How to run a cash-only practice and thrive

After Brian Forrest, MD, finished his family medicine residency program at Wake Forest University in North Carolina in 2001, he received a lucrative salaried job offer from a major academic medical center in the Raleigh-Durham region.

Despite the prestige of the organization and the lure of job security, Forrest declined the offer.

Forrest's practice, which he named Access Healthcare, is cash-only. He does not accept insurance or Medicare and won't file reimbursement paperwork for patients. He sees, at most, 16 patients a day and goes home by 5 p.m.

His minimum annual income nearly doubles that of a typical family physician in his region, according to Medical Economics 2009 compensation survey. His estimated net pre-tax income is between $270,000 and $495,000 a year and he doesn't require patients to pay a "concierge" or membership fee to establish at his practice. The estimate is based on his monthly revenue and expenses (see "By the numbers"; Forrest declined to reveal his exact net income).

With 2,500 active patients, Forrest's schedule is full. He recently hired a part-time family physician who works nights and Saturdays and still accepts new patients.

How does Forrest do it? He keeps his expenses low with no insurance administration duties (except for preauthorizing medications and tests for his insured patients) and negotiates low fees for lab work. But low overhead alone will not make a successful practice. The time and attention Forrest gives his patients, and lower prices, created a community buzz and profitable practice in less than a year.

"Patients get five minutes of wait and 50 minutes with me," Forrest says. "In most offices, they get 50 minutes of gobbledygook and five minutes with the doctor."

Forrest isn't alone. "Micropractices" - solo doctors who work with minimum staff and overhead to keep costs low so they can see fewer patients - are nationwide. Gordon Moore, MD, opened his own micropractice in 2001 and runs a nonprofit organization, Ideal Medical Practices, which advises practices. Moore couldn't say how many physicians practiced with this model, but more than 850 physicians and others subscribe to his organization's electronic mailing list and hundreds of physicians list their micropractices on the Ideal Medical Practices Web site ( http://www.idealmedicalpractices.org).