Opening a Pediatric practice as a Pediatric Nurse Practitioner

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pendflx
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Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by pendflx » Sun May 19, 2019 3:29 pm

Hi,
I’ve been a Peds NP for about 10 years and am growing more interesting in potentially running my own office one day. I’ve done some research online and understand that my next step is probably to create a business plan. But I figured part of my research could be to poll those bogleheads with related experienced.

Background:
Peds NP of 10 years with expertise and comfort in general Peds, Peds diabetes, and Peds mental health. Currently work in a state with full practice authority but am actually considering moving to South Florida (which doesn’t yet have authority). I could either try to find a sponsor or just wait a few years and hope they’re granted full autonomy authority. I understand some of the challenges around selecting an ideal location, needing to build a patient following, and the headaches associated with having a larger office (currently at a 10 provider office). I’d actually like to be the sole provider or potentially have just 1-2 other NPs after I get it things moving. I don’t have aspirations of growing beyond that. I also have a significant other who has more business experience who wwould help me run the business.

In case you’re wondering, my goals for considering this route include:
1. Since I was a young child, I dreamed of being a business owner. I pride myself on being self sufficient, independent, and setting a good example for others that you can do anything you put your mind to.
2. It seems like FL tends to pay lower on average than what I’m used to in MD. I want to go through the motions of researching the viability of my own practice so I can make sure I’m educated about whether I’m wasting time and money working at a discount for others vs. working for myself.
3. I’m not immune to hard work and my significant other is extremely supportive of my goals. My goal is not to work less or to just avoid having a boss. My goal is to continue working hard, build something I can be proud of from scratch, and earn more money so I have more financial independence, freedom, and optionality 15-20 years from now.

Questions:
1. Do you have any great business plan examples or templates besides what pops up on the first page of google?
2. I really don’t have any idea of the financial modeling variables so that I can determine if this is a lucrative endeavor and how risky it is. Are there templates highlighting key variables such as startup costs, patient loads, supplies, office, fees, insurance, marketing, etc. specific to a peds office?

Thanks!!

runner3081
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by runner3081 » Mon May 20, 2019 10:13 am

I work in healthcare and have been in the field for more than 15 years. In this regulatory, financial and competitive field, there is zero chance I would ever suggest that someone open up a small private practice.

The sheer amount of money and time spent to meet government regulations, in itself, would be difficult. Then, add billing/coding, collections, sourcing patients, and on and on...

obgraham
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by obgraham » Mon May 20, 2019 11:02 am

Indeed. The overhead will kill you.

Health care has moved beyond the small private practice model. Efficiency snd volume are now key. As a small practice, you may well enjoy it more, but it is going to be tough to make it an economic success.

That said there is probably a place for the "niche" or concierge practice. But is that what you really want?

TigerNest
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by TigerNest » Mon May 20, 2019 11:06 am

Who will your first patient be? What will your first 10 clients look like? How would they find you? Why would they choose you over everyone else?

Business plans are helpful planning tools, but before you get there you should decide on your how you’re differentiated - is it you offer lower costs, better service (I.e less wait times, easier to schedule, longer time per patient?) Each has trade offs.

Are you planning to open your own clinic? Who will be your referral sources, or do you plan to do direct marketing?

Once you’ve decided that, you can figure out what it will take to run the practice (I.e. rent, equipment, insurance), how much it will cost, and how many patients you’ll need to break even or make enough of a profit to cover your salary. Then run some scenarios in case your estimates are too optimistic. you can decide if it makes sense at that point.

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SkierMom
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by SkierMom » Mon May 20, 2019 11:25 am

Would this business model idea work in a different country with less bureaucratic medical tape?

Ever think about the Caribbean? Bahamas or Bermuda? New Zealand?

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dm200
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by dm200 » Mon May 20, 2019 11:49 am

Is such a NP practice allowed in your state?

It has been a long time since our son was young, but I think we would always have seen a Pediatrician or a Family Practice Physician for our son, and it would have been OK if some visits, etc. might have been with a NP in that Physician's office. Just a 'guess', but I think finding a sufficient number of patients to sustain the practice would be a real challenge.

Recently, here in Virginia, the law has changed to allow NPs to have practices - without being with a Physician. I am curious how many NPs will do this.

Can NPs see both children and adults in the same practice? Are there separate (adult and children) training and licensing requirements?

decapod10
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by decapod10 » Mon May 20, 2019 12:58 pm

Reiterating what others have said, I think it will be a challenge. Opening a solo practice as a doctor is already extremely challenging these days. It’s not very commonly done among new doctors, except for a few circumstances.

It will be doubly difficult for you because even though you may be an excellent clinician, it will be hard for you to attract business because you are now competing against physicians. You need to get patients either by:

1. Self referral

2. Referrals from other health care providers

For self referrals, if someone is just picking a name randomly from their insurance website, they will most likely pick a physician over an NP, because remember they don’t know anything about you other than seeing your name and credentials on a list. Many people don’t do any additional research than that.

For referrals from other physicians, they will also pretty much always refer to other physicians over an NP.

In order to overcome this, you will need to fill a special role. If you have a role/specialty that no other doctor has in the area, or if you go to an underserved area, maybe that would work. You will need an angle to gain an advantage.

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dm200
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by dm200 » Mon May 20, 2019 1:04 pm

A friend of ours is a Nurse Practitioner and a few years ago, she moved to another location and was employed full time by a private boarding school (High School age, as I recall). After a year or two, she decided to return back here. She now works in a Physician's office as a Nurse Practitioner.

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SevenBridgesRoad
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by SevenBridgesRoad » Mon May 20, 2019 1:16 pm

Retired MD here. My prior organization hired NPs in many specialties, peds included. No physician oversight needed or expected. Oregon is a very good environment for NPs; widely accepted by patients and physicians.

A residency buddy and I set up our own private family practice back when we completed residency. This was in the mid-1980s. Much simpler regulatory and payer environment. Our first shock was the Stark regulations. Then CLIA. Then PPO contracts. The Medicare added complexity. Employee management headaches. Etc. For the first several years as we built a practice, we made very little money ourselves. Your employees and vendors expect to be paid and your paycheck is the funding variable. Lots and lots to think about. The dream and reality are different. Even taking a short vacation becomes problematic.

Fortunately we were able to sell our practice (and ourselves) to a hospital system. Never went back to the private side.

Fast-forward to today. Everything is infinitely more complex. I would never recommend starting a small private practice today. My advice would be to look for a well-run multi-specialty group where NPs are reasonably happy.

That said, I understand dreams and ambitions. If you really want to head down this path, there are a ton of resources available to help you understand the business of running a private practice. Start with your national association, AANP. Here's a link: https://www.aanp.org/practice/practice-management. Make sure you pick an area with a shortage of providers. And keep your costs very, very low.

I hate to be such a downer, but honestly its a lot tougher than it looks. Good luck and let us know what you decide to do.
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

Glockenspiel
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Glockenspiel » Mon May 20, 2019 1:32 pm

dm200 wrote:
Mon May 20, 2019 11:49 am
Is such a NP practice allowed in your state?

Recently, here in Virginia, the law has changed to allow NPs to have practices - without being with a Physician. I am curious how many NPs will do this.
I know one person who has their own independent practice as an NP in the rural oil field areas of North Dakota. But, they are a family NP, not Peds. I think she does fine for her area, and I think North Dakota is likely an easier place to meet regulations, but this is also a very underserved location, healthcare-wise, so this person is filling an unmet need. I highly doubt that South Florida has many areas that are underserved. Also, I would not want to open a practice in Florida due to the limited authority that NPs currently have in the state.

I also, would try to find a multi-specialty private practice owned by the providers, and work to become a part-owner.

HomeStretch
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by HomeStretch » Mon May 20, 2019 1:38 pm

Before you even run the numbers, your business plan needs to evaluate the competitive landscape in your area to see if a sole NP pediatrics practice is viable.

If you can’t compete profitably against physician practices head-on for routine/emergency medical care, perhaps a supporting practice (that receives physician referrals) is viable for ongoing pediatric issues like nutrition, weight/cholesterol/diabetes management, new parent breastfeeding assistance, CPR classes, etc.

