Monday, October 11, 2004

Going Solo Together

There are probably as many ways to configure a high quality, low overhead practice model as there are physicians. Greg and Heather Sharp are a physician couple who have set up a shared practice. The following describes how they did it:


Practice Design
On Sept 6th we opened our practice in Woodland Park, CO. Some of you may recognize this as the home of Michelle Eads, who has been a wonderful help and encouragement to us and pointed us to this listserve group initially. We are a husband and wife pair of family doctors who are sharing one full time practice. We are drawing from Gordon Moore's low-overhead, high-quality model of practice, my Father's home office in Houghton Lake, MI and the SimpleCare approach to practice billing. We have one insurance contract and offer a 25% discount for anyone who pays at the time of service by cash, check or credit card. We hope to attract the uninsured, those with high-deductible insurance/HSA, and anyone who doesn't meet their plan's annual deductible and wants accessible, personal, and affordable care. That being said, over two thirds of our first month's patients (28 in all) have had the one insurance we contracted with. In the name of simplicity, and to fully commit to a discounted fee for service model we have opted out of Medicare and Medicaid. This has been a challenging decision and we are not sure yet if this will be a permanent decision, but we would like to give a hassle-free approach a fair try.

We remodeled 750 sq ft in a professional building next to the town post office with a small office, one exam/consultation room (10x14 is a nice size), one procedure room, a restroom, and waiting room. We are paying $12/sq ft/yr plus triple net expenses that comes to just over $1000/month for a two year lease. The landlord split the remodeling costs with us 50/50 but this had to be negotiated. We are quite happy with the amount of space that will allow both of us to be in the office from time to time.

We are using Amazing Charts for EMR (and eagerly awaiting the next version), but are not using much beyond the patient record and prescription/order writing features. We have had good results with "printing" orders and scripts to the fax machine and have them sent directly to pharmacy, lab, etc. We are using Microsoft outlook to store patient demographics and business contacts which helps with storing fax numbers for use with sending faxes as described above as well as improved mobility with patient contact info in our PDA, and emailing with patients which Amazing Charts messaging does not support. In order to allow us to schedule appointments remotely, we are using the calendar within Outlook which also will interface with a PDA. We looked into PDA/cell technology that would allow real time synchronization with the office Outlook remotely but don't feel the technology is quite there yet.

We bought one new Dell desktop with hyperthreading processor and it has handled everything well so far. We enjoy our dual flat-screen monitors as well, which make running several programs simultaneously so much easier. We wired our office with Cat5e cable for additional computers and bought a network ready Brother printer (HL5170DN) with extra paper tray that has worked extremely well. The additional tray is used for a green security paper for printing prescriptions out of amazing charts when we can't fax them to the pharmacy. Our current network of the computer and printer only required a netgear VPS318 router that is VPN ready (Virtual Private Network for home access).

We just purchased a Visioneer one touch 7300 USB scanner this week and am happy with the one-touch scanning to PDF files which can then be marked with comments/highlights on the computer and stored to a patient file library on the hard-drive allowing us to go paperless. This requires the full adobe acrobat program, not just the free acrobat reader. We have a CD-RW drive which we are using to backup our files weekly.

We currently have one cell phone, one voice line at the office, and one fax line. We tried to put the fax and phone on the same line with a distinctive ring feature, put this was not practical because we wanted to forward calls. We are forwarding calls after one ring to the cell phone while one of us is with a patient so that the other one at home takes the call. We have voicemail on the cell phone. For office calls that aren't answered (when call forwarding is off) we have an answering machine with a message that includes our cell number for urgent issues. With only one person in the office, we also ordered call waiting so that we can avoid patients getting a busy signal if we are on the office line.

We are using QuickbooksPro2004 for our practice accounting as well as patient billing. We are also using the Quickbooks card swiper and merchant services for credit card service (VISA, MC, Discover, Amex). No problems so far with credit cards. The swiper was cheap, it auto-enters everything into Quickbooks, it takes up minimal space on our desk and there is a discounted card-swiped rate for transactions. For insurance claims, we are producing HCFA 1500 forms with the EZClaim software and then printing them and mailing them in or giving them to patients for reimbursement from insurances we don't participate with. EZ Claim also has an EZ Link module which exports the HCFA 1500 data to Quickbooks as invoices so that we can track our accounts receivable/insurance payments. At my Dad's recommendation we also purchased FlashCode which has been very helpful in building our fee schedule and exporting CPT and ICD-9 codes to Amazing charts, EZClaim and Quickbooks (for invoices/cash and credit receipts). The FlashCode customer service has been the best I've seen. I am still waiting on the Quickbooks Customer Manager software which should eliminate double entry of data between Quickbooks and Outlook.

We were fortunate to get used exam room equipment from our former employer when they sold the practice to the local hospital. We were able to get exam tables, an autoclave, surgical instruments, mayo stands, trash cans and procedure lights from them for a good deal. We also had some exam instruments left over from medical school. Most of our new medical equipment purchases have been for disposable items. These supplies have cost roughly $2650. I have our inventory lists as an Excel file for any of you who might be interested.

As has been said on the listserve before, word of mouth seems to be the primary method of marketing that works. We had an article about our practice in the local paper business section that was also very productive. Newspaper ads have been disappointing, but without a listing in the phone book they probably serve a purpose. Most of our patients have come from personal contacts around town, and the local chamber of commerce has been a great help. They are holding a ribbon-cutting ceremony for us in a couple of weeks. We left a full practice 3 hours away to come to a new town, so we knew that we would have to count on slow growth. We have actually been quite happy with how our model has been received and with our panel of 28 patients after one month. The female aspect of our male-female team is undoubtedly an asset in marketing to the community. Our future plans include arranging talks at the senior center, to civic groups and hopefully in the schools to spread the word about what we are doing. Dr. Eads' practice has already made the public here more receptive to a non-traditional format of practice.

With the help of my brother and the websites of others on this listserve, we do have a practice website which describes our practice philosophy in more detail. It's We hope to make it more interactive for patients in the future.

We hopefully have the bulk of our startup costs behind us and have currently borrowed $26,000. We don't plan on having a salary for a few more months. We are paying student loans with the proceeds from the sale of our previous home in Alamosa and living with family until the practice is established. We have a cash-flow projection that has us paying off our start-up loan by the end of our first year and a joint salary of $70,000. Only time will tell how close this is to reality. We have planned for the long haul with advisors telling us to count on up to 18 months to break even. I don't think it will take that long because thanks to low-overhead, it's no longer that hard to break even. We are enjoying this new pace of practice and the freedom of setting up a new business immensely.

Thanks again to all of you. I hope this is helpful. We really appreciate the encouragement of you like-minded pioneers out there.

Greg and Heather Sharp MD
Ideal Family Healthcare, PC
PO Box 4918
Woodland Park, CO


Congratulations to Greg and Heather for taking the leap! While I don't expect this practice model to replace what's out there now, the fact that more and more physicians are trying this shows that there is a unfulfilled need for this kind of simpler and more personal kind of medicine that is greatly satisfying to physicians and patients alike. This isn't how most of primary care medicine is delivered now, but perhaps it should be.