A Doctor's Worth

Finance and the PCP

Margaret Curtis, MD — Tue, 28 Aug 2018 01:47:10 GMT

Today a patient told me that when she grows up she is going to be a doctor, a superhero and Elsa. Obviously I have the best job in medicine: I get to talk to kids all day, and my job is as awe-inspiring as "superhero" and "Elsa".

What I don't have is the income potential of many specialists. I spend a lot of time (too much) on physician finance websites and they are by and large populated by high earners: anesthesia, radiology, surgery. The primary care physicians seem to be scarce. Maybe that's because they don't make enough money to invest. (Says my husband. Urologists are hilarious.) Maybe they are too busy undergoing what a colleague calls "death by a thousand well-child checks". Or maybe those of us in primary care haven't learned what our more procedure-based colleagues seem to know already: that being an excellent physician and being financially savvy are not mutually exclusive.

The culture of service that exists throughout medicine competes with the culture of prestige attached to highly specialized fields. The greater prestige is paired with higher salary and no one could be blamed for thinking that those of us who go into primary care are a little dim. I won't go into the value of primary care, to our patients, to society and to the specialists who wouldn't have referrals without us (you're welcome). I also won't go into the absurdity of paying pediatric specialists the same as or less than general pediatricians, despite their 3 years of fellowship and literally life-saving skills. I will save those topics for another time and talk about how primary care physicians can be smarter with their money.

The paucity of PCPs on the personal finance scene is ironic, because we need to shepherd our assets even more carefully than the specialists. Doctors of any stripe can (and do) blow their money in foolish ways, but $600,000/year offers a lot more leeway than $180,000. Surgical specialists, radiologists and anesthesiologists (among others) also have opportunities for auxiliary income, such as ownership in surgical centers and imaging centers, that aren't available to primary care doctors thanks to Stark Law. Good thing my patients are so cute.

So here are some ways those of us in primary care can be as savvy as our colleagues:

-negotiate like you mean it. Remember, the medical system doesn't work without us.

-know your contract, know how you earn a bonus and then do it. If you need help maximizing your billing, use some CME money for a coding course, or ask someone from the compliance office to sit down with you. Don't leave money on the table.

-learn to do procedures that you commonly refer out, such as placing long-acting contraceptives. If these are considered within your scope of practice and are covered by your malpractice, you can build a more procedure-based practice.

-if you supervise residents or midlevels, make sure you are paid adequately and/or are capturing appropriate RVUs.

-change the culture. Not just the culture that says that primary care isn't prestigious or intellectually rigorous, but the one that says we PCPs are too pure of heart to think about money. We can be pure of heart AND think about money.

Pediatricians have bills to pay, too. Unlike superheroes and Elsa.

Addendum: before anyone tells me that superheroes come from all walks of life, let me say two things:

1. I have a teenage son at home and have seen enough Marvel movies to be a near-expert. That is how I know:

2. Superheroes are either independently wealthy (Ironman, Batman, Black Panther) or attach themselves to someone who is (Antman). Those suits don't come cheap. Those of modest means (Spiderman, Deadpool) get their powers via some ghastly exposure, and they have to slave away at menial jobs while saving the world - much like a PCP. My analogy has now come full circle.

How To Feel Like A Have, Not A Have-not

Margaret Curtis, MD — Sun, 27 Mar 2022 13:35:50 GMT

In March 2020 I wrote my last blog post, about the impending wave of COVID. The last two years – almost exactly – of turbulent water under the bridge have taught us many things, gratitude most of all: gratitude for the health we have, for family and the friends who count as family, for meaningful work that keeps us grounded. So I thought a post about gratitude would be a fitting re-entry entry.

In March 2022 I travelled with my family to Jackson Hole, Wyoming. We wanted a family vacation, our first in almost three years, and I wanted the kids to see one of my favorite places in the world.

I lived in Jackson for a few years between college and medical school. I worked three jobs, tried to ski a big mountain and generally blew off steam from my East Coast upbringing. I knew at the time that I wouldn’t be able to buy a home there, and I hope I didn’t spend much time complaining about it. I mostly just couldn’t believe my luck at living in one of the most beautiful places in the world. Jackson is an easy place for someone in her twenties to have a good time.

Jackson is also an easy place to feel like a have-not. That was true twenty years ago when houses sold for $1 million, and is even more true today when the same houses sell for $5 million. Wealth and conspicuous consumption are everywhere. But I wanted to enjoy the time we had in the mountains rather than fret over what I don’t have – in Jackson or anywhere. So how to maintain a sense of “enough” in a world that is always suggesting we should want more?

This view is free

First and most obvious: count your blessings, as often as you can. Remember that experiences bring more joy than possessions. Learn cheap hobbies.

Don’t confuse the trappings of wealth with actual wealth. Re-read The Millionaire Next Door if you aren’t sure what I’m talking about.

Finally, surround yourself with those who think like you do. I don’t mean you should only be friends with people who earn less than you do – that would be a creepy way to choose your friends – but you should (mostly) be friends with people who also count their blessings. Be especially wary of anyone who says “must be nice….”. That phrase has never been followed by anything but grasping and jealousy.

If your friends enjoy your cheap hobbies and joyful experiences, you will be able to count them among your many blessings.

Relative Value

Margaret Curtis, MD — Sat, 28 Mar 2020 15:05:57 GMT

One week ago the first case of SARS-COVID 19 was diagnosed in my state, at my hospital. The next day, I sat in my office looking out the window at the bright yellow tent erected outside the ER entrance to triage and test potential new cases. I wore scrubs and a face mask at work for the first time in years. Like the rest of you, I thought about the wave that was about to break over all of us.

