I had a question from a doctor the other day and he was asking
me how I got to the $1,000,000 mark.
He was hovering around the $70,000 per month in
collections. In some months I do 80, most I
do 90 or sometimes even 100. When he saw it, it was 120 that
month. And so I wanted to take a little
moment and explain how would as I get to this and maybe some
obvious things I haven't mentioned before about getting
your practice past the $1,000,000 mark.
I think the first thing I have to explain is most of my
practice is based on optimization of my current
patient load. And I want to explain the
difference because if you don't have a increased demand and a
big patient load, like none of the other stuff that I'm going
to talk about is possible. So what does that mean?
So my my typical date most, most days, Monday through Friday, I
start at 8:00 in the morning and the last patient in the morning
is at 11:30. So I finish about noon and then
I start up again at about 1:00. And then in my last patient of
the day is at 4:00, I see three patients an hour.
Each patient gets 20 minutes. Now this is for new patients or
established patients. The only difference is on my
Fridays where I double book every patient and I have a nail
tech seeing other patients, but that doesn't really Bing bring
in a ton of revenue. It just really gives me a person
that can see some patients and reduce the other days that we
have to do routine care and she can do some carry flexes that
take a little bit longer and things like that.
So she doesn't bring in a ton of revenue, but she kind of frees,
frees me up. So what I mean by having a full
schedule or having more demand than you need is that with that
high demand schedule, meaning every slot is filled, then you
can optimize your your schedule for more profitable patients.
Until you get to that point, your whole focus is on getting
more patients. OK.
So I want to, I want to repeat that again.
I know it sounds obvious, but for some people it might not be.
Many times we think that we need more profitable patients where
in the beginning you just need patients.
You just need more, more butts in the door, in your in your
treatment room. OK, once you have developed a
throughput, then you can optimize.
So let me explain kind of some scenarios.
So let's say you're by yourself and every single one of your
slots is filled, then you can optimize.
But sometimes we pull a trigger when we get very full and then
we we hire another doctor. When you hire that other doctor,
unless you instruct your staff to fill your schedule 1st and
then their schedule with the overflow, you're going to shoot
yourself in the foot, OK? Because you're going to be
taking money out of your pocket and you can't be optimized and
you're going to be giving it to the associate that might be
salaried. OK.
And and that is a big, that's a mistake that we've made a couple
of times in our practice. So I'm just kind of helping you
out. So there are different phases.
Sometimes you can be supply constrained, meaning there's too
much supply. And then other times there can
be a demand restraint where there's too much demand.
It's better to be in the demand constrained.
In my opinion, it's always better to have more demand
because then you can get optimal pricing, OK?
You can increase your privacy value if there's more demand
than you can fill, which means there's more people wanting
appointments than you can give them appointments.
Okay so the way we've done that is with the three, we have 4
doctors in our practice, 3 doctors are very full every
single day, okay and the overflow goes to the newer Dr.
that's not as filled. That's how we do it and that's
why I've made recently this urgent care page to help kind of
fill up his schedule and it does fill up our schedule a little
bit. OK, So I want to I want to
clarify. So once you have more demand
than you can treat, then you can move to phase two.
Until you have more demand than you can treat, you are going to
see as many patients and see them back as often as allowable
and profitable and, you know, feasible.
So what do I mean by that? So until you have too much
demand, you're going to probably see your perinicias at 2 weeks
and at 4 weeks you're going to see a follow up maybe or just
two weeks. You're going to see your
matrixectomies at 2 weeks and four weeks you're going to see
your fractures. You can see them every two, two
weeks. You're going to, you know, all
these types of things you're going to do because you don't
have enough demand, you're going to try to fill with office
visits and procedures and, and things like that.
So once, once you get, once your, your schedule is totally
filled and you have more demand, then and only then are you going
to start to optimize. And this is what that other
doctor was asking me. He was asking me, well, how is
it that you can get to 80,000 or 120,000 per month in production?
So because once you get the, once you have the demand there,
then you can increase your profit.
Now there's only a few ways, There's only a few big levers
that we have legally as podiatrists to get more profit
because I can't charge insurance.
I can charge them as much as I want, but they're only going to
pay so much, right? So I'm kind of capped with
insurance. I can only, you know, see so
many patients without reducing the quality of my visits.
