1. Cash Practice John Cianca, MD

2. 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

3. Background Fellowship trained in MSK Board credentials – Sports Medicine – Acupuncture – Ultrasound Began practice in 1993 – Faculty: BCM Solo practice since 2004

4. 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

5. How I Got Here My academic practice My leap of faith Where am I now Job satisfaction Wealth

7. 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

8. 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

9. 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

10. 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

11. Job Satisfaction Can you be happy or fulfilled as an indentured servant manacled by RVUs?

13. Cash Practice: Guidelines

14. Cash Practice: Can You Do It Area of expertise What is it that you do clinically Established reputation Collegial support Patient referrals

15. 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

16. Setting Fees Fairness vs greed Time Complexity No insurance > less constraints Adjust fee if it seems fair

17. Fees 99201- $175 99202 - $225 99203 - $325 99204 - $350 99205 - $400 99211 - $80 99212 - $100 99213 - $130 99214 - $200 99215 - $250

18. Fees 20600 – 20610 - $85 20552 - $100 20553 - $155 97810 - $90 97813 - $120 0232T - $850 J7325 - $500 76881 - $150 76882 - $50 76970 - $75 76942 - $100

19. 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

20. Patient Filing Super bill with CPT coding and ICD-9/10 codes and charges Walk them through the process Be available for questions

22. 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