Practice since then has felt like running, tripping and stumbling, on a treadmill that keeps accelerating. The pace of change has been breathtaking and it still isn't fast enough, because our opponent got a head start on us. We are hobbled by our lack of knowledge, equipment, foresight, and by the the very business of healthcare.

As hospitals have pivoted to a wartime model, they have had to stop all elective procedures and outpatient visits. Suspending elective care saves resources and protects our patients (and ourselves) from exposure. This has been absolutely essential, and financially devastating, especially for smaller and rural hospitals that already exist on a knife edge of financial viability.

Ideally we would also furlough essential workers - not just doctors and nurses but respiratory therapists, rad techs, support staff - to keep teams healthy and ready to fill in when front-line teams are exposed and quarantined. We haven't seen our way clear to doing this. Instead, staff are going without pay, hours cut, redeployed or losing their jobs.

I consider myself incredibly fortunate to have a job when so many don't. Many physicians in private practice are wondering how they will keep their clinics open. They have lost their livelihoods. I also am fortunate that I can be of use, and like many others I want to do more.

They also serve who only stand and wait. Like many other outpatient physicians, my clinic days are now filled with answering phone calls, managing my own and my colleagues' overflowing inboxes, strategizing with staff and learning everything I can about COVID - including brushing up on my vent management skills (1). There is not CPT or E/M code for any of this.

I also try to fill an even more essential function: I keep my patients out of the Emergency Department. I manage their acute infections, their mental health crises, their minor traumas so they don't spiral and require admission to the hospital. I am not on the front line, but I am supporting the flank. According to the system we use to pay for physician care, none of this has any value. This was evident even before this viral pandemic: we pay for action, intervention, risk and Hail-Marys. We don't pay for patience, wisdom and prevention.

I am here. Send me. While we in the outpatient clinics watch our practices dwindle, there are physicians and practitioners in EDs and ICUs who are busier than they ever wanted to be. They are also risking their own and their families' health. No amount of compensation could be enough. What is the Relative Value of an anesthesiologist who volunteers for a hospital "intubation team", knowing she will be tasked with the procedure that puts her at highest risk of contracting SARS-CoVID19? Or every single healthcare provider who reports to work with inadequate protective gear? Or the hourly-wage employee who cleans the room where a COVID-19 patient has died? There is no metric that applies.

This experience has been entirely transformative, on every level. I hope and believe we will emerge with a new appreciation for community, connection, health and freedom. I hope we also learn a new appreciation for what is most valuable in doctoring, and is beyond measure.

(1). I have now read two references (in the New York Times and our local paper) to "pediatricians might be pressed into service in the ICU!" as if a. we aren't already busy taking care of sick people and b. we aren't actual physicians. But that is a rant for another time.

When You Don't Know What To Do, Do The Work In Front Of You

Margaret Curtis, MD — Sat, 14 Mar 2020 16:25:40 GMT

I don't know who first said this. I have seen it attributed to Calvin Coolidge, the Buddha and a Christian missionary named Elisabeth Elliot. There is probably a refrigerator magnet with this saying on it available for purchase somewhere. I think of it quite often, when I am feeling overwhelmed with tasks, needs, wants and decisions. Start with what is literally in front of you - the kitchen sink, the in-box, the patient who needs your undivided attention - and your next steps will start to declare themselves to you.

If you don't know where to begin in understanding personal finance - and none of us do, at first - start where you are. And if you don't know even know where that is, I would like to place two tasks in front of you.

The first is to read a book called The Millionaire Next Door. This book will change how you view wealth.

The second task is to track your spending. I did this by downloading credit card and bank statements and creating an Excel spreadsheet, although there are plenty of free templates you can use instead. The important thing is use a system that is intuitive to you and simple enough to go back to multiple times, because you will. When I first laid out our spending years ago the process took many hours spread out over at least a month. Now when I go back to revise the numbers I can do so in a few minutes. This is, in my opinion, the absolute essential first step in mastering your finances. All the investing acumen in the world is worthless without knowing where all the money goes. You will probably find some surprises and some expenses that you didn't even know you had. I certainly did.

Speaking of Quiet Cal,

“There is no dignity quite so impressive, and no independence quite so important, as living within your means.” ― Calvin Coolidge

In Which I Negotiate Like A Man

Margaret Curtis, MD — Sun, 10 Nov 2019 20:52:39 GMT

My husband recently reminded me that I have not yet received my sign-on bonus - for the job I started 8 months ago. Which I was not initially offered and had to ask for. Which is included in my contract, which I also had to ask for. Since he knows there is a fine line between supporting and micromanaging, he was struggling to find the right words until he finally blurted out:

"A man would never put up with this."

That got me on my horse like nothing else. The next day, and almost every day since, I have been calling, emailing and even showing up at HR to discuss my errant bonus. Person who cuts checks is out today? I'd like to speak to whoever is covering. This has to go through legal for a promissory note? Sure, I will call over there. Promissory note has the wrong date on it? Try again, please and thank you.

And my gentle persistence and insistence that I get the sign-on bonus that every other new employee gets - worked . A mere 8 1/2 months after starting, I have my check in hand. (It will go straight into the high-yield savings account, and every year on the anniversary of my hire I can transfer another third into a taxable investing account. After three years of employment it's mine free and clear).

Being paid according to the terms of my contract may not seem like much of a victory, but for me it is. I went up against a bureaucracy that is not set up to look after my interests, and I did it with calm and efficiency.

I don't know if this is truly "negotiating like a man". I do know that the training young women receive, that is reinforced at every level of our education, to be conciliatory, self-sacrificing and pleasant can leave us with pretty poor negotiating skills. Adopting an attitude of healthy entitlement got me a lot farther than "going along to get along" or, the opposite, walking into negotiation with guns blazing. Those are the two extremes that someone who has been taught to avoid conflict tend to fall back on. I have tried both and neither has served me well. If I have to borrow calm assertiveness from a (fictive, stereotyped) male until I actually have my own, so be it.