That's why I, I cap it at 3 and maybe there's some quick
follow-ups for add-ons. OK, which I, which I talk about
and I, and So what are some of the ways that you can then
produce more revenue? So let's let's go into this.
This, this doctor asked me this and that's why I want to, I want
to clarify. So once you once you're fully,
once you have a filled demand schedule, why still aren't you
producing the $1,000,000 mark? It's usually because it's low
value patients, OK. And I'm not saying the value of
a human being, OK, all people have value.
And I, I, I like seeing patients, but you also have a
business to run, you have children to feed and things like
that. So low, low reimbursement
patients. So what do we do for low
reimbursement patients? We either spread the time out
between we see when we see them or we don't see them back, or we
put them all together so we can make it a little bit more
profitable. Those are the ways that we can
do it. So give me an give me an
example. Most paranicias are fine.
I give them nice instructions afterwards and most I don't need
to see back so I don't see them back.
Before I had all the demand I would see them back OK in two
weeks. Second thing I major exectomies
I used to see at 2 weeks and four weeks OK.
It was a low level visit. I wanted to reduce that.
Now I see them once at three weeks.
That's rationale and not that I, you know, I like the patients,
it's just I think 1 is necessary.
I even know some doctors that don't, don't see them back at
all. OK, that's a, that's a kind of a
doctor preference. So that's another example.
The third example, which I think is the most elegant one that
really this isn't mine. I, I learned this at the a APPM.
Actually, we were doing it at about the same time as the A
APPM. There's a lecture on this.
So we had implemented it and there was another doctor from
Chicago that implemented it and, and we found the same benefit.
And that was to, to put all of our patients in a, a block of
time to make it more effective for our routine care patients.
So all diabetics, all nail care patients, those tend to
reimburse a little bit less than other patients.
You know, you try to optimize it by doing diabetic foot exams
once a year. You can do diabetic shoes.
If you do that, you can do Padnet and, and things like
that. You can optimize it, but they
tend to still glut your schedule in my opinion.
And that's not the type of patient practice we want.
And So what we ended up doing is each doctor has 1/2 day.
My half day is on Fridays. There's one of my other
colleagues does it on Thursday and another one does it on
Tuesday. So we each have these half days
where all we see is the routine patients that's being seen by
our nail tech. One of them has the nail tech
see all the nails and he does just other, another patient
schedule. Another one does similar thing.
And then I do routine and I have my staff do routine.
Mine are all double booked. So it's a it's a busy day, but
it's a way that we can make it most beneficial.
And then we really say no any other time.
So we restrict our access. But what would happen if someone
can't see me Friday morning? Well, then they have to see one
of the other doctors or they have to see my nail tech.
Oh, but but what happens if they want to see?
There's no option. That's just the way that we do
it. OK, So you have a lot of these
questions and if you set up barriers or bumpers, the the
patients aren't going to flow into that.
And that was the same thing we we did initially when we were
learning shockwave. I used to put all my shockwave
at a certain time so I could get practice.
Same thing with ultrasound. I did all my ultrasound at the
same time so I could get faster at it.
So I think there's a benefit to seeing a lot of similar patients
on the same days. It just makes things a little
bit easier. So I want to kind of clarify,
clarify that so #1 would be then taking your low value patients,
putting them all in one day, reducing the amount of time that
you see them back or not see them back at all, OK.
And another, I'll give you another example, let's say
patients that you're going to make recommendations and they
don't take your recommendations, OK?
So those ones I, I don't see back or I see back at a really
long interval because they're not, they're not taking my
recommendations of what I recommend is best for them.
So it's just another way to reduce those.
OK, so #1 would be, would be doing that if I could do it over
again. I have a full schedule.
I would put all my routine and that for a lot of doctors, you
might be scared. You'd be like, well, I've been
putting those in my schedule all along.
What am I going to do with all all that extra time?
Well, then you're going to go back to here, have too much
supply. So you have to get busier.
Then you have to to fill to fill the schedule.
Try the urgent care page. And then you have to work on
building and getting more leads. OK.
That's a whole marketing question beyond the scope of of
this little, little podcast here.
OK, So let's go now to the second thing that I do.
So the first is to put everyone on the same day and reduce the
low value patients. The second thing is to optimize
all of the patients that I see. And I want to give you a couple
examples of how I optimize. You can optimize durable medical
equipment and then you can optimize different types of
procedures. So let's first talk about
durable medical equipment. So for drum medical, first of
all, you have to offer drum medical equipment, OK?
