The Office

The wholesale shuffling of employees triggered by the COVID-19 pandemic has raised many questions about the differences between full-time, part-time, and full-time equivalent employees, and how employment laws apply to them. While rules vary from state to state, some generalizations can be made.

Even the definitions of full-time and part-time vary. For instance, under the Affordable Care Act (ACA), full time means working at least 30 hours per week. Under the Families First Coronavirus Response Act (FFCRA), it is 40 hours.

Full-time equivalent (FTE) is a concept designed to document a part-time workforce in terms of full-time employment, by taking the total hours worked by all part-time employees and dividing by the full-time schedule. Of course, the ACA and the Paycheck Protection Program (PPP) calculate that number differently: The ACA requires you to total all the hours worked by part-time employees per month, and divide by 120. For the PPP, you divide the total part-time hours per week by 40, and round to the nearest tenth. (You can also use a simplified method that assigns a 1.0 for employees who work 40 hours or more per week and 0.5 for those who work fewer; whichever method you choose, you must apply it consistently on all PPP forms.)

FTEs are important for the purposes of the ACA because employers with 50 or more full-timers plus FTEs must offer health coverage to their full-timers and dependents. But most private practitioners need an accurate FTE total to deal with the PPP: If staffing levels weren’t maintained after you received a PPP loan, your loan forgiveness amount may be reduced. Staffing levels are determined by comparing the average number of full-timers plus FTEs during the “covered period” to either the period from Feb. 15 through June 30, 2019, or Jan. 1 through Feb. 28, 2020.

The PPP aside, FTEs have created confusion over when an employee is entitled to overtime pay. Under federal law, overtime is due whenever an employee works more than 40 hours per week; up to 40 hours, the regular wage is paid. (There are exemptions, and a few states use a daily number.) For example, if a part-timer receiving $900 per week for a 30-hour workweek works more than 30 hours, the hours from 30 to 40 would be compensated at their normal wage of $30 per hour ($900 ÷ 30). If the employee worked more than 40 hours, you would pay overtime (in this case $45 per hour, $30 x 1.5) for the hours in excess of 40.

To address a few other employment questions that I am frequently asked:

Under the FFCRA, you must provide both full- and part-time employees with emergency paid sick leave (EPSL) if they’re unable to work from your office or their home because of illness attributable to COVID-19, quarantine, or caring for a sick family member or child whose school is closed. Full-time employees are entitled to up to 80 hours of EPSL, and part-timers an average of what they work every 2 weeks. Some states have their own laws independent from the FFCRA. Check your state or local laws.

• Some states require you to provide meal and rest breaks to both full- and part-time employees. In California, for example, employers must provide a 30-minute meal break after no more than 5 hours of work, unless the total workday is less than 6 hours and both employers and employees consent to waive breaks. California also requires rest breaks after every 4 hours worked. Check the laws in your state.
• You must include part-time employees in a 401(k) retirement plan if they work at least 1,000 hours in a year, which is about 20 hours per week. That rule is changing in 2021 to 500 hours for employees older than 21. There are state-run retirement programs in California, Connecticut, New Jersey, Washington, and Oregon, among other states. Check your state law for details.
• If you offer paid vacations to full-time employees, you do not have to do the same for part-timers. (In fact, there is no requirement in most states to offer vacation time at all.) My office does offer it to part-time employees on a pro rata basis, as do many others in my area. Again, check your state law.

As always, consult with your attorney if it’s not clear which rules apply in your specific situation.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no relevant disclosures related to the topic of this column. Write to him at dermnews@mdedge.com.

The wholesale shuffling of employees triggered by the COVID-19 pandemic has raised many questions about the differences between full-time, part-time, and full-time equivalent employees, and how employment laws apply to them. While rules vary from state to state, some generalizations can be made.

Even the definitions of full-time and part-time vary. For instance, under the Affordable Care Act (ACA), full time means working at least 30 hours per week. Under the Families First Coronavirus Response Act (FFCRA), it is 40 hours.

Full-time equivalent (FTE) is a concept designed to document a part-time workforce in terms of full-time employment, by taking the total hours worked by all part-time employees and dividing by the full-time schedule. Of course, the ACA and the Paycheck Protection Program (PPP) calculate that number differently: The ACA requires you to total all the hours worked by part-time employees per month, and divide by 120. For the PPP, you divide the total part-time hours per week by 40, and round to the nearest tenth. (You can also use a simplified method that assigns a 1.0 for employees who work 40 hours or more per week and 0.5 for those who work fewer; whichever method you choose, you must apply it consistently on all PPP forms.)

FTEs are important for the purposes of the ACA because employers with 50 or more full-timers plus FTEs must offer health coverage to their full-timers and dependents. But most private practitioners need an accurate FTE total to deal with the PPP: If staffing levels weren’t maintained after you received a PPP loan, your loan forgiveness amount may be reduced. Staffing levels are determined by comparing the average number of full-timers plus FTEs during the “covered period” to either the period from Feb. 15 through June 30, 2019, or Jan. 1 through Feb. 28, 2020.

The PPP aside, FTEs have created confusion over when an employee is entitled to overtime pay. Under federal law, overtime is due whenever an employee works more than 40 hours per week; up to 40 hours, the regular wage is paid. (There are exemptions, and a few states use a daily number.) For example, if a part-timer receiving $900 per week for a 30-hour workweek works more than 30 hours, the hours from 30 to 40 would be compensated at their normal wage of $30 per hour ($900 ÷ 30). If the employee worked more than 40 hours, you would pay overtime (in this case $45 per hour, $30 x 1.5) for the hours in excess of 40.

To address a few other employment questions that I am frequently asked:

Under the FFCRA, you must provide both full- and part-time employees with emergency paid sick leave (EPSL) if they’re unable to work from your office or their home because of illness attributable to COVID-19, quarantine, or caring for a sick family member or child whose school is closed. Full-time employees are entitled to up to 80 hours of EPSL, and part-timers an average of what they work every 2 weeks. Some states have their own laws independent from the FFCRA. Check your state or local laws.

• Some states require you to provide meal and rest breaks to both full- and part-time employees. In California, for example, employers must provide a 30-minute meal break after no more than 5 hours of work, unless the total workday is less than 6 hours and both employers and employees consent to waive breaks. California also requires rest breaks after every 4 hours worked. Check the laws in your state.
• You must include part-time employees in a 401(k) retirement plan if they work at least 1,000 hours in a year, which is about 20 hours per week. That rule is changing in 2021 to 500 hours for employees older than 21. There are state-run retirement programs in California, Connecticut, New Jersey, Washington, and Oregon, among other states. Check your state law for details.
• If you offer paid vacations to full-time employees, you do not have to do the same for part-timers. (In fact, there is no requirement in most states to offer vacation time at all.) My office does offer it to part-time employees on a pro rata basis, as do many others in my area. Again, check your state law.

As always, consult with your attorney if it’s not clear which rules apply in your specific situation.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no relevant disclosures related to the topic of this column. Write to him at dermnews@mdedge.com.

The wholesale shuffling of employees triggered by the COVID-19 pandemic has raised many questions about the differences between full-time, part-time, and full-time equivalent employees, and how employment laws apply to them. While rules vary from state to state, some generalizations can be made.

Even the definitions of full-time and part-time vary. For instance, under the Affordable Care Act (ACA), full time means working at least 30 hours per week. Under the Families First Coronavirus Response Act (FFCRA), it is 40 hours.

Full-time equivalent (FTE) is a concept designed to document a part-time workforce in terms of full-time employment, by taking the total hours worked by all part-time employees and dividing by the full-time schedule. Of course, the ACA and the Paycheck Protection Program (PPP) calculate that number differently: The ACA requires you to total all the hours worked by part-time employees per month, and divide by 120. For the PPP, you divide the total part-time hours per week by 40, and round to the nearest tenth. (You can also use a simplified method that assigns a 1.0 for employees who work 40 hours or more per week and 0.5 for those who work fewer; whichever method you choose, you must apply it consistently on all PPP forms.)

FTEs are important for the purposes of the ACA because employers with 50 or more full-timers plus FTEs must offer health coverage to their full-timers and dependents. But most private practitioners need an accurate FTE total to deal with the PPP: If staffing levels weren’t maintained after you received a PPP loan, your loan forgiveness amount may be reduced. Staffing levels are determined by comparing the average number of full-timers plus FTEs during the “covered period” to either the period from Feb. 15 through June 30, 2019, or Jan. 1 through Feb. 28, 2020.

The PPP aside, FTEs have created confusion over when an employee is entitled to overtime pay. Under federal law, overtime is due whenever an employee works more than 40 hours per week; up to 40 hours, the regular wage is paid. (There are exemptions, and a few states use a daily number.) For example, if a part-timer receiving $900 per week for a 30-hour workweek works more than 30 hours, the hours from 30 to 40 would be compensated at their normal wage of $30 per hour ($900 ÷ 30). If the employee worked more than 40 hours, you would pay overtime (in this case $45 per hour, $30 x 1.5) for the hours in excess of 40.

To address a few other employment questions that I am frequently asked:

Under the FFCRA, you must provide both full- and part-time employees with emergency paid sick leave (EPSL) if they’re unable to work from your office or their home because of illness attributable to COVID-19, quarantine, or caring for a sick family member or child whose school is closed. Full-time employees are entitled to up to 80 hours of EPSL, and part-timers an average of what they work every 2 weeks. Some states have their own laws independent from the FFCRA. Check your state or local laws.

• Some states require you to provide meal and rest breaks to both full- and part-time employees. In California, for example, employers must provide a 30-minute meal break after no more than 5 hours of work, unless the total workday is less than 6 hours and both employers and employees consent to waive breaks. California also requires rest breaks after every 4 hours worked. Check the laws in your state.
• You must include part-time employees in a 401(k) retirement plan if they work at least 1,000 hours in a year, which is about 20 hours per week. That rule is changing in 2021 to 500 hours for employees older than 21. There are state-run retirement programs in California, Connecticut, New Jersey, Washington, and Oregon, among other states. Check your state law for details.
• If you offer paid vacations to full-time employees, you do not have to do the same for part-timers. (In fact, there is no requirement in most states to offer vacation time at all.) My office does offer it to part-time employees on a pro rata basis, as do many others in my area. Again, check your state law.

As always, consult with your attorney if it’s not clear which rules apply in your specific situation.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no relevant disclosures related to the topic of this column. Write to him at dermnews@mdedge.com.

Less than a year ago, I wrote a column on retirement strategies; but that was before COVID-19 took down the economy, putting millions out of work and shuttering many of our offices. Add extraordinary racial tensions and an election year like no other, and 2020 has generated fear and uncertainty on an unprecedented level.

