Minding the store

Management in Practice

Maithily Nandedkar

Dr. Nandedkar is a member of the AAD Business and Operations Support Task Force who built a thriving solo practice.

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Ways to keep your practice productive while you’re away

As a solo practitioner, if I don’t work then I don’t get paid. Many of us face the same situation regardless of our practice environment. Most of us take the financial hit for a week of continuing medical education (CME) each year, but what about vacation time? You cannot stay mentally productive or emotionally satisfied if you do not take a break. It is not uncommon to blend CME with vacation to offset the expense of leaving the practice for a period of time. Two weeks feels better and the amount of work upon return is not any more daunting. In a group practice you may have peace of mind regarding coverage if everyone does not go for CME simultaneously.

Yet practicing solo does not mean you have to fly solo. I usually ask a fellow solo-practitioner to cover me while I am away and I reciprocate. However, two weeks of no cash flow can be trouble. Life’s not all about the money but we have to stay practical. Payroll, rent, supplies, and electric bills all add up to significant overhead. How can your practice generate revenue while you are away?

Staff vacation time

One good option is to give the staff time off, too. My full-time staff and I overlap vacation, while my office manager and one other part-time staff member, a medical assistant, work while I am away. They triage patients to the covering physician, perform microdermabrasion procedures, go through inventory, and, most importantly, book patients for the week of my return so that I am not returning to an empty schedule — which can also be a cash-flow killer. Because the rest of the staff are away when I am, we all come back feeling refreshed and ready to see patients again. We have a week when nearly everyone is gone; the following week my office manager goes on her vacation.

Medical care

Another great option to maintain cash flow is to have a physician extender. On the whole, there are more physician assistants (PA) rather than nurse practitioners (NP) in dermatology because our specialty seems to favor the focused nature of a PA rather than the all-purpose care provided by an NP. However, this is a gross generalization and the choice depends not only on the needs of the practice but also on state law. Assuming an NP or PA has met all of the regulatory requirements, what else is required? [pagebreak]

In Virginia, for example, before a PA can actually begin working for a practice, the physician must submit a written protocol to the board of medicine as to the PA’s scope of practice and the degree of supervision necessary. After hire, the physician must then attest to the PA’s competency.

I know my malpractice carrier in Virginia will allow a PA or NP to cover the practice while I am away as long as I am only a phone call away. There is no time limit for this and it can occur intermittently during the week but this does not apply for vacation, which has special rules. For vacation times, the board of medicine in my state requires that there still be a locally covering physician for the PA or NP and that person must attest in writing to the board one month prior to my departure that he or she is supervising the PA or NP. The covering physician is still responsible and will need malpractice coverage for the PA even if he or she did not hire the physician extender. These rules are spelled out at www.dhp.virginia.gov/medicine/advisory/pa/default.asp; your state may have similar requirements.

What does the Centers for Medicare and Medicaid Services (CMS) have to say about it? CMS is fine with a PA or NP providing services as long as the resulting claims are submitted appropriately. An NP may bill CMS directly but a PA cannot; his or her services must be billed by the practice. For more detailed information, I recommend the following guide for rules regarding physician extenders: www.medicarenhic.com/providers/pubs/nonphyguide.pdf.

Another option is a locum tenens. A locum tenens may earn at least $100 per hour plus room and board if he or she is coming from out-of-state. After calculating staff costs and other overhead expenditures to support the locum tenens, this option has never been cost-effective for me.

Cosmetic care

Some states allow anyone to use a laser regardless of physician presence. In these states, some practices allow highly trained staff to operate a laser or IPL to generate revenue while the physician is away. That is the case in Virginia, the state in which I practice; that partly explains the incredible increase in day spas that provide laser services. Maryland, an adjacent state, allows only physicians to use a laser. What you allow (within the realm of state and federal law) depends upon your personal ethics, the skills of your staff, and your malpractice coverage. I personally do not allow my staff to operate the laser without my presence despite years of training, years of appropriate use, and no adverse events. Although the law will allow it, I worry that if something goes wrong my malpractice carrier is unlikely to cover the occurrence. The same rules apply for peels. I do not consider these to be benign. If there is an adverse event then I am liable.

In my personal opinion, I feel microdermabrasion is a different matter. It is a relatively benign yet effective procedure that some of us have in our offices to treat patients with acne or pityrosporum folliculitis. While I am away, I allow my staff to perform these procedures unsupervised. I usually run a special for patients and offer bonuses to the staff. Patients are happy because they have the procedure they want at a reduced price and the staff are happy because they feel empowered to perform this procedure. It is not the same cash flow as if I am there but the staff have contributed to the practice. They are a part of my team; each of them is working toward the common goal of supporting the practice within his or her scope and capacity. My philosophy is that all staff need to be revenue-producing in some way. No law that I could find says that staff cannot use a microdermabrasion machine while I am away. This is what I am comfortable allowing in my practice, not a general rule that should be followed; you need to determine what you are comfortable with and what is allowed in your state.

(Editor’s note: The American Academy of Dermatology’s Position Statement on the Practice of Dermatology states: “The optimum degree of dermatologic care is delivered when a dermatologist ... provides direct, on-site supervision to all non-dermatologist personnel. Each practice should maintain written procedures regarding appropriate delegation and supervision protocols for all personnel within the practice.” The full position statement is available online at www.aad.org/Forms/Policies/ps.aspx.)

The Academy’s Annual Meeting is in San Diego in March; how you support your practice while you are away is up to you. Regardless of whether it is CME or vacation, though, you need to enjoy your time off. Putting procedures in place that work for you and your practice within the confines of the law should allow you to do so.