Expand Your Practice With Procedures

Your bottom line is slipping, you want to offer patients more services, and you and your staff members need new challenges. Adding procedures to your practice might alleviate all of these concerns.

Doing procedures could add tens of thousands of dollars to the bottom line of most family medicine practices, compared with annual income before procedures. That's the assessment of FP Edward Zurad, M.D., of Tunkhannock, Pa., who has taught procedures to family physicians and others for 19 years, often in AAFP courses.

Likewise, FP W.M. Rodney, M.D., of Memphis, who has documented the financial impact of doing procedures, says, "Procedurally enriched physicians can start a practice in almost any over-doctored area and be successful within 24 months." In an article in the March 2004 Journal of Family Practice, Rodney says, "For credibility in the community and in the life cycle of families, the provision of diagnostic and therapeutic procedures trumps prescription-writing every time."

Start with skin surgery, says FP John Pfenninger, M.D., who heads The National Procedures Institute in Midland, Mich. FPs seeking to keep their practices solvent through procedures can quickly incorporate dermatology, says Pfenninger. "In five minutes, I can remove a forearm or wrist lipoma (CPT code 25075 -- see chart below). I can treat a basal cell carcinoma on the face (code 17281) in five minutes." The income for these services is far higher than that for an established patient visit (code 99213), which often takes more than 15 minutes, Pfenninger says. In addition, such skin procedures may require only lidocaine and a blade or a dermatology curette, so there is little cost to get started doing them.

Some family physicians have told Pfenninger they want to begin with more complicated work than skin procedures. "I tell them, 'I'm throwing you a life preserver. Derm will hold you up. Get it mastered, and move on from there."

Payment amounts are much higher for some procedures when they're performed in an office instead of in a hospital or surgicenter, Pfenninger adds. Another plus: "Having family doctors do procedures in the office can reduce total health care costs," he says.

Offering procedures in your office also can lead to higher patient satisfaction. Patients appreciate having various procedures done by their own physician,says FP Edward Jackson, M.D., of Saginaw, Mich. Jackson and his partners teach family medicine residents procedures ranging from removal of lumps, bumps and warts to casting, splinting, endometrial biopsies, colposcopies and vasectomies.

"To go someplace else, even for a single procedure, is a little bit disconcerting to some people," says Jackson. "If I've made the diagnosis, the patient wants me to treat it." For example, when Jackson does family planning with couples, he tells them he also does vasectomies. "The man will say, 'Cool. Let me have it done here, where I'm more comfortable,'" says Jackson.

Pfenninger, a co-author (with FP Grant Fowler, M.D., of Houston) of Pfenninger & Fowler's Procedures for Primary Care, advises family physicians to offer infant circumcisions as a service. It can provide a financial benefit to the family, and the equipment is relatively inexpensive.

Pfenninger cites as an example an uninsured mother in Grand Rapids, Mich., who left the hospital soon after her son was born and before he could be circumcised. To return to the hospital and have the circumcision performed as day surgery would have cost the family about $1,000. The child's parents searched the Internet for circumcision in a physician's office and found Pfenninger, whose office was about 125 miles away. Despite the distance, they drove their son to him for the circumcision and were charged only about $350.

The papoose board used to immobilize infants costs about $250 and the Gomco(TM) clamp costs about $100, says Pfenninger. "Those are paid for with one office circumcision."

Procedures add variety to a practice, says Zurad. "Many family physicians doing procedures walk into the office with a spring in their step and look forward to the day ahead. They have fun with their patients and staff; their staff members are loyal to them and stay with them."

However, doing office-based procedures may require more from your staff members. They probably will need training to assist at many procedures, says Zurad. "Your staff must be attuned to the care and cleaning of instruments to avoid the consequences of infection and equipment malfunction, and they have to provide ongoing care to patients during and after procedures. Any of your current staff members can be trained in all these areas."

Doing procedures does have some downsides. For example, Zurad notes that his liability insurance premium is about $5,000 higher per year since his insurance provider -- about three years ago -- began asking whether he did endoscopies. He calls the higher premium one of the few drawbacks to doing procedures.

He also advises FPs doing procedures with sedation to focus on patients' cardiopulmonary risk issues and the potential consequences of conscious sedation. "We (FPs) understand the patient's cardiovascular and pulmonary issues in many cases better than the subspecialists," says Zurad. "That provides us with an eyes-open view of the patient. We know who can have the procedure safely -- that's a giant 'pro.'"