In my area, a sole NP pediatrics practice would be a hard sell IMO as the excellent multiple-physician practices are open 7 days a week, 12 hours/day at several locations. They always see patients same-day for any non-routine issues. The support staffs are large to handle referrals, insurance submissions, Billings, record management, etc. As a parent, given a choice I would always opt for my child to be seen by a physician.

Topic Author
pendflx
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by pendflx » Mon May 20, 2019 2:39 pm

Glockenspiel wrote:
Mon May 20, 2019 1:32 pm
dm200 wrote:
Mon May 20, 2019 11:49 am
Is such a NP practice allowed in your state?

Recently, here in Virginia, the law has changed to allow NPs to have practices - without being with a Physician. I am curious how many NPs will do this.
I know one person who has their own independent practice as an NP in the rural oil field areas of North Dakota. But, they are a family NP, not Peds. I think she does fine for her area, and I think North Dakota is likely an easier place to meet regulations, but this is also a very underserved location, healthcare-wise, so this person is filling an unmet need. I highly doubt that South Florida has many areas that are underserved. Also, I would not want to open a practice in Florida due to the limited authority that NPs currently have in the state.

I also, would try to find a multi-specialty private practice owned by the providers, and work to become a part-owner.
I've often wondered about ownership partnering. I don't actually know any NP's who are partners in a physician-led practice. Assuming I had a good relationship with the owners of my practice, do you think they may be open to me inquiring about becoming a partner?
What's involved in that? 'Buying' in? What does the money from initial buy-in normally get allocated towards? Then how do partners make a return generally? Your % share left over after all costs at the end of each year?

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pendflx
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by pendflx » Mon May 20, 2019 2:42 pm

SevenBridgesRoad wrote:
Mon May 20, 2019 1:16 pm
Retired MD here. My prior organization hired NPs in many specialties, peds included. No physician oversight needed or expected. Oregon is a very good environment for NPs; widely accepted by patients and physicians.

A residency buddy and I set up our own private family practice back when we completed residency. This was in the mid-1980s. Much simpler regulatory and payer environment. Our first shock was the Stark regulations. Then CLIA. Then PPO contracts. The Medicare added complexity. Employee management headaches. Etc. For the first several years as we built a practice, we made very little money ourselves. Your employees and vendors expect to be paid and your paycheck is the funding variable. Lots and lots to think about. The dream and reality are different. Even taking a short vacation becomes problematic.

Fortunately we were able to sell our practice (and ourselves) to a hospital system. Never went back to the private side.

Fast-forward to today. Everything is infinitely more complex. I would never recommend starting a small private practice today. My advice would be to look for a well-run multi-specialty group where NPs are reasonably happy.

That said, I understand dreams and ambitions. If you really want to head down this path, there are a ton of resources available to help you understand the business of running a private practice. Start with your national association, AANP. Here's a link: https://www.aanp.org/practice/practice-management. Make sure you pick an area with a shortage of providers. And keep your costs very, very low.

I hate to be such a downer, but honestly its a lot tougher than it looks. Good luck and let us know what you decide to do.
Thanks for the sensible advice and link.
We believe we'd only have a shot if we ran this like we would any other business (location being key + capitalizing on a shortage of what I believe we could offer + having some niche specialties that help me standout from the rest + keeping costs as low as possible).

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Blister
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Blister » Mon May 20, 2019 3:59 pm

Being a retired physician and having run a small private practice for several years, I can tell you that there are lots of unforseen headaches associated with the business side. I was happy to sell the practice about 10 years ago and worked for a large group until I retired. The regulations and paperwork required to meet HIPPA, CLIA, and other certifications is overwhelming. You may consider a concierge type practice where you would work cash only but given your pracitce is limited to pediatrics that may be difficult. Undoubtedly you will be seeing Medicaid patients and the reimbursements for those services is limited. Being your own boss does have its advantages but it comes with costs.

just my 2 cents
Everthing works out in the end. If it doesn't then its not the end.

txbabe
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by txbabe » Mon May 20, 2019 5:22 pm

I am an MD who opened a cash only psych practice and do ok. Most NPs who open psych practices succeed by taking medicaid patients. Not sure how an NP only peds practice would work. Around here most peds practice are a combination of pediatrician, NP and PA. The NP and the PA do the more routine cases and the pediatricians will handle the more complex cases. You are thinking of opening a practice with several NPs but no pediatrician? I think that would be a tough sell in the area I live. Have you considered doing something in behavioral health. There is a shortage of child and adolescent psychiatrists.

toofache32
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by toofache32 » Mon May 20, 2019 10:51 pm

pendflx wrote:
Mon May 20, 2019 2:39 pm
Glockenspiel wrote:
Mon May 20, 2019 1:32 pm
dm200 wrote:
Mon May 20, 2019 11:49 am
Is such a NP practice allowed in your state?

Recently, here in Virginia, the law has changed to allow NPs to have practices - without being with a Physician. I am curious how many NPs will do this.
I know one person who has their own independent practice as an NP in the rural oil field areas of North Dakota. But, they are a family NP, not Peds. I think she does fine for her area, and I think North Dakota is likely an easier place to meet regulations, but this is also a very underserved location, healthcare-wise, so this person is filling an unmet need. I highly doubt that South Florida has many areas that are underserved. Also, I would not want to open a practice in Florida due to the limited authority that NPs currently have in the state.

I also, would try to find a multi-specialty private practice owned by the providers, and work to become a part-owner.
I've often wondered about ownership partnering. I don't actually know any NP's who are partners in a physician-led practice. Assuming I had a good relationship with the owners of my practice, do you think they may be open to me inquiring about becoming a partner?
What's involved in that? 'Buying' in? What does the money from initial buy-in normally get allocated towards? Then how do partners make a return generally? Your % share left over after all costs at the end of each year?
If you want to buy-in to a physician practice, the the business deal would be the same as any other physician. I bought in as the 4th physician in my practice. Most deals need a practice valuation by a 3rd party to determine price which is a starting point of negotiations. The money is allocated towards equipment, goodwill, building/land if applicable, etc. If you, as an owner, want to share in the ownership of these things, then you have to buy your share from the others who already own this. Some of the price is also the income opportunity you are buying which is similar to buying an income stream. As an owner, you are also responsible dealing with the headaches of running a business which cuts into your productive time of seeing patients. You have to cancel patients to interview a new front desk staff. You have to stay late to review the day sheets. Come in early to review insurance reports from your practice management software, etc. Meet with vendors to decide the best exam table to replace the one that just broke (which YOU are paying for with your own money).

My buy-in price was about $660,000 for which I took out a 10-year loan and pay about $6300 a month for. You have to do the math and determine if your cash flow can support the debt. For me, I first worked 2 years as an employed associate in the same practice. I received 35% of my collections. The practice ran at about 50% overhead which means the owners receive 50% of their collections. For me to buy in, it meant my income would go from 35% of collections to 50%. I had to calculate that 15% increase and compare it with the cost/debt of buying in. It took me 2 years to cross that "break even" point for buying in to make sense. The downside is that now I am sharing in the risk. My income changes as much as 20% each year because now I am paying overhead which includes another employed associate...I get paid last. For the 3rd quarter of last year, our overhead went up to 66% because we had to replace broken equipment and make other large purchases.

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SevenBridgesRoad
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by SevenBridgesRoad » Tue May 21, 2019 12:19 am

toofache32 wrote:
Mon May 20, 2019 10:51 pm


My buy-in price was about $660,000 for which I took out a 10-year loan and pay about $6300 a month for. You have to do the math and determine if your cash flow can support the debt. For me, I first worked 2 years as an employed associate in the same practice. I received 35% of my collections. The practice ran at about 50% overhead which means the owners receive 50% of their collections. For me to buy in, it meant my income would go from 35% of collections to 50%. I had to calculate that 15% increase and compare it with the cost/debt of buying in. It took me 2 years to cross that "break even" point for buying in to make sense. The downside is that now I am sharing in the risk. My income changes as much as 20% each year because now I am paying overhead which includes another employed associate...I get paid last. For the 3rd quarter of last year, our overhead went up to 66% because we had to replace broken equipment and make other large purchases.
Great real world example. Buy-in for almost $700,000, on borrowed money. Even more realisim: Owning the same place that provides your paycheck is (unnecessarily) risky, at least in health care these days. Retired FP MD. Last gig was CEO of a large physician-owned mulitspecialty group. I've seen almost everything in my 34 years as a doc and a physician executive. These days, buying into a medical group based on a third-party valuation is not as smart as it may sound. Think diversification: you are placing a large amount of your net worth in the same place that provides your paycheck. Same as owning a ton of company stock in the megacorp your paycheck is dependent on. And you will borrow the money to buy-in. Debt. Leverage. For what return?

