Tuesday, February 15, 2005

Solo Practice...One year later

It has been one year since I opened my solo practice with the Gordon Moore (AKA "ideal medicine") model. After 14 years as a staff physician in a managed care organization, I re-started with zero patients.

My numbers:
Patients seen: 201
Patient visits: 357
Average # visits per patient: 1.78
Average # visits per week: 14
Housecalls: 9
M:F ratio: 46% male, 54% female
Average age: 36
Oldest: 91 years old
Youngest: 2 months old
Sources of patients: Word of mouth 41%; Relatives of patients 16%; Paid advertisements 14%; Insurance provider list 12%; Newspaper article 6%; Yellow pages 4%; Referrals 4%; Former patients 2%; Other 1%
Payor mix: PPO insurance 71%, Cash 24%, Medicare 7%, HMO 0%
Time to receive payment via electronic billing: average 7-12 days; longest 122 days; shortest 2 days
Average charge per visit: $114.27
Average payment per visit: $70.06
Total charges: $40,785
Total reimbursement: $17,515
Improved job satisfaction: Priceless

It is a work in progress, and in retrospect, it is a lot more work than I anticipated. But then again, I knew that there was no way I could ever know how hard/easy it would be without actually doing it. Kinda like getting into medical school.

I want to reassure those who may be scared off by my low numbers that my slow startup has been atypical. As I have mentioned elsewhere, other physicians trying this practice model have grown much faster than me, and some have closed their practices to new patients after one year or less.

The biggest challenge for me has been the business side of things. I'm almost over feeling embarrassed about asking patients for copays and sending out bills. It took me a long time to even catch up with submitting claims to insurers, and even now, I am awaiting payments for visits that took place months ago. My wife took it upon herself to enter all my receipts and expenses, mainly because we need to know what to put on our tax return. (Thanks, honey!)

Growing the practice has been the other challenge. I am still intending to come up with a postcard-type ad that I can send via a direct marketing mailing list. One thing I'm learning about being a local business person is that community involvement can be a bottomless pit. First I joined Kiwanis and got to know some other members of the community. Then I joined the Chamber of Commerce, and volunteered to be on a committee to help grow the Chamber. Now I'm on the verge of volunteering to chair another committee for the local Relay for Life, a fundraiser for the American Cancer Society. These are all worthwhile events, and they are a way for others in the community to get to know me. But sometimes I worry that I might become so busy with these other activities that I don't have (enough) time to spend on my practice and my family. That is, after all, one of the main reasons I left my former job.

Another potential activity that is coming up pertains to the purpose of this blog, which is provide motivation for others who may wish to go solo, too. There has been an e-mail listserve (started by Dr. Gordon Moore) which has been sharing information and experiences for the past year. Recently, someone suggested that we get together and become an official organization dedicated to fostering this new practice model. We are in the process of writing a grant proposal to fund a project to demonstrate how this "ideal practice" model may provide better health care than traditional models.

I'm not quite sure what defines this "ideal practice" model that Dr. Moore started. His original goal was to strip away non-essentials and have a bare bones, low overhead kind of practice that allowed him to schedule patients for same day visits and spend oodles of time with patients, without having to generate the kind of income that is required to support the typical number of office staff. In return, he was less frazzled, regained his autonomy, and managed to maintain his income level. This is the same model I have been following, except that I'm still frazzled and I have nowhere near my former income level yet. But I do spend oodles of face time with patients.

However, other physicians in our group work with a nurse, PA or clinic assistant. Some partner with other physicians. Some work part-time, some full-time. Some see a few patients a day. Others see 20-25 patients a day. At least one of us charges a retainer fee ($50 per year). We all use electronic medical records rather than paper charts.

Recently, concierge medicine has been in the news. The main selling points to patients of these practices are that they get better and more immediate access to, and more undivided attention from, their doctor. However, I think our "ideal medicine" practices share many features in common with concierge or boutique practices:
- Nicer and less crowded reception areas.
- Priority/same day/ guaranteed next day/ extended/ Saturday appointments. (I see patients on Sundays sometimes)
- 24-hour pager, cell phone, home phone access to the physician.
- House calls and out of office care. (some practices)
- Preventive care/weight loss/nutrition/wellness advice.
- Telephone and email consultations.
- Comprehensive physicals.

On the other hand, some concierge practices have features that you won't find in an "ideal medicine" practice:
- Spa-like amenities and decor.
- Personalized mini CD-rom containing medical history and related information.
- Preventive care/weight loss/nutrition/wellness programs.
- Accompanying patients to appointments with specialists. (Then again, 4 months ago I picked up a patient from her house and drove her to her GI appointment because her ride didn't show up. So I suppose this could apply to both. Although I'll bet a concierge doctor wouldn't offer to be a chauffeur.)
- A retainer fee of $1000 to $20000 per year. (Definitely worth it for spa-like amenities and a personalized CD.)

I keep calling our practice model "ideal medicine" not because it is ideal, but because we are striving to practice the ideal kind of medicine that patients and physicians both want. The medical care you want and need, when you want and need it. The time for patients and doctors to build a relationship. Greater satisfaction for everybody. It may be that this practice model will end up having a different moniker. Whatever it will ultimately be called, it is part of a grassroots movement to fix a broken healthcare system.

As they say, "Mighty oaks from little acorns grow." And we must be a little nutty to think we can solve the current U.S. healthcare system. But we've got to start somewhere. Why not here?