In Search of New Revenue

Pediatrician Jennifer Shu spends most of her week treating coughs and colds at Children's Medical Group in Atlanta. But she performs an even greater public service on her days off. The consultant, author, and parenting guru dedicates at least one day a week to media gigs - conducting interviews, editing content for publications, and working with companies she supports to help promote their message. "I've been practicing for 16 years and I love that too, but you can reach so many more patients through the media when you're trying to get a public health message out," she says.

You can also make a lot of money. While news outlets don't pay for interviews, Shu notes, they do help promote her practice and her latest book, "Heading Home with Your Newborn," which she coauthored with colleague Laura Jana. And the editing jobs, which consume "a few hours" of her time, pay enough to compensate her for seeing patients just three days a week. (She takes one day off for personal time.) But the biggest checks, by far, come from private companies - such as juvenile product manufacturers and health food outfits - that hire her as a medical expert. Shu occasionally earns between $10,000 and $20,000 for half-day events in which she conducts a series of satellite television or radio interviews about such topics as healthy eating habits and dealing with the common cold. "Done the right way, if it's something you believe in, you can be compensated well," she says.

Like Shu, many physicians are looking for ways to boost their bottom line - and redefine their careers - amid declining reimbursement. Some simply squeeze in more patients, but not all practices are scalable. After all, you can only eke out so much efficiency without impacting quality of care. For those with an entrepreneurial mindset, however, there are a number of ways to create supplemental income without putting your practice on hold. A few options, like becoming an expert witness or hosting patient education seminars, can easily be done in your down time, while others, such as serving as a medical director or becoming a part-time consultant, require a bigger time commitment. Here are 10 options worth considering:

In-house dispensing

You could make $50,000 or more per year by opening an in-house pharmacy. Thanks to changes in the Medicare Part D program, physicians are now able to dispense prescription drugs to patients directly at the point of care - and get reimbursed for it. Because it requires special billing and contracting with private insurers, however, most practices use third-party vendors like QuiqMeds, Dr. Dispense, PrimaryRx, MedX Sales, or Physician Partner, which stock their offices with the most commonly prescribed drugs and handle the administrative hassles for them. For its part, MedX Sales claims practices profit approximately $8 to $10 per medication dispensed. Dr. Dispense, which offers an integrated software solution that adjudicates claims through existing electronic health records, says the typical small practice generates $4,000 to $5,000 per month (or $60,000 a year) using its program after the cost of medication. Physicians' Pharmaceutical Corp., meanwhile, which enables doctors to fill the actual prescriptions they write using an in-house certified prescription technician - rather than using prepackaged quantities and dosages - says some of its clients are just breaking even while other high prescribing offices are making "hundreds of thousands of dollars."

Become a medical director

The aging population presents opportunity for those with a medical degree. Long term care facilities, including hospice, home health agencies, and nursing homes, are required by federal law to retain a medical director who can coordinate patient care, establish procedures for quality assurance, and provide administrative oversight. They often look to family physicians and internists, particularly those with a geriatrics subspecialty, who perform their duties in addition to maintaining their full-time practices. Karyn Leible, president of the American Medical Directors Association, says such positions pay an average of $150 an hour. And the time commitment varies. As chief clinical officer of Pinon Management in Lakewood, Co., a consulting firm for nursing homes and assisted living facilities, Leible says her group expects at least four hours a month from each of the medical directors in the 13 homes they manage. Other facilities, though, require up to 10 hours of work each month, paying anywhere from $1,000 to $3,000 monthly.

Embrace the Web

For the computer savvy, the Web is a channel worth pursuing. Many of the larger health plans now offer in-network doctors an opportunity to conduct online medical consultations with patients through real-time videoconferencing or secure chat. Most plans reimburse less for online encounters, normally between $30 and $40 per 10-minute visit, but the advantage is that you can hold them when and where you like - after hours, over the weekends and from the convenience of your own home.

If you're looking for greater flexibility you can also sign on with an online care service company like American Well in Boston through any of its participating health plans. The company has created a Web portal that allows physicians to hold online visits, review clinical information, prescribe medication, and suggest follow-up care. Even if your physical waiting room is full, you can indicate via software that you're willing to accept "Web walk-ins" from just your own patient base. Or you can switch to accepting online visits from other health plan members for the next, say, 20 minutes, to fill in for a no-show. The system also supports a fee-for-service model, allowing specialists who have established a reputation to set their own rate. The head of oncology for a major metro hospital, for example, might be able to charge $300 for a 10-minute online visit.