Not surprisingly, my e-mail has been dominated for months by questions about the short- and long-term financial consequences of this annus horribilis on our practices and retirement plans. Most physicians have felt the downturn acutely, of course. Revenues have declined, non-COVID-19-related hospital visits plunged, and only recently have we seen hospitals resuming elective procedures. As I write this, my practice is approaching its prepandemic volume; but many patients have been avoiding hospitals and doctors’ offices for fear of COVID-19 exposure. With no real end in sight, who can say when this trend will finally correct itself?

Long term, the outlook is not nearly so grim. I have always written that downturns – even steep ones – are inevitable; and rather than fear them, you should expect them and plan for them. Younger physicians with riskier investments have plenty of time to rebound. Physicians nearing retirement, if they have done everything right, probably have the least to lose. Ideally, they will be at or near their savings target and will have transitioned to less vulnerable assets. And remember, you don’t need to have 100% of your retirement money to retire; a sound retirement plan will continue to generate investment returns as you move through retirement.

In short, the essentials of postpandemic financial planning remain the same as before: Make a plan and stick to it.

By way of a brief review, the basics of a good plan are a budget, an emergency fund, disability insurance, and retiring your debt as quickly as possible. All of these have been covered individually in previous columns.

An essential component of your plan should be a list of long-term goals – and it should be more specific than simply accumulating a pile of cash. What do you plan to accomplish with the money? If it’s travel, helping your grandkids with college expenses, hobbies, or something else, make a list. Review it regularly, and modify it if your goals change.

Time to trot out another hoary old cliché: Saving for retirement is a marathon, not a sprint. If the pandemic has temporarily derailed your retirement strategy – forcing you, for example, to make retirement account withdrawals to cover expenses, or raid your emergency fund – no worries! When things have stabilized, it’s time to recommit to your retirement plan. Once again, with so many other issues to deal with, retaining the services of a qualified financial professional is usually a far better strategy than going it alone.

Many readers have expressed the fear that their retirement savings would never recover from the COVID-19 hit – but my own financial adviser pointed out that as I write this, in August, conservative portfolio values are about level with similar portfolios on Jan. 1, 2020. “Good plans are built to withstand difficult times,” she said. “Sometimes staying the course is the most difficult, disciplined course of action.”

“If your gut tells you that things will only get worse,” writes Kimberly Lankford in AARP’s magazine, “know that your gut is a terrible economic forecaster.” The University of Michigan’s Index of Consumer Sentiment hit rock bottom in 2008, during the Great Recession; yet only 4 months later, the U.S. economy began its longest expansion in modern history. The point is that it is important to maintain a long-term approach, and not make changes based on short-term events.

COVID-19 (or whatever else comes along) then becomes a matter of statement pain, not long-term financial pain. The key to recovery has nothing to do with a financial change, an investment strategy change, or a holding change, and everything to do with realigning your long-term goals.

So, moving on from COVID-19 is actually quite simple: Fill your retirement plan to its legal limit and let it grow, tax-deferred. Then invest for the long term, with your target amount in mind. And once again, the earlier you start and the longer you stick with it, the better.

 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Less than a year ago, I wrote a column on retirement strategies; but that was before COVID-19 took down the economy, putting millions out of work and shuttering many of our offices. Add extraordinary racial tensions and an election year like no other, and 2020 has generated fear and uncertainty on an unprecedented level.

Not surprisingly, my e-mail has been dominated for months by questions about the short- and long-term financial consequences of this annus horribilis on our practices and retirement plans. Most physicians have felt the downturn acutely, of course. Revenues have declined, non-COVID-19-related hospital visits plunged, and only recently have we seen hospitals resuming elective procedures. As I write this, my practice is approaching its prepandemic volume; but many patients have been avoiding hospitals and doctors’ offices for fear of COVID-19 exposure. With no real end in sight, who can say when this trend will finally correct itself?

Long term, the outlook is not nearly so grim. I have always written that downturns – even steep ones – are inevitable; and rather than fear them, you should expect them and plan for them. Younger physicians with riskier investments have plenty of time to rebound. Physicians nearing retirement, if they have done everything right, probably have the least to lose. Ideally, they will be at or near their savings target and will have transitioned to less vulnerable assets. And remember, you don’t need to have 100% of your retirement money to retire; a sound retirement plan will continue to generate investment returns as you move through retirement.

In short, the essentials of postpandemic financial planning remain the same as before: Make a plan and stick to it.

By way of a brief review, the basics of a good plan are a budget, an emergency fund, disability insurance, and retiring your debt as quickly as possible. All of these have been covered individually in previous columns.

An essential component of your plan should be a list of long-term goals – and it should be more specific than simply accumulating a pile of cash. What do you plan to accomplish with the money? If it’s travel, helping your grandkids with college expenses, hobbies, or something else, make a list. Review it regularly, and modify it if your goals change.

Time to trot out another hoary old cliché: Saving for retirement is a marathon, not a sprint. If the pandemic has temporarily derailed your retirement strategy – forcing you, for example, to make retirement account withdrawals to cover expenses, or raid your emergency fund – no worries! When things have stabilized, it’s time to recommit to your retirement plan. Once again, with so many other issues to deal with, retaining the services of a qualified financial professional is usually a far better strategy than going it alone.

Many readers have expressed the fear that their retirement savings would never recover from the COVID-19 hit – but my own financial adviser pointed out that as I write this, in August, conservative portfolio values are about level with similar portfolios on Jan. 1, 2020. “Good plans are built to withstand difficult times,” she said. “Sometimes staying the course is the most difficult, disciplined course of action.”

“If your gut tells you that things will only get worse,” writes Kimberly Lankford in AARP’s magazine, “know that your gut is a terrible economic forecaster.” The University of Michigan’s Index of Consumer Sentiment hit rock bottom in 2008, during the Great Recession; yet only 4 months later, the U.S. economy began its longest expansion in modern history. The point is that it is important to maintain a long-term approach, and not make changes based on short-term events.

COVID-19 (or whatever else comes along) then becomes a matter of statement pain, not long-term financial pain. The key to recovery has nothing to do with a financial change, an investment strategy change, or a holding change, and everything to do with realigning your long-term goals.

So, moving on from COVID-19 is actually quite simple: Fill your retirement plan to its legal limit and let it grow, tax-deferred. Then invest for the long term, with your target amount in mind. And once again, the earlier you start and the longer you stick with it, the better.

 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Less than a year ago, I wrote a column on retirement strategies; but that was before COVID-19 took down the economy, putting millions out of work and shuttering many of our offices. Add extraordinary racial tensions and an election year like no other, and 2020 has generated fear and uncertainty on an unprecedented level.

Not surprisingly, my e-mail has been dominated for months by questions about the short- and long-term financial consequences of this annus horribilis on our practices and retirement plans. Most physicians have felt the downturn acutely, of course. Revenues have declined, non-COVID-19-related hospital visits plunged, and only recently have we seen hospitals resuming elective procedures. As I write this, my practice is approaching its prepandemic volume; but many patients have been avoiding hospitals and doctors’ offices for fear of COVID-19 exposure. With no real end in sight, who can say when this trend will finally correct itself?

Long term, the outlook is not nearly so grim. I have always written that downturns – even steep ones – are inevitable; and rather than fear them, you should expect them and plan for them. Younger physicians with riskier investments have plenty of time to rebound. Physicians nearing retirement, if they have done everything right, probably have the least to lose. Ideally, they will be at or near their savings target and will have transitioned to less vulnerable assets. And remember, you don’t need to have 100% of your retirement money to retire; a sound retirement plan will continue to generate investment returns as you move through retirement.

In short, the essentials of postpandemic financial planning remain the same as before: Make a plan and stick to it.

By way of a brief review, the basics of a good plan are a budget, an emergency fund, disability insurance, and retiring your debt as quickly as possible. All of these have been covered individually in previous columns.

An essential component of your plan should be a list of long-term goals – and it should be more specific than simply accumulating a pile of cash. What do you plan to accomplish with the money? If it’s travel, helping your grandkids with college expenses, hobbies, or something else, make a list. Review it regularly, and modify it if your goals change.

Time to trot out another hoary old cliché: Saving for retirement is a marathon, not a sprint. If the pandemic has temporarily derailed your retirement strategy – forcing you, for example, to make retirement account withdrawals to cover expenses, or raid your emergency fund – no worries! When things have stabilized, it’s time to recommit to your retirement plan. Once again, with so many other issues to deal with, retaining the services of a qualified financial professional is usually a far better strategy than going it alone.

Many readers have expressed the fear that their retirement savings would never recover from the COVID-19 hit – but my own financial adviser pointed out that as I write this, in August, conservative portfolio values are about level with similar portfolios on Jan. 1, 2020. “Good plans are built to withstand difficult times,” she said. “Sometimes staying the course is the most difficult, disciplined course of action.”

“If your gut tells you that things will only get worse,” writes Kimberly Lankford in AARP’s magazine, “know that your gut is a terrible economic forecaster.” The University of Michigan’s Index of Consumer Sentiment hit rock bottom in 2008, during the Great Recession; yet only 4 months later, the U.S. economy began its longest expansion in modern history. The point is that it is important to maintain a long-term approach, and not make changes based on short-term events.

COVID-19 (or whatever else comes along) then becomes a matter of statement pain, not long-term financial pain. The key to recovery has nothing to do with a financial change, an investment strategy change, or a holding change, and everything to do with realigning your long-term goals.

So, moving on from COVID-19 is actually quite simple: Fill your retirement plan to its legal limit and let it grow, tax-deferred. Then invest for the long term, with your target amount in mind. And once again, the earlier you start and the longer you stick with it, the better.

 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

As more and more reopened medical practices ramp up toward normal activity, the safety of patients and health care workers alike remains paramount. As always, the responsibility for enforcing all the new safety guidelines ultimately rests with the Occupational Health and Safety Administration (OSHA).

Most of the modified guidelines are already familiar: wear masks (and other personal protective equipment as necessary); maintain social distancing; have hand cleaner, soap, and water readily available; and sanitize between patient examinations.

It is also important to remember that COVID-19 is now a reportable disease; check with your local health authorities as to where and how. Also remember that, if you decide to screen employees and/or patients for fevers and other symptoms of COVID-19, those data are subject to HIPAA rules and must be kept confidential.

Now might be a good time to confirm that you remain in compliance with both the new and old regulations. Even if you hold regular safety meetings – which often is not the case – it is always a good idea to occasionally conduct a comprehensive review, which could save you a lot in fines.