Second, the third-party valuations are mostly voodoo. Like inflated home appraisals, only worse...many times worse. Seems like a science, but its not. "Goodwill"? A made-up number which fewer and fewer buyers will pay.

Third, the market for "buying into a practice" has shrunk dramatically. Many docs and APPs "just want a job and steady paycheck". They aren't interested in owning the practice. Partners in the practice have a huge amount of their net worth tied up in the belief a young provider will pay them at retirement to buy-in. More and more providers are not willing to buy-in, because they can become employed without taking on risk and debt (for the buy-in), and they can invest their money outside the practice (say, in index funds...for safe diversification). Its a Ponzi scheme in many ways: a youngster will cash me out and get stuck with something no one else will buy in the future. If there are fewer and fewer buyers, eventually a provider-owner is stuck with valueless shares. The music stops and not everyone has a chair.
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

ny_rn
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by ny_rn » Tue May 21, 2019 3:42 am

Just a thought since you have the entrepreneur mindset...

You could create various pediatric videos on YouTube, create and sell merchandise, phone consultations, speaking engagements, etc. If successful, you could reach millions and make money at the same time. You'll own your own "practice" and run it anywhere in the world.

toofache32
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by toofache32 » Tue May 21, 2019 10:38 am

SevenBridgesRoad wrote:
Tue May 21, 2019 12:19 am
toofache32 wrote:
Mon May 20, 2019 10:51 pm


My buy-in price was about $660,000 for which I took out a 10-year loan and pay about $6300 a month for. You have to do the math and determine if your cash flow can support the debt. For me, I first worked 2 years as an employed associate in the same practice. I received 35% of my collections. The practice ran at about 50% overhead which means the owners receive 50% of their collections. For me to buy in, it meant my income would go from 35% of collections to 50%. I had to calculate that 15% increase and compare it with the cost/debt of buying in. It took me 2 years to cross that "break even" point for buying in to make sense. The downside is that now I am sharing in the risk. My income changes as much as 20% each year because now I am paying overhead which includes another employed associate...I get paid last. For the 3rd quarter of last year, our overhead went up to 66% because we had to replace broken equipment and make other large purchases.
Great real world example. Buy-in for almost $700,000, on borrowed money. Even more realisim: Owning the same place that provides your paycheck is (unnecessarily) risky, at least in health care these days. Retired FP MD. Last gig was CEO of a large physician-owned mulitspecialty group. I've seen almost everything in my 34 years as a doc and a physician executive. These days, buying into a medical group based on a third-party valuation is not as smart as it may sound. Think diversification: you are placing a large amount of your net worth in the same place that provides your paycheck. Same as owning a ton of company stock in the megacorp your paycheck is dependent on. And you will borrow the money to buy-in. Debt. Leverage. For what return?

Second, the third-party valuations are mostly voodoo. Like inflated home appraisals, only worse...many times worse. Seems like a science, but its not. "Goodwill"? A made-up number which fewer and fewer buyers will pay.

Third, the market for "buying into a practice" has shrunk dramatically. Many docs and APPs "just want a job and steady paycheck". They aren't interested in owning the practice. Partners in the practice have a huge amount of their net worth tied up in the belief a young provider will pay them at retirement to buy-in. More and more providers are not willing to buy-in, because they can become employed without taking on risk and debt (for the buy-in), and they can invest their money outside the practice (say, in index funds...for safe diversification). Its a Ponzi scheme in many ways: a youngster will cash me out and get stuck with something no one else will buy in the future. If there are fewer and fewer buyers, eventually a provider-owner is stuck with valueless shares. The music stops and not everyone has a chair.

This is definitely the view of an administrator and one of the hidden problems with medicine. Yoke the Ox and take some of their pay.
In my model, I can never be fired. I don't have some clipboard administrator standing over me telling me how many patients I need to see per hour. I get my share of the 15% of the associates' production. Yes, someone will buy my share when I retire in 9 years. And the real estate will continue to appreciate.
Goodwill is very much alive in a referral-based practice like mine. It would have cost me the same amount to build my own practice, but that would have been much slower to build up a referral base. One of my co-residents did this and it took over a year before he could bring home a steady paycheck. I came in to a busy practice with a large referral base and therefore an automatic income stream.

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SevenBridgesRoad
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by SevenBridgesRoad » Tue May 21, 2019 12:42 pm

toofache32 wrote:
Tue May 21, 2019 10:38 am
In my model, I can never be fired. I don't have some clipboard administrator standing over me telling me how many patients I need to see per hour. I get my share of the 15% of the associates' production. Yes, someone will buy my share when I retire in 9 years. And the real estate will continue to appreciate.
Goodwill is very much alive in a referral-based practice like mine. It would have cost me the same amount to build my own practice, but that would have been much slower to build up a referral base. One of my co-residents did this and it took over a year before he could bring home a steady paycheck. I came in to a busy practice with a large referral base and therefore an automatic income stream.
Insults unnecessary my friend.
I have a good friend who is a retired dentist. Retired two years ago. Good practice in nice area. Tried to sell his practice. No takers. Had to walk away eventually, stuck with a storage shed of medical records. So it depends. Owner beware.
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

TropikThunder
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by TropikThunder » Tue May 21, 2019 12:46 pm

toofache32 wrote:
Tue May 21, 2019 10:38 am
SevenBridgesRoad wrote:
Tue May 21, 2019 12:19 am
toofache32 wrote:
Mon May 20, 2019 10:51 pm


My buy-in price was about $660,000 for which I took out a 10-year loan and pay about $6300 a month for. You have to do the math and determine if your cash flow can support the debt. For me, I first worked 2 years as an employed associate in the same practice. I received 35% of my collections. The practice ran at about 50% overhead which means the owners receive 50% of their collections. For me to buy in, it meant my income would go from 35% of collections to 50%. I had to calculate that 15% increase and compare it with the cost/debt of buying in. It took me 2 years to cross that "break even" point for buying in to make sense. The downside is that now I am sharing in the risk. My income changes as much as 20% each year because now I am paying overhead which includes another employed associate...I get paid last. For the 3rd quarter of last year, our overhead went up to 66% because we had to replace broken equipment and make other large purchases.
Great real world example. Buy-in for almost $700,000, on borrowed money. Even more realisim: Owning the same place that provides your paycheck is (unnecessarily) risky, at least in health care these days. Retired FP MD. Last gig was CEO of a large physician-owned mulitspecialty group. I've seen almost everything in my 34 years as a doc and a physician executive. These days, buying into a medical group based on a third-party valuation is not as smart as it may sound. Think diversification: you are placing a large amount of your net worth in the same place that provides your paycheck. Same as owning a ton of company stock in the megacorp your paycheck is dependent on. And you will borrow the money to buy-in. Debt. Leverage. For what return?

Second, the third-party valuations are mostly voodoo. Like inflated home appraisals, only worse...many times worse. Seems like a science, but its not. "Goodwill"? A made-up number which fewer and fewer buyers will pay.

Third, the market for "buying into a practice" has shrunk dramatically. Many docs and APPs "just want a job and steady paycheck". They aren't interested in owning the practice. Partners in the practice have a huge amount of their net worth tied up in the belief a young provider will pay them at retirement to buy-in. More and more providers are not willing to buy-in, because they can become employed without taking on risk and debt (for the buy-in), and they can invest their money outside the practice (say, in index funds...for safe diversification). Its a Ponzi scheme in many ways: a youngster will cash me out and get stuck with something no one else will buy in the future. If there are fewer and fewer buyers, eventually a provider-owner is stuck with valueless shares. The music stops and not everyone has a chair.