Become a consultant

If you're looking for a career transition, or a chance to reduce your office hours prior to retirement, you could establish your own consulting business. Many organizations require the expertise of a physician, including healthcare systems, pharmaceutical firms, technology or device companies, and insurance companies. And chances are you've got more to offer than you think. For instance, if you helped orchestrate a successful merger or created a physician integration tool kit that would be useful to other organizations, these types of skills are directly marketable. "It takes a special mindset, but there are a lot of physicians who have expertise that they've developed by virtue of working on committees for information technology implementation or those related to quality assurance," says Francine Gaillour, a former internist and executive director of physicianleadership.com, a Web site that focuses on executive coaching. "You need to put some thought into what your service is, how you're going to deliver it to a client (group seminars, training classes), how you'll price it, and how you'll market it," says Gaillour, author of "Physician's Definitive Guide to Career Transitions." The average consulting rate ranges from $350 to $500 an hour, or $3,000 to $7,000 per day, depending on the type of consulting or training provided, she says.

Stop sending patients away

Ancillary services are a tempting proposition for practices looking for a quick fix to their bottom line. And they can be profitable, if implemented with care. Vivian M. Luce, regional director for physician recruiting firm Cjeka Search in St. Louis, says one of her clients, a Midwest single specialty practice, makes an extra $350,000 a year by doing cosmetic Botox injections. Other practice consultants suggest the most successful groups average 20 percent to 35 percent returns on imaging services, such as radiology, CT, and MRI scans. Data from the Medical Group Management Association's 2010 Cost Survey for Orthopedic Practices also reveal that the median independent orthopedic surgery group realized $57,886 per physician in net revenue (after operating costs) for MRI services, and $41,887 per physician for diagnostic radiology (X-ray) services.

But many practices also lose money on ancillaries. Before jumping in, conduct an in-house audit of the referrals you write monthly for things such as medical imaging, diagnostic testing, physical therapy, and laboratory services. Once you've identified an area of potential demand, research your local market to determine whether it's already saturated and contact your payers to determine how much they reimburse for that service. Some payers contract exclusively with national labs and won't pay at all for in-practice services.

Group classes

You spend hours each week on patient education and you don't get paid for it. Try hosting education seminars for groups of patients managing the same risk factor - say, diabetes, asthma, or obesity - and charge for it. Such sessions, which provide a more detailed overview than you would normally have time for during a well visit, help enhance compliance and can be conducted in your waiting room or at a local community center during lunch or after hours. But do your homework first. Medicare does not cover group counseling at all, and while codes exist for such sessions (99411 - a group setting for preventive medicine counseling and/or risk factor reduction session of roughly 30 minutes in length, and 99412 for sessions up to 60 minutes), not all private payers are willing to reimburse, says Rhonda Buckholtz, vice president of business and member development for the American Academy of Professional Coders in Salt Lake City. You may still be able to charge patients out-of-pocket for the class, but check with your health plans first to be sure you're allowed to charge for noncovered services, and be sure your patients understand what their financial obligation might be upfront. "I would caution doctors to do careful research with all contracted payers to see what restrictions or requirements they may have before jumping in to provide these services," says Buckholtz.

Media mogul

As Shu discovered, becoming a media expert can be rewarding, both professionally and financially. Apart from one-time gigs, she notes, physicians who get put on a one- or two-year retainer by product manufacturers or pharmaceutical firms "can easily make six figures," during which time they would make themselves available for press and video conferences and advise on product development. Those best suited are comfortable in front of a camera - and still practicing medicine. "Seeing patients and staying current in my field is what makes me relevant," Shu insists. Be prepared, though, for an unpredictable source of income, and always maintain a professional standard. "You need to be very careful about ethics," says Shu. "It's important to be transparent so that viewers understand you are getting paid to mention or promote a product. And you want to be careful not to provide direct medical advice or tell strangers what to do with their health."{C}

Become an expert witness

You spend plenty on malpractice insurance. Let the legal system pay you back. Attorneys need physicians to help their clients in cases involving an injured plaintiff. Groups such as American Medical Forensic Specialists, Rieback Medical-Legal Consultants, and National Medical Consultants collect physician CVs and connect them with attorneys seeking their area of expertise. For its part, National Medical Consultants in Bayside, N.Y., pays physicians $375 an hour to review charts and perform pretrial work, including written reports and communications with attorneys. For a deposition, in which the lawyers come to you, it's $2,000 for half a day, plus any prep work required (normally two additional hours reimbursed at $375 a pop). And they pay $6,000 a day if you go to trial, which is normally scheduled on Monday or Friday to minimize time away from your practice. To maintain credibility, Gene DeBlasio, a pediatrician and president of National Medical Consultants, says legal work should constitute less than 5 percent of your income or you'll look "like a professional witness."