So get your OSHA logs out, and walk through your office. Start by making sure you have an official OSHA poster, which enumerates employee rights and explains how to file complaints. Every office must have one posted in plain site, and is what an OSHA inspector will look for first. They are available for free at OSHA’s website or you can order one by calling 800-321-OSHA.

How long have you had your written exposure control plan for blood-borne pathogens? This plan should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, as well as your implementation of universal precautions. It should be updated annually to reflect changes in technology – and new threats, such as COVID-19.

Review your list of hazardous substances, which all employees have a right to know about. OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are classified as “hazardous.” Also remember that you’re probably using new disinfectants, which may need to be added to your list. For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.

It is not necessary to adopt every new safety device as it comes on the market, but you should document which ones you are using and which ones you decide not to use – and why. For example, if you and your employees decide against buying a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it is worth, you still should document how you made that decision and why you believe that your current protocol is as good or better.

All at-risk employees should be provided with hepatitis B vaccine at no cost to them. And after any exposure to dangerous pathogens – which now include COVID-19 – you also must provide and pay for appropriate medical treatment and follow-up.

Another important consideration in your review: Electrical devices and their power sources in the office. All electrically powered equipment – medical or clerical – must operate safely and should all be examined. It is particularly important to check how wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it and that circuit breakers are present and functioning.

Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.

Medical and dental offices are not required to keep an injury and illness log under federal OSHA regulations, which other businesses must. However, your state may have a requirement that supersedes the federal law so you should check with your state, or with your local OSHA office, regarding any such requirements.

It is important to take OSHA regulations seriously because failure to comply with them can result in stiff penalties running into many thousands of dollars.

To be certain you are complying with all the rules, you can call your local OSHA office and request an inspection. This is the easiest and cheapest way because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they discover.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

As more and more reopened medical practices ramp up toward normal activity, the safety of patients and health care workers alike remains paramount. As always, the responsibility for enforcing all the new safety guidelines ultimately rests with the Occupational Health and Safety Administration (OSHA).

Most of the modified guidelines are already familiar: wear masks (and other personal protective equipment as necessary); maintain social distancing; have hand cleaner, soap, and water readily available; and sanitize between patient examinations.

It is also important to remember that COVID-19 is now a reportable disease; check with your local health authorities as to where and how. Also remember that, if you decide to screen employees and/or patients for fevers and other symptoms of COVID-19, those data are subject to HIPAA rules and must be kept confidential.

Now might be a good time to confirm that you remain in compliance with both the new and old regulations. Even if you hold regular safety meetings – which often is not the case – it is always a good idea to occasionally conduct a comprehensive review, which could save you a lot in fines.

So get your OSHA logs out, and walk through your office. Start by making sure you have an official OSHA poster, which enumerates employee rights and explains how to file complaints. Every office must have one posted in plain site, and is what an OSHA inspector will look for first. They are available for free at OSHA’s website or you can order one by calling 800-321-OSHA.

How long have you had your written exposure control plan for blood-borne pathogens? This plan should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, as well as your implementation of universal precautions. It should be updated annually to reflect changes in technology – and new threats, such as COVID-19.

Review your list of hazardous substances, which all employees have a right to know about. OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are classified as “hazardous.” Also remember that you’re probably using new disinfectants, which may need to be added to your list. For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.

It is not necessary to adopt every new safety device as it comes on the market, but you should document which ones you are using and which ones you decide not to use – and why. For example, if you and your employees decide against buying a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it is worth, you still should document how you made that decision and why you believe that your current protocol is as good or better.

All at-risk employees should be provided with hepatitis B vaccine at no cost to them. And after any exposure to dangerous pathogens – which now include COVID-19 – you also must provide and pay for appropriate medical treatment and follow-up.

Another important consideration in your review: Electrical devices and their power sources in the office. All electrically powered equipment – medical or clerical – must operate safely and should all be examined. It is particularly important to check how wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it and that circuit breakers are present and functioning.

Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.

Medical and dental offices are not required to keep an injury and illness log under federal OSHA regulations, which other businesses must. However, your state may have a requirement that supersedes the federal law so you should check with your state, or with your local OSHA office, regarding any such requirements.

It is important to take OSHA regulations seriously because failure to comply with them can result in stiff penalties running into many thousands of dollars.

To be certain you are complying with all the rules, you can call your local OSHA office and request an inspection. This is the easiest and cheapest way because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they discover.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

As more and more reopened medical practices ramp up toward normal activity, the safety of patients and health care workers alike remains paramount. As always, the responsibility for enforcing all the new safety guidelines ultimately rests with the Occupational Health and Safety Administration (OSHA).

Most of the modified guidelines are already familiar: wear masks (and other personal protective equipment as necessary); maintain social distancing; have hand cleaner, soap, and water readily available; and sanitize between patient examinations.

It is also important to remember that COVID-19 is now a reportable disease; check with your local health authorities as to where and how. Also remember that, if you decide to screen employees and/or patients for fevers and other symptoms of COVID-19, those data are subject to HIPAA rules and must be kept confidential.

Now might be a good time to confirm that you remain in compliance with both the new and old regulations. Even if you hold regular safety meetings – which often is not the case – it is always a good idea to occasionally conduct a comprehensive review, which could save you a lot in fines.

So get your OSHA logs out, and walk through your office. Start by making sure you have an official OSHA poster, which enumerates employee rights and explains how to file complaints. Every office must have one posted in plain site, and is what an OSHA inspector will look for first. They are available for free at OSHA’s website or you can order one by calling 800-321-OSHA.

How long have you had your written exposure control plan for blood-borne pathogens? This plan should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, as well as your implementation of universal precautions. It should be updated annually to reflect changes in technology – and new threats, such as COVID-19.

Review your list of hazardous substances, which all employees have a right to know about. OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are classified as “hazardous.” Also remember that you’re probably using new disinfectants, which may need to be added to your list. For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.

It is not necessary to adopt every new safety device as it comes on the market, but you should document which ones you are using and which ones you decide not to use – and why. For example, if you and your employees decide against buying a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it is worth, you still should document how you made that decision and why you believe that your current protocol is as good or better.

All at-risk employees should be provided with hepatitis B vaccine at no cost to them. And after any exposure to dangerous pathogens – which now include COVID-19 – you also must provide and pay for appropriate medical treatment and follow-up.

Another important consideration in your review: Electrical devices and their power sources in the office. All electrically powered equipment – medical or clerical – must operate safely and should all be examined. It is particularly important to check how wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it and that circuit breakers are present and functioning.

Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.

Medical and dental offices are not required to keep an injury and illness log under federal OSHA regulations, which other businesses must. However, your state may have a requirement that supersedes the federal law so you should check with your state, or with your local OSHA office, regarding any such requirements.

It is important to take OSHA regulations seriously because failure to comply with them can result in stiff penalties running into many thousands of dollars.

To be certain you are complying with all the rules, you can call your local OSHA office and request an inspection. This is the easiest and cheapest way because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they discover.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

On April 16, the White House released federal guidelines for reopening American businesses – followed 3 days later by specific recommendations from the Centers for Medicare and Medicaid Services for health care practices in areas with a low incidence of COVID-19. Since then, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

Depending on where you live, you may have already reopened (or even never closed), or you may be awaiting the relaxation of restrictions in your state. (As I write this on June 10, the stay-at-home order in my state, New Jersey, is being rescinded.)

The big question, of course, is whether patients can be convinced that it is safe to leave their homes and come to your office. The answer may depend on how well you time your reopening and adhere to the appropriate federal, state, and independent guidelines.

The federal guidelines have three sections: criteria, which outline conditions each region or state should satisfy before reopening; preparedness, which lists how states should prepare for reopening; and phase guidelines, which detail responsibilities of individuals and employers during distinct reopening phases.

You should pay the most attention to the “criteria” section. The key question to ask: “Has my state or region satisfied the basic criteria for reopening?”

Those criteria are as follows:

• Symptoms reported within a 14-day period should be on a downward trajectory.
• Cases documented (or positive tests as a percentage of total tests) within a 14-day period should also be on a downward trajectory.
• Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk health care workers.

If your area meets these criteria, you can proceed to the CMS recommendations. They cover general advice related to personal protective equipment (PPE), workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway: As long as your area has the resources to quickly respond to a surge of COVID-19 cases, you can start offering care to non-COVID patients. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management before moving on to preventive and cosmetic services.

The American Medical Association has issued its own checklist of criteria for reopening your practice to supplement the federal guidelines. Highlights include the following:

• Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after visiting your office.
• Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.
• Patient safety is your top concern. Encourage patients to visit without companions whenever possible, and of course, all individuals who visit the office should wear a cloth face covering.
• Screen employees for fevers and other symptoms of COVID-19; remember that those records are subject to HIPAA rules and must be kept confidential. Minimize contact between employees as much as possible.
• Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. Consider creating a script that office staff can use to contact patients 24 hours before they come in. Use this as a chance to ask about symptoms, and explain any reopening logistics they should know about.
• Contact your malpractice insurance carrier to discuss whether you need to make any changes to your coverage.

This would also be a great time to review your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy – for example, if you must inform coworkers or patients that they have come into contact with someone who tested positive. Make a plan that follows HIPAA guidelines during COVID-19. Also, make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

Another useful resource is the Medical Group Management Association’s COVID-19 Medical Practice Reopening Checklist. You can use it to confirm that you are addressing all the important items, and that you haven’t missed anything.

As for me, I am advising patients who are reluctant to seek treatment that many medical problems pose more risk than COVID-19, faster treatment means better outcomes, and because we maintain strict disinfection protocols, they are far less likely to be infected with COVID-19 in my office than, say, at a grocery store.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

On April 16, the White House released federal guidelines for reopening American businesses – followed 3 days later by specific recommendations from the Centers for Medicare and Medicaid Services for health care practices in areas with a low incidence of COVID-19. Since then, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

Depending on where you live, you may have already reopened (or even never closed), or you may be awaiting the relaxation of restrictions in your state. (As I write this on June 10, the stay-at-home order in my state, New Jersey, is being rescinded.)

The big question, of course, is whether patients can be convinced that it is safe to leave their homes and come to your office. The answer may depend on how well you time your reopening and adhere to the appropriate federal, state, and independent guidelines.

The federal guidelines have three sections: criteria, which outline conditions each region or state should satisfy before reopening; preparedness, which lists how states should prepare for reopening; and phase guidelines, which detail responsibilities of individuals and employers during distinct reopening phases.

You should pay the most attention to the “criteria” section. The key question to ask: “Has my state or region satisfied the basic criteria for reopening?”

