Solo is Beautiful

OK, I've been in practice for a little over a week, my first ad came out 4 days ago, and I've only had one phone call from a potential patient so far. Time to worry yet? Not according to other doctors who've gone through opening their own solo practices before me.

From the Practice Improvement Forum, a forum for physicians trying to improve their clinical practices, Jim, a family physician in Kansas, commented on his experiences when he opened his own solo practice:

"I had a part-time job so that I was rather deliberate in setting this practice up. I had a good business model except for a specific marketing plan. I thought that was too difficult and that the pressure to find good local physicians would naturally drive the process. I was wrong.

I had not solicited patients at my last job because I felt uncomfortable doing so. I did take names of people who asked where I would be so that I could send announcements to them.

After I set up my practice up, I watched the phone. It did not ring. Very. Often.
Time went by and my increasing anxiety and deteriorating financial situation opened by mind towards marketing."

I'll be happy when the number of phone calls from patients exceeds the number of phone calls I get from telemarketers.

John, a family doctor in Virginia, opened his practice in April 2003:

"I assumed the patients would be beating down the doors when they heard about what I was doing. That did not happen, and so I had to turn more to marketing than I ever thought I would. With that said, I did recently talk a reporter into doing an article about my practice in the local paper (she is mainly interested in the home visits, but I feel its all a package deal). I believe that will be the push I need to get over the hump.

Everyone that comes here loves it, but our growth has not been anything like has been suggested either. People are interested and we are growing, but it has been slow."

And the newspaper article on John did come out, although you have to register in order to read it (but you can just enter fake data).

Nancy, a family doctor in New Mexico, wrote:

"It still has taken 6 months to come close to filling my panel. I wasn't really busy on an everyday until 3-4 months after I went fulltime. Word of mouth takes a while, and getting around to seeing a doctor, even a good one, isn't always high on people's lists."

So that's what it looks like at the beginning of the process. Here's what I hope to find later on down the road, as described by Josie, another family doctor in Virginia, after 5 months of solo practice:

"Here's what I LOVE about my practice:

I choose my own schedule. Not only when I work, but whom I see and when. I decide on a case-by-case basis when and how to fit people in. (Well, I can't control those walk-ins...but otherwise I know what's coming, and what the problems are).

These are very much MY people. I'm not seeing them for another doctor. I take care of them in a much more direct and complete way than I used to. I find great satisfaction in setting up a referral appointment immediately, calling the drug store to find out the name of the "little pink pill" while they're sitting there, etc. I don't have to track my nurse down because there is no nurse. I have the luxury of time to be able to take care of those things now, and the patients love it.

Call is not onerous. I get about 10 calls a week, all of them appropriate, and almost never when I'm asleep. Sure, my practice follows the 80/20 rule (80% of the call from 20% of the people), but since they're not some other doctor's people, and I know them, it's quick and easy to take care of the calls.

My patients walk into my waiting room, which has a comfy couch and big over-stuffed chair, and a giant stuffed dragon for kids, and they are in awe of how cozy it is. They exclaim over and over how much they love it. One patient left me a note saying that she had stopped by after being in physical therapy down the hall and simply rested and relaxed on my couch for a few minutes listening to the soothing music I had on the CD player.

I'm getting new patients like crazy. I had a patient who left her previous doctor because she had been called "non-compliant". I came to see how this happened when I sent for the records. The doctor had written, "call patient and check for non-compliance" on her lab results, and the nurse had apparently taken him literally. If he hadn't been seeing 35 patients a day, he would have had time, perhaps, to call the patient himself and not put the blaming message across. (I know this doc, and he is a total sweetheart). It turns out she was afraid of possible side effects of her meds, but had never been able to take the time to discuss her fears and get them in perspective.

It's MINE. I am responsible for the mail, the cleanliness, ordering supplies, the music, the scheduling, etc. Since it's very small, I can handle it, and there is joy in taking care of many of the small things. The way other women perhaps are "house proud" or men like keeping a neat yard, I get satisfaction from watering the plants, ordering purple top tubes, and maybe most of all opening the checks and stamping "FOR DEPOSIT ONLY" on them! ;-)

Ok I hope I haven't bored you all to death. I guess I'm past the initial scary time and into the honeymoon...sure is great, thank you Gordon, I would never have had the guts to do this without your inspiration!"