So if you don't, you have to do that.
That's a no brainer. That's going to bring in a lot
of revenue. You have to know to bill it, so
you get paid and then you have to optimize it.
So the main way I optimize it is every patient that has a
fracture gets a Cam boot. That's pretty obvious.
Every surgical patient gets a Cam boot.
Every kind of ulcer patient is getting like a Cam boot or a
surgical shoe. OK, these are just obvious
things. Really bad tendonitis are going
to get a boot. But the real, I think difference
that that I, I, I've, I've learned is that every patient
with Aquinas, which is mostly all of my plantar fasciitis,
Achilles tendonitis patients are getting night splint.
And if they have it on both sides, they get bilateral night
splints and that's always covered by insurance.
OK, Even bilateral are covered for patients.
So instead of wearing it just three hours one day, they're
going to wear on each side. So that's six hours.
It's too much time. That's why I give them
bilateral. So really optimizing your DME
and you have to have a really good system.
So let me explain this. I know this might not seem
obvious, but if it is a hassle every time you do DME, you're
not going to do it. If it's complex, you're not
going to do it. Just like when I talk to people,
patients about doing or doctors about doing biopsies, if
biopsies aren't easy, you're not going to do them.
You're, you know, So it's my process is I hit the little
button I have in my treatment room, which calls my assistant.
I said I need. Once you see a Lyda with Abby,
they get that. I numb it up, have my, my 2mm
punch biopsies right in the treatment room.
They're sitting in the bottom drawer along with the little
little containers, the liquid in there.
And I do it and I put the patient's, there's always a post
it note with the patient's name. I put the post it note there
with the location I did it at. And my, my scribe does
everything else in my note. So it takes me literally no
time. Nail sample, same thing.
Take a little nail sample and send it out.
I don't consider a nail sample a biopsy, but I don't want to get
off. Of course, it's just a nail
sample, but it has to be really simple, really easy.
So all DME has to be easy. So the, you know, I hit my
little button, staff comes in and say they need a Cam boot.
My staff many times they know this, they need a Cam boot.
They're going to get what I call the Pelto specialist.
So they're going to get night splint foam rollering and
morning stretch. That's what I do for most
patients with Aquinas. So this is the process that you
can optimize your DME. OK.
That's the second thing I would say is optimize your DME has to
be a real easy, easy process. You have to have enough of the
DME so you don't run out, OK? So that is going to take you up
to the kind of the next level in production, OK?
Next thing would be learning to optimize your procedures.
So what I'm talking about in terms of, so let's talk about
imaging, imaging and procedures. So imaging would be getting
X-rays. So every single patient with
foot pain gets X-rays. Every patient with once again,
foot pain gets X-rays. My staff knows that.
So what does that mean? Facing with a really bad callus?
They're going to get an X-ray because there could be a Bony
deformity underneath it that they're dealing with.
So every, every patient gets X-rays.
So I do a lot of X-rays for all Achilles and plantar fasciitis.
They're getting 2 views of the foot and two of the heel.
Otherwise there might be getting three of the foot or they might
get a getting of the ankle. So a lot of X-rays, every
patient that has other type of soft tissue issues, neuroma,
Achilles, plantar fasciitis, things like that, they're all
getting at some time. An ultrasound might be the first
visit, might be the second visit.
So they're all getting an ultrasound.
And in my case, ultrasounds are not covered by insurance.
So they're paying. And I, the way I explain it to
patients, I say this is ultrasound.
Insurance usually doesn't cover it unless you have Medicare.
It costs $100 and it's as many ultrasounds as I want to get.
So that means I can do 1 today, I can do one in a few months
when I see you back so we can compare views.
And I use that as an educational tool.
Sometimes I'll do it on both sides.
I don't charge them for both sides, but just to explain and
show them how one area is damaged and the other isn't.
So the you have to really optimize every patient.
And this is something that highly has to do with your staff
in terms of doing the, the views of the X-rays, knowing when you
need DME and making the consents, if you do consents
really easy. So that's, that's the imaging.
So the other thing is doing procedures.