This is definitely the view of an administrator and one of the hidden problems with medicine. Yoke the Ox and take some of their pay.
In my model, I can never be fired. I don't have some clipboard administrator standing over me telling me how many patients I need to see per hour. I get my share of the 15% of the associates' production. Yes, someone will buy my share when I retire in 9 years. And the real estate will continue to appreciate.
Goodwill is very much alive in a referral-based practice like mine. It would have cost me the same amount to build my own practice, but that would have been much slower to build up a referral base. One of my co-residents did this and it took over a year before he could bring home a steady paycheck. I came in to a busy practice with a large referral base and therefore an automatic income stream.
Interesting to read both sides of this. It’s probably not unique to medicine either, I can see similar pros and cons for lawyers especially and likely most other professional skills. Like most things, it will be a personal decision how much one values freedom vs security. I don’t have an entrepreneurial mindset but others do.

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dm200
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by dm200 » Tue May 21, 2019 3:57 pm

These days, there seem to be "professional" associations for almost everyone.

I know that Nurse Practitioners often lobby state governments for expanded capabilities - so there must be some entity that represents NPs. I might contact such a NP organization in your state to discuss your situation.

decapod10
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by decapod10 » Tue May 21, 2019 4:18 pm

TropikThunder wrote:
Tue May 21, 2019 12:46 pm

Interesting to read both sides of this. It’s probably not unique to medicine either, I can see similar pros and cons for lawyers especially and likely most other professional skills. Like most things, it will be a personal decision how much one values freedom vs security. I don’t have an entrepreneurial mindset but others do.
Yes, it definitely varies based on the person. I'd honestly rather just be the worker bee and collect my paycheck than have to make all these business decisions and worry about overhead, even though it means giving up some freedom. I think in Medicine, this has been the general trend over time, but not universal by any means. It also depends on the specialty as well. Specialties that are more cash based (Cosmetic Surgery comes to mind) tend to be a lot more interested in establishing their own business since they don't deal with insurance that much, they have more freedom in terms of what they charge and what they want to offer, and also more focus/interest on establishing a "brand".

Also, in my limited experience, group practices I've seen don't have much of a buy-in these days relatively speaking ($10k-$50k) because it's such a turn off, but again my first hand experience is very small in this matter.

staythecourse
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by staythecourse » Tue May 21, 2019 4:31 pm

runner3081 wrote:
Mon May 20, 2019 10:13 am
I work in healthcare and have been in the field for more than 15 years. In this regulatory, financial and competitive field, there is zero chance I would ever suggest that someone open up a small private practice.

The sheer amount of money and time spent to meet government regulations, in itself, would be difficult. Then, add billing/coding, collections, sourcing patients, and on and on...
Glad I didn't listen to you 4-5 years ago when I went solo. It was a piece of cake and love that I can do whatever I like whenever I like. The whole "difficulty" is overkill and mostly propagated by those who have never done/ tried it.

My overhead is super low. Funny being a boglehead makes being a business owner much easier, i.e. cut out all the fat. Regulations are not onerous. For medicare for value based payment I decided the 2-5% cut is not worth spending money/ time trying to meet all their reg and will accept 95 cents on the dollar for that group of insured patients. I don't take medicaid so that makes those regulations irrelevant. Billing is outsourced (5%) who does my licensing for free. Hiring is easy at the beginning as you are a one man show so you only need one person (especially if you are just starting). EMR is $100/ month with Practice fusion (used to be free).

The biggest cost are first time cost... first, last, security for lease, buying equipment and furniture for office, etc... The biggest issue is if the OP is the main provider for the family. There is about 3-6 month lag of spending money and seeing patients until money starts to actually come in via insurance company. You have to have money via the spouse or money set aside to live off for 6 months before it really starts going.

Like anybody I give the advice don't do it to be rich, but if you really want independence and to be your own boss. Also, don't do it unless you really like the business side of it, i.e. you CRAVE it!

I went from thinking about hitting my numbers ASAP to retire early (hated my old practice) and now likely will practice forever as I can do whatever I want whenever I want. As I say often, docs put too much of a premium on $$$ and discount independence.

In the end medicine is very easy to figure out the one who owns the patient charts will always have more power. I never see admin of the hospitals care to even talk to their employeed docs. Now when I come around they are always willing to talk as they think I will send them business for outpatient work.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

decapod10
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by decapod10 » Tue May 21, 2019 5:02 pm

staythecourse wrote:
Tue May 21, 2019 4:31 pm
runner3081 wrote:
Mon May 20, 2019 10:13 am
I work in healthcare and have been in the field for more than 15 years. In this regulatory, financial and competitive field, there is zero chance I would ever suggest that someone open up a small private practice.

The sheer amount of money and time spent to meet government regulations, in itself, would be difficult. Then, add billing/coding, collections, sourcing patients, and on and on...
Glad I didn't listen to you 4-5 years ago when I went solo. It was a piece of cake and love that I can do whatever I like whenever I like. The whole "difficulty" is overkill and mostly propagated by those who have never done/ tried it.

My overhead is super low. Funny being a boglehead makes being a business owner much easier, i.e. cut out all the fat. Regulations are not onerous. For medicare for value based payment I decided the 2-5% cut is not worth spending money/ time trying to meet all their reg and will accept 95 cents on the dollar for that group of insured patients. I don't take medicaid so that makes those regulations irrelevant. Billing is outsourced (5%) who does my licensing for free. Hiring is easy at the beginning as you are a one man show so you only need one person (especially if you are just starting). EMR is $100/ month with Practice fusion (used to be free).

The biggest cost are first time cost... first, last, security for lease, buying equipment and furniture for office, etc... The biggest issue is if the OP is the main provider for the family. There is about 3-6 month lag of spending money and seeing patients until money starts to actually come in via insurance company. You have to have money via the spouse or money set aside to live off for 6 months before it really starts going.

Like anybody I give the advice don't do it to be rich, but if you really want independence and to be your own boss. Also, don't do it unless you really like the business side of it, i.e. you CRAVE it!

I went from thinking about hitting my numbers ASAP to retire early (hated my old practice) and now likely will practice forever as I can do whatever I want whenever I want. As I say often, docs put too much of a premium on $$$ and discount independence.

In the end medicine is very easy to figure out the one who owns the patient charts will always have more power. I never see admin of the hospitals care to even talk to their employeed docs. Now when I come around they are always willing to talk as they think I will send them business for outpatient work.

Good luck.
My father is a solo practitioner, and certainly he wouldn't have it any other way. In the California Bay Area, it doesn't seem all that common to open a solo practice, but I'd be interested to know how feasible it is these days. Are you in a metropolitan area? Or do you think it's only possible in less popular areas?

staythecourse
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by staythecourse » Tue May 21, 2019 5:56 pm

decapod10 wrote:
Tue May 21, 2019 5:02 pm
My father is a solo practitioner, and certainly he wouldn't have it any other way. In the California Bay Area, it doesn't seem all that common to open a solo practice, but I'd be interested to know how feasible it is these days. Are you in a metropolitan area? Or do you think it's only possible in less popular areas?
I live in a large metro area and practice at the very edge of the city. I'm a specialist so maybe a bit different. To be honest, there will always be a desire of patients for private practice. It is more streamlined and the doctor has an "ownership" of the patient. With so many doctors being employed mostly due to the "I just want to check in and out and collect a paycheck" there is less interest in providers of really caring to make an effort with patients and it shows. Here's an example... One of my patients who I had not seen for a year is miserable and shows up without an appointment at 8:00 when I start the clinic. I just add her on. I call a primary to make an appointment who is employed by academics who has very specific appointments slots for new patients/ follow ups/ annual physicals. What a pain to have to find a specific day/ time just because he only does physicals on x day, but new patient evals on y day. If my patient that I saw had to go through those 2 experiences who do you think they continue their care to going forward?

I love being private and really feel an ownership of the patient and their health. I have patients come in without notice just to tell me their husband passed away. Do you think that would ever happen in an employed corporate model?