Those criteria are as follows:

• Symptoms reported within a 14-day period should be on a downward trajectory.
• Cases documented (or positive tests as a percentage of total tests) within a 14-day period should also be on a downward trajectory.
• Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk health care workers.

If your area meets these criteria, you can proceed to the CMS recommendations. They cover general advice related to personal protective equipment (PPE), workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway: As long as your area has the resources to quickly respond to a surge of COVID-19 cases, you can start offering care to non-COVID patients. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management before moving on to preventive and cosmetic services.

The American Medical Association has issued its own checklist of criteria for reopening your practice to supplement the federal guidelines. Highlights include the following:

• Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after visiting your office.
• Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.
• Patient safety is your top concern. Encourage patients to visit without companions whenever possible, and of course, all individuals who visit the office should wear a cloth face covering.
• Screen employees for fevers and other symptoms of COVID-19; remember that those records are subject to HIPAA rules and must be kept confidential. Minimize contact between employees as much as possible.
• Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. Consider creating a script that office staff can use to contact patients 24 hours before they come in. Use this as a chance to ask about symptoms, and explain any reopening logistics they should know about.
• Contact your malpractice insurance carrier to discuss whether you need to make any changes to your coverage.

This would also be a great time to review your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy – for example, if you must inform coworkers or patients that they have come into contact with someone who tested positive. Make a plan that follows HIPAA guidelines during COVID-19. Also, make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

Another useful resource is the Medical Group Management Association’s COVID-19 Medical Practice Reopening Checklist. You can use it to confirm that you are addressing all the important items, and that you haven’t missed anything.

As for me, I am advising patients who are reluctant to seek treatment that many medical problems pose more risk than COVID-19, faster treatment means better outcomes, and because we maintain strict disinfection protocols, they are far less likely to be infected with COVID-19 in my office than, say, at a grocery store.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

On April 16, the White House released federal guidelines for reopening American businesses – followed 3 days later by specific recommendations from the Centers for Medicare and Medicaid Services for health care practices in areas with a low incidence of COVID-19. Since then, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

Depending on where you live, you may have already reopened (or even never closed), or you may be awaiting the relaxation of restrictions in your state. (As I write this on June 10, the stay-at-home order in my state, New Jersey, is being rescinded.)

The big question, of course, is whether patients can be convinced that it is safe to leave their homes and come to your office. The answer may depend on how well you time your reopening and adhere to the appropriate federal, state, and independent guidelines.

The federal guidelines have three sections: criteria, which outline conditions each region or state should satisfy before reopening; preparedness, which lists how states should prepare for reopening; and phase guidelines, which detail responsibilities of individuals and employers during distinct reopening phases.

You should pay the most attention to the “criteria” section. The key question to ask: “Has my state or region satisfied the basic criteria for reopening?”

Those criteria are as follows:

• Symptoms reported within a 14-day period should be on a downward trajectory.
• Cases documented (or positive tests as a percentage of total tests) within a 14-day period should also be on a downward trajectory.
• Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk health care workers.

If your area meets these criteria, you can proceed to the CMS recommendations. They cover general advice related to personal protective equipment (PPE), workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway: As long as your area has the resources to quickly respond to a surge of COVID-19 cases, you can start offering care to non-COVID patients. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management before moving on to preventive and cosmetic services.

The American Medical Association has issued its own checklist of criteria for reopening your practice to supplement the federal guidelines. Highlights include the following:

• Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after visiting your office.
• Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.
• Patient safety is your top concern. Encourage patients to visit without companions whenever possible, and of course, all individuals who visit the office should wear a cloth face covering.
• Screen employees for fevers and other symptoms of COVID-19; remember that those records are subject to HIPAA rules and must be kept confidential. Minimize contact between employees as much as possible.
• Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. Consider creating a script that office staff can use to contact patients 24 hours before they come in. Use this as a chance to ask about symptoms, and explain any reopening logistics they should know about.
• Contact your malpractice insurance carrier to discuss whether you need to make any changes to your coverage.

This would also be a great time to review your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy – for example, if you must inform coworkers or patients that they have come into contact with someone who tested positive. Make a plan that follows HIPAA guidelines during COVID-19. Also, make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

Another useful resource is the Medical Group Management Association’s COVID-19 Medical Practice Reopening Checklist. You can use it to confirm that you are addressing all the important items, and that you haven’t missed anything.

As for me, I am advising patients who are reluctant to seek treatment that many medical problems pose more risk than COVID-19, faster treatment means better outcomes, and because we maintain strict disinfection protocols, they are far less likely to be infected with COVID-19 in my office than, say, at a grocery store.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

While discussing the difficult decisions to be made if the SARS-CoV-2 pandemic outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster loan programs in my last column, I suggested calculating your overhead – that is, the cost structure supporting the generation of revenue within your practice. Once you know your overhead, you can consider options for managing both costs and revenue during this critical period and beyond.

Kativ/iStockphoto

Based on the flood of questions I’ve received, it appears that many private practitioners do not know how to do those things. Those who do are prone to comparing their overhead figures with those of other offices or with some arbitrary national average. For example, an internist who has calculated his or her practice’s overhead at 65% is dismayed when a surgical colleague reports an overhead of only 35%. Or perhaps the internist reads that the “average” overhead for a practice of that size should never be more than, say, 50%.

First, it is essential to compare apples to apples. Medical practices have entirely different cost structures than do surgical practices. Within those categories, overheads can still vary widely. For example, a neurologist who spends most of the day doing consults in inpatient settings will have substantially different costs than does a dermatologist whose practice is almost entirely office based. Even within similar practices, what one office incorporates in its cost structure may be quite different than another. One may include performance bonuses, while another may factor in automobile allowances – or not. It is important to understand what you are comparing.

Once you have a firm understanding of your overhead, you must decide how to measure it. Typically, that is done as either a percentage (expenses divided by revenue) or as a straight dollar figure.

While everyone’s situation will be different, most accountants and practice consultants recommend looking at percentages. As I have written many times in the past, lower overhead cost, in dollars, doesn’t necessarily mean lower expenses. If your practice can generate more revenue by increasing your expenses, the higher revenue per dollar will result in a lower percentage.

For example, hypothetical Practice A generates $1,000,000 per year on costs of $500,000; Practice B generates $3,000,000 on costs of $1,000,000. Practice B has double the overhead costs of A; yet it brings in triple the revenue, generating more revenue per dollar spent, and making its overhead percentage lower (33% vs. 50%).

Of course, to manage your overhead percentage, you must look at both costs and revenue. Once again, everyone’s situation is different; but here are some general tips for managing costs:

• If you don’t have a budget, create one now, and measure your actual costs against it. Many private practices still operate without budgets, but you can’t manage what you don’t measure.
• Understand your costs. What drives them? What causes them to increase? Which ones are fixed, and which are variable?
• Get competitive bids on a regular basis for supplies, equipment, and outsourced services. Review your invoices monthly to ensure there is no “cost creep” – extra charges, or continued charges for discontinued items. One practice I worked with discovered that it was still making monthly lease payments on equipment that it had disposed of years before!

Equally important is managing revenue. To do this efficiently:

• Maximize documentation and coding. Other columnists and I have written extensively on this subject over the years.
• Ensure that your bookkeeping team challenges all claim denials, and follows up in a timely manner.
• Train your staff in effective patient collection techniques, and make sure they keep up on rule changes. If you haven’t started asking each patient for a credit card number, so that you can bill patient-owed portions after insurance payments come in, now would be a good time to start.
• Evaluate new ways of generating revenue; think outside the box.

Managing overhead requires conscious, consistent, and continuous oversight.

As I wrote in the May column, I sincerely hope that all of our practices will return to some semblance of normal in the coming months; but we cannot assume a best possible scenario. And even ideal scenarios suggest that overhead management will be more important than ever in future years.

As always, consult with your own attorney, accountant, and other business advisers before making any life-altering decisions.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures. Write to him at dermnews@mdedge.com.

While discussing the difficult decisions to be made if the SARS-CoV-2 pandemic outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster loan programs in my last column, I suggested calculating your overhead – that is, the cost structure supporting the generation of revenue within your practice. Once you know your overhead, you can consider options for managing both costs and revenue during this critical period and beyond.

Kativ/iStockphoto

Based on the flood of questions I’ve received, it appears that many private practitioners do not know how to do those things. Those who do are prone to comparing their overhead figures with those of other offices or with some arbitrary national average. For example, an internist who has calculated his or her practice’s overhead at 65% is dismayed when a surgical colleague reports an overhead of only 35%. Or perhaps the internist reads that the “average” overhead for a practice of that size should never be more than, say, 50%.

First, it is essential to compare apples to apples. Medical practices have entirely different cost structures than do surgical practices. Within those categories, overheads can still vary widely. For example, a neurologist who spends most of the day doing consults in inpatient settings will have substantially different costs than does a dermatologist whose practice is almost entirely office based. Even within similar practices, what one office incorporates in its cost structure may be quite different than another. One may include performance bonuses, while another may factor in automobile allowances – or not. It is important to understand what you are comparing.

Once you have a firm understanding of your overhead, you must decide how to measure it. Typically, that is done as either a percentage (expenses divided by revenue) or as a straight dollar figure.

While everyone’s situation will be different, most accountants and practice consultants recommend looking at percentages. As I have written many times in the past, lower overhead cost, in dollars, doesn’t necessarily mean lower expenses. If your practice can generate more revenue by increasing your expenses, the higher revenue per dollar will result in a lower percentage.

For example, hypothetical Practice A generates $1,000,000 per year on costs of $500,000; Practice B generates $3,000,000 on costs of $1,000,000. Practice B has double the overhead costs of A; yet it brings in triple the revenue, generating more revenue per dollar spent, and making its overhead percentage lower (33% vs. 50%).

Of course, to manage your overhead percentage, you must look at both costs and revenue. Once again, everyone’s situation is different; but here are some general tips for managing costs:

• If you don’t have a budget, create one now, and measure your actual costs against it. Many private practices still operate without budgets, but you can’t manage what you don’t measure.
• Understand your costs. What drives them? What causes them to increase? Which ones are fixed, and which are variable?
• Get competitive bids on a regular basis for supplies, equipment, and outsourced services. Review your invoices monthly to ensure there is no “cost creep” – extra charges, or continued charges for discontinued items. One practice I worked with discovered that it was still making monthly lease payments on equipment that it had disposed of years before!

