're in a large health system, chances are really good, they're gonna have specialists that are on the same medical record. So you can share your patient medical records back and forth pretty seamlessly. And you know, or theoretically you know, that they're gonna get back to you timely, you're gonna get results promptly, and you're gonna be able to close that care loop with your patient. You don't have to theoretically worry about collections. So you bill your charge out and your revenue cycle for the health system ideally is working to collect the revenue. And again, you're gonna get your compensation regardless of what the rev cycle team is doing. The downside, turning a health system around is oftentimes like an aircraft carrier or as a buddy of mine who works in a very large consulting company said, it's like turning around multiple aircraft carriers just depending on the size of the healthcare entity. I work with a 3000 provider medical group. I can tell you they probably can't make a decision and get it effected within six months. Seat at the decision making table, do you or your service line leader in your specialty or do you have a seat at the table to help drive the decision making process? The new guy and gal on the block, the same thing applies to private practice as does with the health system. And maybe again, it's predicated on the scale and size. Do you have a say on who gets hired down the road? And I don't mean you get hired, you work six months and you get to say who gets hired or fired. But ideally you will get to interview new physicians in your service line. The pro rata P&L, sometimes you'll get an allocation that is not based on your clinic size or your number of physicians, it's based on the fact that you're in the system. And so that could mean an inflated pro rata piece on the P&L. And then for me again, that means the accrual accounting allocations. Academic medical centers. You'll have community and physician board leadership. Physician leadership in many times, and again, I think I would take a step back here because I've done enough work with academic med centers. There are some where you get employed at the medical center really with the goal of doing research and teaching and a lot of the academic pieces versus day-to-day care. I also have seen those where the faculty practice relies very heavily on revenue generated by the, or excuse me, the university relies very heavily on the revenue generated by the faculty practice. And we'll talk a little bit about that. The work between the faculty practice and the ambulatory, well, I kind of just covered this, sorry, I skipped it. Some systems require aggressive patient volumes per clinician and some do not. I have dealt, like I said, I've dealt with some where the clinician's commitment to care, to face-to-face clinical time is a half day a week. And in many instances, they have not even parsed that out into any structural, anything with structural integrity, i.e. we need you to see one new patient in the morning and five rechecks. And that needs to be between 8 a.m. and 12 p.m. In many instances, it has been, hey, you need to be in the clinic half day a week. And sometimes that means showing up at 10 and leaving at 11.30. Some clinicians show up at 8.30 and leave at 12.30. Those arrangements, to my way of thinking, need to have teeth. And I think many systems, if frankly, in this day and age, and with grant money and funding mechanisms being altered, many faculty practices need to understand the value of generating some revenue in their practices. Sometimes those, the teaching research-heavy locations that I've seen, little less in guaranteed comp, but you certainly have very good pension plans down the road. There's some give-get with not, with a requirement, with no requirement of seeing, you know, 40, 50 patients a day, five days a week. There's a little give-get there. Questions are the same. Hypothetically, if you're looking for a position in an academic med center or a hospital or a private practice, you should ask similar questions. And they're gonna deviate a little bit just because of the structure of, and nature of the delivery models, or as I call the care delivery platforms. Policy procedures should be everywhere you look for a job, regardless. Patient-facing time commitment is important. A private practice, if you're an internal medicine doctor, you may be seeing, depending on the structure and how well the practice is run, you may be seeing 20 to 50 patients a day. If you're in family practice, you may be seeing 18 to 28. It really depends. But you need to understand what that looks like and how you deliver care. Can you meet those expectations? And are you comfortable giving quality care, seeing 25 patients a day? Strategic plan we discussed, coding review and compliance we've discussed, and the revenue cycle in AR is the same or similar to the health systems. The funding mechanisms are different in the academic med center. The pluses and minuses, relative safety, as with the health system, guaranteed comp. The access to specialists and micro subspecialists. I've dealt with health systems that have sub, sub, subspecialists, which is just fascinating and very cool. And then not worrying about the collections aspect. And depending on the system, fixed clinic time versus research time. Again, the minuses are fairly similar, especially if you're near a large academic med center. Aircraft carrier analogy, generally lower comp relative to peer groups. Are you a cog in the wheel? Or are you valued in what you bring to the table on a daily basis? There are instances I have seen, being in this forever and ever on, where there's a lack of coordination and symbiosis