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Brave New Practice

Time to be a Trailblazer!
Trailblazer: a person who makes a new track through
wild country; a pioneer; an innovator: He was a
trailblazer for many ideas that are now standard fare.
Grab you gumption not your ankles!
Gumption: courage and energy; initiative;
resourcefulness: It took a lot of gumption to do a job
that hard. (Of uncertain origin.)

Mission
Preserve Hippocratic, ethical medicine centered on
the patient-physician relationship
Based on Trust- liberating, innovative
Get government out of medicine, forge alternate
universe option to single payer, socialized medicine
Based on Fear, abusive, stagnant
Save the patients, practice, and future of profession

State of Practice
Ophthalmology and Ophthalmic surgery for over 20 years,
thousands of loyal patients with valid, long-standing patientphysician relationships
Combination of office and surgical practice for patients of all
ages spanning 4 generations
Most common operation- cataract surgery which is
predominantly in Medicare population
New technology not covered items or services
LASIK and refractive surgery not covered by insurance

Where I was
Finished residency ophthalmology, joined faculty at UTHSCSA in
Department of Ophthalmology, remained in academic medicine for 5
years. Quality Assurance, CPT, RVUs evolving
Started Solo Private practice, office sharing with established solo
practitioner. Took out $100,000 line of credit. Participated in Medicare
and Medicaid and began entering into agreements with commercial
insurers
Purchased office mates practice in 5 years. Continued office sharing
arrangement. Learned of PQRS at AAO/ASCRS. I resisted- office mate
went all in.
Opted out of Medicaid
Built office building with colleagues and paid it of

Where I was
Obama elected (2008), Obamacare passed (2010)
Changed Medicare status to Non-participating (2009) (58% of
practice was Medicare)
Changed office mate from older phasing out to younger revving
up (2012) (48% of practice was Medicare)
2014- Began to wean of commercial insurance, refused to be in
network for Obamacare plans- fought AETNA for a year
October 1,2015 opted out of Medicare and all 3 rd party
commercial insurance (41% of practice was Medicare)

Transition Process
Understand your practice from
income/expense standpoint
Understand your payer mix- Medicare,
Medicaid, Commercial, Private pay, Charity
Understand 3rd party payer dynamics
Understand healthcare law

Transition
Opt out of Medicaid- provide true charity
unchained
Change Medicare status to Nonparticipatinggets patients and staf used to exchanging $
and seeing what item and services actually
cost/ glimpse of skin in the game

Transition
Evaluate payer mix- Medicare and commercial
Make spreadsheet for top (20) codes and all payers.
Compare high, low, average, Medicare, and your
assessed value for each.
Create your own customized fee schedule
Drop the lowest payer, let things re-equilibrate
Communication with and education of patients is key

Transition
Re-determine what percentage of your revenue and
what percentage of patients come from each payer
Once again, drop the lowest commercial payer.
Notify patients you are committed to them and
encourage them to stay in your care utilizing their out of
network benefits.
Pause, re-equilibrate, reassess, and repeat- until theyre
all gone- let last few go at once

Transition
Negotiate fees with surgery center- Medicare
as reference point
Negotiate fees with anesthesiologist
Create billing models- direct pay v. hybrid
model
Communication key- Letters, follow-up letters,
phone calls, social media, website

Transition
Visit with family
Visit with banker- take out line of credit (I have
a line of credit for $200,000 but have not used
it)
Visit with CPA
Heart to heart with staf- trim, cross train,
cheer lead

Go Time!
Saddle Up!
Follow AAPS Opt Out instructions and abundant
resources and support systems
Opt Out- October 1, 2015 for me. How about you?
Terminate outside billing company (sad,
unintended consequences)

Where I am now
Assess revenue
Assess expenses
Ongoing, relentless education- staf, patients,
colleagues
Copays, cost-sharing, premiums, deductibles, innetwork vs. out-of network, billable vs. allowable,
transparent fee schedule

Where I am now
Seven Months Post Opt Out vs. Seven Months Pre Opt Out
# of Patients

# of Patient Encounters

Gross Collections

Pre Opt Out

100%

100%

100%

Post Opt Out

73.5%

70.1%

93.65%

Total Change

(26.5%)

(29.9%)

(6.35%)

Where I am now
Collections and Billing Service
Gross Collections Billing Expenses

Net Collections

Pre Opt Out

100%

7%

93%

Post Opt Out

93.65%

93.65%

Total Change (6.35%)

0.65%

Where I am now
Post opt Out vs. Pre Opt Out (Billing service effect)
# of Patients