I feel the same way about Gordon. Gordon is Dr. Gordon Moore, who started this concept of a low overhead, solo practice as a means of improving the practice model to the benefit of both patients and physicians.

I am reminded of a book I read in college, Small is Beautiful by E.F. Schumacher, and am surprised at how much the concepts of this book are reflected in the "Solo-Solo" doctor model:

Schumacher maintains that man's current pursuit of profit and progress, which promotes giant organizations and increased specialization, has in fact resulted in gross economic inefficiency, environmental pollution, and inhumane working conditions.

Sounds a lot like our current American health care system to me.

Schumacher challenges the doctrine of economic, technological, and scientific specialization and proposes a system for Intermediate Technology, based on smaller working units, co-operative ownership, and regional workplaces using local labor and resources. With the emphasis on the person not the product, Small is Beautiful points the way to a world in which Capital serves People instead of People serving Capital.

"Emphasis on the person" is right. This is what being a doctor is all about. That and marketing.

How to Find Patients

"So how are you going to find patients?"

That was the one question everyone kept asking me when I told them of my idea of opening a solo practice. And I still have yet to find the answer since I've had no patients yet. I knew things would be slow, until more and more people found out about me. I always figured word of mouth would be my best method of generating new patients. Unfortunately, not enough mouths know about me yet. There probably has to be a critical mass of people who know about me before someone who needs my services decides to call me for an appointment.

Plan 1: Open House (last week), for family and close friends, some former co-workers. About 60 people attended. Another 40 people were sent flyers/email, so they at least know about my practice now. Result: anecdotal reports from here and there of people who know people who are thinking of coming to see me.

Plan 2: Newspaper ad appearing in small local weekly newspaper tomorrow. Since I have no patients yet, it will a photo of one of our local friends' family (which I took myself with my digital camera for the ad). I did the layout myself on my Mac, and borrowed a tagline from a few years back used by the American Board of Family Practice: "Would you like to have a doctor who specializes in you?" I hope to feature a different local family every 2 weeks, and since South Pasadena is such a small town I figure many residents will recognize at least one of the families and reinforce the "neighborhood" aspect of my practice. South Pasadena only has a population of about 25,000. Since my aim is to reach a panel of 1000 patients, I'm very optimistic of reaching that goal within the local community.

Plan 3: Call local Catholic church and place ad in their weekly bulletin. While I am not a member of this church, I've had 2 people urge me to put an ad in it, if only to spread the word that I am out there. Makes sense to me and this I will do tomorrow.

Plan 4: Go around to local medical establishments and hand out business cards/brochures. I already handed out business cards to the Ob-Gyn doctor next door to me. There's also a plastic surgeon, and a rehabilitation medicine office in town whom I haven't met yet. I handed out some cards to a local pharmacy, but there are at least 3 others in town I haven't hit yet. This reminds me of when my parents bought a restaurant when we were growing up, and we would go across the street to the Target parking lot and put flyers under all the windshield wipers. I hope I won't have to do that, but whatever it takes, right?

Plan 5: Blood pressure screening at local Senior Center Health Fair next month.

Plan 6: Give monthly health awareness lectures at same Senior Center. My first talk is scheduled in April on "Mad Cow Disease". I offered a variety of topics concentrating mainly on senior-related issues, but they chose Mad Cow disease as the topic they'd like to hear first. Certainly a "sexier" subject than Osteoporosis.

Plan 7: Get on the local hospital's online referral database. I sent in my information yesterday and hey! Whattayaknow! I'm there already! Someone's on the ball at Huntington!

Plan 8: Get on various insurance plans as a provider. This will probably be the second biggest source of new patients, next to word of mouth. I've been told it may take up to 3 months from the time I apply until acceptance.

