How doctors should think? Who are physicians? How do they boost their practice? How they should think about Revenue Streams.

Disclaimer

Copyright © Year – All Rights Reserved

Learn How You Can

Change Your Practice

for the Better!

How Doctors Should Think

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All ideas, views and thoughts expressed in this book are the author’s own. References have

been provided wherever possible. This eBook is not meant for promotional or advertising

purposes.

Examples of people and other organizations are mentioned as case studies only. Any

comments which could be deemed as negative or as criticism are completely unintentional

on the author’s part.

All information contained here is meant to be taken as a guideline. It is understood that the

reader claims responsibility for their own actions and interpretations of the advice

provided herein.

The author does not claim nor was any guarantee made regarding success through this

book. This eBook is not meant to be a substitute for professional advice. Therefore, they

cannot be held responsible should any losses, risks, liability or damages that might be

linked, directly or indirectly, with the information contained within this book should occur.

Contents

Disclaimer .........................................................................................................................................................................1

Chapter 1 –Introduction ............................................................................................................................................4

Chapter 2 - The Core Question – What is a Physician? ...............................................................................7

Don’t be a Caterpillar .............................................................................................................................................7

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What is a Physician? ...............................................................................................................................................9

Chapter 3 –Thinking for a Change ..................................................................................................................... 12

Chapter 4 –When Going in the Wrong Direction, Don’t Speed Up ..................................................... 15

Chapter 5 –Dot Thinking ........................................................................................................................................ 18

Chapter 6 – Two SD to the Right ......................................................................................................................... 21

Chapter 7 – Be More like George ........................................................................................................................ 24

Chapter 8 – Secrets to Boost Your Practice ................................................................................................... 27

Get Computerized ................................................................................................................................................. 27

Take Control of Your Office .............................................................................................................................. 28

Create a Niche ......................................................................................................................................................... 29

Offer One-Stop Shopping ................................................................................................................................... 31

Hire As Few Employees as Possible ............................................................................................................. 31

Pay As Little Rent As Possible ......................................................................................................................... 35

Chapter 9 – Doctors Have to Know Their Business ................................................................................... 37

Chapter 10 – Why Did You Sign Contracts with Insurance Companies ........................................... 42

Chapter 11 – In Network, Out of Network ..................................................................................................... 49

Review ........................................................................................................................................................................ 54

Chapter 12 – Cash Only and Concierge Practice ......................................................................................... 54

Concierge Practices .............................................................................................................................................. 57

Chapter 13 – The Value of Intellectual Distribution ................................................................................. 59

Chapter 14 – How Doctors Should Think About Revenue Streams ................................................... 62

Time Testing and Treatment ........................................................................................................................... 62

Testing ........................................................................................................................................................................ 66

Treatment ................................................................................................................................................................. 70

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Chapter 1 –Introduction

One thing I have learned by reading a lot of personal development books is that if you see

someone who is doing something you want to do, find out how they did it and follow the

same steps. Success has a methodology to it. There is a science to living the life that you

want to live. The most important first step is to decide that you want something different.

This is a lesson that I learned when I was disenchanted with the life I was living. I was a

doctor with a large practice, 6 doctors, working hard but barely able to make ends meet in

my practice and at home. One of the drawbacks associated with being the owner of a

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business and an employer is that when money is short, all employees must be paid but the

owners don’t have to be paid. After missing several paychecks, a decision was made. My

wife said something has to change.

Close to that time, I was introduced to the Anthony Robbins’ series of tapes entitled

“Personal Power.” What I learned from listening to over 20 hours of tapes is that for

anything to change, the most important first step is deciding to change. The power any

person has is the ability to decide and act on that decision. But first you have to make a

committed decision. The power to decide is everyone’s personal power.

Most doctors today feel like they have no power. I hear doctors all the time telling me how

they are controlled by the pharmaceutical industry, forcing them to use their drugs by

advertising on television and how the insurance company has control over the number of

patients they have to see and what tests and treatments the doctor can offer the patient.

Doctors feel trapped with no way out.

Why? Because they look around, and all their colleagues are doing the same thing and

voicing the same complaints. Doctors are drawn to other doctors who are suffering because

misery loves company.

Let me share what I have learned. The only way you lose power is if you willfully give your

power away. Doctors gave their power to insurance companies. Managed care

representatives came into offices and told doctors to sign a contract or they would no

longer be able to see patients with that particular insurance. Doctors buckled under the

fear they will have an empty waiting room.

Let’s look at this in a different way. The insurance company is selling to the consumer

access to health care. How can they deliver access to health care unless they have

healthcare providers in the network? What would happen if no doctor signed the contract

to discount their fees and allow the insurance company to control medical decision-

making?

The insurance company would have nothing of value to sell to the consumer. In the

previously described scenario, who has the power: the insurance company or the doctor?

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The insurance company has no one that can provide healthcare. The insurance company

only employs business people. If the doctor did not willfully sign the contract, which gives

away the doctor’s power, the insurance company would fold.

Because doctors gave this power away, physicians are going bankrupt, closing their

practices and selling their practice to the hospital. Why? Doctors relinquished their power.

Doctors complain the pharmaceutical industry has all the power. Doctors comment that

they are helpless because of the pharmaceutical industry lobbyist in Washington influence

Congress and leave the doctor no choice but to prescribe medication. This is another

example of willful surrender of power. The pharmaceutical representative, Congress, the

president or the patient cannot force you to write and sign a prescription. Prescription

rights have only been given to doctors in most states. If doctors stopped writing

prescriptions, the pharmaceutical industry would fold in days.

Every dollar in medicine is generated from a doctor or a doctor’s order. Doctors order all of

the tests and treatments that the patient receives. Each company that provides the test and

treatments are businesses that attempt to generate a profit. Without a doctors order none

of those companies could generate any income.

Doctors unknowingly have ALL the power in medicine. Doctors need to realize this fact.

Doctors also need to stop relinquishing their power to others. When I realized this, I

stopped signing contracts given to me by insurance companies. I terminated all existing

contracts with insurance companies. I don’t allow any pharmaceutical representatives in

my office. I use few pharmaceutical drugs and I am not forced to see 30 patients a day to

make ends meet because I discounted my rates.

I am thankful to Tony Robbins for opening my eyes to the power I possessed.

This book is a personal and professional discovery of how to take back control of all aspects

of your professional and personal life as a physician. This journey started me, my wife and

my family when we stopped thinking like most doctors and started thinking how a doctor

should think.

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Chapter 2 - The Core Question – What is a Physician?

First, let’s go over a story.

Don’t be a Caterpillar

One of the books that taught me a different way of

thinking is “What The Bible Says About Healthy

Living” by Rex Russell, M.D. This book told a story

that has become what I am known for after

physicians hear me speak. I have used this story to

illustrate how dangerous it is to follow blindly behind

leaders.

The story goes like this. There is a type of caterpillar called a processionary caterpillar. The

processionary caterpillar will pick a leader and the other caterpillars will proceed to follow

the lead caterpillar. Instinctively, the lead caterpillar will lead the caterpillars to food and

shelter to assure the survival of all the caterpillars. This is the outcome when the lead

caterpillar follows caterpillar instincts.

However, if the caterpillar is influenced, manipulated,

pressured and repositioned, for example, a human

Processionary caterpillar line

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intervenes and forces the caterpillars into a circle formation, the caterpillars will die.

Why? Because caterpillars think the other caterpillar in front of them is following the lead

caterpillar. They all assume the leader is going to lead them to food and shelter. They

assume the lead caterpillar is following caterpillar instincts and not just doing what they

see the caterpillar in front of them doing. They don’t know that the lead caterpillar has

been forced to form a circle that leads to nowhere. This is what happens when one does

not follow their instincts and succumbs to outside forces. They go around in circles and

eventually die.

In medicine, the natural instinct leaders should follow is science and physiology. As

physicians, we all took an oath to first do no harm. Hippocrates also said let your food be

your medicine and your medicine be your food. Our leaders in medicine have let outside

influences force them into disregarding these instincts. Our outcome is the same as the

caterpillars: healthcare is going around in circles and credibility is dying.

Because medicine often disregards science and physiology, we recommend treatments that

have no scientific basis and disrupt physiology. This is why we continue to discover the

consequences of our recommendations years later.

Also, because we allow the pharmaceutical industry, insurance companies, and the

government to impose their instincts on the medical community, science and physiology

are ignored and the bottom-line rules all.

Because we disregard “First do no harm,” we allow drug companies to air commercials

about drugs that are forced to tell you about the 20 side effects and possible death the drug

can cause. The juxtaposition of dangerous side effects being read and the image on the

screen depicting happy people that have supposedly taken the medicine make us numb to

the dangers of the medication.

Because we disregard “let food be your medicine”, we genetically modify our food, which

disrupts its nutritional qualities. Now, the body recognizes these foods as foreign to the

body and causes inflammation. Inflammation has been linked to almost every chronic

condition patients’ experience.

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Finally, in business, we follow the crowd. Doctors sign contracts that benefit the insurance

company and the insurance company business model. That same contract is awful for the

doctors’ business. The contract forces the doctor to spend less time with the patients, work

more and get paid less.

Why would a doctor do that? Because that is what the other doctors are doing. This

business model ignores every natural business instinct. But, because doctors don’t learn to

think like a business person, they are gullible to the astute business practices of the

pharmaceutical industry and the insurance industry.

What is a Physician?

The reason why I ask this question is that after years of practicing medicine I did not feel

like I was doing what I thought I would be doing when I dreamed of being a doctor when I

was 12 years old. I decided to look up the definition of a physician and how I could restore

the dream that I had as a 12-year old.

I looked up the definition of restore.

–verb (used with object), -stored, -stor·ing.

1. to bring back into existence, use, or the like; reestablish: to restore order.

Restore order.

The order in medicine needs to be restored. I spent several years learning physiology and

biochemistry. This is the basic science of how the body works. Medicine does not follow

science and physiology. Order means that someone is leading and others follow in a specific

order.

As I characterized in my caterpillar story, the order has been disrupted. Science and

physiology has been removed from the leadership position. Medicine is led more by what

the insurance company will reimburse. Medicine is being led by the medication that is the

most profitable to the pharmaceutical company.

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2. to bring back to a former, original, or normal condition, as a building, statue, or

painting. Patients want to be restored to their original normal condition. I ask

patients when they last felt normal or good. Patients can remember feeling good.

They can tell you the event that led to them not feeling good any more. Patients long

to be restored to normal again. Feeling normal does not mean relieving symptoms

24 hours at a time. Patients want to feel normal without medication like they

remember.

3. to bring back to a state of health, soundness, or vigor. Patients and doctors want

to be healthy, have a sound body and vigorous health. There is a difference between

not being sick and being healthy. Doctors have been trained to identify sickness not

restoring health. A patient may not be sick but not back to the normal health they

remember.

This is often the ‘disconnect’ between doctor and patient. The patient complains that

they don’t feel normal. Their vigorous health is a distant memory. The doctor

proceeds to prove they are not sick. The ‘disconnect’ is that they are both right. The

patient is not “sick”, and the patient does not have normal vigorous health either.