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

decapod10
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by decapod10 » Tue May 21, 2019 6:07 pm

staythecourse wrote:
Tue May 21, 2019 5:56 pm
decapod10 wrote:
Tue May 21, 2019 5:02 pm
My father is a solo practitioner, and certainly he wouldn't have it any other way. In the California Bay Area, it doesn't seem all that common to open a solo practice, but I'd be interested to know how feasible it is these days. Are you in a metropolitan area? Or do you think it's only possible in less popular areas?
I live in a large metro area and practice at the very edge of the city. I'm a specialist so maybe a bit different. To be honest, there will always be a desire of patients for private practice. It is more streamlined and the doctor has an "ownership" of the patient. With so many doctors being employed mostly due to the "I just want to check in and out and collect a paycheck" there is less interest in providers of really caring to make an effort with patients and it shows. Here's an example... One of my patients who I had not seen for a year is miserable and shows up without an appointment at 8:00 when I start the clinic. I just add her on. I call a primary to make an appointment who is employed by academics who has very specific appointments slots for new patients/ follow ups/ annual physicals. What a pain to have to find a specific day/ time just because he only does physicals on x day, but new patient evals on y day. If my patient that I saw had to go through those 2 experiences who do you think they continue their care to going forward?

I love being private and really feel an ownership of the patient and their health. I have patients come in without notice just to tell me their husband passed away. Do you think that would ever happen in an employed corporate model?

Good luck.
Thanks, appreciate the info.

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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Nowizard » Tue May 21, 2019 6:20 pm

As a retired, solo practitioner, I can say it perfectly fit my personality during practice which ended about ten years ago. Though it did not influence the decision, the increasing complexity of insurance and the ever increasing regulations were becoming quite onerous in the trade-off of between having a practice without a practice manager and the expenses of having one. A primary factor at the time, and a huge, continuing expense today, is the EMR's and the very substantial cost of setting up the software, purchasing the hardware and requirement of an IT consultant to monitor the system for functionality and avoidance of hacks. I advised my son to not go into a solo practice, and he is with a large organization that provides all the supportive aspects of practice. Additionally, it would be quite a risk to go to an area where you had no reputation. Hospital systems are gobbling up private practices for many reasons but do have benefits in terms of support and referrals. It may be difficult to accept the "one down" position of working in the office of a physician, but the choice of going out independently is possibly one that is a dream but one you may not be ready for if you are at the point of considering developing a business plan. Small businesses, even those with promise, fail primarily due to under capitalization. If you do not have deep pockets, it will be a challenge. I hope this does not come across as a downer of your dream, but it is challenging for anyone to establish a solo practice these days unless there are substantial contacts leading to referrals and an adequate funding pattern for the very substantial set-up costs. I would like to add that doing what you love is crucial, and I resisted numerous "opportunities" to establish a group practice or join one. I know how important it is psychologically to attend to your own desires and values. I suspect most solo practitioners fall into one of two groups: 1. Those who are competent but who have a personality that is more of a desire to serve than to obtain prestige and high income, 2. Those who are not offered jobs in larger practices for various reasons. That is not to disparage the desire or competency of those who are in practice groups but primarily a statement related to personality factors.

Tim

toofache32
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by toofache32 » Tue May 21, 2019 10:32 pm

SevenBridgesRoad wrote:
Tue May 21, 2019 12:42 pm
toofache32 wrote:
Tue May 21, 2019 10:38 am
In my model, I can never be fired. I don't have some clipboard administrator standing over me telling me how many patients I need to see per hour. I get my share of the 15% of the associates' production. Yes, someone will buy my share when I retire in 9 years. And the real estate will continue to appreciate.
Goodwill is very much alive in a referral-based practice like mine. It would have cost me the same amount to build my own practice, but that would have been much slower to build up a referral base. One of my co-residents did this and it took over a year before he could bring home a steady paycheck. I came in to a busy practice with a large referral base and therefore an automatic income stream.
Insults unnecessary my friend.
I have a good friend who is a retired dentist. Retired two years ago. Good practice in nice area. Tried to sell his practice. No takers. Had to walk away eventually, stuck with a storage shed of medical records. So it depends. Owner beware.
I don't mean to be insulting but this is the reality that many physicians have encountered. Three of my colleagues (and others) were recruited for a hospital job and given a 3-year contract with good pay and benefits. Then after 1 year, they were fired. The next day the hospital contacted them to "re-hire" them on new conditions including a 30% pay cut. The hospital administrators new that once you have moved to town and have a house you like, your wife has her friends, and the kids are in school, it's tough to leave. I say this begrudgingly because my current hospital CEO is a rock star and I love him. I walk down the hall with him while he asks me my opinions of new initiatives the hospital is creating and if I think he is heading in the right direction. And we pass the janitor in the hall and he says "hey Ramone good to see you...how did your mom's surgery go last week?" He gets to know everyone like the real people they are. He is the exception in my experience.

There is definitely a group of patients that recognize and value the idea of the doctor being in charge. I actually have 2 jobs. One is my private practice and the other is 1.5 days a week in an "employed" hospital setting. In my own office, I have control over everything. In the hospital, I am no different from other employees like the lady checking in patients at the front desk. In the hospital practice, patients complain about long waits and how that nurse was in a bad mood. As an employee, I simply say "yes I agree the wait is too long and yes Becky is usually in a bad mood. Here is the phone number to Patient Relations. Good luck with that." Patients complain to me as if I have control. But in my private practice, Becky knows I sign her paycheck and she knows I fired Emily a few months ago for lagging on the job. I run a tight ship because I can. In the employed setting, I cannot.

Rwsawbones
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Rwsawbones » Tue May 21, 2019 11:12 pm

You might look into taking over the practice of a solo soon to retire pediatrician. You will then have a template for your own practice without which it is almost impossible to form a practice these days. The retiring MD will be invaluable As your practice become busier you can bring additional NPs and MDs on board

ERguy101
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by ERguy101 » Wed May 22, 2019 6:21 am

pendflx wrote:
Mon May 20, 2019 2:42 pm
SevenBridgesRoad wrote:
Mon May 20, 2019 1:16 pm
Retired MD here. My prior organization hired NPs in many specialties, peds included. No physician oversight needed or expected. Oregon is a very good environment for NPs; widely accepted by patients and physicians.

A residency buddy and I set up our own private family practice back when we completed residency. This was in the mid-1980s. Much simpler regulatory and payer environment. Our first shock was the Stark regulations. Then CLIA. Then PPO contracts. The Medicare added complexity. Employee management headaches. Etc. For the first several years as we built a practice, we made very little money ourselves. Your employees and vendors expect to be paid and your paycheck is the funding variable. Lots and lots to think about. The dream and reality are different. Even taking a short vacation becomes problematic.

Fortunately we were able to sell our practice (and ourselves) to a hospital system. Never went back to the private side.

Fast-forward to today. Everything is infinitely more complex. I would never recommend starting a small private practice today. My advice would be to look for a well-run multi-specialty group where NPs are reasonably happy.

That said, I understand dreams and ambitions. If you really want to head down this path, there are a ton of resources available to help you understand the business of running a private practice. Start with your national association, AANP. Here's a link: https://www.aanp.org/practice/practice-management. Make sure you pick an area with a shortage of providers. And keep your costs very, very low.

I hate to be such a downer, but honestly its a lot tougher than it looks. Good luck and let us know what you decide to do.
Thanks for the sensible advice and link.
We believe we'd only have a shot if we ran this like we would any other business (location being key + capitalizing on a shortage of what I believe we could offer + having some niche specialties that help me standout from the rest + keeping costs as low as possible).

Don't be discouraged. I think there is a big market for a NP pediatric clinic. I'm an ER doc, and ALL DAY LONG we see are medicaid pediatric patients because they couldn't get in with their primary, or they didn't bother to call. If you could capture that patient population, it would be a big market, and the ERs would appreciate it. I know for a fact our ERs would gladly give out your clinic information upon discharge of these patients that had absolutely no reason to be in the emergency room eating up valuable resources.

In my area, I don't know if this is true nationwide, rural health clinics are a big deal. Medicaid will reimburse something like $140 flat fee for whatever office level you code, in a rural health setting. The same visit would pay much less in an urban setting. If you could setup your pediatric clinic in a rural setting, you could do quite well.