Even better than a check is a check plus another patina of professional confidence overlaid on the old ones. And the timing couldn't be better, because not long after getting my bonus I got an email about a reassignment of exam rooms in my office. I think this will go well.

Some Good Relationship Advice

Margaret Curtis, MD — Sat, 22 Jun 2019 22:02:16 GMT

"Choose the right person" is the best relationship advice I have never heard. If you are in a relationship with someone who just isn't your match, I don't have much to offer you - sorry. If, however, you know your partner is the right person for you, and your goals and values generally align, then the odds are good that you will be able to figure the rest out.

Even so the two of you will probably struggle with money. The only way I know of to avoid any financial conflict is to have essentially infinite funds or have one partner make every single decision. The first only works if you have Saudi-oil-level income (and maybe not even then) and the second is a recipe for disaster - just ask anyone who has woken up to find that their ex emptied the kids' piggy banks and left.

Some couples do an end-run around this problem by keeping their finances entirely separate, but unless you plan to live in separate houses, too, this won't keep you from the tough conversations.

My next best piece of advice is to figure out where your partner got his/her attitude toward money. Someone who grew up with not-enough may need a certain amount in the bank to feel secure, or may have a weakness for buying some particular item(s) that represent safety. My kids mostly wear hand-me-downs, but they sleep under down comforters and brushed-flannel sheets. By the time I could get to the bottom of this in therapy the kids will be out of the house, so my husband just accepts this as the cost of being married to me.

The alchemy of personality + life experience with money creates some very strong habits. We can all change these habits, but it takes some work. While your partner is working on their own attitude, you can work on yours.

It also helps to understand how your partner sees money. I work better on the large scale, and watching the nickels and dimes makes me slightly anxious. My husband finds the micro-finance comforting. He likes to think of money in separate “buckets”, I have one big mental “bucket”. Since the goal is to be more than the sum of our parts, we try to play to each of our strengths.

And a few more things I have learned along the way:

1. The only people whose opinion matter are you and your spouse. Don't bother to make a budget/buy a book/solicit advice from people online and show it to your spouse. No one has ever been won over by "everyone on this forum says I’m right.”

2. Listen to yourself first and last. If you feel uneasy, either you need to educate yourself more or you need to make changes.

3. Financial problems aren't really about money. They are about attitudes, control, fears, you name it. Money just adds stress to the fault lines that already exist in any relationship.

So, if you and your Perfect Match are going around and around about the same money issues, you may need to stop talking about money, and starting talking about everything else - with the help of a good therapist if need be. The money stuff will still be there when you are done, and you will be all the better for it.

Bouncing Back and Bouncing Forward

Margaret Curtis, MD — Sat, 20 Apr 2019 17:40:20 GMT

I applied three times for employed physician jobs at the institution where I did my residency. Twice I went through the interview process and was subsequently told I didn't get the position. The third time I submitted my name I wasn't offered an interview.

The fact that I cringe writing that - and that I will now quickly tell you I have two Ivy degrees, won a teaching award as a resident and passed my boards first time out - says a lot about me and the physician culture. About me: I am pretty sure even my facade isn't good enough. About physician culture: if you aren't going from triumph to triumph, you are not one of us and you should just call your mom right now and ask her to pick you up.

Neither of these attitudes allow any room for the inevitable twists and turns of life and career. They also don't allow much room for personal growth. Most people applying for jobs expect a certain number of rejections; they even see rejection as it's own form of success. Like I told my kids when they were learning to ski: if you never fall, you aren't trying anything hard. And if you never try anything hard, you won't get better.

But it is still easier to tell our kids and our friends that than it is to tell ourselves. I don't have a magic solution to dealing with rejection when you/we are deeply invested in feeling successful, but here are a few steps that can only help:

1. Go easy on yourself. Forgive yourself for the time you spent post-rejection watching time-lapse videos of people frosting cupcakes. Tell your perfectionist voice to pipe down for a while.

2. Remember: it's not you, and it's not me. It's Us. Many terrific people don't get terrific jobs because they aren't the best fit for that position, or that culture, or that moment.

3. Reflect but don't wallow. Ask for feedback and then decide if you can or should make the changes required. I spoke to everyone up to the CMO at my residency program, and the only feedback I received (from the CMO) was that I am "something of a maverick". (That actually made me laugh so hard coffee came out my nose.) Something to do with how I prescribed azithromycin one time - so, not something I am can use to better myself or my practice. That said:

4. If you are at a party and more than one person tells you that you're drunk, it's time to sit down. Applying to the same institution after getting rejected was understandable - it was for a different job - but applying the third time was just asking for it. If you have failed to match into a certain speciality, or not succeeded in running your own practice, maybe you don't need to just try harder. Maybe you need to try something else.

Now I can report that I have a wonderful job. I am supported, respected and believe I am of service to my patients and my group. Getting from there to here took several years, plenty of self-doubt and self-reflection, and one not-so-great job. But now I can honestly say it all got better.

My Life As A Stock Picker

Margaret Curtis, MD — Sun, 14 Apr 2019 01:50:06 GMT

About four years ago I started listening to a podcast on value investing. Up until then, my view of the stock market had been largely shaped by watching my father squander his inheritance - literally millions of dollars - day trading. He died almost penniless and I steered clear of anything close to active investing. I kept my money in mutual funds with the word "stable" in the title. When I got married, I turned my employee retirement funds over to an investment manager at a large bank that my husband had been using. I slept well at night.