4. to put back to a former place, or to a former position, rank, etc.: to restore the king

to his throne. I remember when I was 12 years old I had surgery. The doctor who

took care of me seemed like a god. Doctors were held in such high regard at the

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time. That is when I decided that I wanted to be a doctor. I thought that was the

highest goal I could ever reach. I don’t think, no, I know, that is not the case

anymore.

Managed care came in to medicine and gave the message to patients that doctors are

worth no more than $10 to $20 co-pay. Doctors have lost their position in society

and their authority when it comes to healthcare. Patients will take the advice of a

GNC store clerk over the advice of a doctor. Patients are now more concerned about

maintaining health than waiting for disease and eradicating the disease.

The other definition I looked up was “physician.”

The definition includes, “a person who is skilled in the art of HEALING.” I equate healing to

what happens when someone breaks a bone. When someone breaks a bone, an x-ray is

done to see what is broken, out of place, out of line.

The bone is put back in place. The bone is kept in place for a certain period of time. When

the bone is “healed”, the cast is removed and no further treatment is needed. There is no

need for the patient to take medicine for the rest of their life to maintain or manage the

broken bone once the bone has healed.

There are few things doctors know how to heal. As an ob/gyn, I healed few conditions. I

managed bleeding with birth control pills. I removed organs that relieved symptoms. I gave

antidepressants to manage mood swings but I did not know how to heal or correct

hormonal imbalances. I did not know how to heal the effects of stress. I did not know how

to help the gut heal. Because after you allow the body to heal itself by putting what is

broken back in line, continued therapy is no longer needed.

When I speak to physicians, I challenge them to be careful referring to themselves as a

physician if they don’t know how to heal anything.Only if you know how to heal something

can you be called a physician. It is in the definition of the term, after all. Reclaiming

personal power is not going to cut it, on its own. You have to be a true physician.

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And this is the way you and all other doctors should think. You need to know how to heal

the human body, at least the part of the body you specialize in treating. Combine this with

reclaiming your independence from the business in the healthcare sector and you become a

physician in the true sense of the word.

Chapter 3 –Thinking for a Change

One of the most life changing books I have ever read is the book “Thinking for a Change” by

John Maxwell. The book has been renamed “How Successful People Think”. The premise of

this book is that for anything in your life to change, the way you think must change first.

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If you are not thinking then it is imperative that you start thinking. The one quote that was

particularly impactful to me was the following:

“The problem with popular thinking is that it doesn’t require you to think at all. It is easier

to do what other people do and hope that they thought it out.”

I think most physicians have been forced not to think. This has led to physicians being

much less effective in the healthcare arena. In the book “How Doctors Think” by Jerome

Groopman, M.D., he points out how doctors have been programmed not to think. Doctors

have been forced to except treatment algorithms that have been thought out by some

committee. They have treatment guidelines enforced on them by insurance companies.

Moreover, the state medical board wants doctors in a particular area to practice under the

same guidelines. The standard of care states doctors should do what most reasonable

physicians in their area are doing. This epitomizes the quote about popular thinking.

Legally, doctors should do what other doctors in their area are doing and hope that they

thought it out.

Not only have doctors been forced not to think about how they practice medicine, they

have also been forced to think like everyone else about the business model they follow in

their practice. I saw who I thought were successful physicians have overcrowded waiting

rooms.

Patients would wait for 2 and 3 hours to spend 15 minutes with the doctor. The physician

would spend late hours at the office and the hospital. It often led to them neglecting their

families, which often led to the break-up of the family. Most doctors strive to duplicate this

model because that is what popular thinking projects as a successful doctor.

Remember, popular thinking does not require you to think at all. This is a prime example.

If you think about it, why would anyone call this success, especially now, with managed

care forcing doctors to accept less for doing what I saw doctors doing in the 1980s and

1990s.

Here are a few questions you should ponder on:

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1. Do patients want to be in a crowded waiting room?

2. Do patients want to wait 2 hours for a 15-minute appointment, deal with rude staff

members and have the doctor make a decision about their health after 15 minutes?

3. Do doctors want to work all day and night?

4. Do doctors want to make decisions after 15 minutes of contact with a patient?

5. Do doctors want to work more and make less?

6. Do doctors want to lose their spouse and children to an unfulfilling profession?

The only way this will change is if doctors and patients begin to “Think for a Change.”

This is my main motivation behind writing this book. I am not saying that it is easy to break

away from the pack and go on your own way. In fact, most doctors fear they may be

ostracized from the medical community if they so much as think about reclaiming their

independence.

This book will challenge doctors, healthcare providers, patients and practice managers to

start thinking differently. I will discuss how my wife and I completely changed everything

in our lives by having the courage to make one change. That one change gave us the

courage to make more and more changes. We continue to change as we continue to think

about everything in our lives and how to make it better.

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Chapter 4 –When Going in the Wrong Direction, Don’t Speed

Up

The only way the caterpillar can survive and live a long healthy life is to follow the natural

instincts of the caterpillar. (See Chapter 2, “Don’t be a Caterpillar”). The caterpillar

eventually dies because of poor leadership, in fact blind leadership. The caterpillar trusts

the caterpillar in front, believing that he knows where to go. Don’t be a caterpillar. Get out

of line.

The only way you can discover whether you are in a caterpillar line is to actually leave the

line and take a look at the activity of the line. In other words, as long as you are in the

caterpillar line, you are unaware that you are actually not going anywhere. There must be a

time when you must make a conscious decision to slow down, stop what you are doing and

examine yourself, your actions and the direction you are heading in.

If you are traveling down the wrong highway or going in circles, you have to take the time

to look around and notice that you are seeing the same landmarks. If you blindly look

straight ahead, you will go further in the wrong direction and it will take you longer to

reach your desired destination.

If you look around and see that you are not headed in the right direction, you need to pull

off to the side of the road, stop and re-chart your course and then move towards the

desired goal. Nowadays, even the GPS in the car notices the wrong landmarks immediately

and recalculates.

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The problem most doctors have is that they, like the caterpillar, do not realize that the lead

physicians have been influenced by outside influences and are following instincts other

than their own. The instinct of the insurance company and the pharmaceutical industry is

to increase the value of the stock for the shareholders who own the company.

This is the fiduciary duty of any publically traded company. These companies are doing

what they are legally bound to do. These companies achieve their goal at the expense of the

doctors. The insurance company increases the value of its stock by collecting more

premiums and paying out less in reimbursements to doctors and hospitals. Instinctively,

these companies try to sell their insurance to more and more people for the highest price

the market will bear.

Secondly, the insurance company goes to the doctor and intimidates them into signing a

contract that discounts the physician’s fee to the lowest possible price. In order to make

this work, the insurance company must accommodate all of the people they sold insurance

to so they tell the doctor to spend less time with each patient.

Great, the insurance company’s instincts have been followed and met. This is awful for the

doctor and the patient. The doctor is working harder for less money. The patient is

spending less time with the doctor. The doctor doesn’t really know the patient, the patient

doesn’t really know the doctor, and so the cycle continues.

Where there is no relationship, there is no trust. When the goal of the doctor is to see as

many patients as quickly as possible, mistakes will happen and snap diagnoses will be the

order of the day.

Now, this is where the pharmaceutical company gets into the act. The one unique thing a

licensed physician can do is write a prescription. The pharmaceutical company needs the

physician to make money and therefore increase the value of their stock. (Instinct) In the

past, the pharmaceutical representative would wine and dine the doctor, take them on

expensive trips and label them as an educational expense. The laws have changed and this

is no longer possible.

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How did the pharmaceutical company solve this problem? They went for direct to

consumer advertising. The pharmaceutical companies create conditions that are based on

symptoms and have no definitive diagnostic test, for instance, depression, chronic fatigue,

attention deficit, irritable bowel, and erectile dysfunction. There is no way the doctor can

prove that the patient doesn’t have these conditions.

Next, create a commercial that glorifies the particular drug. At the end of the commercial

you usually hear, ask your doctor “is this drug right for me?” The patient sees this

commercial 10 times. They are convinced that they have one of these conditions. They have

seen the imagery in the commercial that shows how happy people are when they are taking

the advertised drug.

The patient asks the doctor for the drug. The doctor has no way of testing whether the

patient has the condition or not. He has only ten minutes to see the patient. The quickest

and easiest way to stay on schedule is to write the prescription and move on to the next

patient. Again, the pharmaceutical company wins, drug sold, profit made, and stockholders

happy. Again, doctor and patient lose.

The doctor has opened himself up to the possibility of missing the true diagnosis, or maybe

the doctor gave a patient a drug they did not need. Now there is the possibility that the

patient will have one of the many side effects the commercial mentions while the imagery

of the happy people is shown in the commercial.

STOP!!!!!!

The doctor is the only one in this equation who took the Hippocratic Oath: “First do no

harm.” The doctor’s responsibility is to instinctively not harm the patient. The insurance

company has not sworn to this oath. The pharmaceutical company has not sworn to this

oath. They have no obligation to the patient. Only the doctor does.

If seeing a patient for only ten minutes harms the patient, then stop. If blindly writing

prescriptions may harm the patients, stop. If signing a contract with an insurance company

could possibly lead to doing harm to a patient, then don’t sign the contract.

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It is that simple. If you follow the correct instincts, order will be restored. The insurance

company does not have a network of doctors to offer to their customers if no doctors sign

the contract. The pharmaceutical company representatives cannot write prescriptions.

Only the doctors can do that.

If the doctor refuses to write prescriptions that can harm the patient, the pharmaceutical

company loses, and the doctor and the patient win. Now, the doctor is being led by the

correct instincts. The insurance company is no longer leading the line. These entities are

following the true leaders in medicine science, physiology and the safety of the patient.

Chapter 5 –Dot Thinking

I spend a lot of time thinking about thinking. Why, because everything begins with a

thought. I am not the first one to say this but it bears repeating. Physicians especially need

to realize this fact. Thinking is the first step towards change. I want to be a part of changing

the standard of care in medicine. The definition of standard of care is “are you doing what

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most reasonable physicians in your area are doing?”. That definition forces physicians into

dot thinking.

What is dot thinking? If you put a small dot in the middle of a blank whiteboard or a piece

of paper and ask most people what they see, they will say they see the dot. Even though the

dot may only occupy 1/100th of the surface area as compared to the rest of the picture,

most people focus on the dot. Most people don’t mention the blank space that contains

infinite possibilities for creativity and more interesting objects and pictures to be

represented on the blank space.

As an ob/gyn for over 15 years, I was mesmerized by the dot. I only focused on giving

young women birth control pills for almost any menstrual complaint. Older women were

prescribed estrogen for any complaint (Pre WHI). If the women continued to complain, I

prescribed an antidepressant. If none of these therapies worked, the next step was to

remove any or all of the pelvic organs.

That was my dot. That is the standard of care dot for ob/gyn. My colleagues never

questioned me because they were doing the same thing. By default, this became the

standard of care.

