NEW ORLEANS – Like many other specialties – particularly cognitive specialties – neurology is under pressure to figure out how best to survive in an environment in which expenses are rising, but income is declining. So what are some strategies for staying in practice, choosing what type of practice is best, ensuring a steady income stream, and staying sane?
At the recent annual meeting of the American Academy of Neurology, several neurologists offered their personal take on preserving the pleasures of practice while maintaining revenues.
Dr. Laurence J. Kinsella
Dr. Laurence J. Kinsella, codirector of neurology for SSM Neurosciences Institute, St. Louis, noted that although median income for neurologists had risen fairly steadily since the mid-1990s, a neurologist’s value was very much dependent on what area of the country he or she practices in, whether it is urban or rural, and whether the practice is academic or private, or interventionist or cognitive.*
Choosing where to practice and the best type of practice is dependent on which options offer the best proximity to family or accommodation of a spouse’s needs, as well as the most professional growth, leadership potential, and collegiality, among other factors, said Dr. Kinsella, who is also vice chair of the AAN’s government affairs committee.
In the assessment of a group practice, for instance, be aware that survey data and published research have shown that the average turnover is 7% per year, and 60% of those who leave do so in the first 5 years. The biggest reasons for leaving include practice issues; compensation and location issues; and spousal concerns. Some questions to raise are whether the senior partners are advocates for equity for all partners, and whether the path to partnership is clearly stated, Dr. Kinsella said.
Before signing a contract with any group, it’s worthwhile to consult with an attorney who specializes in health care, he said. Keep in mind that everything is negotiable. Some key components to explore include salary and bonus; productivity scale; call schedule; pension and profit sharing; termination; and malpractice, health, and disability insurance.
"The most important thing is, you have to pay attention and be limber and adjust your models as things change."
Whether you take the academic, private, solo, or group path, the reimbursement challenges will be the same. The elimination of the Medicare consult codes in 2010 have led to a 6%-20% reduction in reimbursement, according to AAN survey data, Dr. Kinsella said.
There is a tool to assess the impact on a practice at www.mitsi.org/. One way to make up for lost revenue is to take a closer look at evaluation and management (E&M) codes, he added. At least 60% of neurologists’ billing is for E&M services. AAN provides templates for determining efficient and appropriate use of E&M codes. Dr. Kinsella said he advocated for the use of prolonged service codes such as 99354 (31-74 minutes) and 99355 (for each additional 30 minutes). "I’d encourage you to get comfortable with these. They are very good to use," he said.
Most neurologists also bill at level 4, then level 5 and level 3 for E&M, and they should be billing primarily level 5, Dr. Kinsella said. A level 5 consult requires more than just a single diagnosis.
Some 40% of neurology practice now comes from neurophysiology, such as sleep studies and electromyography/nerve conduction studies. These procedures pay better than E&M and thus are worth adding into a practice, he said.
Some other revenue-generating ideas include taking on a hospital directorship, such as stroke director; participating in clinical trials; giving botulinum toxin injections and nerve blocks for rotator cuff injuries, for instance; doing skin biopsies for small fiber neuropathy; and doing chart reviews for legal cases and interpretation of images.
Consider also moonlighting as a neurohospitalist. Dr. Kinsella’s practice offered 24/7 coverage to a hospital that suddenly lost a group of neurologists, which worked out well.
"The key is to leverage your scarcity," Dr. Kinsella said, noting that neurologists are in sparse supply and that many hospitals need coverage for call, stroke centers, and telemedicine.
Another avenue is to offer coverage for rural health clinics. Medicare has been assisting rural hospitals and clinics to recruit neurologists. With higher reimbursement in place to help these centers, working for a rural clinic can "cover your windshield cost" to make the drive and take the time away from practice, he said.
His suggestions for keeping practice fun? Get a clinical appointment to teach residents. Or have a different area of practice every day.