I started listening to the podcast, therefore, on a whim. The host walked slowly through investing in the style of Warren Buffett and Charlie Munger and explained how they value companies and decide when to buy. I was fascinated: I had never known that equity investing could be approached rationally. I listened to every single podcast, some multiple times, and I bought the book. I started doing research on individual stocks using this particular pundit's methods. I kept a watchlist of stocks that I would buy, and at what prices.

If you have been paying any attention at all, you know that we are in a historic bull market. Stocks in general are expensive, and it is hard to find a bargain that Warren Buffett might approve of. I did find one company, a medical supply manufacturer which met all my criteria, and I pulled the trigger. I bought 10 shares.

Still there was one part of my podcaster's system that I just couldn't figure out. No matter how many times I listened to him explain it, I couldn't fit his formula for buying and selling into a logical framework. Then I realized: it was a gimmick. Because it is hard to make money (or sell books) touting "buy good companies and hold them forever", he had devised a quasi-mathematical formula for when to sell. Not Buffet-worthy at all.

So I kept reading. I found the Bogleheads and I found physician-specific websites. I read "Heads I Win, Tails I Win" and Berkshire Hathaway stockholder reports. Everyone said the same thing: put your money in index funds. Investing in entire markets and avoiding high fees is eminently logical. Even better, it requires minimal research and effort: more time for my day job.

So when I moved my retirement accounts back to my own control (which is a story for another day), I painstakingly sold every investment I didn't understand and put the money into index funds in my desired asset allocation. (This process took longer than it might have because after every trade I hit the "how did we do? thumbs up" button. I want people to feel good about themselves.) Now my retirement accounts fit my financial plan: simple, understandable and low-maintenance.

I am officially retired from stock picking. I have moved on to other podcasts and other reading. That stock I bought? As of today it's up 66%. If I didn't know better, I would say stock-picking was easy.

Calculating Your Hourly Wage

Margaret Curtis, MD — Wed, 30 Jan 2019 15:14:23 GMT

You may have heard this logic: "I get paid $150 per hour as a physician, so it doesn't make sense for me to mow my own when I can pay someone $15 per hour to do it". You may have even used this logic yourself. There are two problems with this line of reasoning:

The first problem is that it is a short, slippery slope between paying $15/hour for gutter cleaning and paying $160 for a cut, color and blow-out that takes two hours. These expenses add up fast and before you know it you are digging a hole.

The second problem is that the math is faulty. Let's figure out your actual hourly wage:

If you are a family physician making $225,000 per year (about the national average), working 32 hours per week your hourly wage is $145.63. Of course you probably work more than that, so your hourly wage is actually lower, but we will start there.

Now subtract your taxes. If you max your contribution to a 401k or 403b, your taxable income will be 205,000 (taxes are also more complicated than this, but bear with me). We will estimate 24% federal (a moderate estimate), 5% state (low to moderate) and payroll tax: Social Security tax is 6.2% on the first $128,700 of income and Medicare tax is 1.45% of entire salary. That gives us:

Federal tax $49,440

State tax $10,3000

Social Security $8,240

Medicare $2987

Grand Total $70,967

Your after-tax hourly wage is $84.40. Fingers crossed you don't have to pay the Alternative Minimum Tax.

Do you have student loans? Paying these is obligatory, and paying off the average medical school debt of $200,000 at 4% interest over 10 years will cost roughly $2000 per month. You are down to $69.40 per hour.

Now subtract out those doctor-specific expenses: CME, MOC, occupation-specific disability insurance, extra childcare when you are on-call. What you have left is what you can use to buy food and pay for housing. Mowing your own lawn is starting to look better and better.

As time goes on you will be able to save more of what you earn, and you might decide to start outsourcing more chores. Or you might not. At least you will know your math is right.

Money Management for Couples: Joint and Individual Accounts

Margaret Curtis, MD — Sun, 20 Jan 2019 23:17:27 GMT

My husband and I have always shared all our money and owned our property jointly. Only our retirement accounts are individual, because legally these can only have one owner. I even gave him a 49% ownership share in the Best Dog Ever, the one that preceded my husband (you will note I kept a controlling share).

I am a staunch believer that women should have full knowledge and control over their own money, but it never occurred to me that my husband and I would keep our finances separate after we got married. We did this because that’s what our parents did and because we assumed marriage meant merged assets - and neither of those is a particularly good reason.

There are good arguments both for and against separate accounts for couples. There are also circumstances in which asset ownership matters a good deal. (note: I use the word "marriage" frequently here, but this goes just as much for long-term relationships. I also do not assume opposite-sex or same-sex.):

Separate and Equal: reasons to have individual accounts

1. Protecting assets. Like a prenup, separate accounts can protect what you bring into the relationship. This is especially important if either of you has kids, has been married before or has spent a long time in the workforce building up assets.

2. Autonomy. Some people, by temperament or training, need to have control over their own money. All of us should know where our money is and how to access it in an emergency.

3. Fairness. Some couples split shared expenses down the middle, but in cases of income disparity (as with a physician and a non-physician) it is common to contribute in proportion to one's income. Actually, joint accounts do exactly the same thing, but if separate accounts make you feel more certain of the fairness of your arrangement then so be it.

What's Mine Is Yours: reasons to have joint accounts

1. Simplicity. Trying to keep track of twice the number of bank accounts would drive me to drink.

2. Transparency. One partner's spending is less likely to reach disastrous proportions - as long as the other partner is paying attention.

3. Fairness. We contribute equally to the household in money+time. Most of what we earn goes to savings, daily expenses etc, and we each have a small, equal amount of "fun money" to do with as we please each month. This arrangement seems fair to us.

You will notice that "fairness" can be said to apply to either arrangement. You will also notice that I did not bring up "trust". Pooling your money is an act of trust, and so is ceding complete control to a partner of money you may, presumably, need to rely on. You can define "fairness" and "trust" in ways that seem most reasonable to you. And to make any of these work, you still have to understand your and your household's finances. There is no arrangement that relieves you of this responsibility. I do more of the money management, so I regularly update my husband and I keep detailed records of where it all lives, for him and for our estate executor.