ERguy101
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by ERguy101 » Wed May 22, 2019 6:33 am

SevenBridgesRoad wrote:
Tue May 21, 2019 12:42 pm
toofache32 wrote:
Tue May 21, 2019 10:38 am
In my model, I can never be fired. I don't have some clipboard administrator standing over me telling me how many patients I need to see per hour. I get my share of the 15% of the associates' production. Yes, someone will buy my share when I retire in 9 years. And the real estate will continue to appreciate.
Goodwill is very much alive in a referral-based practice like mine. It would have cost me the same amount to build my own practice, but that would have been much slower to build up a referral base. One of my co-residents did this and it took over a year before he could bring home a steady paycheck. I came in to a busy practice with a large referral base and therefore an automatic income stream.
Insults unnecessary my friend.
I have a good friend who is a retired dentist. Retired two years ago. Good practice in nice area. Tried to sell his practice. No takers. Had to walk away eventually, stuck with a storage shed of medical records. So it depends. Owner beware.
My dad has the same issue. Retired, orthopedic, 30+ years in practice. There's so much business in our city there's absolutely no reason for anyone to BUY the practice, it's completely pointless. So he has a storage shed full of records, and still has to pay someone to like respond to record requests from lawyers, etc. Even in retirement he still has to pay someone to manage his practice.

ERguy101
Posts: 151
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by ERguy101 » Wed May 22, 2019 6:39 am

staythecourse wrote:
Tue May 21, 2019 4:31 pm
runner3081 wrote:
Mon May 20, 2019 10:13 am
I work in healthcare and have been in the field for more than 15 years. In this regulatory, financial and competitive field, there is zero chance I would ever suggest that someone open up a small private practice.

The sheer amount of money and time spent to meet government regulations, in itself, would be difficult. Then, add billing/coding, collections, sourcing patients, and on and on...
Glad I didn't listen to you 4-5 years ago when I went solo. It was a piece of cake and love that I can do whatever I like whenever I like. The whole "difficulty" is overkill and mostly propagated by those who have never done/ tried it.

My overhead is super low. Funny being a boglehead makes being a business owner much easier, i.e. cut out all the fat. Regulations are not onerous. For medicare for value based payment I decided the 2-5% cut is not worth spending money/ time trying to meet all their reg and will accept 95 cents on the dollar for that group of insured patients. I don't take medicaid so that makes those regulations irrelevant. Billing is outsourced (5%) who does my licensing for free. Hiring is easy at the beginning as you are a one man show so you only need one person (especially if you are just starting). EMR is $100/ month with Practice fusion (used to be free).

The biggest cost are first time cost... first, last, security for lease, buying equipment and furniture for office, etc... The biggest issue is if the OP is the main provider for the family. There is about 3-6 month lag of spending money and seeing patients until money starts to actually come in via insurance company. You have to have money via the spouse or money set aside to live off for 6 months before it really starts going.

Like anybody I give the advice don't do it to be rich, but if you really want independence and to be your own boss. Also, don't do it unless you really like the business side of it, i.e. you CRAVE it!

I went from thinking about hitting my numbers ASAP to retire early (hated my old practice) and now likely will practice forever as I can do whatever I want whenever I want. As I say often, docs put too much of a premium on $$$ and discount independence.

In the end medicine is very easy to figure out the one who owns the patient charts will always have more power. I never see admin of the hospitals care to even talk to their employeed docs. Now when I come around they are always willing to talk as they think I will send them business for outpatient work.

Good luck.
I've thought of opening some kind of practice, this seems like what I would want to do. How do you outsource billing? I've seen some EMRs advertise they handle billing, is that similar? When you say the outsourced billing did your licensing, do you mean credentialing, IE with Blue Cross, etc?

staythecourse
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by staythecourse » Wed May 22, 2019 11:15 am

ERguy101 wrote:
Wed May 22, 2019 6:39 am
staythecourse wrote:
Tue May 21, 2019 4:31 pm
runner3081 wrote:
Mon May 20, 2019 10:13 am
I work in healthcare and have been in the field for more than 15 years. In this regulatory, financial and competitive field, there is zero chance I would ever suggest that someone open up a small private practice.

The sheer amount of money and time spent to meet government regulations, in itself, would be difficult. Then, add billing/coding, collections, sourcing patients, and on and on...
Glad I didn't listen to you 4-5 years ago when I went solo. It was a piece of cake and love that I can do whatever I like whenever I like. The whole "difficulty" is overkill and mostly propagated by those who have never done/ tried it.

My overhead is super low. Funny being a boglehead makes being a business owner much easier, i.e. cut out all the fat. Regulations are not onerous. For medicare for value based payment I decided the 2-5% cut is not worth spending money/ time trying to meet all their reg and will accept 95 cents on the dollar for that group of insured patients. I don't take medicaid so that makes those regulations irrelevant. Billing is outsourced (5%) who does my licensing for free. Hiring is easy at the beginning as you are a one man show so you only need one person (especially if you are just starting). EMR is $100/ month with Practice fusion (used to be free).

The biggest cost are first time cost... first, last, security for lease, buying equipment and furniture for office, etc... The biggest issue is if the OP is the main provider for the family. There is about 3-6 month lag of spending money and seeing patients until money starts to actually come in via insurance company. You have to have money via the spouse or money set aside to live off for 6 months before it really starts going.

Like anybody I give the advice don't do it to be rich, but if you really want independence and to be your own boss. Also, don't do it unless you really like the business side of it, i.e. you CRAVE it!

I went from thinking about hitting my numbers ASAP to retire early (hated my old practice) and now likely will practice forever as I can do whatever I want whenever I want. As I say often, docs put too much of a premium on $$$ and discount independence.

In the end medicine is very easy to figure out the one who owns the patient charts will always have more power. I never see admin of the hospitals care to even talk to their employeed docs. Now when I come around they are always willing to talk as they think I will send them business for outpatient work.

Good luck.
I've thought of opening some kind of practice, this seems like what I would want to do. How do you outsource billing? I've seen some EMRs advertise they handle billing, is that similar? When you say the outsourced billing did your licensing, do you mean credentialing, IE with Blue Cross, etc?
There are billing companies that do the billing. Just reach out to some private guys in your area and find out who they use. For a small practice it is not cost effective to bring the billing in house. My billing folks I am sure are not unique in doing credentialing (I do my own medical/ DEA/ state lincenses). It makes it easy since they do so many groups in my specialty they will only sign me up for the ones that make sense financially and keep me OON for those that don't.

Good luck.

p.s. Again I am not supporting everyone should go solo (private is another story as I am AGAINST being employed by random business folks). Only do it if you like the business aspect and value freedom.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

staythecourse
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by staythecourse » Wed May 22, 2019 11:21 am

For the OP, even consider an urgent care peds practice and just take cash. No schedules just handle walk ins.

Heck, I would even rent a bus, fill it with all the stuff you need, and just drive it to the communities. Each day a different area of the city. There are SO MANY ways to make money in medicine if folks just think out of the box. Having 2 kids and being settled financially take some of the edge of me wanting to pursue these ventures, but there are plenty out there for those who have some drive. This would cut down significant on the overhead AND give you great access to new patient populations.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

a_movable_life
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by a_movable_life » Wed May 22, 2019 12:42 pm

Hello,

Fellow Nurse Practitioner here. I have also thought of going into private solo practice. My specialty is psych, and there seems to be more of an acceptable business model of "Cash only" psych practices. There also is a shortage so people may be more willing to take an appointment in the next 2 weeks for 400-500 dollars for an intake versus waiting 2-4 months at the local "Large multi-specialty practice." Especially where the follow up visits are 15 minutes long.

Peds/Family as other people have said, you can be competing with large practices that are open 6-7 days a week 12 hours a day. You don't have the option of being open 4 hours a day 3 days a week, and not having an answering service. Nervous parents want to be able to reach you. This was my goal was to reduce my hours as part of FIRE and keep all the deductions of a small business.

Your overhead is going to be different as you need exam room equipment and all the other "Doctors office" furnishings.

Right now their seems to be a big push to get NP's to go into private practice. AANP sends me invitations for CME webinars about once a month. Wendy Wright who is a NP who owns two medium sized practices in New Hampshire has a few seminars about this as well. You may have heard her board review as a taped seminar for CME.

I'm a little suspicious who is paying for some of this "Free" content. A couple thousand NP's all opening businesses generates lots of loan commissions and buys a lot of office supplies.