between the faculty practice and the university vis-a-vis scheduling, patient volumes, revenue generation, et cetera. And sometimes communication breakdowns can occur, but that can occur anywhere. So general thoughts relative to employment. And oh, by the way, we didn't really speak to private equity, and that has gained more and more of a play in the employment model. Private equity practices are out there. They are hiring physicians. They are acquiring medical groups. The methodology for reimbursement or for, excuse me, for compensating clinicians varies by each model. And you would need to understand if you get into a private equity organization, how that compensation works and how a sale of the entity will impact you. And will you have an opportunity to enjoy an equity piece at the table? Many private equity plays in the healthcare space and in other business verticals are grow the thing and flip the thing and make more money. And so the question is, what happens to you if you are a widget maker in that entity, or even if you're an equity member in that entity? And you really need to understand that if you're going into a private equity funded delivery model. And we'll tell you this, while some private equity models don't have a load of production requirement, i.e. seeing numbers of patients, some do, and you need to be very cognizant of what is expected of you if you are joining. And if you're in a practice that is getting ready to sell to a PE model, there are tax consequences, which I can't speak to because I am not a CPA, but there are certainly operational aspects I can speak to. And there are consequences on the sale price where you give up some compensation for theoretical or real long-term revenue gain when the entity gets sold. So you really need to understand what role you play. These are all the thoughts and questions we had in the other healthcare platforms where you might be hired, but it's also understanding on a sale of the entity, what happens to me? What's the expectation? So in a nutshell, and again, generally speaking, those are some of the different models that are out there. This is not all inclusive, as I said before, and this is not to limit you in what you can and should do. To my way of thinking, you should go blaze a trail and love what you do. I hate to hear stories of healthcare providers, clinicians, PAs, NPs, physicians who go out and then hate medicine because the paperwork and the legal aspects of it and the fear of being sued. I love to hear stories of clinicians who love what they do because all of the noise of the care delivery process, the operational noise is taken off of their plates. And that's not to say you shouldn't be aware of what goes on in the operations, but you should have a high functioning model that enables you to see patients and enjoy medicine. So I will end with that. Oh, I have some assorted thoughts here too. Actually basically covered these. I will tell you this also, when you're looking at comp models, if you're in a big city, you can look at this as supply and demand, honestly. When you're in a health system, there are some comp limiters on what they're allowed to pay from a fair market value perspective. But when you go to a big city, if you wanna be in New York and you're gonna be one of 10,000 cardiologists or 20,000 cardiologists in New York, you may need to take a little cut in pay because that's apparently where a lot of cardiologists wanna be. If you are going out into rural Nevada, you may actually get a pretty good bump in pay to be a internal medicine physician in rural Nevada. It really depends on what you want for lifestyle, what you wanna do. If you're in Nevada, you're gonna make a little more money maybe, and maybe you're gonna be able to hike the mountains every weekend and maybe that fits. So it's lifestyle. It's how much access you need into other quality of life things. If you have a significant other, will they want to be there? Can they be there? It's really lifestyle and all the things that go into making life rich and valuable outside of compensation. So we covered all of these general thoughts. You'll be able to review this slide deck at your leisure. We talked about cash-based accounting and we covered all of these. And so as I had suggested earlier in the conversation this afternoon, we are going to have a module eight that is really a dynamic Q&A session that will be recorded May 10th, 2023. As of right now, it will begin at 6 p.m. Central, 7 p.m. Eastern time. And my understanding from the executive team at AOA is it will be recorded. So if there are folks on the West Coast, that will be available to them. If you want to get your questions in, please email them to PhysicianServicesAtOsteopathic.org and the deadline will be on the 10th of May so that we have the opportunity to review those ahead of time. As of right now, this may or may not be dynamic. We might be able to take some questions on the fly. I just don't know. In any event, I appreciate y'all tuning in and spending about 45 minutes with me today. As I said before, this is not an end-all be-all, but the goal with this and all of the other modules is to really give you a broader understanding of the dynamism of the healthcare delivery model, hopefully not to bore you to tears with it, but to educate you so that you're higher up on the curve in terms of understanding what goes into day-to-day practice management and operations. And with that, I'll again thank you for your time and hope that you join me for module two.

Medical Practice Management

Healthcare Models

Private Practices

Health Systems

Academic Medical Centers

Business Fundamentals

Private Equity

Revenue Cycles

Career Development