Equally important is managing revenue. To do this efficiently:

• Maximize documentation and coding. Other columnists and I have written extensively on this subject over the years.
• Ensure that your bookkeeping team challenges all claim denials, and follows up in a timely manner.
• Train your staff in effective patient collection techniques, and make sure they keep up on rule changes. If you haven’t started asking each patient for a credit card number, so that you can bill patient-owed portions after insurance payments come in, now would be a good time to start.
• Evaluate new ways of generating revenue; think outside the box.

Managing overhead requires conscious, consistent, and continuous oversight.

As I wrote in the May column, I sincerely hope that all of our practices will return to some semblance of normal in the coming months; but we cannot assume a best possible scenario. And even ideal scenarios suggest that overhead management will be more important than ever in future years.

As always, consult with your own attorney, accountant, and other business advisers before making any life-altering decisions.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures. Write to him at dermnews@mdedge.com.

While discussing the difficult decisions to be made if the SARS-CoV-2 pandemic outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster loan programs in my last column, I suggested calculating your overhead – that is, the cost structure supporting the generation of revenue within your practice. Once you know your overhead, you can consider options for managing both costs and revenue during this critical period and beyond.

Kativ/iStockphoto

Based on the flood of questions I’ve received, it appears that many private practitioners do not know how to do those things. Those who do are prone to comparing their overhead figures with those of other offices or with some arbitrary national average. For example, an internist who has calculated his or her practice’s overhead at 65% is dismayed when a surgical colleague reports an overhead of only 35%. Or perhaps the internist reads that the “average” overhead for a practice of that size should never be more than, say, 50%.

First, it is essential to compare apples to apples. Medical practices have entirely different cost structures than do surgical practices. Within those categories, overheads can still vary widely. For example, a neurologist who spends most of the day doing consults in inpatient settings will have substantially different costs than does a dermatologist whose practice is almost entirely office based. Even within similar practices, what one office incorporates in its cost structure may be quite different than another. One may include performance bonuses, while another may factor in automobile allowances – or not. It is important to understand what you are comparing.

Once you have a firm understanding of your overhead, you must decide how to measure it. Typically, that is done as either a percentage (expenses divided by revenue) or as a straight dollar figure.

While everyone’s situation will be different, most accountants and practice consultants recommend looking at percentages. As I have written many times in the past, lower overhead cost, in dollars, doesn’t necessarily mean lower expenses. If your practice can generate more revenue by increasing your expenses, the higher revenue per dollar will result in a lower percentage.

For example, hypothetical Practice A generates $1,000,000 per year on costs of $500,000; Practice B generates $3,000,000 on costs of $1,000,000. Practice B has double the overhead costs of A; yet it brings in triple the revenue, generating more revenue per dollar spent, and making its overhead percentage lower (33% vs. 50%).

Of course, to manage your overhead percentage, you must look at both costs and revenue. Once again, everyone’s situation is different; but here are some general tips for managing costs:

• If you don’t have a budget, create one now, and measure your actual costs against it. Many private practices still operate without budgets, but you can’t manage what you don’t measure.
• Understand your costs. What drives them? What causes them to increase? Which ones are fixed, and which are variable?
• Get competitive bids on a regular basis for supplies, equipment, and outsourced services. Review your invoices monthly to ensure there is no “cost creep” – extra charges, or continued charges for discontinued items. One practice I worked with discovered that it was still making monthly lease payments on equipment that it had disposed of years before!

Equally important is managing revenue. To do this efficiently:

• Maximize documentation and coding. Other columnists and I have written extensively on this subject over the years.
• Ensure that your bookkeeping team challenges all claim denials, and follows up in a timely manner.
• Train your staff in effective patient collection techniques, and make sure they keep up on rule changes. If you haven’t started asking each patient for a credit card number, so that you can bill patient-owed portions after insurance payments come in, now would be a good time to start.
• Evaluate new ways of generating revenue; think outside the box.

Managing overhead requires conscious, consistent, and continuous oversight.

As I wrote in the May column, I sincerely hope that all of our practices will return to some semblance of normal in the coming months; but we cannot assume a best possible scenario. And even ideal scenarios suggest that overhead management will be more important than ever in future years.

As always, consult with your own attorney, accountant, and other business advisers before making any life-altering decisions.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures. Write to him at dermnews@mdedge.com.

“There are decades where nothing happens,” wrote Vladimir Lenin, “and there are weeks where decades happen.” Barely a dozen weeks ago, no one knew that the SARS-CoV-2 virus existed. Now, it has spread to almost every country on Earth, infecting over 1.8 million people whom we know about, and many more whom we do not. In so doing, it has crashed economies and health care systems, filled hospitals, emptied public spaces, and separated people from their workplaces and their friends on a scale that few of us have ever witnessed.

It has also triggered an avalanche of questions as to why our initial response was so thoroughly lethargic, rudderless, and uncoordinated; while there is plenty of blame to go around, that is for another time. The glaring question for many – including physicians trying to keep our private practices viable – is: What now?

The answer depends, of course, on how the pandemic plays out. No one yet knows exactly what will happen, but much depends on two properties of the virus, both of which are currently unknown. First: seasonality. Coronaviruses tend to thrive in winter and wane in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect. As I write this in mid-April, we wait anxiously to see what – if anything – summer temperatures do to its transmission in the Northern Hemisphere.

The second wild card is duration of immunity. Determining that will involve developing accurate serologic tests and administering them widely. Immune citizens, once identified, can return to work, care for the vulnerable, and anchor the economy during future outbreaks.

Even if we do get a summer hiatus, seasonal viruses typically return as winter approaches. We could conceivably still be mopping up from this outbreak when the virus – if it is seasonal – comes roaring back in October or November. Will we be ready? Or will it catch us with our pants amidships yet again?

I can envision two possibilities: Assuming we luck into a seasonal reprieve in the next few weeks, infection rates should drop, which could allow our private practices to return toward some semblance of normal – if health workers and patients alike can be convinced that our offices and clinics are safe. This might be accomplished as part of our overall preparation for a potential winter recurrence, by checking every patient’s temperature at the waiting room door. Similarly, all students should get a daily temperature check at school, as should all commuters, airline passengers, and individuals at any sizable gathering. Every fever should trigger a COVID-19 test, and every positive test should launch aggressive contact tracing and quarantines. Meanwhile, treatments and vaccines should get fast-tracked.

That’s what should happen. If it doesn’t, and COVID-19 recurs next winter, worse than before, it is anybody’s guess whether most private medical practices will be able to weather a second onslaught. Further government funding is not assured. We won’t have a vaccine by November. Chloroquine, hydroxychloroquine, and azithromycin might turn out to be helpful, but we can’t count on them.

Even if we do get lucky with seasonality, the question remains of how long it will take to restore public confidence and reboot the economy. Economies generally do not function like light switches that can be turned off for a while then simply turned back on, but act more like campfires. If you pour a bucket of water on one, it takes some time to get it cranked up again. After the “Great Recession” of 2008, it took nearly 10 years.

So now, with great reluctance, I must trot out a hoary old cliché: Hope for the best, but plan for the worst. Everyone’s situation will be different, of course, but I can make a few general suggestions. Perform a difficult mental exercise: What will you do if SARS-CoV-2 outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster programs? Do the math – how long can you keep your practice afloat without floating further loans or dipping into personal savings? If you don’t know how many patients you need to see per day to break even, figure it out – now. On what day will you run out of money? When will you start putting your future at risk?

None of us thought we would ever have to face questions like these, of course – and how ironic is it that a medical emergency has forced them upon us? I sincerely hope that none of us will need to actually confront this Hobson’s choice in the coming months, but far better to address the hypothetical now than the reality later. As always, consult with your own attorney, accountant, and other business advisors before making any life-altering decisions.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com. He has no disclosures.

“There are decades where nothing happens,” wrote Vladimir Lenin, “and there are weeks where decades happen.” Barely a dozen weeks ago, no one knew that the SARS-CoV-2 virus existed. Now, it has spread to almost every country on Earth, infecting over 1.8 million people whom we know about, and many more whom we do not. In so doing, it has crashed economies and health care systems, filled hospitals, emptied public spaces, and separated people from their workplaces and their friends on a scale that few of us have ever witnessed.

It has also triggered an avalanche of questions as to why our initial response was so thoroughly lethargic, rudderless, and uncoordinated; while there is plenty of blame to go around, that is for another time. The glaring question for many – including physicians trying to keep our private practices viable – is: What now?

The answer depends, of course, on how the pandemic plays out. No one yet knows exactly what will happen, but much depends on two properties of the virus, both of which are currently unknown. First: seasonality. Coronaviruses tend to thrive in winter and wane in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect. As I write this in mid-April, we wait anxiously to see what – if anything – summer temperatures do to its transmission in the Northern Hemisphere.

The second wild card is duration of immunity. Determining that will involve developing accurate serologic tests and administering them widely. Immune citizens, once identified, can return to work, care for the vulnerable, and anchor the economy during future outbreaks.

Even if we do get a summer hiatus, seasonal viruses typically return as winter approaches. We could conceivably still be mopping up from this outbreak when the virus – if it is seasonal – comes roaring back in October or November. Will we be ready? Or will it catch us with our pants amidships yet again?

I can envision two possibilities: Assuming we luck into a seasonal reprieve in the next few weeks, infection rates should drop, which could allow our private practices to return toward some semblance of normal – if health workers and patients alike can be convinced that our offices and clinics are safe. This might be accomplished as part of our overall preparation for a potential winter recurrence, by checking every patient’s temperature at the waiting room door. Similarly, all students should get a daily temperature check at school, as should all commuters, airline passengers, and individuals at any sizable gathering. Every fever should trigger a COVID-19 test, and every positive test should launch aggressive contact tracing and quarantines. Meanwhile, treatments and vaccines should get fast-tracked.

That’s what should happen. If it doesn’t, and COVID-19 recurs next winter, worse than before, it is anybody’s guess whether most private medical practices will be able to weather a second onslaught. Further government funding is not assured. We won’t have a vaccine by November. Chloroquine, hydroxychloroquine, and azithromycin might turn out to be helpful, but we can’t count on them.

Even if we do get lucky with seasonality, the question remains of how long it will take to restore public confidence and reboot the economy. Economies generally do not function like light switches that can be turned off for a while then simply turned back on, but act more like campfires. If you pour a bucket of water on one, it takes some time to get it cranked up again. After the “Great Recession” of 2008, it took nearly 10 years.

So now, with great reluctance, I must trot out a hoary old cliché: Hope for the best, but plan for the worst. Everyone’s situation will be different, of course, but I can make a few general suggestions. Perform a difficult mental exercise: What will you do if SARS-CoV-2 outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster programs? Do the math – how long can you keep your practice afloat without floating further loans or dipping into personal savings? If you don’t know how many patients you need to see per day to break even, figure it out – now. On what day will you run out of money? When will you start putting your future at risk?