Clinical trials

Though the days of easy money in the clinical trial arena are over, working with pharmaceutical firms remains financially viable for practices that are willing to commit the resources. Upstate Neurology Consultants in Albany, N.Y., for example, has a separate clinical research center with a dedicated staff and research coordinator. Their long-time connections within the industry make it a profitable line of work, but administrator Bill Henderson cautions that federal regulators have toughened up protocols, making it cost-prohibitive for some practices to participate in drug trials. At the same time, he says, pharmaceutical firms are sending more studies offshore, while the flurry of mergers and acquisitions in the industry have wreaked havoc on the continuity of clinical research. "How much you can make is all over the board, "he says. "If I told you that you could make $30,000 in a study if your patient participated for the next three years that sounds great, but if you can only recruit one subject and they drop out after six months, you only get paid for the work you've done up to that point. You have to work very, very hard for every penny you make in this.”While some practices make upwards of $100,000 in extra income doing clinical trials, most realize a smaller revenue bump. Others never break even. You can search for ongoing clinical trials on clinicaltrials.gov from the National Institutes of Health, centerwatch.com, Veritas Medicine's Web site pharmalicensing.com, and pharmaceutical firm AstraZeneca's site for healthcare professionals, clinicaltrialdoctors.com.

Charge rent

In the transition to electronic health records, many medical offices suddenly have vacant office space where paper charts were once stored. A little advice? Dust off the cobwebs and put that square footage to work. Physical therapists, massage therapists, acupuncturists, and dieticians, for example, often have need of professional space and could serve as a passive source of income. According to commercial real estate data firm CoStar in Washington, D.C., national rates for medical office buildings are about $22 per square foot. If your practice owns the building, you can lease to whoever you want. If you rent, however, you'll have to get permission from your landlord to sublease. (Not all will allow it, and those that do will want final say in who you bring on board - including a review of their credit history.) Remember, though, that fees given in exchange for referrals to your new tenant are illegal under Stark rules. Also, remember to always charge the fair-market value for rent, so you don't run afoul of any anti-kickback statues.

Roundup

If the aforementioned options fail to appeal, there are a few more ways to bring in extra cash:

• Try marketing your practice to local businesses as a specialist in worker's compensation physicals and employee drug screenings, including pre-employment testing. (But be prepared for a paperwork parade.)

• Consider moonlighting, or taking extra hours at outside healthcare facilities, including local hospitals or urgent care centers, which pay anywhere from $50 to $130 per hour, depending on your location and demand for your specialty.

• Work smarter. You can boost your profit margin significantly by using resources wisely. You might, for instance, focus exclusively on more complex patients, which are reimbursed at a higher rate, and use midlevel providers for routine care.

• Reduce your no-shows. Try implementing reminder calls (in addition to any automated system) two days before each appointment, says Atlanta-based practice management consultant Elizabeth Woodcock. At the very least, reach out to patients who missed their last appointment, new patients, and those scheduled for procedures. That leaves time to fill their slot if they suddenly have a conflict. "Reducing no-shows by even two a day - or filling those two slots - can equate to $10,000 or more per year in income (not just revenue),”says Woodcock.{C}

As reimbursement falls and overhead costs climb, doctors in all specialties are expressing frustration over having to work harder for the same (or less) pay. One solution is to create supplemental income streams by leveraging your medical degree. It takes an entrepreneurial spirit and, often, a willingness to tread outside your comfort zone, but it also gives you a chance to boost your bottom line - and the personal satisfaction of practicing medicine on your own terms. Hey, it's either that or picking stocks.

In Summary

Consider these ideas for boosting your income:

• In-house pharmacies can add $50,000 or more to your bottom line.

• Most payers reimburse for online consultations, which can be done after hours or as needed to fill in for a no-show.

• Average consulting rates range from $3,000 to $7,000 per day, depending on your area of expertise and type of training provided.

• You can make up to $6,000 a day as an expert witness, but legal work should constitute no more than 5 percent of your income.

• It often pays to sublet unused space. Just be mindful of Stark rules when it comes to referrals.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 12 years. Her work has appeared on CNNMoney.com, Bankrate.com, and Healthy Family magazine. She can be reached via editor@physicianspractice.com.

This article originally appeared in the February 2011 issue of Physicians Practice.