What's a micropractice?

December 1, 2006

Some doctors are using high-tech to reclaim an older, leaner style of medical practice. Supporters think it's a recipe for better outcomes and lower costs

For five years before opening her innovative solo practice in Woodland Park, CO, FP Michelle Eads worked in a very traditional, very busy primary care group. Located in Colorado Springs, it employed lots of doctors, operated with an enormous overhead, and processed scores of patients each day.

"I was forced to crank them through as fast as I could," says Eads, whose panel numbered more than 2,000 patients, most of whom she never got to know very well. "After five years of that, I knew I wanted to do something different."

At the heart of Eads' practice is her electronic health record, which has built-in practice management software that, as she says, "makes billing quite painless." With a panel of only 400 patients who have access to her 24/7, she's able to give many of her patients one-hour appointments.

"The amount of time I spend at work each week is similar to the time I spent in my previous job," she says, "but my satisfaction is so much higher. I'm happy to be a doctor again."

Eads is not alone. Tired of practicing treadmill medicine, doctors across the country have decided to jump off the fast track and use 21st century technology to recapture what Moore calls a Norman Rockwell style of practice. The official term for this approach is the "ideal micropractice," which, as Moore and his colleagues have written, "strips a primary care office to its essential components so that it is capable of delivering patient-centered, collaborative care." (For additional information, go to http://www.idealmicropractice.org.)

The results to date have been impressive. Not only are doctors happier-and, in some cases, able to earn close to what they could in a traditional practice-but patient feedback has been equally upbeat. In published studies, patients report high levels of satisfaction in areas such as access, efficiency, continuity of care, and doctor awareness of their key concerns.

"Despite passionate dedication and professionalism in primary care, we only achieve what we should be a little over half of the time," says Moore. "And it's this failure at the primary care end that, down the road, drives a lot of very costly specialty and hospital care. I'm after practices that can deliver much better outcomes and help lower the total cost of US healthcare."

We talked to three doctors who, in their small ways, are moving in this direction.

John E. Brady, FP

Newport News, VA

Before opening The Village Doctor in his hometown, John Brady worked in a six-physician family practice located 30 minutes away in Suffolk, VA. It was a fast-paced operation, requiring that he see a new patient every 10 to 15 minutes. But it wasn't just the pace of traditional practice life that bothered him-it was also the sense of being split between two communities, the one he worked in and the one he lived in. His new office, located in a renovated single-family house built in 1919, not only brought him back home but also permitted him to practice a very different style of medicine.

To do that, he's made efforts to keep his overhead low-currently, it's running between $7,000 and $8,000 a month, including the cost of paying off his start-up loans. He has one helper, an LPN, whose office used to be the family dining room. He also has an electronic health record, which has charting, scheduling, and billing components built in, as well as a database that serves as a patient registry.

Because he's kept his overhead in check, he's able to limit the size of his practice, which is now capped at 1,500 patients. In an average week (Wednesday afternoons are reserved for administrative chores), he sees approximately 70 patients. New ones get a one-hour appointment; established ones a half hour.

The generous appointment slots permit him to get to know his patients really well. "The woman with diabetes may be less concerned about her illness than about her husband who has dementia," he says. "I can spend time with her and find out what's really on her mind."

To assist him in this effort, he uses a tool that many micropractice doctors now employ. It's a web-based patient medical and healthcare survey called the How's Your Health Quiz (available at http://www.howsyourhealth.org), which was developed by John Wasson and his colleagues in the Department of Community and Family Medicine at Dartmouth Medical School in New Hampshire. With information from the survey in hand (patients must elect to share their survey with their doctor), Brady is not only able to assess his individual patients but also his entire patient population.

Basically healthy patients who know how to take care of themselves may require comparatively little extra assistance-what Wasson calls "autopilot care." Patients with serious chronic conditions who aren't self-directed may need greater support, including more frequent and longer visits, telephone follow-up, and more patient education material.

And how has Brady's new style of practice affected his bottom line? "I'm probably making about 20 percent less than I would be if I were employed in a traditional group practice in this area," he says. "But that gap will probably narrow and may even disappear once my start-up loans are paid off."

For now, however, he isn't complaining: "There are probably more than a few doctors out there who would be willing to cut their salary by 20 percent or so to really love what they do again."

Jean M. Antonucci, FP

Farmington, ME

Working a three-quarter schedule, Jean Antonucci expects her micropractice to net approximately $64,000 this year. Her goal is to gross slightly over $100,000, which she figures will yield a net income of roughly $80,000. She could make more, she says, if she put in another day each week, but "my life is important to me, so I've structured my practice so that I can achieve a balance between my life and my work."

Her office-a one-woman affair that operates out of two rented rooms in a standard-looking medical building-also permits her "to practice medicine the way I think it should be practiced."

Her previous experience in medicine did just the opposite.