Plan 9: Yellow Pages. I thought I had submitted my order, having spoken to a SBC Smart Pages rep by phone a few months ago. The first guy I talked to was pushing me to buy a large color ad, when all I wanted was a single line ad, since I had heard that very few people find a doctor that way. When he found out what I wanted, he seemed to lose interest and said he would call me back. He never did. The second guy I talked to was more helpful, but apparently, needed to have the 1st guy call me back to confirm the order. Which he never did. That probably explains why I'm listed as "South Pasadena Family". But at least I'm listed under Physicians! They got that part right! (Maybe I shouldn't have told them I get phone service through AT&T).

Plan 10: Postcard mailers targeted to South Pasadena residents. I'm considering this down the road if I don't get enough patients in the next few months.

I'll be patient. I'm giving myself 2 years to build up my practice to its "full capacity". And if things don't work out, there's always...

Plan 11: Sticking flyers under windshield wipers of cars at Big Lots (South Pasadena has no Target).

They're (We're) Out There

For a change, I thought I'd link to websites of some of the other doctors taking part in this "redesign" or "revolution" in medical practice that I am trying to emulate in my practice.

It all started with Dr. Gordon Moore, who started his solo practice in 2001, and is still going strong. As he says on his website:

My goal has always been to create a practice capable of delivering care that is safe, effective, patient-centered, efficient, timely, and equitable.  I chose the "solo" option so that I could make changes quickly.  My goal was not "solo practice;" this has merely been my means to the end.

That certainly resonates with me. While I was at Kaiser, changes came very slowly. It's the difference between a blue whale turning left vs. a bottle-nosed dolphin turning left. I get to be the dolphin now. If a patient needs a prescription refill at Kaiser, they have to call the 1 800 number, wade through the phone message telephone tree, leave a message, the message goes to the pharmacy triage system, it gets typed in to an online pharmacy refill database which directs the refill request to the doctor, who is supposed to go through all the refill requests for his patients for that day. Approve/deny/change the prescription, which goes back to the pharmacy for processing. May take up to 48 hrs. Unless you need it sooner, then you need to leave a voice message for your doctor.

Even though I have no patients yet, I did call in a refill of an allergy medicine, Zyrtec, for a friend last week. I did it as a favor and refused payment. I mean, Claritin is available OTC, so how hard can refilling Zyrtec be? I called the local pharmacy and gave orders for the prescription. Done, right? Wrong. They called me back a few hours later because Zyrtec is "non-formulary", meaning it's not on their "approved" list of medications (read: it is more expensive that their formulary choice). No big deal, I said, I'll authorize that he didn't get adequate relief with Claritin, their formulary choice. Hold on, the pharmacist said. Don't tell us, you have to call the patient's insurance company's prior authorization number and tell them. Really? I said. So I called, expecting them to tell me they can't accept my prescription since I am not part of their network yet. But they just took my information and faxed me a form to sign and fax back to them. So much for being a dolphin. But now I'm a smarter dolphin and will remember where the obstacles are next time.

Another doctor who has set up his own solo practice, Dr. James Sturgis, can be found here at Prairie Village Family Medicine in Kansas:

My goal is to offer current and effective medical care in a practice recalling the best of the old-fashioned doctor's office: easy and immediate access without waiting, scant administrative hassle, lots of time spent with the doctor and a physician's appreciation for each patient's unique nature and circumstances.

Dr. Wes Bradford is another family physician who has opened his own practice in Redondo Beach, CA following this solo practice model. He comments:

A major but widely unappreciated factor is that doctors (especially in primary care) have twice as much documentation and monitoring expected now as forty years ago, but within the same allotted 15 minute visit. Imagine the stress of having to write a full-page clinical note during the visit, covering the past, present and future tests, consultations, medications, patient instructions and legal requirements, often for several separate problems in the same visit. This can easily take 10 minutes of the 15 minute visit, leaving little time left over for meaningful interaction with the patient. The doctor and patient both feel like they're on an assembly-line conveyor belt.

     Trying to do all of the above correctly inevitably takes more than the scheduled 15 minutes of time. Then patients still in the waiting room wonder why the doctor is never on time, while the clinical business managers say he's "unproductive and inefficient" because he "takes too much time". Nobody accounts for his having twice the workload in the same time allotment as in the past. Yet how can a doctor take twice as much time for each patient when the overhead expense is already 70 to 80%, with practice expenses climbing while reimbursements are fixed or dropping?

