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Fighting back, part 2: The quest for independence


The fight against the pressures facing independent primary care practices can take many forms. For some, it has meant joining forces with other practices to attain the benefits that come with size without sacrificing their day-to-day autonomy. Others are taking a different route-minimizing the bureaucratic obstacles to practicing medicine by adopting direct pay practice models.

The fight against the pressures facing independent primary care practices can take many forms. For some, it has meant joining forces with other practices to attain the benefits that come with size without sacrificing their day-to-day autonomy. Others are taking a different route-minimizing the bureaucratic obstacles to practicing medicine by adopting direct pay practice models. 

Independence through direct pay

The lure of a direct pay model became apparent to Brian Forrest, MD, after working as an employed physician with two large integrated systems in his native North Carolina.

“As an employee I had absolutely no control of my own schedule. They just wanted to run as many people through there as they could,” he says. “It was all based on how many people you could roll through the door and how good a coder you were.”

He recalls the aftermath of one day where he saw 63 patients. “I couldn’t sleep that night, wondering ‘what did I forget? How many tests did I miss, how many prescriptions didn’t I give?’

The Definitive Guide to an EHR Switch




Forrest’s solution was to found Access Healthcare, which he describes as “a direct primary care micro practice model,” in Apex, North Carolina. Apex accepts no third-party reimbursements, either public or commercial. Instead, patients pay a monthly membership fee ranging from $45 to $85, plus a $20 “scheduling charge” to cover the variable overhead of the visit, primarily lab work.

Related:Choosing independence: Tips on moving to a private practice

The different fees are designed to cover additional services, Forrest explains. While the overwhelming majority of patients opt for the basic $45 monthly charge, for an additional $20 per month Access will provide a patient with up to four generic prescription medications. “If the patient can pay just one monthly fee and not have to bother with going to the pharmacy to get their prescription filled, it’s something they really like,” he says.

Other services beyond the basic level Access can provide include monthly massages and visits from a dietician, who will go grocery shopping with the patient and teach him or her how to read nutrition labels.  

“These are all services people told us they needed over the years.” Forrest says. “Imagine for $20 a month having someone come to your house 12 times a year and be willing to shop with you or review food diaries. We’ve had three patients in the last year who’ve lost over 100 pounds doing this.”


NEXT: Technology, other ways to improve efficiency


Forrest estimates Access’s net profit per-patient is two to three times that of the typical fee-for-service primary care practice, despite charging patients about 80% less than the typical practice. He’s able to accomplish that by keeping overhead low. The practice has three providers including Forrest, and two staff members who function as medical assistants, receptionists, and referral coordinators. (Forrest calls them “the ultimate cross-trained patient care coordinators.”)

“They are able to handle all that since we don’t file insurance there’s no reasons for billing and coders, and all that bureaucracy goes out the window,” he explains. “It’s a complete contrast to the idea of traditional insurance, where three-fourths of your job is making sure you get paid for the visit.”

Forrest says he schedules one patient per hour, even though most visits take less time than that, so as to create availabilities for walk-ins. During a typical eight-hour day he will see between 12 and 15 patients.

Related:Satisfaction with EHR systems grows among physicians

Access also looks to technology-specifically, its electronic health record system-to help improve efficiency and keep costs down. Without having to worry about meaningful use and Medicare quality initiatives, Forrest says, providers can focus on using the system for charting.

“We use an EHR that’s really intuitive and that allows me to get all my notes done in about 30 seconds per patient and in a much more complete way than when I was writing them down or dictating them,” he says. “Now when a patient walks out our door their note’s completely done.”

The system’s e-prescribing feature is also a significant improvement over writing out prescriptions manually, he says, particularly when refilling multiple medications for a patient. Instead of having to write the patient’s name and medication directions on each script, “now you can do each of those refills in less than five seconds. And when the bulk of people’s prescriptions don’t necessarily change every visit, it really speeds that workflow up.”