Ask women if they think this should be the standard for their care. I have asked. I have

spoken in front of thousands of women and asked if this is acceptable. I always receive a

resounding NO. The loudest NO was from my wife when she began to have hormone

problems and was on the standard treatment. I was able to see firsthand how ineffective

the treatments were that I had learned and was prescribing to my patients. That experience

started my wife and me on a journey exploring the area outside the dot.

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We began to explore ways of testing hormone levels to guide treatment. We learned that

stress and cortisol affected hormones. We learned about how the gut and the

gastrointestinal (GI) system affect the metabolism of hormones. We rediscovered

physiology. We discovered ways to identify abnormal physiology and help the body restore

normalcy.

Furthermore, we are discovering how to detect and slow down mental decline associated

with aging. We have discovered how to run a practice that is above the present standard of

care. We have discovered how to have a practice that treats patients like human beings. We

have a practice that respects the patient’s time and the patients respect our time. All this

started because we took our eyes off the dot and began to explore the infinite possibilities

outside the dot.

Every specialty in medicine has a dot. Medical school, residency, medical specialty societies

like the American College of Obstetrics and Gynecology, and state medical boards all

strongly encourage you to focus on the dot of that particular specialty. There can be severe

consequences for the doctor who looks away from the dot.

Remember, I told you that I never got questioned or ridiculed by my colleagues as long as I

practiced dot ob/gyn. As soon as I started practicing differently, I was ridiculed by my

partner and had to leave my former practice. I was targeted by my hospital. I left the

hospital and stopped practicing inpatient medicine. I did this because I had the knowledge

and the courage to do it. Most doctors do not have the knowledge or courage to realize they

can survive outside the dot.

However, there can be huge rewards for the doctor and patient who explore other options.

I have never enjoyed medicine and the relationship with my patients more. I encourage

every physician and healthcare provider to take a moment and look away from the dot.

There are exciting experiences waiting for you there. The rest of this book will explore the

infinite possibilities outside the dot.

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Chapter 6 – Two SD to the Right

Physicians today are in crisis mode. Most doctors are

working harder and making less. What is the cause of

this? I think it is because we are afraid of being two

standard deviations to the right. The book “Outliers: The

Story of Success” by Malcolm Gladwell, clearly states that

to be successful, you have to function outside the bell-

shaped curve.

The legal definition of standard of care discourages being an outlier and decreases the

chances of success. The legal definition of standard of care requires physicians to do what

most reasonable physicians are doing in their area.

There are several problems with that definition. It does not

set any scientific standards that govern the doctor. Even if

most doctors are practicing therapies and treatments that

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are not scientifically proven or even harmful, these treatments can become the standard of

care.

This is why we see so many dogmatic thoughts change with time and experience. A

treatment or medication is heavily marketed to physicians. Most of the physicians begin

doing the treatment or prescribing the drug. This becomes the standard of care.

Often later, the side effects of the drug become obvious as more and more people take the

drug or undergo the procedure. What is most shocking is that even if the science suggests

that the treatment, procedure or medication is ineffective or harmful, if most physicians are

still doing it is still the standard of care.

Here are a few examples of this:

Science states that mammograms for women under 50 years of age are ineffective at

diagnosing breast cancer. It is still a standard of care

Science states that screening for prostate cancer using PSA is ineffective and may be

harmful when it leads to unnecessary biopsies and procedures.

Science dictates that prescribing antibiotics for non-bacterial infections leads to

drug resistance and a disturbance in gut bacteria balance.

Science states that most menopausal women are not estrogen deficient. However,

the standard of care is to give women more estrogen.

Science states that over 50% of heart attacks occur in people who have normal

cholesterol levels. This means that 50% of people who have elevated cholesterol

don’t have heart attacks. However, the standard of care is everyone gets a statin

drug to prevent heart attacks.

If a doctor tries to follow science rather than the standard of care, there can be devastating

consequences. Colleagues will ostracize you. They will call these doctors quacks and

voodoo doctors. Some will call the state board of medical examiners so that they can

intimidate the doctor to follow the standard of care.

Most of these doctors that I have been associated with who dare to not be ordinary get

reported to the state board, and not because they are causing harm to the patient. Doctors

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report the doctors that I have described to the state board because the doctor is harming

their pocketbook.

Doctors who go above and beyond the standard of care and offer the patient something

different and effective are attractive to the baby boomer generation of patients. The baby

boomers have always done things differently and rejected authority and the status quo. As

the standard of care doctor sees these patients go to the outlier doctors, they will use any

means necessary to stop them.

Another problem is that insurance companies are determined to keep physicians in the

bell-shaped curve. Insurance companies threaten and intimidate doctors if they stray

outside of the bell-shaped curve. Insurance companies enter doctors’ offices and coerce

them into signing in-network contracts. The insurance company tells the doctor that the

only way they can see the patients enrolled in their plan is to sign a contract and agree to

discount their fees by 30% to 40%.

The contract also gives the insurance company the right to discipline the doctor if the

doctor strays outside of 2 standard deviations of the bell shaped curve. This situation

effects the doctor and the patient negatively and the insurance company positively.

The doctor is forced to be ordinary. All doctors are doing the same thing. No one is doing

extraordinary work because there is no incentive to do more. If you do try to offer

something more or different, the doctor runs the risk of being audited and punished by the

insurance company. As the book Outliers and any other business book will tell you…”No

one values ordinary.” Ordinary doctors receive ordinary pay. Patients receive ordinary

treatment.

The insurance company is able to greatly control costs. The insurance company gets

discounted rates from the physician and can make sure the doctor does not order

treatments that can cost them money.

I enjoy being 2 standard deviations to the right. My patients enjoy being treated like a

person and not as a part of an assembly line. My family enjoys the fact that I am not

working all the time. My finances enjoy not being stretched to the limit. In this book, I will

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discuss the benefits of not being ordinary. But it all begins with how doctors think and how

doctors should think.

Chapter 7 – Be More like George

It is imperative that you understand that for anything to change in your life or your

practice, you must change the way you think. Also, you must take ownership of your

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situation and understand that you are where you are because of the decisions you have

made.

It is not the insurance companies’ fault that you are where you are. It is not the

pharmaceutical companies’ fault that you are where you are. It is not your patients’ fault,

your families’ fault, the economy’s fault, and it is not the government’s fault. It is your fault.

You created the situation you are in. Now, think, how can I create a situation I do want. You

should be able to do that also.

I love to watch Seinfeld reruns. I watch them every day when I come home from work. If

you are familiar with the character George on the show, you know that he is a lovable loser.

He is Jerry’s best friend but not nearly as successful as Jerry is as a comedian.

In one episode Jerry and George are talking and George has an epiphany. George realizes

that all of his decisions have been wrong and have gotten him nowhere. He realizes that he

only has himself to blame. He makes the decision to do the opposite of what he would

normally do. Whatever naturally comes to mind, he would immediately do the opposite.

Can you guess what happened? His life made an 180o turn. Every decision he now made

was correct. He had unbelievable success. What happened was he did the opposite of what

he had been doing and he got the opposite results, i.e. success.

It seems simple. However, it is incredibly hard to do. It is difficult to stop and take a look at

your own actions and how the actions you do routinely almost without thinking could be

the cause your present situation. What is the present situation of most doctors? The 2014

practice profitability report states that:

Physicians are more than twice as likely to anticipate eroding profits rather than

increasing profits

When physicians were asked why they had this negative view, they said:

Declining reimbursements (60%)

Rising costs (50%)

More paperwork and less time with the patients

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The trend that the doctors were most excited about was increasing patient engagement and

spending more time with the patient.

Sixty percent of the doctors in the study complained about declining reimbursements.

What led to the declining reimbursements? The doctor signed a contract and agreed to

accept less money for their services. Why are the doctors’ costs rising? Because they signed

the contract they have to see more patients. This requires more space and more employees.

Why do they have more paperwork? The contract they signed requires them to submit

more paperwork in order to get the lower reimbursement. Why can’t the doctor spend

more time with the patient? The contract the doctor signed obligated him or her to see the

patients in the network and have the minimum amount of time to wait for an appointment

date. The doctor is forced to give minimum service to a maximum number of patients.

If one stops and thinks about this situation, it makes no sense. The problem is the doctor

does not have time to think and evaluate their situation like George did while talking to

Jerry. Another study in the magazine Medical Economics showed how doctors lost more

and more money each year from 2009 to 2012.

In its financial section, the survey found wafer-thin operating margins among those

physician practices. In 2010, only organizations in the western United States came closest

to breaking even, with an average loss of $27 per physician. By contrast, the Eastern region

averaged a loss of $1,597 per physician, whereas the Southern region averaged a loss of

$1,870. The worst performance was in the Northern region, with a $10,669 loss per

physician in 2010, which was even worse than the $9,943 loss per physician in 2009.

Do you know why? Every year when the doctor, the office manager, the accountant, and

even the practice consultant see that the profit margin is smaller at the end of the year, they

will all come to the same conclusion: we need to see more patients, hire more staff, and

open a satellite office so we can see more patients.

This is the kiss of death for a practice. This is George following his original thought and

decision-making process. This is the definition of insane: doing more of the same thing

expecting a different and better result. Doctors must make an 180o change in the way they

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think about their practice. Doctors have to come to the realization that this poor decision-

making has caused the problems they are complaining about in the study.

The next few chapters will discuss how to get the opposite result by implementing opposite

thinking and opposite actions.

Chapter 8 – Secrets to Boost Your Practice

I have talked about thinking differently up to now. Now I am going to talk about acting

differently. Thought without action is a daydream.

If you are going to change your practice and boost your income, you are going to have to be

the leader of your office caterpillar line. You don’t have to do everything in your office. You

just have to lead everyone in the right direction. Even though I was doing these things prior

to reading the article, there was an article in Medscape in 2011 titled “Ten Secrets to Boost

Your Practice.”

Get Computerized

I am going to discuss all the reasons why you must keep financial and medical records on

your computer. I will also discredit the objections to becoming computerized. First, let’s

take care of the objections.

What if the computer crashes or the file gets deleted? All Electronic Medical Record

systems (EMR) have onsite backups and offsite backups. Usually, there are multiple back-

up files. Let me ask you a question: how many backup copies of paper charts do you have?

What happens when you lose or misplace a paper chart? If you were a doctor in New

Orleans during Hurricane Katrina, would you have wanted paper charts or an EMR?

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With EMR systems:

a) You never misplace a chart. How much time is spent looking for one chart or pulling

and re-filing a chart after placing a piece of paper in the chart? Thinking differently

forces you to realize you are paying someone $10 an hour to spend an hour to find

one chart that you will be reimbursed $50 for seeing the patient. Subtract $ 10 from

that payment before you walk into the exam room.

o You have access to the patient chart form anywhere there is an internet

connection. You can view charts while on vacation, on your mobile device, etc.

o You don’t have to pay for office space to house chart racks. The space devoted to

storing charts is non- revenue producing space. Also, you have to pay for chart

folders, chart dividers and you have to pay someone to assemble the chart. All

these expenses result in less money for you, the owner.

b) Your EMR system should be accompanied by a practice management system. Learn

how to manage your practice with this system. Yes, you learn how to manage your

practice. The practice management portion will allow you to schedule patients, see

all your financial transactions, and evaluate your practice in all areas.