None of us thought we would ever have to face questions like these, of course – and how ironic is it that a medical emergency has forced them upon us? I sincerely hope that none of us will need to actually confront this Hobson’s choice in the coming months, but far better to address the hypothetical now than the reality later. As always, consult with your own attorney, accountant, and other business advisors before making any life-altering decisions.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com. He has no disclosures.

“There are decades where nothing happens,” wrote Vladimir Lenin, “and there are weeks where decades happen.” Barely a dozen weeks ago, no one knew that the SARS-CoV-2 virus existed. Now, it has spread to almost every country on Earth, infecting over 1.8 million people whom we know about, and many more whom we do not. In so doing, it has crashed economies and health care systems, filled hospitals, emptied public spaces, and separated people from their workplaces and their friends on a scale that few of us have ever witnessed.

It has also triggered an avalanche of questions as to why our initial response was so thoroughly lethargic, rudderless, and uncoordinated; while there is plenty of blame to go around, that is for another time. The glaring question for many – including physicians trying to keep our private practices viable – is: What now?

The answer depends, of course, on how the pandemic plays out. No one yet knows exactly what will happen, but much depends on two properties of the virus, both of which are currently unknown. First: seasonality. Coronaviruses tend to thrive in winter and wane in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect. As I write this in mid-April, we wait anxiously to see what – if anything – summer temperatures do to its transmission in the Northern Hemisphere.

The second wild card is duration of immunity. Determining that will involve developing accurate serologic tests and administering them widely. Immune citizens, once identified, can return to work, care for the vulnerable, and anchor the economy during future outbreaks.

Even if we do get a summer hiatus, seasonal viruses typically return as winter approaches. We could conceivably still be mopping up from this outbreak when the virus – if it is seasonal – comes roaring back in October or November. Will we be ready? Or will it catch us with our pants amidships yet again?

I can envision two possibilities: Assuming we luck into a seasonal reprieve in the next few weeks, infection rates should drop, which could allow our private practices to return toward some semblance of normal – if health workers and patients alike can be convinced that our offices and clinics are safe. This might be accomplished as part of our overall preparation for a potential winter recurrence, by checking every patient’s temperature at the waiting room door. Similarly, all students should get a daily temperature check at school, as should all commuters, airline passengers, and individuals at any sizable gathering. Every fever should trigger a COVID-19 test, and every positive test should launch aggressive contact tracing and quarantines. Meanwhile, treatments and vaccines should get fast-tracked.

That’s what should happen. If it doesn’t, and COVID-19 recurs next winter, worse than before, it is anybody’s guess whether most private medical practices will be able to weather a second onslaught. Further government funding is not assured. We won’t have a vaccine by November. Chloroquine, hydroxychloroquine, and azithromycin might turn out to be helpful, but we can’t count on them.

Even if we do get lucky with seasonality, the question remains of how long it will take to restore public confidence and reboot the economy. Economies generally do not function like light switches that can be turned off for a while then simply turned back on, but act more like campfires. If you pour a bucket of water on one, it takes some time to get it cranked up again. After the “Great Recession” of 2008, it took nearly 10 years.

So now, with great reluctance, I must trot out a hoary old cliché: Hope for the best, but plan for the worst. Everyone’s situation will be different, of course, but I can make a few general suggestions. Perform a difficult mental exercise: What will you do if SARS-CoV-2 outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster programs? Do the math – how long can you keep your practice afloat without floating further loans or dipping into personal savings? If you don’t know how many patients you need to see per day to break even, figure it out – now. On what day will you run out of money? When will you start putting your future at risk?

None of us thought we would ever have to face questions like these, of course – and how ironic is it that a medical emergency has forced them upon us? I sincerely hope that none of us will need to actually confront this Hobson’s choice in the coming months, but far better to address the hypothetical now than the reality later. As always, consult with your own attorney, accountant, and other business advisors before making any life-altering decisions.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com. He has no disclosures.

In his book, “Scam Me If You Can,” fraud expert Frank Abagnale relates the case of a 5-year-old boy whose pediatrician’s computer was hacked, compromising his name, birth date, Social Security number, insurance information, and medical records. The result was a bureaucratic nightmare that may well continue for the rest of that unfortunate young patient’s life. One can only speculate on the difficulties he might have as adult in obtaining a line of credit, or in proving his medical identity to physicians and hospitals.

tomprout/E+

Medical identity theft is increasingly popular with scam artists, because it is so lucrative. Everything a crook needs to commit ordinary identity theft – your Social Security number, bank account numbers, etc. – sells for about $25 on the black market; add health insurance and medical records, and the price can jump to $1,000 or more. That’s because there is a far greater potential yield from medical identity theft – and once your personal information and medical records are breached, they are in the Cloud for the rest of your life, available to anyone who wants to buy them. Older patients are particularly vulnerable: Medicare billing scams cost taxpayers more than $60 billion a year.

If your office’s computer system does not have effective fraud protection, you could be held liable for any fraud committed with information stolen from it – and if the information is resold years later and reused to commit more fraud, you’ll be liable for that, too. That’s why I strongly recommend that you invest in high-quality security technology and software, so that in the event of a breach, the security company will at least share in the fault and the liability. (As always, I have no financial interest in any product or industry mentioned in this column.)

Even with adequate protection, breaches can still occur, so all medical offices should have a breach response plan in place, covering how to halt security breaches, and how to handle any lost or stolen data. Your computer and security vendors can help with formulating such a plan. Patients affected by a breach need to be contacted as well, so they may put a freeze on accounts or send out fraud alerts.

Patients also need to be aware of the risks. If your EHR includes an online portal to communicate protected information to patients, it may be secure on your end, but patients are unlikely to have similar protection on their home computers. If you offer online patient portal services, you should make your patients aware of measures they can take to protect their data once it arrives on their computers or phones.

Patients should also be warned of the risks that come with sharing medical information with others. If they are asked to reveal medical data via phone or email, they need to ask who is requesting it, and why. Any unsolicited calls inquiring about their medical information, from someone who can’t or won’t confirm their identity, should be considered extremely suspicious.

We tell our patients to protect their insurance numbers as carefully as they guard their Social Security number and other valuable data, and to shred any medical paperwork they no longer need, including labels on prescription bottles. And if they see something on an Explanation of Benefits that doesn’t look right, they should question it immediately. We encourage them to take advantage of the free services at MyMedicare.gov, including Medicare Summary Notices provided every 3 months (if any services or medical supplies are received during that period), to make sure they’re being billed only for services they have received.

Your staff should be made aware of the potential for “friendly fraud,” which is defined as theft of identity and medical information by patients’ friends or family members. (According to some studies, as much as 50% of all medical identity theft may be committed this way.) Staffers should never divulge insurance numbers, diagnoses, lab reports, or any other privileged information to family or friends, whether by phone, fax, mail, or in person, without written permission from the patient. And when callers claiming to be patients request information about themselves, your employees should be alert for “red flags.” For example, legitimate patients won’t stumble over simple questions (such as “What is your birth date?”) or request test results or diagnoses that they should already know about.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

In his book, “Scam Me If You Can,” fraud expert Frank Abagnale relates the case of a 5-year-old boy whose pediatrician’s computer was hacked, compromising his name, birth date, Social Security number, insurance information, and medical records. The result was a bureaucratic nightmare that may well continue for the rest of that unfortunate young patient’s life. One can only speculate on the difficulties he might have as adult in obtaining a line of credit, or in proving his medical identity to physicians and hospitals.

tomprout/E+

Medical identity theft is increasingly popular with scam artists, because it is so lucrative. Everything a crook needs to commit ordinary identity theft – your Social Security number, bank account numbers, etc. – sells for about $25 on the black market; add health insurance and medical records, and the price can jump to $1,000 or more. That’s because there is a far greater potential yield from medical identity theft – and once your personal information and medical records are breached, they are in the Cloud for the rest of your life, available to anyone who wants to buy them. Older patients are particularly vulnerable: Medicare billing scams cost taxpayers more than $60 billion a year.

If your office’s computer system does not have effective fraud protection, you could be held liable for any fraud committed with information stolen from it – and if the information is resold years later and reused to commit more fraud, you’ll be liable for that, too. That’s why I strongly recommend that you invest in high-quality security technology and software, so that in the event of a breach, the security company will at least share in the fault and the liability. (As always, I have no financial interest in any product or industry mentioned in this column.)

Even with adequate protection, breaches can still occur, so all medical offices should have a breach response plan in place, covering how to halt security breaches, and how to handle any lost or stolen data. Your computer and security vendors can help with formulating such a plan. Patients affected by a breach need to be contacted as well, so they may put a freeze on accounts or send out fraud alerts.

Patients also need to be aware of the risks. If your EHR includes an online portal to communicate protected information to patients, it may be secure on your end, but patients are unlikely to have similar protection on their home computers. If you offer online patient portal services, you should make your patients aware of measures they can take to protect their data once it arrives on their computers or phones.

Patients should also be warned of the risks that come with sharing medical information with others. If they are asked to reveal medical data via phone or email, they need to ask who is requesting it, and why. Any unsolicited calls inquiring about their medical information, from someone who can’t or won’t confirm their identity, should be considered extremely suspicious.

We tell our patients to protect their insurance numbers as carefully as they guard their Social Security number and other valuable data, and to shred any medical paperwork they no longer need, including labels on prescription bottles. And if they see something on an Explanation of Benefits that doesn’t look right, they should question it immediately. We encourage them to take advantage of the free services at MyMedicare.gov, including Medicare Summary Notices provided every 3 months (if any services or medical supplies are received during that period), to make sure they’re being billed only for services they have received.

Your staff should be made aware of the potential for “friendly fraud,” which is defined as theft of identity and medical information by patients’ friends or family members. (According to some studies, as much as 50% of all medical identity theft may be committed this way.) Staffers should never divulge insurance numbers, diagnoses, lab reports, or any other privileged information to family or friends, whether by phone, fax, mail, or in person, without written permission from the patient. And when callers claiming to be patients request information about themselves, your employees should be alert for “red flags.” For example, legitimate patients won’t stumble over simple questions (such as “What is your birth date?”) or request test results or diagnoses that they should already know about.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

In his book, “Scam Me If You Can,” fraud expert Frank Abagnale relates the case of a 5-year-old boy whose pediatrician’s computer was hacked, compromising his name, birth date, Social Security number, insurance information, and medical records. The result was a bureaucratic nightmare that may well continue for the rest of that unfortunate young patient’s life. One can only speculate on the difficulties he might have as adult in obtaining a line of credit, or in proving his medical identity to physicians and hospitals.

tomprout/E+

Medical identity theft is increasingly popular with scam artists, because it is so lucrative. Everything a crook needs to commit ordinary identity theft – your Social Security number, bank account numbers, etc. – sells for about $25 on the black market; add health insurance and medical records, and the price can jump to $1,000 or more. That’s because there is a far greater potential yield from medical identity theft – and once your personal information and medical records are breached, they are in the Cloud for the rest of your life, available to anyone who wants to buy them. Older patients are particularly vulnerable: Medicare billing scams cost taxpayers more than $60 billion a year.