Access recommends a mail-order pharmacy to its patients that, in addition to being cheaper than most retail pharmacies, will generate a weekly report of which patients didn’t take delivery of their prescriptions. “We love that, because it allows us to call the patient and say ‘we sent this prescription but apparently you told the pharmacy not to fill it, and what happened there?’ It really helps with compliance,” Forrest says.

Forrest says he is contacted frequently by other doctors wanting to know about his model.

Typically, “they either sold their practice to a hospital system or they went to work for a system right out of residency, and now they’ve had enough, because they’re seeing the same things I did. It’s all based just on seeing as many patients as they can and coding as high as they can. We’re seeing a huge number of those folks saying they want to change over to a direct care model where they don’t have to deal with that baloney.”


NEXT: Returning to independence


Returning to independence

Lisa Klein, MD, FACC, a pediatric cardiologist in Louisville, Kentucky, is one who has tired of “the baloney” that frequently accompanies health system employment and has decided to strike out on her own. When she spoke with Medical Economics she had recently given notice at UK Healthcare and was in the process of setting up her own practice.

“I decided to leave corporate/academic medicine because I felt tired of being told how many patients I needed to see and when I needed to be there, and having every aspect of my professional life micromanaged,” she explains. “After 23 years of being in practice I just got fed up with it.” Before UK HealthCare she had worked with a practice owned by the University of Louisville Hospital, and the Sanger Heart and Vascular Institute in North Carolina, part of Carolinas HealthCare System.

Klein will be starting small in her new practice to reduce the financial risk. At the outset, she says, her staff will consist of a receptionist, an electrocardiogram technician, and two others who she says will be “clinical-service type employees.” She is leasing office space and equipment from an adult cardiologist practice. (“I’m basically leasing the whole operation,” she says.) In addition, she will be using an outside vendor for billing and many other administrative tasks.

Related:How to survive in independent practice

Financing for her start-up is coming from proceeds of the house her family sold when they left North Carolina to return to Louisville, along with a loan from her husband. “I don’t want to take a public loan if I don’t have to,” she explains.

To begin building up a patient base, Klein is contacting pediatricians in the Louisville region, many of whom she knows from her previous practice. “I tell them, ‘this is what I’m doing and I’d really appreciate if you’d refer me patients,’” she says. “They’ve all been very supportive and say just let us know when you go live.”

She also plans on visiting many of them personally with gifts of organic fruit and vegetables, rather than more traditional fare like donuts and pizza. “I feel like I should practice what I preach,” she explains. “Also, my focus is going to be on a more personalized type of preventive approach, so I feel like getting off on that sort of foot would be beneficial.” A marketing communications firm is developing a logo and website for the practice.

Klein acknowledges that self-employment will bring its own challenges, including a reduction in income. But she’s willing to accept those in return for the ability to practice medicine how she sees fit.

“The only way I can do what I feel is best for the patient is not to care too much about how much income I’m generating,” she says. “Now I’ll be at the mercy of the insurance companies, but I’ll still have more control over my day-to-day life. I’ll be available to my patients but I won’t have to be available to an entire medical center.”


NEXT: Carving out your niche


Carving out your niche

Even as an employee of a hospital or health system, there are ways of carving out some independence, provided you know what you want and are savvy about getting it.

Mary Ann Bauman, MD, an Oklahoma City internist and Medical Economics editorial adviser, discovered a few years ago when she decided to look for ways to reduce her practice hours.

A 26-year employee of Integris Baptist Health Center, Bauman wanted to devote more time to traveling on behalf of the American Heart Association (where she is a national board member), and visiting her parents and other family members around the country. She found the solution from a patient who described how he shared his job, spending two months on and two months off.

“I started thinking, ‘You could do that reasonably well in primary care medicine, ‘because you see most of your patients at one month, three months, six months or one year intervals,” she says. “So you could do it if you had someone who practiced the same way you did and could see patients when you weren’t there.”

Related:IPAs: Joining forces to retain independence

Bauman sounded out a younger colleague-Erin Glasgow, MD--who wanted to spend more time with her pre-teen children. Together they approached Integris administrators and sold them on the idea. Now, Bauman says, she sees patients the equivalent of five half-days per week, 24 weeks per year. Glasgow sees patients the other two-and-a-half days.