And as some one else posted you are "Not a doctor" neither am I. My patients that I see on my various Locums contracts are all Medicaid and don't get a choice. They see me or they see nobody. Your patient's may decline to see you if there is a doctor available. You probably have experienced that. I know I have.

The other thing to consider is if you can get to the "Sweet spot" that owning a business entails to get the maximum tax and retirement benefits. If you are working 40-60 hours a week and at the end of the year not making considerably more and capturing a big chunk of "Both sides" of the 401K Employee and Employer match, etc. it may not be worth it.

I changed to Locums as a way to speed up my path to FIRE. I do miss the collegiality of working in a 15+ member team, and having a couple very senior people to ask when I got really stumped. I sometimes regret leaving.

masonstone
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by masonstone » Thu May 23, 2019 10:30 am

Would people go to a nurse as opposed to a medical doctor to take care of their kids? I mean, I understand if the nurse works for the doctor so they have oversight of a doctor, but would they actually go to one without that physician oversight? Not having an MD will definitely affect both the numbers of the clientele as well as their socio-economics so that you both have few patients and those patients have bad insurance making a successful practice even more difficult.

BuckyBadger
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by BuckyBadger » Thu May 23, 2019 11:05 am

masonstone wrote:
Thu May 23, 2019 10:30 am
Would people go to a nurse as opposed to a medical doctor to take care of their kids? I mean, I understand if the nurse works for the doctor so they have oversight of a doctor, but would they actually go to one without that physician oversight? Not having an MD will definitely affect both the numbers of the clientele as well as their socio-economics so that you both have few patients and those patients have bad insurance making a successful practice even more difficult.
Are you familiar with the role of a Nurse Practitioner? Your dismissive use of the term "a nurse" and your belief that only poorly insured people of a lot socio economic class would go to one makes me think not.

staythecourse
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by staythecourse » Thu May 23, 2019 11:07 am

masonstone wrote:
Thu May 23, 2019 10:30 am
Would people go to a nurse as opposed to a medical doctor to take care of their kids? I mean, I understand if the nurse works for the doctor so they have oversight of a doctor, but would they actually go to one without that physician oversight? Not having an MD will definitely affect both the numbers of the clientele as well as their socio-economics so that you both have few patients and those patients have bad insurance making a successful practice even more difficult.
True.

If I was the OP and was starting a standard vanilla medical practice I would only do this if I really want to be my own boss AND love the business end AND accept you may make less money doing more non billable work, i.e. running a business.

If I was the OP, I would however consider doing this as a cash pay only practice and focus on some niche that nobody else is doing. How about pediatric eating disorders (obesity and anorexia)? If you specialized in that arena you could slowly grow the model and hire a nutritionist and psychologist. Finding a niche service that families would pay out of pocket that no one else is doing would be my angle. Go read up and shadow some big obesity clinics in the country for a month or 2 and implement the same system in private. This would make a KILLING!!

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

masonstone
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by masonstone » Thu May 23, 2019 11:08 am

BuckyBadger wrote:
Thu May 23, 2019 11:05 am
masonstone wrote:
Thu May 23, 2019 10:30 am
Would people go to a nurse as opposed to a medical doctor to take care of their kids? I mean, I understand if the nurse works for the doctor so they have oversight of a doctor, but would they actually go to one without that physician oversight? Not having an MD will definitely affect both the numbers of the clientele as well as their socio-economics so that you both have few patients and those patients have bad insurance making a successful practice even more difficult.
Are you familiar with the role of a Nurse Practitioner? Your dismissive use of the term "a nurse" and your belief that only poorly insured people of a lot socio economic class would go to one makes me think not.
I'm very familiar with the role of an Nurse Practitioner. Considering they did not go to medical school and went to nursing school, I'm not sure why you get offended when I call a nurse practitioner a Nurse.

BuckyBadger
Posts: 1017
Joined: Tue Nov 01, 2011 11:28 am

Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by BuckyBadger » Thu May 23, 2019 11:10 am

masonstone wrote:
Thu May 23, 2019 11:08 am
BuckyBadger wrote:
Thu May 23, 2019 11:05 am
masonstone wrote:
Thu May 23, 2019 10:30 am
Would people go to a nurse as opposed to a medical doctor to take care of their kids? I mean, I understand if the nurse works for the doctor so they have oversight of a doctor, but would they actually go to one without that physician oversight? Not having an MD will definitely affect both the numbers of the clientele as well as their socio-economics so that you both have few patients and those patients have bad insurance making a successful practice even more difficult.
Are you familiar with the role of a Nurse Practitioner? Your dismissive use of the term "a nurse" and your belief that only poorly insured people of a lot socio economic class would go to one makes me think not.
I'm very familiar with the role of an Nurse Practitioner. Considering they did not go to medical school and went to nursing school, I'm not sure why you get offended when I call a nurse practitioner a Nurse.
And do you know what NPs can and cannot do as compared to MDs?

masonstone
Posts: 498
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by masonstone » Thu May 23, 2019 11:14 am

BuckyBadger wrote:
Thu May 23, 2019 11:10 am
masonstone wrote:
Thu May 23, 2019 11:08 am
BuckyBadger wrote:
Thu May 23, 2019 11:05 am
masonstone wrote:
Thu May 23, 2019 10:30 am
Would people go to a nurse as opposed to a medical doctor to take care of their kids? I mean, I understand if the nurse works for the doctor so they have oversight of a doctor, but would they actually go to one without that physician oversight? Not having an MD will definitely affect both the numbers of the clientele as well as their socio-economics so that you both have few patients and those patients have bad insurance making a successful practice even more difficult.
Are you familiar with the role of a Nurse Practitioner? Your dismissive use of the term "a nurse" and your belief that only poorly insured people of a lot socio economic class would go to one makes me think not.
I'm very familiar with the role of an Nurse Practitioner. Considering they did not go to medical school and went to nursing school, I'm not sure why you get offended when I call a nurse practitioner a Nurse.
And do you know what NPs can and cannot do as compared to MDs?
Yes I do, they shouldn’t be practicing unsupervised due to not going to medical school and potential for both over-testing and delayed diagnosis.

WillRetire
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by WillRetire » Thu May 23, 2019 11:39 am

OP: Consider that the trend since ACA became law is for small practices to join larger ones in order to deal with increased administrative costs.

Also consider that unless you are in-network with popular insurance plans, your clientele will be limited. Most of the phone calls to your office will be questions about insurance accepted and if in-network (two different things).

What about heading up a satellite office that is part of an existing larger medical practice or medical center? Rural areas would greatly benefit from having an NP nearby.

Cyanide123
Posts: 195
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Cyanide123 » Thu May 23, 2019 12:04 pm

masonstone wrote:
Thu May 23, 2019 11:14 am


Yes I do, they shouldn’t be practicing unsupervised due to not going to medical school and potential for both over-testing and delayed diagnosis.
That's going to upset a few people :P there are two kinds of nurse practitioners. Ones that have legit years of nursing experience prior to becoming a NP, and the other category are those who have minimal nursing and real world experience and just go from nursing school to an online NP school. The latter category usually has a fairly weak foundation of pathophysiology, they just have never been educated on it. They usually just want the highest paying job with the least amount of work/training/time. These are usually the NPs that are in over their head due to the lack of experience.

The fairly experienced nurses with many years of experience who then become NPs can actually do a decent job. I've worked with some very good NPs. The trick is knowing when to ask for help. As a rule, routine pediatric care isn't difficult. My intern family medicine wife could easily do routine pediatric care with her limited less than 1 year experience. Most kids are just not sick and they don't have extensive past medical histories, they are just easy patients. That's probably 80-90 percent of pediatrics. So someone with 10 years of experience should be easily able to handle that. The complex cases can be difficult though, in fact if my child was ever critically sick, I wouldn't even trust a pediatrician to be able to manage a critically sick crashing patient, they are just not good at it as they don't frequently see it.