Take Control of Your Office

This leads me to my next point. Learn how to do everything in your office, especially your

office manager’s job. Traditionally, doctors think it is noble to say, “I just want to see

patients, I will let someone else handle the business part of the practice.” I have heard it

said a thousand times.

Let me inform you something: if you don’t pay attention to your business, someone else

will watch the profits go into their pockets. This is from personal experience; if you do not

carefully watch your business or have someone like a loving spouse watching your

business, it will not be consistently profitable.

If your office manager or administrator leaves abruptly, who is going to teach the new

person what to do? While you are trying to find someone else, what happens to your billing

and reimbursements? How do you know they are going to do things correctly? Who is

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going to teach the new person? If you do not know how to run your own practice, and if you

don’t know how to evaluate your practice you are in a vulnerable position.

The vulnerability puts you in a weak management position. Because your office manager

holds the key to your cash flow, you become a hostage. If the manager makes demands or

threatens to leave, you cannot make objective decisions because you are afraid that if the

manager leaves, your money will be interrupted.

The solution is to never allow anyone in your office to know how to do something that you

do not know how to do or that is not in a written procedure manual. All businesses have

written policy and procedure manuals. How you want your office run should be written

down in a policy and procedure manual. This is important for a smoothly operating

practice but can be helpful medico-legally.

Most medical practices have a few staff that come and go. Verbal communication and

training does not work. Verbal training getsconfusing with time. Everything that takes

place in an office needs to be written down so any new employee knows what needs to be

done and how it should be done. Also, it makes you think about every aspect of your office

and ensures that the office reflects you and not the employees.

Create a Niche

You will go broke waiting for sick patients to walk through your door. There are

not enough sick patients to go around. Consider doing wellness medicine, which

widens the scope of patients to everyone.

When I was practicing traditional gynecology, I would see 20 patients a day, hoping that

someone would come in with a large uterus, an ovarian cyst, wanting a tubal ligation or had

heavy vaginal bleeding. If that did not happen, I was frustrated. No procedures, no big

reimbursements.

I would think to myself, “Why are these patients coming to the office? They are not sick.”

What if I could do more than tell the 20 patients that day that they don’t need surgery?

What if my niche was to take the people that were not “sick” and make them better?

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So, well they stopped going to doctor after doctor. That is what I did. I studied wellness or

functional medicine. Functional medicine helps the patient function better.

Most patients are not hypochondriacs. They are not coming to the doctor to kill time. For

some reason, they feel like something is not right. I have learned that women are in touch

with their body. Most of the time, when a woman tells a doctor something is wrong, the

woman is right.

I created the niche of becoming an expert at identifying and treating hormonal imbalances.

Hormonal imbalances are the major underlying cause for most female problems. The 20

women I was seeing in a day may not have reached the disease state but they were

experiencing the symptoms of hormonal imbalances. Now, I could test and treat all of the

women that were coming into my office on any given day.

From that I discovered that the hormone cortisol that is released in response to stress can

be the cause of a myriad of common problems, like insomnia, gastrointestinal problem,

fatigue, anxiety, and depression. Once I learned how to test and treat cortisol problems, I

could help my patients function even better.

Then I learned how stress, antibiotics, antacid medication, yeast and parasites could affect

gastrointestinal function. I learned how to test and treat the gut so I could help that one

patient really become healthy. I used my obstetrical knowledge to understand how adult

heart rate variability relates to fetal heart rate variability. These discoveries continued and

I continue to learn every day.

I hope you understand that what happened is that I am not frustrated because the nail that

fit my hammer did not come into the office today. Now I have so many tools in my toolbox I

can help almost any patient function better physically or a better term is help their

particular physiology function better.

What this does for the business side of medicine is that instead of trying to do one big

procedure, like a hysterectomy, and then trying to find the next big uterus, I can have one

patient that is not sick but is not well and provide several different services.

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Providing several services for one patient is better than doing only one procedure on

several patients. The quote from the Medscape article states it like this: rivers of money do

not run by doctors’, only rivulets. But add them up and you have a mighty stream.

Offer One-Stop Shopping

The best way to boost your practice revenue is to offer as many services as possible. My

rule of thumb as to whether a service is added to our office consists of 3 criteria:

i. Is it good for the patient?

ii. Does the procedure provide me, as a physician, good information that I can use

to help the patient?

iii. Is it good for my business?

The first two criteria must be met before I consider the business aspect. If it is not good for

the patient, I do not care if it is good for my business. My first priority is the patient.

Whenever the first priority is money, trouble will eventually follow.

When you practice medicine based on physiology, the answer to most questions are in the

physiology book. A physician just has to remember what they have already learned.

Socrates said, “Learning is remembering.” I just had to remember how hormones

functioned together, how the gut functioned and how the adrenal gland functioned. As long

as a patient is not legitimately sick, I can help them. I let the sick patients see the doctors

that are looking for sick patients. I am happy to see the rest of the patients who want to

become truly well.

Hire As Few Employees as Possible

Employees are your most expensive budget item. They cost much more than their hourly

wage. The payroll taxes, health insurance and vacation time increases the cost to you, the

business owner.

For just a minute, I want you to put yourself into the employees’ shoes. I had to do this to

understand what was going on in my office. I had a lot of employees whom I was paying. All

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my money was going to them and there was none left over for me, because the law

mandates that you pay your employees. There is no law that the business owner must be

paid.

The employee is hired to do a certain job, let’s say front office work. You hire them at $12

an hour. You, as the business owner, want your practice to grow. You want to see more

patients. The usual picture of growth for most doctors is to see more patients.

Remember, the employee was hired when your practice was at a certain stage. If your

practice grows, the employee has to do more work for the same amount of money. The

employee usually does not want to do that. He or she is not going to take on more

responsibility because they won’t get their cost of living raise until the end of the year.

The employees go to you or the office manager and say that they need you to hire another

employee to help if you want to see more patients. Your goal is to see more patients. This is

not happening with the current staff so you hire another employee.

Now, you have two employees at $10 to $12 per hour. The first employee trains the second

employee. They begin to think alike and establish a culture of doing what they were hired

for and not any more. Why should you do more if you are not going to make any more

money for working harder?

These two employees eventually will both come to you and tell you or the office manager

that the reason you aren’t seeing more patients is that it is too much work for them to keep

up and that they need help. Now, you have 3 employees. The first two employees will pass

on the office culture of doing as little as possible for what you are being paid.

This is not the scenario you want to create. First, I want to explain the difference between

being a business owner and being self-employed. When you are self-employed, you are

employed by you. Employees only get paid when they show up for work.

When I had an Ob-Gyn practice, if I did not come to work, no money was generated. Also,

any money that I generated was paid to my employees and my other expenses before I

received any of the money I generated.

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On the other hand, businesses are a separate entity from you personally. The business

should be able to generate money even if the business owner is not there. As a doctor, you

must begin to think like a business owner and avoid being self-employed.

Now, back to the employees; first, everyone in the office needs to understand how the

practice makes money. The employee also needs to know what activities they participate in

that generate money.

Our office has many services and most of those services do not require my participation.

Our office makes most of its money by performing in-office functional medicine testing and

functional medicine lab testing. We also make money from providing in-office treatments.

The three rivulets that support our stream of revenue are my time, my staff performing the

testing procedures, and the staff participating in the treatment. I am involved in providing

my time to evaluate the tests and the success of the treatment. I am paid for my time. My

staff participates in the testing and treatment. Those two rivulets can flow whether I am

there or not. Now my staff is producing income.

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Now, how do you change that non-productive culture that I previously described? Simply

speaking, create a culture where everyone is rewarded based on practice profit. Profit is

made when you subtract expenses from the total amount of funds collected by the practice.

The most expensive line item in a practice is employee cost. The staff needs to understand

that their income goes down with the more employees the practice has to hire. Now, the

employees are not as interested in having more employees share the practice profit.

Decreasing expenses now becomes everyone’s focus. This incentivizes the staff to not

waste time or money. More patients on the schedule was viewed as more work but now it

is viewed as more money. Making sure the patients are offered all the revenue producing

services is a priority, not a chore.

The doctor now has productive staff that has bought into helping the business become

profitable and not expecting the doctor to generate all the revenue. Many parts of the

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business can function without the doctor being involved. The doctor can now pay him or

herself, fund retirement and then share a percentage of the profit with the staff.

Now that you understand this concept, it is important to hire staff that understands and

buys into the concept. There are employees that like security and there are employees that

like opportunity. Employees that like security want to know how much they are going to

make and do not want to take any chances. Other employees that think that they can

enhance your productivity want the opportunity to make more money if they perform well.

We ask each potential employee would they rather take a higher starting wage or take a

lower wage to start but have the opportunity to make significant productivity bonuses? We

never hire the person that wants the secure higher starting wage.

That person is not going to fit in the culture that you are trying to create. A person that

wants to add value to the practice would love to be paid based on their contribution to the

increased success of the practice. This is a profit sharing plan you are offering the

employee. This is a great benefit. If the person is sophisticated enough in their thinking to

recognize the opportunity, he/she could be a good employee.

Pay As Little Rent As Possible

Let’s make it clear: you are in business to deliver a valuable service and be paid based on

the value of that service. You are not paid based on how large your office is or how

beautifully it is decorated. If a physician is offering a service and information that is helping

people get well, the patient does not care how your office looks as long as it is clean and

organized.

In a business, not only do the employees need to be productive, the physical office itself

needs to consist of revenue generating space. This is why computerization is so important.

Electronic medical records don’t take up any space. Paper medical records take up rooms

full of space and space which requires you to pay rent.

If you do not need medical space, do not pay higher rent because it is medical space. If you

are not using specialized medical equipment that needs special drainage or electrical

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wiring, you do not need medical space. Regular office space or even a living space can be

used to practice medicine that focuses on wellness.

These are some basic business concepts that all physicians should think about. These are

business practices that are two standard deviations to the right. These are business

practices that are outside the caterpillar line and opposite of how most doctors think. The

only way to get a different result is to take different actions.

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Chapter 9 – Doctors Have to Know Their Business

The first thing doctors need to know is how much it costs to see a patient. Any business

needs to know the cost of the service they are providing and make sure the reimbursement

covers the costs plus the desired profit. Doctors need to determine the desired minimum

profit for their service and make sure they do not sign a contract that goes below that

number.

A simple calculation can be computed by taking the average monthly overhead costs and

dividing it by the average number of patients seen each month. If a doctor sees a patient

every 15 minutes for 7 hours a day, 5 days a week, the cost per 15 minutes looks like this.

