Practice Overhaul Contest: Turnaround help for income and expense woes

In July 2007, we announced the winner of our Practice Overhaul Contest, selected from more than 300 entries in which physicians described their most pressing practice problems. The prize-free advice and counsel from two certified healthcare business consultants-went to FP Alan T. Falkoff of High Ridge Family Practice in Stamford, CT, in part because the difficulties he described in his entry are shared by physicians nationwide. Chief among these are high employee turnover and stagnant income. (For more on the contest, see "," July 6, 2007.)

The consultants, Michael P. Brady, president of Healthcare Business Consultants in Asheville, NC, and Michael D. Brown, president of Health Care Economics in Indianapolis, after crunching numbers provided by Falkoff, spent a day and a half observing practice operations, and talking with Falkoff, his partners-pediatrician David M. Berkun and FP Joshua B. Herbert-and their support staff. They then prepared a detailed report. Here's what they suggested, along with the High Ridge owners' responses.

High Ridge Family Practice's situation-the need to find ways of covering overhead, coupled with the desire not to compromise patient care-is typical of many primary care practices during these times of stagnant and declining reimbursement, the consultants acknowledge. Chief among their recommendations: To appreciably amplify profits, the doctors have to increase patient volume.

Even the best advice, however, can be difficult to apply in everyday practice, either because the recommendations conflict with group culture, call for more changes than the owners are prepared to make, or fall by the wayside in the rush to complete everyday activities. The High Ridge partners, who spent many hours reviewing the consultants' report, have already begun putting some of the recommendations into effect, while rejecting others as contrary to the way they want to practice medicine.

How many patients are too many?

Not long after the consultants' visit, HRFP moved from relatively cramped quarters to an almost 11,000-square-foot office suite-effectively tripling its workspace. It is Alan Falkoff's hope that despite the costs of the move and increased rent and maintenance expenses, the practice will take in more money by, as he puts it, "working smarter, not more."

That includes increasing reimbursement by coding more effectively, leveraging and maximizing fee schedules, improving workflow, and adding new services. Worthy goals, Brady and Brown say, but they still assert that it's virtually impossible to bring substantially more income into a primary care practice without increasing productivity.

The "right" number of patient visits, Brady and Brown maintain, is 25 to 28 per day for a pediatrician and 30 to 35 per FP. Each High Ridge physician sees an average of 16 to 20 patients daily, typically allotting 20 minutes per patient visit. The doctors spend from 12 to 17 minutes with each patient-although preventive health exams, presurgical clearance exams, and other complex encounters can take much longer. That deliberate pace is a cornerstone of their practice philosophy. "Thirty to 35 patients per day leads to staff and physician burnout, dissatisfied patients, lower quality of medicine, less ability to meet quality goals, more errors, and poorer follow-up," Falkoff says.