Bauman emphasizes that the arrangement took a great deal of preparation, especially when it came to minimizing the impact on other providers.

“We always call in once or twice a day and the staff has permission to call us anytime with questions,” she says. “So even though we’re part-time, it’s never a burden on our partners. That’s really important in making this model work.”

Similarly, they stayed in the same call rotation. “That’s the other thing that frustrates your partners, is if they have to do double-duty on call because you’re part-time,” Bauman says. She and Glasgow coordinate schedules travel schedules so that each can cover for the other when one is out of town.


NEXT: Minimal impact on collegues


As a result of these actions, she says, the impact on her colleagues has been minimal. She still attends weekly physician staff meetings and continues with her women’s health-related activities for Integris. “And I’m in and out of the office, bringing things I’ve worked on at home. So it’s not like I’m gone for long periods of time.

“Some of the high producers in other clinics around the system have said they’re watching us closely because they would like to try something like this,” she adds. “So I think we’re pioneering something that looks very attractive to others.”

A bigger challenge than not imposing on other providers has been the impact on staff members. As part of the job-sharing arrangement the physicians agreed to merge their nursing staffs. But that has required overcoming what Bauman calls “pod-it is.” “It’s the attitude of, ‘I work for this doctor and I’ll help you out, but I don’t feel any responsibility to the other doctor,” Bauman says.

The problem surfaced when one the physicians would send in orders for a patient on a day when she didn’t have office hours. “The work wasn’t always getting done,” she says. “So then we set up a system where the nurse whose doctor is in takes care of their doctor, and the other one does referrals and correspondence of both doctors.

“We knew going in that the staff situation would be our biggest challenge, and it is,” she says.

Related:Collaboration is the key to small practice survival

On a personal level, she adds, the decrease in practice time has required both financial and psychological adjustments. She was prepared for the former, but the latter came as a surprise. “I knew my income was going down, because I wouldn’t be seeing as many patients. But the emotional response I had to the change was very challenging, because it felt like I was not being productive. That might not be true for everyone, but it certainly was for me.”

Bauman offers two pieces of advice to other employed physicians seeking a job-sharing arrangement. First and foremost is “to have a partner that practices the same way you do. And I would sit down with the person and hammer out questions like ‘are you going to be upset if I ask you to see a patient for me? What about taking calls when I’m not there? What are you comfortable with in terms of things like staff members doing prescription refills?’ Things like that are critical, because you could end up hating each other.”

Second is to find a champion among the system’s administration. “If you have an existing relationship with someone, that’s where I would start, because they can really grease the skids for you,” she says. In her case it was the boss of her immediate manager . “He kind of smoothed it over with everyone else. “

In presenting your case to administrators, she adds, detailed preparation is vital. That means presenting information such as how much time you actually spent seeing patients in the previous year, how much time you expect to do so while job-sharing, and what the financial impact is likely to be. “Do your homework ahead of time so you really know your practice, and hammer out as many details as possible before you start.”


NEXT: Private practice survival tips


Private practice survival tips

Join forces

Consider joining an independent physician association (IPA) to align with other physicians. Some have found that membership helps them negotiate tricky situations with payers where they might not otherwise get reimbursed.

Look for high-impact savings

The major expense items that practices need to get right are occupancy and personnel costs. Find ways to save on property costs and how to get the most form your employees.

Focus on billing practices

Make sure that someone in the practice has clear accountability for checking that all services get billed. Physicians can eliminate work that isn’t reimbursed through better claims management.

Ensure collections

Check on referrals and insurance authorizations before providing services and ask patients for copays at the time of check-in.

Review the fee schedule

You may discover you’re losing money in ways you may not be aware of. Regular review and calibration of your fee schedule could help.

Editor’s note:

This is the second installment of our two-part series, “Fighting Back.” Part I explored tools and strategies practices are using to resist the pressure to give up their independence and join a hospital or health system. Part II looks at one physician who chose direct primary care as an alternative to hospital employment, another who is leaving a health system for independent practice, and a third who has reduced her practice hours despite being a hospital system employee.


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