I try to optimize for doing procedures in as many patients
as I can. And I try to make it as
efficient as possible. So I can do it most of the time
the same day. So for example, patients come
in, have an ingrown toenail, I'm going to do an Ind that day,
chronic ingrown toenail, I'm going to do a matrixectomy that
day, a flexible hammertoe with a kind of a pre ulcerative or an
ulcer. I'm going to do a flexor
tenotomy that day. All the procedures I have them
do that same day. The only reason I would stage a
procedure is if they have a really bad paronychia, I'm going
to do maybe an I and D and then maybe in three or four weeks I'm
going to do a matrix ectomy. OK, so I'm going to stage do one
and then do the other. But most of the time I try to
make it as efficient as possible to do all the procedures.
The I guess The only exception would probably be like an
exostectomy or I need Amis pack. So I'm I'm doing an MIS surgery,
shaving down bone. I'm usually scheduling that just
because patients don't want to do that the same day.
But most of the the other other procedures I'm doing fracture
care, which isn't really a procedure, but that has to be
used when you think there's a fracture or there is a fracture
doing that has a little bit longer global, but you have to
know how to build that appropriately.
And those I only see one time for the most part in four weeks
and then I don't see them back after that.
So that makes it more profitable because you get paid more
upfront, but then there's less follow up care.
Same thing. I, I don't really do much ulcer
care. So I don't want to go in too
much in depth, but you have to have a procedure to make it
profitable. So I guess debridement and then
I also have collagen, the Amera Amera X collagen, but I do not
do a lot of ulcer care. I tend to refer them once they
get too bad over to the wound care center.
Just something that something that I really like a lot.
So we talked about imaging, we talked about procedures.
One of the procedures that is really big for me is doing
shockwave just because I really believe it.
I do not do that much cortisone. I do it once in a while if
someone maybe they've had a cortisone for a plantar fascia
or for an aroma or a first MPJ or for gout or something like
that. So I do some cortisone, but I
don't do a ton of cortisone. A couple of efficiencies that we
do in our office just to make it once again more efficient was we
have both anesthetics and cortisones pre drawn up and then
they're disposed of at the end of every day.
So we try not to leave them till the next day, but we do have
them pre drawn up for the about the number of patients that
we're going to need each day. That just saves US time having
the staff or the doctor draw them up.
So making it very, very efficient.
So kind of getting me the cortisone or the injection them
up and having, you know, staff prep everything else.
So the, the, the procedures such as Shockwave, I tend to try to
do that as well the same day. I'll, I'll, I'll say, hey, we'll
see if we can try to fit you in. Sometimes it can be long though,
because you're doing X-rays, you're doing an ultrasound and
you might do Shockwave. So it might put you behind a
little bit unless you have a very efficient system.
Same thing with Swift. You can try to do that the same
day. That's a little bit easier.
The, the only challenge with both Shockwave and Swift, in my
opinion, are that the machines are kind of room dependent.
We don't have them on a like a swivel, a swivel trailer where
we can move them from room to room.
We have them in a, in a treatment room.
So if you're in a different treatment room, our office is a
little bit small, so it's harder for us to swift, a little bit
easier to move to another treatment room.
But those are things that really helped me increase the value of
my treatments. Now some people ask me, well,
how do you do so much shockwave? How do you do so much swift?
I guess procedures a little bit easier to explain the, the way I
do it is I use my treatment sheets.
So if you don't have my treatment seats, shoot me an
e-mail don@podiatrypracticemastery.com.
I'll send you my link to my treatment sheets.
Look at the one on wart, look at the one on plantar fascia,
Achilles. Look at those.
Basically it's a sheet that I, I put on a clipboard and I go
through it with the patients and I say this is how I treat these
things The, and it has the highlights of those treatments
and it makes it very easy and it makes a very rational decision
for them to do those treatments. So it's very easy.
I haven't talked about orthotics.
Orthotics are something that I'm always planting the seed with
patients. It's on my treatment sheet and
I'm always recommending it if it's appropriate for patients
along with shoes along with UFOs and all these other
recommendations. I do not sell UFOs, probably
should. I think it would be a good
revenue generator. I do have a many other products
that I do sell. I haven't really talked about
selling products. I think if you do products, you
have to have protocols for those products.
I think it makes it a lot easier.
So for example, every Matrix gets an Amerigel kit, every
plantar fasciitis and Achilles tendon gets a foam roller, a
night splint and a morning stretch.
