Cash Practice

John Cianca, MD

Disclosures• Owner: Musculoskeletal Ultrasound Consultants, LLC• Medical Director: Houston Marathon Committee• Instructor: Advanced Health Education Center• AAPM&R

– Medical Education Committee– Ultrasound Task Force– Early Career Task force– QPPR-MEC work group– Annual Assembly: Practice Tract Director

Background

• Fellowship trained in MSK• Board credentials

– Sports Medicine– Acupuncture– Ultrasound

• Began practice in 1993– Faculty: BCM

• Solo practice since 2004

Philosophy

• I value sincerity• I am angered by injustice• I care about what I do and how I do it• I try to remain true to my ideals• Clinically, I need to know why• Education is my primary objective• Medicine as a ministry

How I Got Here

• My academic practice• My leap of faith• Where am I now• Job satisfaction• Wealth

RVUs

– Relative Value Units (RVU)• Payment = [(RVU work x GPCI work) + (RVU PE

x GPCI PE) + (RVU malpractice X GPCI malpractice)] x conversion factor (region determination)

– GPCI = geographic practice cost indices– PE = Practice expense

RVUs = Satan’s Pitchfork

CARE

• Merriam Webster– Care: to be interested in or concerned about

something– Synonyms: conscientiousness, heedfulness,

meticulousness, scrupulousness

• Health is precious and we are entrusted as its guardians

• Care before Cash

Questions of Time

• Care requires thoughtfulness• We must take time to listen• We must afford ourselves time to consider, to

think, to be compassionate• Can we do this in 10-15 minute visits• Can we do this seeing 20-30 patients / day• Can you be happy this way• Who benefits in this format

Physician Errors

• “ Most process breakdowns were related to the clinical encounter, wherein practitioners are always pressed for time to make decisions”

Singh H, Giardina TD, et al. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med Mar 25 2013:173(6)418-425

Job Satisfaction

• Can you be happy or fulfilled as an indentured servant manacled by RVUs?

Cash Practice: Guidelines

Cash Practice: Can You Do It

• Area of expertise• What is it that you do clinically• Established reputation• Collegial support• Patient referrals

Cash Practice: Infrastructure

• Keep it simple• Don’t over build• Be efficient

– One employee• phones / scheduling / check in and check out / rooms• In office accounting with CPA oversight

Setting Fees

• Fairness vs greed• Time • Complexity• No insurance > less constraints • Adjust fee if it seems fair

Fees

• 99201- $175• 99202 - $225• 99203 - $325• 99204 - $350• 99205 - $400

• 99211 - $80• 99212 - $100• 99213 - $130• 99214 - $200• 99215 - $250

Fees

• 20600 – 20610 - $85• 20552 - $100• 20553 - $155• 97810 - $90• 97813 - $120

• 0232T - $850 • J7325 - $500

• 76881 - $150• 76882 - $50• 76970 - $75• 76942 - $100

Day to Day Schedule

• 6-10 patients per day typical• 8-12 is ideal• 45-60 minute new evals• 20-30 minute follow ups• Leaves time for add on patients or procedures

Patient Filing

• Super bill with CPT coding and ICD-9/10 codes and charges

• Walk them through the process• Be available for questions

Closing Thoughts

• Gratified by what I do• What I miss • What I don’t miss• Consider it but be realistic• Consider why you became a physician• Lead by being better