If your office’s computer system does not have effective fraud protection, you could be held liable for any fraud committed with information stolen from it – and if the information is resold years later and reused to commit more fraud, you’ll be liable for that, too. That’s why I strongly recommend that you invest in high-quality security technology and software, so that in the event of a breach, the security company will at least share in the fault and the liability. (As always, I have no financial interest in any product or industry mentioned in this column.)

Even with adequate protection, breaches can still occur, so all medical offices should have a breach response plan in place, covering how to halt security breaches, and how to handle any lost or stolen data. Your computer and security vendors can help with formulating such a plan. Patients affected by a breach need to be contacted as well, so they may put a freeze on accounts or send out fraud alerts.

Patients also need to be aware of the risks. If your EHR includes an online portal to communicate protected information to patients, it may be secure on your end, but patients are unlikely to have similar protection on their home computers. If you offer online patient portal services, you should make your patients aware of measures they can take to protect their data once it arrives on their computers or phones.

Patients should also be warned of the risks that come with sharing medical information with others. If they are asked to reveal medical data via phone or email, they need to ask who is requesting it, and why. Any unsolicited calls inquiring about their medical information, from someone who can’t or won’t confirm their identity, should be considered extremely suspicious.

We tell our patients to protect their insurance numbers as carefully as they guard their Social Security number and other valuable data, and to shred any medical paperwork they no longer need, including labels on prescription bottles. And if they see something on an Explanation of Benefits that doesn’t look right, they should question it immediately. We encourage them to take advantage of the free services at MyMedicare.gov, including Medicare Summary Notices provided every 3 months (if any services or medical supplies are received during that period), to make sure they’re being billed only for services they have received.

Your staff should be made aware of the potential for “friendly fraud,” which is defined as theft of identity and medical information by patients’ friends or family members. (According to some studies, as much as 50% of all medical identity theft may be committed this way.) Staffers should never divulge insurance numbers, diagnoses, lab reports, or any other privileged information to family or friends, whether by phone, fax, mail, or in person, without written permission from the patient. And when callers claiming to be patients request information about themselves, your employees should be alert for “red flags.” For example, legitimate patients won’t stumble over simple questions (such as “What is your birth date?”) or request test results or diagnoses that they should already know about.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Did you notice that your practice slows down in February? In fact, if you plot your patient census over a few years, you may find that it dips every February. And you will discover other slow periods, perhaps in December, and busy months during other parts of the year.

Seasonality is yet another of those basic business concepts that most physicians have never heard of, because of the conspicuous lack of business training in medical schools. Seasonal fluctuations exist in one form or another in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January or February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are out of school, and summer slumps to vacationing customers. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change, by running some ads, or doing an e-mail blast; but unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep pockets game requiring long, expensive campaigns that are only practical for large corporations.

For example, soup was traditionally consumed during the winter months since time immemorial. After years of pervasive advertising extolling its nutritional virtues (remember “Soup is Good Food”?), the soup industry succeeded in convincing the public to use their product year-round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean there is nothing we can do about our practices’ seasonal variations? Not at all; but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

First, you need to know what that behavior is, because it varies from practice to practice, even within the same state or city. Plotting your seasonality is easy; you can make a graph on Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2 or 3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively you can plot patient visits per month, if you wish; I do both.

Once you know your seasonality, review your options. Modify your own habits when necessary. If you typically take a vacation in August, for example, that’s not a great idea if August is one of your busiest months; consider vacationing during predictable slow periods instead.

Though I have said that you can’t change most seasonal behavior, it is possible to “retrain” some of your long-time, loyal patients to come in during your slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November each year, urging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive; why not advertise during slow periods to fill those empty slots? But once again, you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response to their ads. So don’t try to move the mountain to Mohammed. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

In short, then, try to “flatten” your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, your seasonal peaks. Once in your practice, some of them can then be shifted into your slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Did you notice that your practice slows down in February? In fact, if you plot your patient census over a few years, you may find that it dips every February. And you will discover other slow periods, perhaps in December, and busy months during other parts of the year.

Seasonality is yet another of those basic business concepts that most physicians have never heard of, because of the conspicuous lack of business training in medical schools. Seasonal fluctuations exist in one form or another in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January or February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are out of school, and summer slumps to vacationing customers. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change, by running some ads, or doing an e-mail blast; but unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep pockets game requiring long, expensive campaigns that are only practical for large corporations.

For example, soup was traditionally consumed during the winter months since time immemorial. After years of pervasive advertising extolling its nutritional virtues (remember “Soup is Good Food”?), the soup industry succeeded in convincing the public to use their product year-round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean there is nothing we can do about our practices’ seasonal variations? Not at all; but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

First, you need to know what that behavior is, because it varies from practice to practice, even within the same state or city. Plotting your seasonality is easy; you can make a graph on Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2 or 3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively you can plot patient visits per month, if you wish; I do both.

Once you know your seasonality, review your options. Modify your own habits when necessary. If you typically take a vacation in August, for example, that’s not a great idea if August is one of your busiest months; consider vacationing during predictable slow periods instead.

Though I have said that you can’t change most seasonal behavior, it is possible to “retrain” some of your long-time, loyal patients to come in during your slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November each year, urging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive; why not advertise during slow periods to fill those empty slots? But once again, you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response to their ads. So don’t try to move the mountain to Mohammed. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

In short, then, try to “flatten” your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, your seasonal peaks. Once in your practice, some of them can then be shifted into your slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Did you notice that your practice slows down in February? In fact, if you plot your patient census over a few years, you may find that it dips every February. And you will discover other slow periods, perhaps in December, and busy months during other parts of the year.

Seasonality is yet another of those basic business concepts that most physicians have never heard of, because of the conspicuous lack of business training in medical schools. Seasonal fluctuations exist in one form or another in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January or February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are out of school, and summer slumps to vacationing customers. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change, by running some ads, or doing an e-mail blast; but unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep pockets game requiring long, expensive campaigns that are only practical for large corporations.

For example, soup was traditionally consumed during the winter months since time immemorial. After years of pervasive advertising extolling its nutritional virtues (remember “Soup is Good Food”?), the soup industry succeeded in convincing the public to use their product year-round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean there is nothing we can do about our practices’ seasonal variations? Not at all; but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

First, you need to know what that behavior is, because it varies from practice to practice, even within the same state or city. Plotting your seasonality is easy; you can make a graph on Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2 or 3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively you can plot patient visits per month, if you wish; I do both.

Once you know your seasonality, review your options. Modify your own habits when necessary. If you typically take a vacation in August, for example, that’s not a great idea if August is one of your busiest months; consider vacationing during predictable slow periods instead.

Though I have said that you can’t change most seasonal behavior, it is possible to “retrain” some of your long-time, loyal patients to come in during your slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November each year, urging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive; why not advertise during slow periods to fill those empty slots? But once again, you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response to their ads. So don’t try to move the mountain to Mohammed. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

In short, then, try to “flatten” your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, your seasonal peaks. Once in your practice, some of them can then be shifted into your slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Many medical offices are following a popular trend in the business world: They are replacing employee sick leave, vacation, and any other miscellaneous time benefits with a combination of all of them, collectively referred to as “paid time off” (PTO). There are several reasons why this is a good idea, but it is not without disadvantages, and you should carefully consider all the pros and cons before adopting it.

Employees generally like the concept because most never use all their sick leave. Allowing them to take the difference as extra vacation time makes them happy, and makes your office more attractive to excellent prospects. They also appreciate being treated more like adults who can make time off decisions for themselves.

Employers like it because there is less paperwork and less abuse of sick leave. They don’t have to make any decisions about whether an employee is really sick or not; reasons for absence are now irrelevant, so feigned illnesses are a thing of the past. If an employee requests a day off with adequate notice, and there is adequate coverage of that employee’s duties, you don’t need to know (or care) about the reason for the request.

Critics say employees are absent more frequently under a PTO system, since employees who never used their full allotment of sick leave will typically use all of their PTO; but that, in a sense, is the idea. Time off is necessary and important for good office morale, and should be taken by all employees, as well as by all employers. (Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”)

Besides, you should be suspicious of any employee who won’t take vacations. They are often embezzlers who fear that their illicit modus operandi will be discovered during their absence. (More on that next month.)

chokkicx/Digital Vision Vectors

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Many medical offices are following a popular trend in the business world: They are replacing employee sick leave, vacation, and any other miscellaneous time benefits with a combination of all of them, collectively referred to as “paid time off” (PTO). There are several reasons why this is a good idea, but it is not without disadvantages, and you should carefully consider all the pros and cons before adopting it.

Employees generally like the concept because most never use all their sick leave. Allowing them to take the difference as extra vacation time makes them happy, and makes your office more attractive to excellent prospects. They also appreciate being treated more like adults who can make time off decisions for themselves.

Employers like it because there is less paperwork and less abuse of sick leave. They don’t have to make any decisions about whether an employee is really sick or not; reasons for absence are now irrelevant, so feigned illnesses are a thing of the past. If an employee requests a day off with adequate notice, and there is adequate coverage of that employee’s duties, you don’t need to know (or care) about the reason for the request.

Critics say employees are absent more frequently under a PTO system, since employees who never used their full allotment of sick leave will typically use all of their PTO; but that, in a sense, is the idea. Time off is necessary and important for good office morale, and should be taken by all employees, as well as by all employers. (Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”)

Besides, you should be suspicious of any employee who won’t take vacations. They are often embezzlers who fear that their illicit modus operandi will be discovered during their absence. (More on that next month.)

chokkicx/Digital Vision Vectors

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Many medical offices are following a popular trend in the business world: They are replacing employee sick leave, vacation, and any other miscellaneous time benefits with a combination of all of them, collectively referred to as “paid time off” (PTO). There are several reasons why this is a good idea, but it is not without disadvantages, and you should carefully consider all the pros and cons before adopting it.