Expenses Cost/ 15 min Medicare

payment-cost

Cost/hour Profit/hour

10,000 16.3 61.00-

16.3=44.7

65.00 $178.80

15,000 24.4 36.6 97.00 $146

20,000 32.50 28.50 130.00 $114

25,000 40.60 20.40 162.40 $81.60

30,000 48.70 12.30 194.80 $49.20

50,000 83.33 (-22.33)

333.32 (-89.32)

As you can see, if you bill for 15 minutes of time for a Medicare patient, the reimbursement

in my state is $61.00. Once the overhead reaches $50,000, the practice is losing $22.33

every 15 minutes or $89.32 /hour. Most doctors have not done this calculation. If they did,

they would be forced to make some changes.

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The other thing a lot of doctors do not know is how much each insurance company pays for

their most common charges. Most doctors that I have talked to do not look at the

explanation of benefits (EOB) that is provided by the insurance company. The EOB explains

what charges are being paid and how much they are paying.

When I began doing this some 15 years ago, I was shocked at how little I was being paid for

the services rendered. I often found that I was not being paid at all. Because I did not know

my business and did not understand insurance, I lost a lot of money unnecessarily.

I often saw patients that hadn’t met their deductible and my front office did not collect the

proper amount for the visit. They were lazy or untrained and only collected the co-pay.

That meant I collected $10 or $25 for a $100 office visit. My office mistake cost me

$75.00.Even when my office collected the co-pay properly, I often saw that the payment I

received plus the co-pay did not cover my overhead cost for that patient. I don’t think that

most doctors understand that if your overhead is not covered by the reimbursement

received, the doctor actually paid money to see the patient.

In the example above, if your overhead is $83 per 15 minutes and a Medicare patient or a

private insurance patient was seen that does not pay $83, the doctor paid to see that

patient.

I tell doctors that are in-network to start examining the EOBs from each insurance

company. I tell the doctors to not have any sharp objects nearby and not to sit by open

windows in high buildings. When the doctor realizes how little they are being paid, they

may attempt suicide.

A simple look at the numbers will help the doctor and the office manager make some

critical decisions. The decision seems simple but it is a difficult concept for most doctors to

grasp. If the contract with the insurance company is not helping your business, you have to

STOP seeing those patients, or you have to renegotiate the contract. Remember, not only is

the overhead not being met, the doctor is not making any profit. The goal of a business is to

make a profit.

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Now that we have numbers to work with, it is easy to see that in order to make a profit, one

either has to lower overhead or take insurances that reimburse more. One solution is to

lower the overhead. The problem most doctors have is that lowering overhead is difficult.

It is difficult to quickly reduce the rent because most doctors are in 5 to 10-year leases. The

most expensive expense is employee expense. Because the doctor is seeing so many

patients, it takes a lot of staff to manage the patient traffic, phone calls and recordkeeping.

Solution number two is to stop taking insurances that do not cover the cost of seeing the

patient. This is a must. No matter what the insurance company says, you will not make a

profit by seeing more patients when you are losing money on each patient. If the number of

patients/hour increases, your overhead will go up. The office will need more staff and more

supplies.

Eventually, there will be a need for more space. The fallacy seems obvious, that you cannot

make a profit by seeing more patients when you are losing money on each patient seen.

However, at the end of the year, when the practice profit is stagnant or declining, the

answer to the problem seems to always be we have to see more patients.

Even when I read medical practice management journals, most of the experts advise

doctors to increase the number of patients seen. The professionals suggest adding

physician assistants and nurse practitioners.

Due to this advice and trend, nurse practitioner salaries have increased to over $94,000. In

2011, the average salary was $74,000 to $90,000. That is a big increase in overhead, not to

mention the benefit costs the nurse practitioner will expect to be provided. The nurse

practitioner will also need support staff.

This is another situation where you need to be like George and do the opposite. The correct

move is to cancel the contract you have with this insurance company and stop seeing those

patients. Stop contractually losing money! Algebra teaches that if you subtract a negative, it

is a positive. Math is math. Remove the negative and it will equal a positive. Adding more

negatives together equals a larger negative. This simple math concept that we all learned

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by the 5th grade holds true in the business of medicine. No matter who tries to tell you that,

this does not hold true so don’t believe them.

I recently read in Medical Economics an article about challenges doctors will face in 2015.

Of course, declining reimbursements was one of the challenges. One of the solutions was to

extend hours to include early mornings, late evenings and weekends to accommodate more

patients. Again, the suggestion includes working harder and longer and neglecting your

family to add more negatives.

The doctor should evaluate all of the insurance contracts they have. Closely evaluate all the

EOBs and determine which insurance companies must be eliminated. Now remember, just

because the office cancels the contract does not mean the office can no longer see the

patient.

If the insurance is a non-HMO, the patient can be seen but now will be an out of network

patient. Out of network will have a different deductible, but the doctor can collect enough

money to cover cost and make a profit. I will explain Out of network in a later chapter.

Now, the doctor can spend more time with patients that have insurance plans that are good

for the practice. Some doctors feel bad about refusing to see patients with certain

insurances. What must be considered is that if you continue to lose money, your practice

will close. If your practice closes, no one wins. Not you, nor your patients or your family.

Also, seeing more patients for less time in a more chaotic office environment is not good for

any of the patients. It increases the chance of mistakes, which increases the doctor’s risk of

being sued for malpractice. There is nothing more stressful for any doctor than defending

themselves in a malpractice case.

Let’s review:

1. Know your per patient cost 2. Learn to read and evaluate explanation of benefits (EOB) 3. Evaluate and compare reimbursement and per patient cost for each insurance

company 4. If the reimbursement is less than the cost, remove the negative (subtracting a

negative is a positive).

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5. Spend more time with patients with insurance plans that are favorable for your business.

And now number 6. Offer those remaining patients more services

Or, the office has to offer more insurance reimbursable services. In the book “Good to

Great” the author, Jim Collins gives the example of Walgreens vs. Eckerd’s drug stores.

Walgreens concept was to build stores convenient to the customer and increase per

customer profit. This means have each customer buy multiple goods and services at each

visit.

Because the stores were convenient (all on corner lots) customers visited more often and

Walgreens offered such a variety of items, customers visited when they didn’t need a

prescription filled. The customers that did need a prescription filled would most likely buy

something else while they were waiting on their prescription

This is the same concept used by fuel stations. Companies like QT or RaceTrac that sell gas

at the lowest prices do not make money from selling gas. They make money by selling

snacks and coffee. Business is business. Physicians have to offer more services. Services

that are insurance reimbursable are desirable.

Patients do not necessarily want to pay more money out of their pocket at each visit. If

there are more services that will benefit the patient, if the service gives the physician more

information to further help the patient, and the service is good for the business of the

practice, then it should be considered.

I am always on the lookout for insurance reimbursable tests and services that will allow me

to take better care of patients. There are a lot of non-routine tests and treatments a doctor

can provide that insurance companies deem reimbursable. Some services are more

necessary in some types of practices than others.

For the primary care doctor who routinely does not perform surgeries or other procedures

that reimburse at a higher rate, these added tests can double or triple the per 15-minute

revenue. If a doctor is receiving $300 per visit instead of $61 per visit, maybe the doctor

can see patients every 30 minutes instead of every 15 minutes.

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Let’s do the math: if a doctor could provide in-office testing that is relevant to the care of

every patient, through proper documentation and billing he could receive $300 per visit

instead of for example $61 per visit and see each patient for 30 minutes. In 7 hours, the

doctor could see 14 patients. The doctor would make $600 per hour and $4,200 a day.

If we look at the example of the $50,000 overhead, we calculated that it costs $83.33 per 15

minutes or $332/hour. Now the doctor is making $268/hour ($600-332) instead of losing

almost $90 per hour. By subtracting the negative of $90, the net gain is $358/hour ($268 –

(-$90) = $358.

Wait a minute. The overhead was $83.33 per 15 minutes! But since my staff only has to

process 2 patients per hour instead of 4, my overhead should decrease. I won’t need as

much staff, my waiting room can be smaller and my supply costs will decrease. I won’t need

that nurse practitioner or PA and I don’t have to work on weekends.

So, in simple words, think differently and be an outlier. Make a 180 degree change in

thinking and actions and you get the opposite result

Chapter 10 – Why Did You Sign Contracts with Insurance

Companies

In changing the way you think, you have to ask questions. You have to ask good questions.

You have to examine some things that seem to be a given. I was a young physician when

managed care began in the early 1990s. How most doctors understood the process was

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that insurance companies would form a network of physicians that would be available to

the insurance company policyholders.

The physicians had to pass a credentialing process because the insurance company wanted

to make sure the doctors in the network were of the highest quality. In exchange for

excluding the less qualified doctors and placing your name in the insurance companies’

network book that policyholders received, the doctors were asked to discount their fees.

The doctors were also asked to allow the insurance company to be involved in managing

cost by determining what test, procedures and treatments were medically necessary. These

measures were supposed to increase quality of care because only the GOOD doctors were

included. Also, the insurance company convinced everyone that they had businesspeople

that could better manage the cost of healthcare than the individual physician.

That was the plan. I remember doctors panicking trying to sign the contracts with

insurance companies before the other practices were able to sign. Every doctor and

practice wanted to be included in the network of quality doctors. Of course, no doctor

would want to be kept out of a network of doctors that insurance companies have “vetted.”

Only a certain number of doctors were going to be included so the insurance companies

played to doctors’ fears of being excluded. Doctors signed contracts without reading the

fine print. Doctors did not read the bold print. I know this because I was one of those

doctors.

My partner and I panicked. My partner was scheming with other doctors to be in the

included group and beat the other doctors into the network. It was a crazy time. All doctors

feared they would not be able to see their established patients and would definitely not see

any new patients. It was either sign the contract with the insurance company or financial

ruin for the doctor.

If you understand the previous scenario, it is quite obvious why doctors signed contracts

with the insurance company. I am sure you can understand that controlling healthcare cost

was and is important. But let’s look at what has happened in healthcare since the early

1990s.

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Health insurance premiums have gone up. The goal was to decrease healthcare costs.

Looking at this graph, the stated goal has not been achieved. Healthcare cost for the

consumer has been on a steady rise. Premiums have risen 3 times more than earnings and

over 4 times more than inflation. Some would say that is because our healthcare system is

so high in quality and one must pay for quality.

We are far from the highest quality

healthcare system in the world.

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However, we do spend more on healthcare than any other country in the world. Now we

have insurance companies deciding what medical treatments will be paid for and which

will not be paid. Insurance companies can raise premiums at multiples of workers’

earnings and inflation.

What we have is a system where the insurance companies can increase their revenue

without limits and control there expenses without any real guidelines. Insurance

companies can arbitrarily not pay for legitimate medical expenses. By signing the contract,

the physician gave the insurance companies the right to decide how much the doctor would

be paid and what they will be paid for doing.

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Remember, the insurance company has businessmen running it and doctors that the

insurance company pays ,and these doctors are usually stockholders, making decisions on

medical necessity. The insurance company wants to increase its profits. That is the goal of

any business.

The insurance company does not increase its profits by improving the ranking of the

country’s healthcare system as compared to other countries. The insurance company does

not make money by decreasing the cost of insurance to the policyholder. The insurance

company does not make money by offering new innovative treatments. The insurance

company does not make money by increasing doctor compensation.