He goes on to describe the "low overhead" model with no employees and concludes:

By practicing in this unorthodox way, I can afford to spend twice as much time per visit as other doctors without charging more. I can maximize personal service, clinical effectiveness, and time to talk and listen, by minimizing my business complexity and overhead expense. My stress level is much lower, and I hope you will notice the difference in quality of service.

While I know of at least 15 other doctors around the country going solo, I was not able to locate any practice websites for them beyond ones just listing their name and addresses. But just so you know that they're out there, here they are:

Four Corners Family Medicine (Dr. Cindy Cote in Maple Valley, WA
Generations Health Care (Dr. Shaun Thompson in Fort Morgan, CO)
Health and Healing (Dr. Terry Merrifield in Andover, KS)
Flint Hills Family Medicine (Dr. Brent Hrabik in Emporia, KS)
Grace Family Medicine (Dr. Kathleen Meehan-De La Cruz in Hendersonville, NC)

We're out there, but our presence on the Web is not that obvious yet. Hopefully, that will change as more and more physicians learn about and perhaps try this practice model.

Oh yeah. And here's my practice website. It's a free service offered by the American Board of Family Practice, so any board certified family physician can have their own practice website through them.

The Price We Pay?

Huzzah! Today was my first official day as a solo family physician, and I saw a grand total of . . . zero patients. But I expected this.

The only people who know I am open for business are the family, friends and neighbors I invited to my Open House 3 days ago, and all of them looked healthy. Plus, I have the handicap of not being able to accept any third party insurance reimbursement yet. Which I point out to everyone who even hints that they might come see me someday. Perhaps I should stop discouraging them and just ask, "So when shall we schedule your appointment?"

After working at Kaiser for 13 years, I think I don't know the value of my own services, since we always got paid the same no matter how many patients we saw. This is something I will have to overcome, that is, asking people to pay me for my services.

And not feeling guilty about it.

Even though I haven't seen any patients yet, I'm already wondering if I set my prices too high. I had come across this practice in Tennesee which accepted only cash, and their prices ranged from $25 for a simple visit to $75 for a complex visit. But then again, this practice's target population is the uninsured and underinsured.

Two days ago, I decided to model my fee structure after Dr. Gordon Moore, the father of the "solo-solo" practice model. He charges his cash-paying patients $30 for each 15 minute block of time. I don't know how it compares to other local physicians' prices, but I do know that local psychologists are charging $200 an hour, so $30 seemed kind of low to me. However, $50 per 15 minutes seems kind of pricey. Even if I think my services are worth it, patients might balk at a rate they consider too high.

So I settled on a compromise. I would set my fees at $50/15 minutes, but offer a 20 percent discount for "prompt payment", effectively lowering the price to $40 per 15 minutes. I think that is a fair price for this middle to upper middle class area.

The concept of a "fair price" or "standard fee" seems to be a myth anyways. This 1998 study used 4 standardized patients seeing 62 doctors and saw fees that ranged from $16 to $160 for the same patient!

How does one set a fee? The easy way is to see what the doctor across the street charges and you charge the same (or a little less if you are smart). The complicated way is to use the Resource Based Relative Value System (RBRVS, or RVU - Relative Value Units - for short). It was an attempt to level out the payments made for "cognitive" services like a checkup vs. "procedural" services like a heart bypass operation, by assigning each service a "relative value". The hope was so that medical services would be fairly compensated based on the amount of work put in, mental as well as physical.

As this article points out, it hasn't quite turned out as well as planned, but it's better than before:

In 1991, for instance, an internist would have had to perform 72 mid-level office visits to equal the payment for a single coronary artery bypass graft. In 2002, that internist would have to perform only 38 office visits to equal that payment.

At any rate, I have yet to enter the third party payer system, and have to suffer the ups and downs of the local market economy. I hope to generate more interest next week after my advertisement in the local newspaper comes out. In the meantime, I still have to finalize all the forms that my patients will need to fill out when they come see me. So it's just as well that I don't have any patients yet. (It'll give me time to call around and see what the other local doctors are charging.)

Happy Heart Day!

Like I've said before, keeping up with writing a blog is harder than it looks.