Of course there are more than two options: you can decide which assets you title jointly and which to keep separate. Here are a few specific areas to consider:

Debt: student debt cannot be discharged in bankruptcy so be cautious before signing someone else’s loans or taking out loans on behalf of partner - say, because you have a better credit score or a better chance at loan forgiveness.

Credit: there are ways to get out of credit card debt without dying. But any late payment or default will affect your credit score as much as your partner’s. Having a credit card in your name only is an easy way to protect and improve your own credit history, and could be crucial if you need to exit the relationship.

Property: owning property as joint tenants in common can shield it from medical malpractice lawsuits. With property, joint ownership is actually protective. But, the same holds true for late mortgage payments as for late credit card payments - your credit will suffer even if you were not at fault.

Last, I disagree with the notion that keeping your money separate gives one a mental "out" from a relationship. Legal marriage, children and home ownership are mighty barriers but marriages still end, so individual bank accounts are probably not determinative. Or to put it another way: if lack of access to your own money is keeping you in a relationship, then that is a relationship you need to get out of. Joint everything has worked well for me and my husband, but if you want to keep your money in your own name - because it makes you feel better, because you have a different style with money than your spouse, because your grandmother told you a woman should always keep a spare $20 in her purse - then go right ahead.

5 Ways To Get Rich In Primary Care

Margaret Curtis, MD — Thu, 17 Jan 2019 15:14:32 GMT

I have heard of primary care doctors retiring with an eight-figure net worth (heck, we have all heard of secretaries retiring with an eight-figure net worth) so it certainly can be done. This is not the norm, but there is no reason PCPs can't achieve financial independence.

1. Go to inexpensive schools. Going to your state medical school and graduating with low or no debt lets you hit the ground running. This is especially true if the alternative is a foreign medical school paid for with private loans. At a certain level of debt, not only will it be difficult to get ahead as a PCP, you may not even be able to break even.

2. Take advantage of the additional loan repayment programs available to you. Some loan forgiveness programs are primary-care-specific (NHSC scholarships, many state programs) and some have a much greater demand for PCPs because of the populations they serve (Indian Health Service, many more state programs).

3. Go into private practice. This pains me to say, as I have so much respect for academic docs and teachers, but from a strictly financial perspective private practice is the way to go. Negotiate your job contract wisely and maximize your income.

4. Live somewhere cheap. I don't know how a family doc in the Bay Area or Manhattan makes ends meet.

5. Define "rich" for yourself. You may not be able to afford the lifestyle of your classmate who became a Mohs surgeon (and maybe she can't either). But you can certainly have a home, meet all your needs and some of your wants, and retire comfortably. Happiness is not having what you want, it's wanting what you have.

Work Smarter, Not Harder: Coding Routine Visits

Margaret Curtis, MD — Fri, 11 Jan 2019 00:59:05 GMT

Routine visits pretty easy to code, bless 'em. Just pick the right category and you're done.

Except you might be missing all the additional work you are doing for your routine visits. For example:

-applying fluoride varnish (99188)

-scoring and documenting MCHAT (96110) or PHQ9 (96127) tests

-chart review (99354 and 99358)

-transitions of care (99495 and 99496)

Your state Medicaid and private insurers may disallow some of these, or may require a modifier like -25 or -59.

You can also bill for acute care that you perform during routine visits. The additional care must be medically necessary: usually this means something a patient would have made a separate office visit for. You have to include documentation for both the routine and acute care in your note - for example, all your usual physical exam points plus 2-7 for the acute visit. You may also need to “unbundle”, or separate out, the preventive care and acute care services you provide during the same visit.

You “unbundle” services by attaching a modifier to one of the codes. The modifier provides additional information and signals that the additional service you provided was significant and separate from the routine visit. The most commonly used modifier in primary care is -25, which separates routine care from the separate care give for the acute issue. Attach modifier -25 to the routine care code (most EMRs have a drop-down menu or check box for modifiers).

In general, the highest you can code in addition to a routine visit is a level 3 (99213 or 99203) because you can't document enough separate PE and ROS points to justify anything higher. You also can't bill for time spent to justify any level of acute care, because a certain amount of time is already assigned to a routine visit.

Some insurance will pay for both acute and routine care in the same visit, in which case your patient may be happy to have only one one trip to your office and one co-pay. If insurance won't cover these two codes together, patients may prefer to have two separate visits, one for routine care and another to address additional issues. It's worth bringing this up with your patients before addressing their "oh and by the way" concerns during a routine visit, so they won't be surprised when they get their bill for services.

Coding is complex - so much so that even professionals can get lost in the intricacies - but you only have to learn a small segment. If you can give yourself a raise, or more clout in your workplace, by learning these steps then the time spent will be worth it.

More resources:

AAP:

Coding for Pediatric Preventive Care 2018

Coding for Medical Home Visits

Specific Criteria Must Be Met To Use Prolonged Service Codes

Confessions of a Pediatric Practice Management Consultant

AAFP:

Four Coding and Payment Opportunities You Might Be Missing

Are You Getting Paid for Non-Face-to-Face Prolonged Care

Understanding When to Use Modifier -25

Should You Modify Your Use of Modifiers?

You Are A Better Investment Manager Than Your Investment Manager

Margaret Curtis, MD — Mon, 07 Jan 2019 22:12:58 GMT

If the low returns and high fees of mutual funds haven't already convinced you to manage your own money, here are three more reasons you don't need a professional to invest for you:

1. Their results are evaluated quarterly. If they try to ride out a downturn they will have angry investors on their hands - or they might be out of a job. In a bear market, their smartest move is to move into less volatile investments such as bonds, which means they can end up selling low. In other words, they don't have the luxury of taking the long view.