Therefore, they have no incentive to do any of these things. As a result, as you can see in

the two charts below that the income for primary care doctors has remained stagnant for

years. Insurance company profits are booming.

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Profits for insurance companies have steadily increased while profitability for physicians

have remained the same or decreased. The 2014 Practice Profitability Report states that

the percentage of physicians expecting to see a decrease in profitability in 2015 has

increased from 36% to 39%. The cause is believed to be rising costs and declining

reimbursements.

It is quite simple how this situation arose and why it continues. Due to physicians’ desire to

be a part of the network of physicians in an insurance plan, we agreed to discount our

rates. Most doctors saw this as a way to access patients. In essence, what we did was put a

price on cost of acquiring patients. In essence, we gave the insurance company a 20% to

40% discount on every patient.

That is expensive advertising. What physicians received in return is their name in the

provider book or listed on the provider website. This costs the insurance company nothing

but it costs the physician 20 to 40 cents per dollar reimbursed.

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Doctors expect declining reimbursements and increased costs each year. Each year, the

insurance company is going to try to decrease what they spend and increase their revenue.

This is done by decreasing what is paid to the doctor and increasing the number of people

paying premiums.

This means more people in the network that need to be seen. This also means the doctor

must see more patients and be paid less per patient seen. To see more patients, the doctor

needs more space and more staff, which means higher costs for the doctor.

Business 101 would teach that if every year your costs go up and your revenue goes down,

you will have to work harder to stay even. Eventually, if this pattern continues, there are

not enough hours in the day to see enough patients to maintain or increase profits. I have

seen doctors work themselves to death, trying to keep up with increasing costs and

decreasing reimbursements.

Doctors see no way out. What I have learned is that the reason you are where you are is

because of the decisions YOU make. You cannot blame anyone else. If decisions and acting

on decisions got you where you are, decisions can take you where you want to be.

If the contract is not favorable, the doctor can terminate the contract. If the doctor doesn’t

like seeing a lot of patients because there is not enough time to take good care of the

patients, decide to see fewer patients. Decide to do more for that individual patient and

refuse to discount your services.

What I suggest seems radical. I am simply saying, if something is not working, stop doing it.

Stop digging if you are in a hole. This is easy to see when someone else is doing it. This is

hard to see when you are in the hole, especially, when everyone else is also in a hole.

What happens is that all of your colleagues talk about how hard it is to keep digging and no

one comes in and asks the question why you are still digging. Also, what happens is that

when someone tells doctors I can help you get out of the hole, they won’t reach up and grab

the hand that will lift them out of the hole. They don’t believe it is possible to get out.

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It takes knowledge and courage to do this. You have to have the knowledge that there are

other more sensible ways to practice medicine. And courage is the power to let go of the

familiar. Just because your current way of practicing medicine and running your practice is

familiar to you does not mean this is how you should continue to practice.

All change is tough. All change takes courage. All change is uncomfortable. A quote by John

Maxwell states that until one can become comfortable with being uncomfortable, you can

never get better.

Chapter 11 – In Network, Out of Network

We just discussed why the doctor would sign a contract that pays less than the cost of the

service provided.

The cost of ignorance is huge. Doctors who CHOOSE not to learn the rules are ‘helping

insurance companies pick their pockets’, in the words of Karen Zupko. The doctor must

know the rules. I am not a certified coding specialist but I do understand some of the most

basic rules that I did not understand previously.

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We talked about the contracts that doctors sign and why they signed them. They wanted to

be able to see patients. Increasing the number of patients seen was the goal. The doctor

wanted to be on every insurance company’s network. The fear was that if they were not in

the network, they would be unable to see any patients with that particular insurance. This

is what the insurance company told doctors. This is what other doctors told the doctors

joining their practice. This was the accepted dogma.

This dogma was beneficial for the insurance company. The insurance company had most of

the leverage. The insurance company had the patients. The doctor wanted to see the

patients. The insurance company’s lawyers wrote a contract that allowed the doctor access

to the patients under certain conditions. The doctor felt forced to sign the contract no

matter what the reimbursement.

I will insert a pearl of knowledge at this point: any contract is always going to favor the

person or group that wrote the contract. The insurance companies didn’t pay lawyers

thousands or millions of dollars to write a contract that is fair. The insurance company paid

the lawyers to write a contract that favored the insurance company.

Most doctors signed the thick contract on the back page and never read one sentence of the

contract. How do I know? That is what I did when I first opened my private practice. I

needed patients no matter what. Doctors that choose not to learn the rules will get pick

pocketed. This is what has happened and this reality is causing many doctors to go

bankrupt or sell their practices to hospitals.

These are some basic rules doctors need to understand about insurance companies and

insurance policies. Doctors understand in-network. This is when the doctor signs a

contract. This is what I have been describing. When the doctor does not sign a contract, the

rules do not state the patient cannot be seen by the doctor.

The rules are that the doctor can see the patient but there is no contract between the

doctor and the insurance company. The only contract is between the insurance company

and the patient. The patient has a contract with the insurance company. The contract is that

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if the patient pays the premium, the insurance company will pay for reasonable medical

care by a licensed health care professional.

Now let’s discuss the usual insurance contract between the patient and the insurance

company. The patient pays the premium. The insurance policy will have in-network

benefits and out of network benefits and a deductible. In-network applies to the doctors

who have signed the contract. Usually, they will have a deductible that must be paid and

after that amount has been paid, the patient will pay a co-pay at each visit.

Usually, the deductible is anywhere from $250 to $5,000 dollars. The co-pay is anywhere

from $10 to $50. The patient has to go to a doctor in the network. The patient has also

agreed to let the insurance company make decisions concerning what type of medical care

will be offered and reimbursed.

Because the doctor has agreed to abide by the in-network contract the doctors has agreed

to discount most if not all of the services offered. The contract will also state what services

will not be paid for or what services must be cleared by the insurance company before they

will be reimbursed.

Most doctors and patients resent the intrusion by the insurance company in medical

decision-making. The contract the insurance company has with the doctor usually lists the

services for which the insurance company will not reimburse the doctor. If the doctor is not

going to be reimbursed, then those services will more than likely not be offered to the

patient.

An example of the vitals of an in-network contract:

Deductible $500

Co-pay after deductible has been met $25

Out of network simply means the doctor and the insurance company have no contractual

agreement. The doctor has not agreed to any discounts. The doctor can charge what the

service is worth. If the insurance does not pay the full amount, the practice can bill the

patient for the balance.

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Most insurance policies have in-network and out of network benefits. Some insurance

policies do not have out of network benefits. HMOs do not have out of network benefits.

HMOs will not pay for any services provided by a non-network doctor.

The key is to know this information before the office schedules an appointment for a

patient. Usually, a policy with out of network benefits will try to discourage the

policyholder from going out of network. This is done by increasing the out of network

deductible.

Also, instead of having a consistent co-pay after the deductible is met, the policyholder is

asked to pay a percentage of the charges. Most of the time the insurance will pay 70% to

80% of the charges and the patient is responsible for the remainder.

Why would a patient want to use their out of network benefit if it is going to cost them

more out of their pocket? That is an excellent question. The only way the patient would be

willing to pay more for something is if there is perceived increased value in the service and

if the service is above average or excellent. No one is going to pay more for average. No one

is going to pay more for something if they can get the same service for a cheaper price.

The key is to be an outlier, not a part of the bell-shaped curve. You need to be unique. What

does Louis Vuitton have that causes a person to pay extraordinary amounts of money for a

handbag? The handbags are unique, hard to find, increased value is perceived and

delivered.

The in-network doctors by contract are encouraged to offer the same services to everyone.

The in-network doctors are encouraged to see patients every 10 minutes. Sometimes,

patients wait two hours to see a doctor for 10 minutes.

What if a patient waited 10 minutes to see a doctor for 2 hours? Would that have increased

value? What if during those two hours, tests were done that were not focused on telling the

patient that you are not sick but were focused on making the patient more well. That would

be out of the ordinary; that would be valuable.

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What is an added benefit is that sometimes out of network is not more expensive than in-

network coverage. Because the doctor has not contractually agreed to collect all

deductibles and co-pays, the doctor can discount charges or even give away services.

Most in-network contracts forbid professional courtesy or any exceptions to the collection

of deductibles and copays. When the doctor is out of network, he or she is an independent

practice and can work with patients to fit their financial situation.

Out of network benefits usually have a total out of pocket amount that the policyholder can

reach. This means the total amount of money that the policyholder will pay for that year of

the policy. For example, if the out of pocket is $2,000, the deductible is $500 and after the

deductible is paid, the policy pays 70% and the patient pays 30%. If the $500 deductible

and the 30% paid throughout the year reaches $2000 the remainder of the charges are paid

at 100% of the allowable reimbursement.

What is the allowable reimbursement? All insurance companies decide how much they will

pay for a certain CPT code. CPT codes are how the doctor’s office communicates what

service, treatment or therapy was performed for or to the patient.

The insurance company decides the most they will reimburse for a particular code no

matter how much the doctor’s office charges for the CPT code. In other words, the doctor’s

office can charge a million dollars for a CPT code. If the maximum allowable

reimbursement is $400, it is the maximum the insurance company will pay for the CPT

code.

If the office is out of network, the office can bill the patient for the other $999,960 or write

it all off or bill for a portion of the remaining amount. If the office is in-network, the

remainder cannot be billed to the patient. The doctor must write off the remainder.

You must understand this point: the insurance company has a maximum amount that it will

pay for a CPT code but it does not have a minimum amount that it will pay. The insurance

will pay nothing for the code if the doctor does not bill the insurance company. The

insurance company will pay nothing for the code if the office does not remain persistent

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through all of the games the insurance company will try to play in order to not pay the

claim.

If the insurance company allows $300 for a CPT code and the office bills $200, the

insurance company will only pay the amount billed even though the insurance company

would pay $300 if the maximum were billed.

Review

If the doctor does not sign a contract to be in-network, the office can see the patient as an out-of-network provider.

Out of network means your charges will not be discounted.

An out-of network practice needs to offer unique services and experiences.

Chapter 12 – Cash Only and Concierge Practice

The frustration of trying to get paid by insurance companies has caused many doctors’

offices to give up and refuses to bill any insurance company. The office has a policy of only

accepting cash for all services. The office refuses to even investigate the patient’s policy.

The office will usually give the patient an itemized receipt and a form for them to bill the

insurance company.

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The doctor’s office, in other words, tells the patient to deal with their insurance company.

The patient is the one that has the contract with the insurance company. It makes sense to

let them deal with the frustration of trying to get reimbursed.

I completely understand this solution. There are only a few problems that I would like to

point out. As I pointed out in the previous chapter, if you are a cash-only practice, you are

an out of network practice. The designation out of network is a better description of the

practice than cash-only.

The reason why out of network is better is because it gives the office the option to bill a

patient’s insurance if the out of network benefits are favorable for the doctor and the

patient. This concept is initially hard for a doctor to understand. I will try to explain.