# of Encounters

Net Collections

Pre Opt Out

100%

100%

93%

Post Opt Out

73.5%

70.1%

93.65%

Total
Change

(26.5%)

(29.9%)

0.65%

Where I am now
I am working 30% less and collecting 1% more. My
patients and staf, my family and I are the beneficiaries.
True access and quality care.
How can I sustain and improve this? How can you do this
too?
Current system squandered my potential to care for more
patients.
I miss being in the OR more as a surgeon at this stage of
my career

Where I am now
Medicare # of Patients
Pre Opt Out

Post Opt Out

Total Change

39.8%

29.3%

(10.5%)

Not Medicare 60.4%

70.7%

10.3%

Medicare

Where I am now
Medicare # of Patient Encounters
Pre Opt Out

Post Opt Out

Total Change

Medicare

41.8%

32%

(9.8%)

Not Medicare

58.2%

68%

9.8%

Where I am now
Medicare % of Collections
Pre Opt Out

Post Opt Out

Total Change

Medicare

41.4%

25.2%

(16.2%)

Not Medicare

58.6%

74.8%

16.2%

Where I am now
Medicare Patient Encounters
Pre Opt Out

Post Opt Out

Change

Me

41%

32%

(9%)

Associate
(participating
MC provider)

35.4%

42.9%

7.5%

What I must do
Identify strengths and weaknesses
Why do patients stay? Why do they leave?
Educate self, staf, patients, family
Stay vigilant-aggressively stay abreast of state and federal
laws, rules, and engage- MACRA rules impossible
What are they up to now?
Protect your autonomy and stay out of trouble

What I Must Do
Stay focused on mission
Dont let you feelings or ego deter me
What we do is like nothing else- we are invested in our
patients to our very core- risky business on call 24/7.
Dont undervalue that.
Be a victor not a victim- say no to burnout and abuse
Alternate universe- work with colleagues to be the paradigm
shift, think outside the box, be the lifeboat

Where am I going?
Action Items- stay on top of out of network/ opted out
caveats- secondary vs. supplement vs. replacement vs.
Tricare. Pursue best targets.
Ongoing education of patients, staf, and colleagues
Refine transparent fee schedule
Refine website, social media, letters, phone calls
Branch out- Alt U, Healthsharing ministries, Networking
(Medibid, Doc Cost, local connections)

 My

fees vs. Colleague in general vicinity- hybrid

model
Laser+
Laser+
Laser+
Laser Astigmatism Astigmatism Lens
Multifocal Lens

Medicare Participating Surgeon

Patient must pay this additional $1395$2395
$3845
Fee for non-covered services
Laser and Premium Lenses
My Fee, Opted-Out, including $1200
$1870$2835 Laser and Premium Lenses
*Patient can use Medicare Part B at Ambulatory Surgical Center for facility fee
regardless of whether surgeons Medicare status is Participating, Non-Participating,
or Opted-Out (Private-Contracted).
**Above fees include additional cost of lens to patient.

Pearls and Pitfalls

Set my practice apart- spend $ on innovation over
government compliance and data collecting
Ongoing evaluation of patient trends
New patients? Am I attracting new patients? How can I do
better?
Loyalty vs. the long good-bye. Am I retaining patients? How
can I do better?
Value in relationship vs. entitlement. Am I a partner or a
punching bag?

Happy Trails
Stay focused and vigilant
Protect and Pursue increasing Autonomyprescription writing/ dispensing, MOC,
licensure, physician owned ASCs, contacts
Medical education- future physicians- pioneers
vs. indentured servants, liberty vs. oppression

Happy Trails
Just Do It! Proudly! No one else can do what we do, nor
will they do it for us. Only we are qualified and
equipped. From one rite of passage to the next
Trailblazer
Gumption
It took a lot of gumption for physician trailblazers to resist
the insolvent government takeover of medicine and create
a viable ethical system that puts the patient first.

Thank You AAPS

The Association of American Physicians and
Surgeons is the ultimate resource for private
and aspiring private physicians and the
ultimate protector of the patient-physician
relationship.
Omnia pro aegroto- All for the patient
Encourage all physicians to become a
member.

Contact Information
Kristin Story Held, M.D.
Stone Oak Ophthalmology
325 Sonterra Blvd., Suite 100
San Antonio, Texas 78258
www.Stoneoakeyes.com
www.krisheldmd.wordpress.com (patient letters)
www.Americandoctors4truth.org
Message me on Twitter- Kris Held,MD @kksheld