2. Their interests may not align with yours. The Expense Ratio for any fund includes both a management fee and fund expenses, which includes the costs of buying and selling stocks. These expenses come out of your returns, not the fund manager's pay. The fund managers have no incentive to minimize turnover (buying and selling equities), but you do. High turnover is both expensive and associated with poorer returns over time.

3. Big funds aren’t nimble. Funds that own a significant stake in individual companies have to buy and sell incrementally or risk changing the price of the very equity they are trying to move. Warren Buffett isn’t a fund manager but owns enough stocks to essentially be one. He famously held on to shares of Coca-Cola when the company was underperforming because, as the owner of 9% of Coke’s stock, if he had sold he would have caused the company and maybe the entire market to tank. As an individual investor, you are nothing if not nimble. You can rebalance, change asset allocations and tax-loss harvest at will. (Which are not the same as turnover. And if you don’t know what these terms mean, don’t worry. You will get there.)

Next time you read an article on why professionals make the best investors, employ a healthy skepticism and remember that you are the best manager of your own money. (And if you don’t believe that yet, you will get there too.)

3 Reasons to Pay Your Student Loans Early

Margaret Curtis, MD — Fri, 04 Jan 2019 10:13:24 GMT

I know better than to join in debates on social media, but sometimes I just can't stop myself from wading into the fray. The gist of a recent discussion on a forum for physician finance:

Post: I have a bunch of student loans. Should I pay them off early?

Respondent #1: No! Just pay the minimum every month! Live Life To The Fullest! Who cares if you still have student loans when you are seventy!

Me: You will care if you still have student loans when you are seventy. You will care a lot.

I was then dismissed as an old biddy who does not Live Life To The Fullest. But my advice about the student loans was spot on. Here is why:

1. Having a monthly debt payment is psychologically draining. If you pay the minimum every month you will never have the satisfaction of watching your loan principal shrink. Even the most debt-inured will get tired of this year after year.

2. Student loan debt will keep you tied to the wrong job or the wrong place. If that's frustrating when you are 30, it's devastating when you are 70.

3. Most importantly, as long as you are carrying student loans, compound interest is working against you rather than for you. For example:

If you have $200,000 in student loans (which is actually below the average), paying 4.8% annually (again, below the average for private loans) paid over a term of 20 years, you will end up paying $311,500, which includes the original principal plus $111,500 in interest. Stretch it out even longer, say to 30 years, and you have paid $177, 759 in interest.

Now imagine you paid off your loans early and invested the saved interest. How much could you earn? $100,000 invested conservatively over 20 years comes out to ...a lot of money, but since you won't actually get to invest all that interest money you saved in one lump sum, a more realistic model is this: imagine you pay off your loans in 10 years, cutting your interest payments by more than half to $52,217. As soon as your loans are paid off you invest your monthly payments of $2,101 per month. Over the next ten years, if you get a 4.8% growth rate (a conservative estimate, and the same as the rate you were paying on your loan), you will end up with $317,365. Even if you only invest the amount you would have paid toward interest ($435/month), after ten years you would have $68,243. You come out $16,206 ahead instead of $111,500 behind. You might actually be able to retire.

So, Respondent #1, that is why you were dead wrong about student loan repayment. And for the record: I am a middle-aged biddy, and I am more than halfway through season 3 of the Great British Bake-off. Life to the fullest, indeed.

Work Smarter, Not Harder: Coding Acute Visits

Margaret Curtis, MD — Thu, 03 Jan 2019 23:00:09 GMT

I am convinced that most primary care docs bill less than they could. We do this because we never learned how to code, because we are overwhelmed by the whole system or because we think we are less likely to be audited if we just bill a level 3 every time.

The first two reasons can be fixed, and the last one is incorrect: You are more likely to be audited if your (or your practice's) "CPT profile" shows an unusual distribution of CPT codes. If you predominantly bill one level, someone reviewing your billing might assume your bills do not reflect the work you performed. Accurate billing, with correct documentation, is "safer" than underbilling.

Accurate billing also pays better. A 99213 is worth 0.97 RVUs and a 99214 is worth 1.5 - more than 50% more. At $35.99 per RVU in 2018, that's a difference of $19.09 per acute visit. Eight acute visits per day, four days a week = $610.88 per week you are leaving on the table when you bill a level 3 for what was actually a level 4. If you billed a level 4 for a visit that met criteria for a level 5, you miss out on $52.90.

To be clear: I am not talking about billing for services you did not provide. This is called "upcoding", which is fraudulent and illegal. I am talking about coding and billing correctly for work you are already doing. First, acute care:

If you are like me you have one of those laminated cards in your office, the one that is covered on both sides with multiple text boxes that say "2 of 3 are necessary.." and "8 of 10 OR one of the below and 7 of the above..."

Someone gave you one of these cards during orientation and you haven't looked at it since because you have suffered enough. Also, you are busy.

Here's my advice: put that card somewhere you can find it, and make your own. Simplify the rules down to the point where they make sense to you and then start using them. Here is the card I have taped to my computer:

I primarily bill based on Assessment/Plan (Medical Decision-Making in coder's language). This works for me because my HPI, ROS and physical exam consistently meet or exceed the requirements (and if they didn't, I would make those parts of each visit more consistent). Most of my patients are established, so I only need 2 out of 3 criteria in Medical Decision-Making. Most of the time I use the "diagnosis" and "risk" categories, which usually correlate well with each other. (If I need to use “risk” as one of the three elements of MDM it is usually chart review plus labs or X-rays). Now I only have to know criteria in those two categories to code appropriately. If I'm unsure, I pull out the big laminated card and double-check. The categories you rely on may be different, but the goal is to have as few variables as possible.