Refusing to investigate a patient’s insurance benefits may shortchange the patient, the

doctor and give the financial advantage to the insurance company. For example, the patient

calls the office and the receptionist tells the patient that the office does not accept

insurance. If the patient just paid her $1,000 insurance premium that month, the idea of

having to pay again may make the patient not come in to the office or delay coming in.

Think of that patient paying $12,000 a year for insurance and being told that it is worthless

in your office. The office may tell the patient that they can use the itemized bill to submit to

their insurance company for reimbursement. In reality, few patients will submit the forms

necessary to receive reimbursement from the insurance company.

The insurance company adds $12,000 to their balance sheet plus the amount that would

have been paid to the doctor or the patient if either one had billed the insurance company

for the services rendered. The patient is minus on their balance sheet the $12,000 plus the

amount paid to the doctor’s office, which on average is $1,000 to $2,000.

Because the doctor usually has to be much more cost-conscious, the doctor may not offer

all of the services the patient needs because it is all coming out of the patient’s pocket.

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If a patient or the patient’s employer is paying a $1,000 a month premium, the benefits are

usually good. Most non-HMO insurances have out of network benefits. A policy with good

out of network benefits usually has these basic elements:

1. A low deductible ($1,000 or less).

2. Pays 70% or more of the allowable amount after the deducible is met.

3. Has a total out of pocket of $3,000 or less

Remember, if you are a cash-only practice or a concierge practice, you are also out of

network. This means you can bill the patients’ insurance. The difference is that you have

not agreed to any discounts and you can bill the patient for the difference between the

price you charge and the amount the insurance company pays.

If the person in my example has this type of insurance, the first visit would go towards her

deductible. Either the doctor’s office or the patient must bill the insurance company. This

notifies the insurance company that the patient paid money for healthcare services.

If no one bills the insurance company, the payment will not count toward fulfillment of the

deductible. This is a disadvantage for the patient with your office and for any other doctor

the patient visits for the rest of the year. The $1,000 is not documented. The patient will

continue to pay until someone bills the insurance company to notify them that the

deductible has been met.

If the insurance company is billed for the initial services and the payment is $1,000, all

other services will be paid at 70% and the patient will pay 30% of the charges. This allows

the doctor to do more for the patient. Cost is not that great of an issue. Now the doctor can

fully evaluate the health of the patient.

The third criterion is the total out of pocket. When the deductible plus the 30% that the

patient pays after the deductible totals the out of pocket (in the example $3,000), the

insurance company pays 100% of the allowable amount. In other words, the patient no

longer has to contribute towards the payment of services rendered.

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This is really important if the doctor has initiated treatments based on initial findings. This

allows the doctor to retest later in the year without additional cost to the patient.

If you have a cash-only practice, not all patients have insurance with these types of benefits.

If the patient’s insurance does not met the criteria, then the doctor’s office should proceed

as usual and collect cash for services rendered. If the office never inquires about insurance

benefits, then the office never knows which patients have insurance that are beneficial to

the patient and the doctor.

Generally, patients at higher socio-economic levels seek unique health, wellness and

preventive medicine services. These patients are more likely to have employer-based

insurances with favorable out of network benefits. Doctors that provide these types of

services are the doctors that are usually cash-based practices. It makes sense to investigate

every patient’s insurance.

Concierge Practices

Most concierge practices charge a patient a retainer fee for a year of service. This fee allows

the doctor to be responsible for a small group of patients. This allows the doctor to avoid

having to see 20 to 30 patients a day to generate enough income to make a small profit.

The fee can be anywhere from $500 to $5,000, or more. A majority of doctors will offer 24-

hour access to the patients, including the doctor’s cell phone number. Usually, the fee is for

access and availability and routine care. Other testing and treatment is usually done at an

extra charge that is usually not billed to the insurance company. Again, it is the patient’s

responsibility.

My first problem with this arrangement is selling 24-hour access. I spent 16 years as an

obstetrician/gynecologist. As an obstetrician, I was forced to offer 24-hour access. Believe

me, it gets old quickly. As one gets older, one realizes that time is the most valuable asset

that one can control.

I do not sell my time cheaply. I will not sell my whole day to someone else if I am not

married to her or they are one of my two children, period. I spent enough time away from

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the people I love while I was delivering babies. That is a personal aversion to the concept.

This may be something that other doctors don’t mind.

The second adjustment I would suggest is to understand all of your patients’ insurance

policies. If the patient is required to pay a retainer out of pocket, that amount of money

should be billed to the insurance company in order for that money to count toward the out

of pocket expenses for the patient.

This is important because it can count toward the patient’s deductible. When the

deductible is met, the doctor’s office can bill the patient’s insurance for services not

covered by the retainer. This means the insurance may cover 50% to 70% of the allowable

reimbursement. As described earlier, when the patient pays enough out of pocket to reach

the maximum out of pocket expenses, the medical services are reimbursed at 100% for the

rest of the year.

Understanding the patient’s insurance helps both the patient and the doctor. The patient

gets credit for the entire out of pocket expense. The doctor is able to fully evaluate the

patient’s health because expense is less of an issue for the patient. Now, the patient is

getting more value from their insurance.

I am bringing up these issues because I am trying to get doctors to not be close-minded

about how they think about their business. It is easy to make decisions based on a past

experience and overreact in order to avoid the pain. All doctors have had bad experiences

with insurance companies and attempting to get paid.

Many doctors gravitate toward new ideas that avoid the pain of trying to get paid. What I

am trying to get across is to not let the insurance company off the hook. The insurance

company should fulfill their obligation to the contract that they have with the patient.

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Chapter 13 – The Value of Intellectual Distribution

“The Wellness Revolution: How To Make A Fortune In The Next Trillion Dollar Industry”, by

Paul Zane Pilzer, is a book that I read several years ago when I was considering changing

the way I practice. I encourage anyone considering adding this type of medicine to your

practice to read this book.

The one thing in the book that stood out to me was his explanation of the value of

intellectual distribution. This is a quote from his book.

“The increasing percentage of distribution cost is why, over the past three decades, the

majority of great personal fortunes have been made by the people who found better ways

of distributing things rather than better ways of making things.” …..

Distribution is really two processes:

1. Educating consumers about products and services that will improve their lives.

2. Physically distributing products and services to consumers.

Distribution is the valuable commodity today. Amazon.com is the king of distribution over

the internet. Google is the king of information distribution. Facebook is the king of

distribution of personal images and information. Wal-Mart, Costco, and Home Depot are all

huge distribution networks. None of these companies manufacture or make any products.

Physicians should be distributing wellness information, products and services. The

sickness care market is closed and government regulated. You cannot distribute

prescription drugs. You have to be a pharmacist. It would cost you a fortune to open a

hospital. We are already participants in the education and distribution of prescription

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drugs and are legally prohibited from being paid for the most valuable service we provide

in this economy.

Let me explain. Please review the definition of distribution: “educating consumers about

products and services and distributing the products and services to consumers”. The

pharmaceutical industry is dependent on the doctor to distribute prescriptions in order for

their product to be delivered to the consumer.

Doctors are the limiting factor in the financial equation for the pharmaceutical industry.

Doctors control prescription drug distribution. The pharmacist fills the prescription but a

prescription is required for that product to be distributed.

Physicians went to school and through training for anywhere from 7 to 10 years after

college to gain the intellect to determine what drug may improve their patient’s lives. The

word may is italicized in the previous sentence because most drugs improve symptoms

temporarily but seldom improves lives in the long run.

Physicians educate the patient about the drug and the possible side effects. Physicians are

responsible for taking care of any problems as a result of the drug. However, the doctors do

not get paid by the manufacturer for the distribution of the product. The pharmaceutical

company makes billions every time the patient fills that prescription but the doctor does

not make a dime for taking part in the successful distribution of the product.

Don’t get me wrong. I understand why the system is set up that way. They don’t want

doctors to prescribe drugs just because they make money off of the drug, even though the

pharmaceutical company makes up conditions that aren’t really medical conditions

because they have a drug that can alleviate a symptom. The pharmaceutical company

bombards the airways with commercials so the patient will come into the physician’s office

and pressure the physician into product distribution.

. Finally, the representative will leave questionnaires, pre-printed prescriptions and

brochures for the patient to read, all promoting the drug.

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The doctor has to handle any problems the drug may cause for the patient. The doctor has

to suffer the consequences of giving a patient the wrong drug.

The doctor and the patient were persuaded to use the drug because of all of the marketing

material for the drug in the office.

. Insurance companies are encouraged to pay for drugs and not safer, more natural

remedies. State medical boards are influenced to investigate and discipline doctors who do

not follow the traditional pharmaceutical based medicine model.

This is a bad scenario for the doctor and the patient but great for the pharmaceutical

industry. The pharmaceutical industry makes billions. Patients suffer. Drug interactions

and mistakes in the administration of drugs is the 9th leading cause of death. Doctors suffer

because they don’t make any money from the drug and usually the drug causes more harm

than good.

Now let’s get back to how doctors should think. The doctor generates all the money

generated in the medical economic system. The medical labs make money only when the

doctor orders the lab test. The medical device company makes money when the doctor

orders the equipment. The pharmaceutical company makes money when the doctor writes

the prescription.

Doctors have to distribute information to the patients. The doctor tells the patient the value

of the test, the drug, and the treatment, etc. The doctor distributes that information for the

company for free. Intellectual distribution is the most valuable commodity in the world

economy and doctors do it for free.

Doctors are legally prohibited from being paid for their intellectual distribution of

pharmaceutical drugs. There is nothing you can do about that except only prescribe drugs

when absolutely necessary. However, labs will allow the doctor to purchase lab tests at

wholesale prices and sell the lab to the patient at retail prices. The difference in price is the

payment to the doctor for intellectual distribution to the patient concerning the importance

of the lab test.

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The same is true with testing equipment in the office. I run tests in the office that allows me

to distribute information to the patient to improve their health. I am paid for that

intellectual distribution. If you sell supplements or other treatments to the patient, the

doctor buys at wholesale and sells at retail. The difference is the payment for intellectual

distribution.

Doctors need to make sure they don’t let other companies profit off their intellectual

distribution without being compensated. This requires the doctor to:

Think differently.

Be an Outlier

Don’t be a caterpillar

Chapter 14 – How Doctors Should Think About Revenue

Streams

Time, Testing and Treatment

The way to increase the revenue of a doctor’s office is to have multiple revenue streams.

Each revenue stream needs to have multiple options because each patient will need

different amounts of time, different tests and different treatments. These are the three

revenue streams doctors should incorporate into their business.

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Normally, the doctor charges for his or her time and procedures. As an ob/gyn I charged for

my time with the patient. I wrote prescriptions and I searched for patients who needed a

procedure. Of course, the obstetric patients all needed to be delivered.

The reimbursement for 9 months of care and hours of managing labor and delivery

continually decreased, making my pay per hour miniscule. The gynecology portion of my

business consisted of seeing 20 patients a day and maybe one or two of them needed a

procedure. However, the reimbursement for the major procedures did not match the skill

and the liability associated with the procedure.