Every patient that has calluses, fissures, IP KS are getting Cara
cream with a pummy bar. Every patient that you go on and
on and on and on. So don't have products that you
don't have protocols for and treatment sheets for because it
just makes it so much easier. You do the same thing every time
you don't build a product. Just kind of sitting there.
Every nail fungus gets my UV light and shoe spray and then
usually the terbenafin or you know, some people do the
Luneala. I tend to talk patients more out
of Luneala than into it just because I don't have the
greatest results. I know some other doctors, they
have just fabulous results and I would love to be there.
I I think if I could get patients better without.
I'm doing the oral that would be great, but I haven't figured
that quite out. So if you found a great way, let
me know. OK.
So we've kind of talked about a lot of the the high points.
I haven't really talked much about surgical procedures.
I don't do a lot of surgery and I do it maybe every two months,
every three months and I do it reluctantly.
I have a very good system of younger doctors that I can refer
to and they, I think they're actually better than me and,
and, and it doesn't Take Me Out of the office.
The problem with surgery, it tends to Take Me Out of the
office. I knew a doctor, I was talking
to him and what he does is he does the first case in the
morning, like from 7:00 to 8:00 and then he goes in to see his
patient. So I think if, if to make it
more efficient being like the first case at a surgical center
would make sense. A full day of surgery.
In my, in my experience, I have a harder time producing enough
revenue to condone being out of the office 'cause I think I do
much more in the office. So those are some of the, some
of the ways to make it much more profitable and to get to the
$1,000,000 mark. Once you have the, once you're,
we have a lot of supply of patients.
So then you can kind of whittle down, whittle down those
patients and kind of see the more more profitable ones, see
them more often, help them more in, in the treatment.
And then there, there also is the aspect of efficiency.
I'm a big efficiency person of buying my time back.
There's a good book by that title, Buy Your Time Back.
But I buy my time back with my scribe.
So I, he does my notes for me. I sign off on the notes.
So it makes me much more efficient, gives me much more
FaceTime with the patients. You can do this similarly with,
with protocols with your own medical assistant.
But I think my scribe by far, he, he, he is what helped me go
to the next level in terms of my production.
So he, I don't have to spend that much time doing notes or
very minimal every 3 or 4 patients.
I'll do that. So if you guys found this
beneficial, let me know, Shoot me an e-mail,
don@podiatrypracticemastery.com. If you want to meet and say,
hey, how can I implement these things, shoot me an e-mail.
I'd love to help you. I do have a lot of resources on
my blog, my website, Podiatry practice mastery.
On the bottom there are a couple of things you might like.
There is certainly my $1,000,000 blueprint kind of going through
all of these things that I talked about today in more in
depth little videos. There is an audit so you can
kind of see how your practice is doing and we could meet up to
talk. So it goes through kind of all
these things I talk about and says, you know, they're kind of
hard questions and you can do that audit there and you could
set up a strategy call with me just to I have some availability
during my lunch hours where I like to meet with people.
I like to help. If I can help you in the half
hour, I will. You tell me your problem.
I'll do the best I can to help you.
And then if you want more help, I'm I'm doing a six month
challenge that's coming up soon where we're going to try to do
these things that we've kind of talked about and implement
these. I think a lot of times it's good
to have ideas, but people have a hard time people me, me as well.
We have a hard time implementing things without accountability
because we are quote UN quote, too busy.
OK, we're kind of busy all the time.
So and, and I guess I want to talk about the last thing about
like it's not so much getting to the $1,000,000 mark, but it's
having a good life on the side. So I do not do any business on
nights, on weekends, I'm not reading business on the
weekends. I, I like to free myself
completely from those things. So I think another key is you
can't be stressed with your practice.
It's not enough to to produce that amount and have no life.
You have to have a life, You have to enjoy yourself.
I think that is a, a key, a key aspect to profits aren't
everything, but I think being busy is just being better,
right? You can give better care.
And I, I think the, the I'm, I'm better at caring for patients
now than I was in the past. And a lot of it is because I've
gotten better at treating those conditions.
And most of the time it's with giving more resources and
educating patients more with my treatment sheets and other types
of things. To simplify something that would
take me 20-30 minutes to explain.
I have it in one video that's on my treatment sheet in AQR code
or on a blog that goes to a blog post with a video.
So it's just educating our patients and putting it all in
places that's much more feasible for them and they understand the
value of the of the treatments. OK, once again, I hope you guys
enjoyed this. I'll talk to you tomorrow.