Employees generally like the concept because most never use all their sick leave. Allowing them to take the difference as extra vacation time makes them happy, and makes your office more attractive to excellent prospects. They also appreciate being treated more like adults who can make time off decisions for themselves.

Employers like it because there is less paperwork and less abuse of sick leave. They don’t have to make any decisions about whether an employee is really sick or not; reasons for absence are now irrelevant, so feigned illnesses are a thing of the past. If an employee requests a day off with adequate notice, and there is adequate coverage of that employee’s duties, you don’t need to know (or care) about the reason for the request.

Critics say employees are absent more frequently under a PTO system, since employees who never used their full allotment of sick leave will typically use all of their PTO; but that, in a sense, is the idea. Time off is necessary and important for good office morale, and should be taken by all employees, as well as by all employers. (Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”)

Besides, you should be suspicious of any employee who won’t take vacations. They are often embezzlers who fear that their illicit modus operandi will be discovered during their absence. (More on that next month.)

chokkicx/Digital Vision Vectors

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

A few years ago, my seemingly indestructible 94-year-old mother suffered a series of medical setbacks. As her health problems accumulated, so did the complexity and cost of her care, progressing from her home to an assisted-living facility to a nursing home. It was heartbreaking – and expensive. My wife likened it to “putting another kid through college” – an elite private college, at that.

designer451/iStock/Getty Images Plus

Medicare, of course, did not cover any of this, except for physician visits and some of her medications. When it was finally over, my wife and I resolved that, should we face a similar situation in our final years, we could not put ourselves or our children through a similar financial ordeal.

Long-term care insurance (LTCI) is designed to prevent such situations by covering hospice services, nursing home stays, assisted living facilities, in-home services, and other end-of-life expenses. (Covered services vary by policy; and as always, I have no financial interest in any product or service mentioned here.)

According to the American Association for Long-Term Care Insurance (AALTCI), the average annual LTCI premium for a 60-year-old couple is $3,490. Not cheap; but there are ways to lower premiums without gutting your coverage.

The best way to keep costs down is to get in early. In general, the younger you are and the better health you are in, the lower your premiums will be. For example – again according to the AALTCI – that “average” annual premium of $3,490 for a hypothetical 60-year-old couple would increase 34%, to $4,675, if they waited until they were 65 to buy the policy. And if their health were to decline in the interim, they might not be able to obtain adequate coverage at all.

You can also lower premiums by decreasing daily benefits, or increasing the “elimination period” – the length of time after you become eligible for benefits that the policy starts paying them; 30-, 60-, and 90-day periods are common. As long as you have sufficient savings to realistically cover costs until the elimination period is over, choosing a longer one can reduce your costs significantly.

Another variable is the maximum length of time the policy will pay out benefits. Ideally, you would want a payout to continue for as long as necessary, but few if any companies are willing to write uncapped policies anymore. Two to five years of benefits is a common time frame. (The “average” premiums quoted above assume a benefit of $150 per day with a 3-year cap and a 90-day elimination period.)

As with any insurance, it is important not to overbuy LTCI. It isn’t necessary to obtain coverage that will pay for 100% of your long-term care costs – just the portion that your projected retirement income (Social Security, pensions, income from savings) may not be sufficient to cover. Buying only the amount of coverage you need will substantially reduce your premium costs over the life of the policy.

If you work for a hospital or a large group, it’s worth checking to see if your employer offers LTCI. Employer-sponsored plans are often offered at discounted group rates, and you can usually keep the policy even if you leave. If you’re a member of any social or religious groups, check their insurance plans as well.

To be sure, there is considerable debate about whether LTCI is worth the cost. Premiums for new policies are rising at a steep clip – 9% annually, according to the AALTCI – and insurers are allowed to raise premiums even after you buy the policy, so you’ll need to factor that possibility into your budget.

But forgoing coverage can be costly too: If you know you will have to cover your own long-term care costs, you won’t be able to spend that money on things you really care about – like your grandkids, or travel, or charitable work. You might even forgo necessary medical care for fear of running out of money.

Everyone must make their own decision. My wife and I decided that a few thousand dollars per year is a fair price to pay for the peace of mind of knowing we will be able to afford proper supportive care, without help from our children or anyone else, regardless of what happens in the years to come.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

A few years ago, my seemingly indestructible 94-year-old mother suffered a series of medical setbacks. As her health problems accumulated, so did the complexity and cost of her care, progressing from her home to an assisted-living facility to a nursing home. It was heartbreaking – and expensive. My wife likened it to “putting another kid through college” – an elite private college, at that.

designer451/iStock/Getty Images Plus

Medicare, of course, did not cover any of this, except for physician visits and some of her medications. When it was finally over, my wife and I resolved that, should we face a similar situation in our final years, we could not put ourselves or our children through a similar financial ordeal.

Long-term care insurance (LTCI) is designed to prevent such situations by covering hospice services, nursing home stays, assisted living facilities, in-home services, and other end-of-life expenses. (Covered services vary by policy; and as always, I have no financial interest in any product or service mentioned here.)

According to the American Association for Long-Term Care Insurance (AALTCI), the average annual LTCI premium for a 60-year-old couple is $3,490. Not cheap; but there are ways to lower premiums without gutting your coverage.

The best way to keep costs down is to get in early. In general, the younger you are and the better health you are in, the lower your premiums will be. For example – again according to the AALTCI – that “average” annual premium of $3,490 for a hypothetical 60-year-old couple would increase 34%, to $4,675, if they waited until they were 65 to buy the policy. And if their health were to decline in the interim, they might not be able to obtain adequate coverage at all.

You can also lower premiums by decreasing daily benefits, or increasing the “elimination period” – the length of time after you become eligible for benefits that the policy starts paying them; 30-, 60-, and 90-day periods are common. As long as you have sufficient savings to realistically cover costs until the elimination period is over, choosing a longer one can reduce your costs significantly.

Another variable is the maximum length of time the policy will pay out benefits. Ideally, you would want a payout to continue for as long as necessary, but few if any companies are willing to write uncapped policies anymore. Two to five years of benefits is a common time frame. (The “average” premiums quoted above assume a benefit of $150 per day with a 3-year cap and a 90-day elimination period.)

As with any insurance, it is important not to overbuy LTCI. It isn’t necessary to obtain coverage that will pay for 100% of your long-term care costs – just the portion that your projected retirement income (Social Security, pensions, income from savings) may not be sufficient to cover. Buying only the amount of coverage you need will substantially reduce your premium costs over the life of the policy.

If you work for a hospital or a large group, it’s worth checking to see if your employer offers LTCI. Employer-sponsored plans are often offered at discounted group rates, and you can usually keep the policy even if you leave. If you’re a member of any social or religious groups, check their insurance plans as well.

To be sure, there is considerable debate about whether LTCI is worth the cost. Premiums for new policies are rising at a steep clip – 9% annually, according to the AALTCI – and insurers are allowed to raise premiums even after you buy the policy, so you’ll need to factor that possibility into your budget.

But forgoing coverage can be costly too: If you know you will have to cover your own long-term care costs, you won’t be able to spend that money on things you really care about – like your grandkids, or travel, or charitable work. You might even forgo necessary medical care for fear of running out of money.

Everyone must make their own decision. My wife and I decided that a few thousand dollars per year is a fair price to pay for the peace of mind of knowing we will be able to afford proper supportive care, without help from our children or anyone else, regardless of what happens in the years to come.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

A few years ago, my seemingly indestructible 94-year-old mother suffered a series of medical setbacks. As her health problems accumulated, so did the complexity and cost of her care, progressing from her home to an assisted-living facility to a nursing home. It was heartbreaking – and expensive. My wife likened it to “putting another kid through college” – an elite private college, at that.

designer451/iStock/Getty Images Plus

Medicare, of course, did not cover any of this, except for physician visits and some of her medications. When it was finally over, my wife and I resolved that, should we face a similar situation in our final years, we could not put ourselves or our children through a similar financial ordeal.

Long-term care insurance (LTCI) is designed to prevent such situations by covering hospice services, nursing home stays, assisted living facilities, in-home services, and other end-of-life expenses. (Covered services vary by policy; and as always, I have no financial interest in any product or service mentioned here.)

According to the American Association for Long-Term Care Insurance (AALTCI), the average annual LTCI premium for a 60-year-old couple is $3,490. Not cheap; but there are ways to lower premiums without gutting your coverage.

The best way to keep costs down is to get in early. In general, the younger you are and the better health you are in, the lower your premiums will be. For example – again according to the AALTCI – that “average” annual premium of $3,490 for a hypothetical 60-year-old couple would increase 34%, to $4,675, if they waited until they were 65 to buy the policy. And if their health were to decline in the interim, they might not be able to obtain adequate coverage at all.

You can also lower premiums by decreasing daily benefits, or increasing the “elimination period” – the length of time after you become eligible for benefits that the policy starts paying them; 30-, 60-, and 90-day periods are common. As long as you have sufficient savings to realistically cover costs until the elimination period is over, choosing a longer one can reduce your costs significantly.

Another variable is the maximum length of time the policy will pay out benefits. Ideally, you would want a payout to continue for as long as necessary, but few if any companies are willing to write uncapped policies anymore. Two to five years of benefits is a common time frame. (The “average” premiums quoted above assume a benefit of $150 per day with a 3-year cap and a 90-day elimination period.)

As with any insurance, it is important not to overbuy LTCI. It isn’t necessary to obtain coverage that will pay for 100% of your long-term care costs – just the portion that your projected retirement income (Social Security, pensions, income from savings) may not be sufficient to cover. Buying only the amount of coverage you need will substantially reduce your premium costs over the life of the policy.

If you work for a hospital or a large group, it’s worth checking to see if your employer offers LTCI. Employer-sponsored plans are often offered at discounted group rates, and you can usually keep the policy even if you leave. If you’re a member of any social or religious groups, check their insurance plans as well.

To be sure, there is considerable debate about whether LTCI is worth the cost. Premiums for new policies are rising at a steep clip – 9% annually, according to the AALTCI – and insurers are allowed to raise premiums even after you buy the policy, so you’ll need to factor that possibility into your budget.

But forgoing coverage can be costly too: If you know you will have to cover your own long-term care costs, you won’t be able to spend that money on things you really care about – like your grandkids, or travel, or charitable work. You might even forgo necessary medical care for fear of running out of money.

Everyone must make their own decision. My wife and I decided that a few thousand dollars per year is a fair price to pay for the peace of mind of knowing we will be able to afford proper supportive care, without help from our children or anyone else, regardless of what happens in the years to come.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.