You can also code for the add-ons that often come with an acute visit. The patient who walked in to clinic and disrupted the afternoon’s schedule? That’s a 99058, services provided on an emergency basis. Interview a patient or caregiver to assess risk? 96160, health risk assessment. Coordinating care for a patient recently discharged from the hospital is a 99495 (moderate complexity) or 99496 (high complexity). Not all insurance companies will pay for all these codes, but you will still be able to maximize your collections for work you are already doing.

If you aren't confident in your system, run it by someone. Ask for a coding audit (if you are an employed physician with a billing department, ask for an audit with a CPC. If you are self-employed, consider hiring a firm to do an audit for you - better than waiting to be audited by CMS). Check the resources below:

Three Billing Codes Physicians Should Use

AAP: Coding Tips

AAFP: 99213 vs 99214: Three Tips for Spotting the Difference

Once you feel ready to use your system regularly, you will find that coding gets much, much easier. Maybe you will earn more money (here's hoping), or at least have leverage when it comes to your next contract negotiation.

Next: Coding Routine Visits.

Many thanks to Lydia Siegel MD MPH for sharing her resources about coding and billing.

When You Are In A Hole, Stop Digging

Margaret Curtis, MD — Sun, 30 Dec 2018 21:10:59 GMT

This is a frequently used phrase in my house. It means “if you are in trouble the first thing you should do is stop doing what got you into trouble“. In context, this might be: you were just told by your parent not to act like a caveman at the dinner table, so now is not the time to make fart noises to lighten the mood.

How this applies to your career and your money:

If you are in the wrong job, fix it or get a new one. You can work on these at the same time: change what you can and send out CVs at the same time.

If your private practice is foundering despite your best efforts, then close up shop and find a job. Better a month too early than a day too late.

If you can’t make financial headway, spend less. Just earning more isn’t the answer: if you live beyond your means the hole will just keep getting deeper. Stop digging.

Lastly, one for finance writers: not one more comment about how doctors’ wives like big houses. Or how there is no pay gap in medicine because every appy pays the same. Not one more. Or you will have to leave the table.

Getting Good Advice

Margaret Curtis, MD — Thu, 27 Dec 2018 21:07:10 GMT

Physicians have a reputation for being bad at managing their finances. The reasons are many, and include: years of delayed gratification; high debt loads; starting our working lives late; our own and other’s expectations.

It also has to do with how we are trained to evaluate information. This article makes an interesting point: physicians are used to exchanging information freely and without bias. The hidden agenda of a salesman may take us unawares. Our motto is “see one, do one, teach one”. Theirs is “those who say don’t know, and those who know don’t say”[1].

I also think we assume that a fellow professional has special knowledge. Professional medical culture has taken this to an extreme – the consult – in which we take the advice of a complete strangers without a single grain of salt. When we see the trappings of professionalism – a nice office, a suit, confidence – we assume competence and integrity[2].

So how can a smart and trusting physician, who never studied finance and isn’t even sure where to start, know if she is getting good advice? I think the single biggest question to ask when you are interviewing a potential advisor is, “what’s in it for you?” (maybe not in those words, exactly). Does the person in front of you have any conflicts of interest? is he paid on commission, employed by a financial products company, needs capital but has been denied a bank loan? If so, you should find a new advisor, or at least get a second opinion.

If you are getting advice from someone with a fiduciary duty, who is paid only by you, you can feel more confident. You still have to educate yourself so you can vet their plans. Even fiduciary planners can wander off the straight and narrow or come up with a really kooky idea. Trust but verify.

The other people who will give you straight answers are total strangers on the Internet. Of course the Internet is full of crackpot theories – I know this just as well as every other doctor alive today. But entire groups of people who have knowledge and nothing to gain are at your fingertips.

At least two excellent groups exist: Bogleheads (index investing, budgeting) and the White Coat Investor (physician finance). (Note: The White Coat Investor also exists on Facebook, but I have found both questions and answers there to be less educated and less thoughtful - I recommend sticking to the WCI forum.)

You have to be educated (again!) so you can pick out the real outliers. Then you can post the particulars of your own situation and be confident that you are getting unbiased opinions back. Post your budget. Post your financial plan. You may get some answers that are downright rude (this is still the Internet) but you can be sure they are honest.

Once you start getting good at this, you will even start offering other people advice. And it will be excellent.

[1] This is an actual saying. It means, “don’t act on hot stock tips, because anyone with real information will keep it to themselves”.

[2] If you really want to get scared, watch “The Big Short”. It will make you want to build a bunker and bury gold under the floorboards.

Lack of Fit and Bias in Medicine

Margaret Curtis, MD — Mon, 24 Dec 2018 09:13:55 GMT

FemInEM, a group of women docs in emergency medicine, does one of my favorite podcasts and hosts an annual conference called FIX (FemInEM Idea Exchange). I have been trying to go for two years but honestly it was easier to get tickets to Hamilton. Some day, some day....

This talk by Dr Nick Gorton on bias in medicine, given at the 2018 FIX conference, is one of the best I have heard: you can watch the video or listen to the podcast.

I hope someday I can meet Dr Gorton and thank him for adding "Schweitzer Zone" to my vocabulary.

Bonus points if you recognize the Hamilton reference.

Making Part-Time Work, Work For You

Margaret Curtis, MD — Tue, 11 Dec 2018 14:47:52 GMT

This is not about all the reasons doctors should or shouldn't go part-time, although there are worthy arguments on both sides. I want to address how part-time physicians can make part-time doctoring work for them and for their practice. First I’m going to tell you about a job I once had:

I was a half-time employee of a small private practice I saw patients two full days per week, at 50% of an already below-average (for my specialty and region) salary. I also took full-time call.