But I am still here. And not only here, but just about ready to go live. Finally!

So although I haven't been posting, I've been busy. I missed my 2nd target start date of Feb. 2nd, but I only just received my city business license a week ago, so I couldn't have started much earlier anyways. My business cards and stationary will be ready for pickup later this morning. Just in time for me to hand them out at my office's Open House today. I've invited about 60 of our closest friends, relatives, kid's teachers, as well as the entire Kaiser clinic where I had worked for the past 13 years. It's the "official" christening of my new practice before I start officially seeing patients on Feb. 17th. If I have any, that is.

In the past few month, I've also ordered lots of medical supplies from Moore Medical. I had also checked out Henry Schein and Besse Medical, but it was taking so long for me to compare prices between them that I just decided to pick the one that had the lowest prices on the first 3 items on my list, and start ordering like crazy. So far, I've ordered about $2000 worth of stuff. Being a family physician, I've got to cover a wider range of needs than other doctors. I need gyn stuff (speculae, cytobrushes, nitrazine paper, pregnancy test kits), derm stuff (verruca-freeze for cryotherapy, scalpels), cards stuff (Nitrostat, ASA, EKG supplies), emergency and wound care stuff (sutures, sterile gloves, bandages, epi-pens), injection stuff (Kenalog, lidocaine, needles & syringes), peds stuff (baby scale, vaccines which need to be refrigerated, vaccines that need to be frozen), and the list goes on and on.

I set up an account with Unilab/Quest so that I can send patients for blood tests.

Other basic medical office stuff include hazardous waste disposal, special cleanup stuff for spilled "fluids", sharps disposal, exam table paper, gowns. My mother-in-law has been making custom-made patient robes, so I'll get to see them this weekend when we visit her. I got set up with First National Merchant Bank to accept credit and debit cards.

Unfortunately, I haven't been able to get my HP 6110 All-in-one to scan into my Mac Powerbook so far, despite several days of trying. It prints, faxes and copies just fine, but always hangs when I try to scan. I've read some posts which mention that HP hasn't released drivers yet for the Mac's latest OS X. If I can't get it to work by Tuesday, I'll have to either get a new scanner, or just copy things with the copier, then bring the copy home where I can use my home scanner. But at least I haven't had to worry about any viruses or worms since my Mac is immune.

I've got as much furniture as my tiny office can hold. There is some space on the walls for artwork. I'm finally having my medical school diploma framed, and it'll be ready in about 2 weeks. My application for hospital privileges is slowly making its way to the appropriate committee, and I've been told to come in on the 26th to pick up my ID badge, and received an invitation to a "New Physician" lunch on March 5th. So I guess I'm in.

I still need to apply to insurers so that I can accept insurance payments. So far, I've only applied to Aetna, because all the others wanted to know if I had hospital privileges yet. Aetna sent me back a provider agreement, but no fee schedule. So I left a message for them to send me one. It doesn't make sense to me to agree to accept their payment for services rendered without me knowing how much I should be paid. Fortunately, I got a provider number so that I could fill out credentialling info online at CAQH, the Council for Affordable Quality Healthcare. That way I only have to fill it out once, and the info can be sent to Blue Cross, Blue Shield, and other insurers.

Now I'm up late working on a brochure I can hand out tomorrow at my Open House. I'm also going to give out reprints of a newspaper article about Dr. Gordon Moore and his unique "solo-solo" practice model. After I start, I've got to gear up marketing to get new patients. I've already signed up to do blood pressure checks at the local Senior Center's health fair next month. Plus I've offered to give free medical lectures at the Senior Center once a month. So far, I'm pegged for "Mad Cow Disease" in April.

I plan to place ads in the local weekly newspaper. My idea is to take a photo of various South Pasadena families to show that I can take care of everyone in the family. Since I have no patients yet, I've asked some of our friends who have helped me get this practice going if they would be willing to pose for the photos, and they've all said, "Yes!".

And strangely enough, I received a call at my office from someone who found my name through this blog to ask about a physician for a relative. I had never dreamed that this blog would be a way to find patients. It's barely even read by the intended audience. But if it helps even one person considering a solo medical practice, then that makes me happy :-)