When I decided to take a different approach to medicine, it was important to figure out how

to make a living doing what I loved. I wanted to help people become more well,

instead of managing disease. In order to do this, it was going to take more time. I decided to

learn the rules of being paid by insurance companies. I searched the CPT code book to

determine how I could be paid for spending extra time with the patient.

It is important to spend time with the patient because until the patient trusts you as a

doctor, they will not tell you the entire story. It has been said that people do not care how

much you know. They want to know how much you care. People spend time with people

they care about. If you really care about a patient, the doctor needs to spend time with the

patient.

If one reads the different surveys that are taken concerning doctor dissatisfaction and/or

patient dissatisfaction, both parties complain about time spent. Doctors complain they miss

having time to form a relationship with their patients. Physicians know and understand

that a patient they have not spent enough time with to get to know them is more likely to

sue them if there is a bad outcome.

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Doctors want to spend more time with patients but the present culture says that to

increase revenue you must see more patients in a shorter amount of time. This pattern has

been followed for years and the results have been bad for both patients and physicians.

I did not know that there were codes that paid based on time spent face to face with the

patient. The normal E&M codes only reach a limit of 60 minutes for a new patient and 45

minutes for an established patient. I have found that I need as much as 90 minutes with a

new patient.

For established patients, the first 1 or 2 return visits take an hour or more. There are test

results to explain and treatment plans to discuss. This takes time. There are codes that

allow a physician to spend as much time as he or she needs to adequately handle the

patient’s concerns.

Please see www.EMuniversity.com. This is a website that teaches doctors the rules of

coding. The best thing about this website is it is a physician teaching physicians about

coding. This doctor is a certified coding specialist. Most of the time, coding classes are given

by insurance companies or medical specialty societies.

I feel like it is a conflict of interest for an insurance company to teach a doctor how to code.

The insurance company does not want to pay me and I want to be paid. It does not make

business sense for the insurance company to teach me how to maximize my

reimbursement. By studying on my own and watching the videos and reading the material

on the EM University website, I learned some valuble information. The code 99354 and

99355 are extended visit codes.

The above statement is copied from the CPT code book.

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This code is used when the physician is providing face-to-face contact that is beyond the

usual service. If the physician is spending 60 to 90 minutes with a patient, taking a history

this is beyond the usual service. Some physicians ask me what do you talk about for 60 to

90 minutes. The physician does not talk for most of that time. The patient talks.

Because I am trained as an ob/gyn, even though I no longer practice the specialty, most of

my patients are women. Women are attuned to their bodies. Their lives, their thoughts,

their feelings and their health are closely connected. They know this and they want to tell a

healthcare provider how these life events have impacted them and their health.

My wife and I have written two books, “Are Your Hormones Making You Sick” and “The

Stress Connection”. Hormones and stress probably affect women more than men and are

two subjects a lot of doctors don’t understand. However, if you can have a patient,

especially a woman, talk to you about her hormonal changes and her stress in her life, it is

usually a long conversation.

The physician’s job is to connect the dots and help the patient understand how hormonal

changes and stress are contributing to their insomnia, weight gain, irritable bowel, chronic

fatigue, irritability , anxiety, hot flashes, and palpitations, etc. This discussion is what takes

up the face to face time. If, like most doctors, the focus is on one specific complaint and the

erradication of a particular symptom with a prescription, then 90 minutes with a patient

seems ridiculous.

The rest of the CPT code requirements for the prolonged visit states that the code should be

used in addition to other physician services, including E& M services at any level. This

means if the physician meets the documentation requirements or time requirements of a

99214 or a 99213 or 99203 and the doctor spends additional time, the prolonged visit code

should be used.

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The addition of these codes can increase reimbursements anywhere from $90 to $150.

As Karen Zupco stated in a quote I referenced in a previous chapter, if you do not know the

rules, the insurance company will pick your pockets. Most doctors will spend more time

with a patient when needed. The time included in the highest new patient E&M code is 60

minutes and 45 minutes for an established patient.

Doctors practicing functional, restorative or anti-aging medicine might spend 90 to 120

minutes with a new patient and bill for 60 minutes. Ignorance of the coding options was

causing many doctors to stop billing insurance or stop practicing wellness type medicine.

Now you understand why a lot of doctors practicing this type of medicine would throw up

their hands and give up taking any type of insurance if the doctor was having to give away

hours of their time for free. However, knowing the rules can solve this problem. Know the

rules and you have a better chance at winning the game.

Testing

Practicing functional, wellness, restorative, anti-aging, non-conventional medicine requires

objective evidience that the patient has certain dysfunctional systems that need correction.

I think testing is critical in this type of practice. Testing is important for the physician and

the patient. Testing helps to pinpoint the problem prior to significant symptoms being

manifested.

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This is what functional medicine testing is designed to do: identify problems before

symptoms of a disease are evident. Conventional medicine delays intervention until disease

symptoms are present and disease testing is positive.

Functional medicine testing identifies the physiologic pathways and organ systems that are

not functionaing at their normal capacity. When the dysfunction is identified, there are

specific treatments, supplements and therapies that are known to improve the function of

that system.

Several of these tests are reimbursed by insurance companies. The reimbursement is a

revenue stream for practices that utilize insurance in the practice. Even if the patient does

not have insurance that will reimburse, the specialized testing adds value to the office visit.

The testing makes the office seem special and not like the other doctors’ offices in the bell-

shaped curve. As I stated in a previous chapter, your office wants to be an outlier. The story

of success is a story of outliers.

I regularly give seminars to teach doctors how to add services in their office. Presently

there are about 15 different services we offer in our office to our patients. Most of them are

reimbursible. The ones that are not reimbursible still give important information that

allows me to determine the best treatment for that particular patient.

Some of the testing we do in the office includes:

Bio-Imbedance analysis - body composition, phase angle (anabolic or catabolic

state), cell membrane integrity, basal metabolic rate, intracellular and extracellular

water (determines toxicity)

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Heart Rate Variability - similar to fetal heart rate variability. Used to determine

physiologic stress or imbalance.

Digital Pulse analysis - early test for arteriosclerosis

EndoPat - test for endothelial dysfunction

Carotid Intimal Thickness (CIMT) identifies carotid artery plaque formation and

measures intimal thickness that correlates with cardiovascular aging.

Basal Metabolic Rate- by measuring respiratory CO2

Measure Nitric oxide

Inflammation work-up includes:

Skin prick testing for IgE allergies

Mental function testing

Outside lab testing:

Rast blood testing for IgE allergies

IgG 4 testing for food sensitivities

Esential Fatty Acid testing

Organic Acid Testing – identies specific nutritional deficiencies

Gastrointestinal testing

These are some examples I introduce to physicians at the Maximum Health Enterprises

Seminars. The idea is to raise your level of service. One can either do less for more people

or do more for fewer people. Doing more for a few people is more beneficial for the

physician and patient.

What Can Happen if You Don’t Change?

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Business failure

Missed paychecks

Long hours

Emotional and psychological burnout

Job dissatisfaction

Lawsuits from medical errors, disgruntled patients and insurance companies

Suboptimal healthcare services

Benefits to physicians:

Better patient healthcare

Less time in office

More time with loved ones

A longer life

Lower cortisol

More time to learn new information and procedures

Better patient satisfaction

More revenue

Reduces risk of medical errors and lawsuits

Benefits to patients:

Lowers out of pocket costs to patients in the long run by restoring health

Reduces healthcare costs by avoiding needless referrals to specialists

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Reduces unnecessary medical procedures, laboratory testing and prescriptions

Improves the patient’s quality of life by ridding them of diseases and chronic

illnesses

Increases longevity

Treatment

Treatment is the third revenue stream. This is an area some doctors have a problem

maximizing. Time with the patient leads to testing and testing leads to treatment. They all

go together. Doctors are familiar with treatment consisting of prescriptions and surgical

procedures. Prescriptions are not a revenue stream for the physician. Prescriptions are

revenue streams for pharmacists and drug companies. Surgical procedures are hard to find

and expose the physician to liability.

In-office treatments and supplement sales are revenue streams for the physician’s office.

The great thing about treatment in-office and retail sales is that insurance and changes in

insurance coverage do not affect this revenue stream. In-office therapy and retail sales of

supplements complement the testing. The testing should lead to therapies and supplement

sales. The tests should be repeated after the therapy or supplements to validate the efficacy

of the treatment or the supplement.

The missing component when using supplements and therapies to improve function is

objective evidence that conditions have improved. The placebo effect is often used as the

reason patients claim to feel better when taking both supplements and drugs. Objective

testing needs to improve to show that an intervention had a positive effect.

There are several tests that can show abnormal function. Physiologic pathways can provide

the clues regarding what is missing from the pathway and causing the pathway to function

abnormally. If the supplement or therapy provides the missing component, the physiologic

pathway should function better. Therefore, the functional test should improve.

One of the tests we use in our office is a mental function test: CNS VS. This is a central

nervous system vital signs test. This test is done on a computer and it tests several areas of

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brain function. When the test shows below average function, we provide an IV therapy that

introduces phosphatidyl choline into the vein followed by glutathione.

We administer this therapy once a week for 6 weeks. Following the completion of the

regimen, we repeat the test. Subjectively, the patient reports better concentration and

clearer thinking. The key is do the test results change? We have been pleasantly surprised

by the improvement in the CNS VS test. This is one example. There are other examples:

Salivary cortisol levels change when adaptogens and phosphatidyl serine are taken

over several months.

Heart rate variability improves with the consumption of Amino Acids and minerals

Digital pulse analysis improves with the oral consumption of arginine and citrilline

which produce nitric oxide.

Endothelial dysfunction measured by EndoPat improves with arginine

Organic acid testing improves with the administration of oral or IV nutrients that

support ATP production in the citric acid cycle

Salivary hormone levels normalize with the proper dosing of bio-identical hormones

Gastrointestinal testing improves with:

o Probiotics

o Prebiotics

o Glutamine

o Digestive enzymes

o Anti-parasitic and anti-fungal herbs

Bio-impedance analysis improves with:

o Detoxification

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o Fat loss

o EFA

o Any increase in cellular health

Evoke improves with:

o Supplements that increase neurotransmitter function

o Measures that improve the function of the blood-brain barrier

o EFA

o Bio-feedback

o Improvement of GI function

o Removal of inflammatory foods

These are examples of how testing leads to treatment which lead to retesting to prove or

disprove the efficacy of treatment. The objective evidence allows one to continue effective

treatment or to redirect treatment that is not effective objectively.

I believe this to be an issue in conventional and functional medicine. In conventional

medicine, so much of what is treated is based on a cluster of symptoms labeled as

syndromes.

Chronic fatigue syndrome

Restless leg syndrome

Irritable Bowel syndrome

There are no real tests to diagnose these syndromes or to determine if the treatment has

corrected the problem. In these situations, several expensive medications, treatments are

offered and many expensive tests are done. Several of these patients get no relief. Several

are considered disabled or become less productive throughout the rest of their lives.

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Functional testing and treatments can provide a different way to look at these problems

and can help some patients that conventional medicine is not equipped to handle.