Dividing call up evenly within a group is common practice, but in this case there was a major kicker: this was in-house call. We covered deliveries, the newborn nursery, the occasional inpatient and the Emergency Department, with no pay differential for carrying the pager or for the number of times we got called in. We also worked weekend clinics, both Saturday and Sunday, doing both acute and routine care. I was going into the hospital in the middle of the night and doing check-ups all day on weekends for exactly half of what my colleagues were getting.

The fact that I even took this job speaks volumes about my outlook at the time, but it also illustrates perfectly the problems part-time physicians can face.

Many practices insist that everyone share equally in the stuff that nobody really wants to do: nights and weekends if you are hospital-based, call if you are outpatient, committees for everyone. If you scale back your clinic you can end up doing proportionately more of what you don’t enjoy and getting paid less for the privilege.

These are the areas can make a part-time arrangement work or not:

Call: There are many ways to make call burden equitable within a group. Call can be pro-rated by FTE or assigned equally to each physician and then “bought” and “sold” by individuals. Everyone can get a base salary for clinic work and then paid on a sliding scale for the call they take. These last two can be a nice opportunity for docs who want to earn extra and can make one person’s part-time status or personal leave less onerous to everyone else. If call is busy, you can get paid a flat fee each time you get called in or you can capture the RVUs you generate on call (which can be significant if you are coming in to do admissions or procedures). Unless call is a mere formality, however, full-time call on a part-time salary is no bargain. You might as well go back to residency.

Compensation: unless you are 100% salaried, pay attention to how a change in your schedule will affect your pay and your practice (beyond just figuring out how much you need to work to qualify for benefits). If you are an established PCP, cutting back patient contact hours might mean you are seeing mostly routine visits, which are less valuable than acutes. If your practice gives bonuses based on a single cutoff point (such as “80% of revenue after meeting overhead“) you are less likely to reach this than if there is a graduated series of thresholds (such as “20% of revenue between 50th and 60th MGMA percentile, 30% of revenue between 60th and 70th etc”). Keep in mind that unless you are job-sharing, some practices hold part-time providers accountable for full-time overhead, with the rationale that the practice still has to employ an MA or nurse for them, has to pay the rent and utilities etc.

Administration and teaching: This is tricky. If you hope to stay or even advance in academics you can't avoid doing administrative work. Your practice may have admin or "citizenship" requirements. Just try to negotiate some time built into your reduced schedule for this kind of work, or be OK with it bleeding into the rest of your life. You will probably have to accept less influence when your group makes decisions that affect you. And be aware that if you take maternity leave you will be assigned to at least one committee while you are away.

These areas may not be important to you, or you may want or need to go part-time so badly that they are insignificant. They may be negotiable. You will be better able to negotiate any new situation if you avoid the powerful mix of naiveté and lack of self-advocacy that led me to take the job I described (and which so many women physicians seem to fall prey to, honestly.)

I lasted 2.5 years in that job; I completed my contract and stayed until the practice could replace me. I now have a fabulous job and a lot more savvy. You can too.

What I Learned From Working With A CFP

Margaret Curtis, MD — Sun, 09 Dec 2018 01:10:46 GMT

I learned a lot from working with a Certified Financial Planner (CFP), about setting financial goals, insurance and college savings. I also learned how murky the world of financial advice is.

My husband and I worked with a Certified Financial Planner for about three years. Our initial meetings with him were very productive. He charged us a flat fee, first hourly and then annually. I consider this money well spent, but I will save you the trouble and share what I learned:

Keep good records. It was sort of like inviting people over for dinner and then cleaning your house so no one knows how you actually live. Before our first meeting we consolidated several bank accounts, dredged up all our old tax records and downloaded statements. This process in and of itself was incredibly useful. Now that we have systems, keeping our records current is easy. This is a necessary but not sufficient first step to managing your own money.
Set goals first. We used to make big decisions (such as buying a car) based on our circumstances (old car died). and then figure out how to pay for it (take money from taxable account). Now, we have a list of wants and needs (replacing a car within 5 years), and we dedicate savings to that goal. Money is kept in appropriate accounts for short-, medium- and long-term needs, so we don’t have to scramble or sell a long-term investment to meet an immediate demand. We save money and stress, and we have a framework for decisions.
Pay attention to fees. Our CFP pointed out that our college savings were kept in a high-fee fund, and pointed us to a lower-fee state 529. Ironically, we later left this CFP because of fees (see below), but this advice got me to examine what we were paying for what we were getting.

After two years of this, our planner offered to take over management of our investments. I was changing jobs and had some retirement money to move, so we transferred those accounts to the mutual fund company our CFP recommended. Today I wouldn’t agree to this, knowing what I now know, but some of us are slow/experiential learners. Now I will save you more money:

Pay attention to hidden fees. Our investments did fine, but we paid about 1% in total fees. These were not obvious in any of the statements we received, but showed up on our tax forms. If you haven’t already heard, these kinds of fees are an incredible drag on investments.
Ask “what is in this for you?”. Our CFP wasn’t actually managing our investments. He had referred us to a mutual fund company which then paid him a percentage. He had a conflict of interest (he explained this by saying that his “planning” gig was separate from his “investment management” gig. Whatevs).

As an aside: being paid a fee for “assets under management” is a common practice for financial planners, but it seems to me that this creates a conflict of interest. AUM fees create an incentive for a planner to recommend investments that benefit the planner, rather than investments that are optimal for you.

By this point we felt we had a good plan going, and we sure as heck didn’t want to continue to pay all these people to watch our money grow. We pulled the money out and invested it in low-cost index funds. We would go back to a CFP if we needed specific planning advice. Mostly, though, we are putting our education to good use.