But the business of a solo practice is brutal. You need to be okay with not having an income for a year at least.

masonstone
Posts: 498
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by masonstone » Thu May 23, 2019 12:14 pm

Cyanide123 wrote:
Thu May 23, 2019 12:04 pm
masonstone wrote:
Thu May 23, 2019 11:14 am


Yes I do, they shouldn’t be practicing unsupervised due to not going to medical school and potential for both over-testing and delayed diagnosis.
That's going to upset a few people :P there are two kinds of nurse practitioners. Ones that have legit years of nursing experience prior to becoming a NP, and the other category are those who have minimal nursing and real world experience and just go from nursing school to an online NP school.
Nurses do not get any pathophysiology training when working as a nurse. Of course everyone can take care of a healthy kid, but that's not what a pediatrician is for. It's to take care of sick kids and diagnose them without undue testing or unnecessary referrals to specialists. Getting an unnecessary CT scan for a kid is a lot more damaging than an unnecessary CT scan from an adult. It's been widely published in the literature that nurse practitioners order significantly more imaging than MDs. Not sure why anyone would trust their most precious possession with someone who isn't the most qualified to the job. I understand if a person takes their kid to a rural clinic manned by an NP where no pediatrician's willing to go, but I can't fathom why anyone would be willing to go to a NP instead of a board certified pediatrician to take care of their loved one.

Cyanide123
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Cyanide123 » Thu May 23, 2019 12:38 pm

masonstone wrote:
Thu May 23, 2019 12:14 pm
Cyanide123 wrote:
Thu May 23, 2019 12:04 pm
masonstone wrote:
Thu May 23, 2019 11:14 am


Yes I do, they shouldn’t be practicing unsupervised due to not going to medical school and potential for both over-testing and delayed diagnosis.
That's going to upset a few people :P there are two kinds of nurse practitioners. Ones that have legit years of nursing experience prior to becoming a NP, and the other category are those who have minimal nursing and real world experience and just go from nursing school to an online NP school.
Nurses do not get any pathophysiology training when working as a nurse. Of course everyone can take care of a healthy kid, but that's not what a pediatrician is for. It's to take care of sick kids and diagnose them without undue testing or unnecessary referrals to specialists. Getting an unnecessary CT scan for a kid is a lot more damaging than an unnecessary CT scan from an adult. It's been widely published in the literature that nurse practitioners order significantly more imaging than MDs. Not sure why anyone would trust their most precious possession with someone who isn't the most qualified to the job. I understand if a person takes their kid to a rural clinic manned by an NP where no pediatrician's willing to go, but I can't fathom why anyone would be willing to go to a NP instead of a board certified pediatrician to take care of their loved one.
Remember, most of pediatrics is taking care of healthy children with routine visits and vaccinations. And that is 80-90 percent of peds. Anyone with a couple years of experience could easily take care of that patient population.

But I do agree, NPs rely on greater testing and imaging. My wife is pregnant, I personally would not take our future child to a NP. But I'm myself an emergency medicine physician, and my wife is a family medicine resident so the whole point of having a pediatrician in our case would be having someone who knows more than us.

But most of the kids I see in the ER, would be perfectly fine following up with a pediatric NP. They are just not sick. It's not hard taking care of a runny nose 😂 the hypotensive, crashing, lethargic kiddos on the other hand, I wouldn't trust a pediatrician. That's the job of an EM or peds EM trained physician.

masonstone
Posts: 498
Joined: Thu Feb 01, 2018 4:01 pm

Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by masonstone » Thu May 23, 2019 12:57 pm

Cyanide123 wrote:
Thu May 23, 2019 12:38 pm
masonstone wrote:
Thu May 23, 2019 12:14 pm
Cyanide123 wrote:
Thu May 23, 2019 12:04 pm
masonstone wrote:
Thu May 23, 2019 11:14 am


Yes I do, they shouldn’t be practicing unsupervised due to not going to medical school and potential for both over-testing and delayed diagnosis.
That's going to upset a few people :P there are two kinds of nurse practitioners. Ones that have legit years of nursing experience prior to becoming a NP, and the other category are those who have minimal nursing and real world experience and just go from nursing school to an online NP school.
Nurses do not get any pathophysiology training when working as a nurse. Of course everyone can take care of a healthy kid, but that's not what a pediatrician is for. It's to take care of sick kids and diagnose them without undue testing or unnecessary referrals to specialists. Getting an unnecessary CT scan for a kid is a lot more damaging than an unnecessary CT scan from an adult. It's been widely published in the literature that nurse practitioners order significantly more imaging than MDs. Not sure why anyone would trust their most precious possession with someone who isn't the most qualified to the job. I understand if a person takes their kid to a rural clinic manned by an NP where no pediatrician's willing to go, but I can't fathom why anyone would be willing to go to a NP instead of a board certified pediatrician to take care of their loved one.
Remember, most of pediatrics is taking care of healthy children with routine visits and vaccinations. And that is 80-90 percent of peds. Anyone with a couple years of experience could easily take care of that patient population.

But I do agree, NPs rely on greater testing and imaging. My wife is pregnant, I personally would not take our future child to a NP. But I'm myself an emergency medicine physician, and my wife is a family medicine resident so the whole point of having a pediatrician in our case would be having someone who knows more than us.

But most of the kids I see in the ER, would be perfectly fine following up with a pediatric NP. They are just not sick. It's not hard taking care of a runny nose 😂 the hypotensive, crashing, lethargic kiddos on the other hand, I wouldn't trust a pediatrician. That's the job of an EM or peds EM trained physician.
I personally wouldn't trust an EM doctor for that either but would take them to an pediatric intensivist :P Not sure why you'd take a healthy kid with runny nose to a clinic anyways.

Cyanide123
Posts: 195
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by Cyanide123 » Thu May 23, 2019 1:06 pm

masonstone wrote:
Thu May 23, 2019 12:57 pm


I personally wouldn't trust an EM doctor for that either but would take them to an pediatric intensivist :P Not sure why you'd take a healthy kid with runny nose to a clinic anyways.
Agreed. I mean we would start the stabilization and feel relatively comfortable with it, but eventually a peds intensivist > ER doctor for sick kids. The sooner that crashing kid is out of my ER and in the ICU the better it is for everyone 😁

People take runny noses to the EMERGENCY room ALL THE TIME. Literally 70 percent of our peds volume is usually viral URIs especially in winter months. So...I wouldn't be surprised if clinics get inundated with stuffy noses in those months too. In fact, these kids should be taken to clinics AND NOT TO THE ER. Patients are terrible at resource utilization.

staythecourse
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by staythecourse » Thu May 23, 2019 1:17 pm

Not sure how this got side tracked to a M.D. vs. N.P. discussion, but the one aspect of that debate that is likely to be true is that most folks will likely want a peds (M.D.) to be the primary care provider for their child. So, I do agree with Mason it would be difficult to build a practice with good insurance. If the OP is considering building a practice in a rural area maybe a bit different, but in a metro area they will need a better niche to attract patients. In reality there are PLENTY of those niches that could be carved out, but folks in medicine are usually not forward thinking enough to do it.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

decapod10
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Re: Opening a Pediatric practice as a Pediatric Nurse Practitioner

Post by decapod10 » Thu May 23, 2019 3:16 pm

staythecourse wrote:
Thu May 23, 2019 1:17 pm
Not sure how this got side tracked to a M.D. vs. N.P. discussion, but the one aspect of that debate that is likely to be true is that most folks will likely want a peds (M.D.) to be the primary care provider for their child. So, I do agree with Mason it would be difficult to build a practice with good insurance. If the OP is considering building a practice in a rural area maybe a bit different, but in a metro area they will need a better niche to attract patients. In reality there are PLENTY of those niches that could be carved out, but folks in medicine are usually not forward thinking enough to do it.

Good luck.
I agree with all your points, NP will be disadvantaged vs. physicians in solo practice, due to perception and bias (rightly or wrongly). Having a niche or going to an underserved area would be ways to fix the problem. But one potential problem is that it may take awhile to find a niche that both fits your experience/training and also is profitable, so there’s an element of risk to it. If things don’t go well for the first year, is it because of marketing? Is it because my niche is just too narrow to attract patients? Maybe it’s just too early. Do I need to switch focus or hang tight? Can I afford to do this much longer or will I run out of cash?

Many physicians find their niche by starting general, then changing their focus as time goes on. If their niche works out, they just stop doing Primary Care and focus on their thing. If their niche isn’t sustainable, they still have their general practice to fall back on while they make adjustments , or they can do a combination of a Primary care plus whatever their interest is. This is relatively common in Internal Medicine specialties. But I think an NP may not have that safety net.

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