Is A "Concierge" Medical Practice for You?

The debate rages over the "good" or the "bad" of a concierge or boutique medical practice, but the trend shows no sign on abating.

In a newspaper article I read online today, it's estimated that there are about 400 such practices around the country.

Fact-o-stat of the day: According to Consumer Reports, Americans on average wait 68 minutes to see a doctor for six minutes.

Rather than enter into the debate, I'd like to focus on the business model of the "concierge" (also called "boutique" or "retainer") practice, and how it differs from a traditional medical practice.

A doctor in a typical primary care practice may serve between 2,000 and 4,000 patients, deriving most his or her revenues from insurance billings at contracted rates, capitated per member per month fees, co-pays, and a certain amount paid in cash. This leads to variable and somewhat unpredictable cash flows, unless the physician's practice is consistently full.

Under this model, patients are allocated a certain amount of time for each appointment, and they "pay as they go", either directly or via insurance - except in the case of capitation.

Expenses tend to be a combination of fixed, variable and semi-variable costs. Rarely is there an influx of capital to be able to invest in practice upgrades. Instead, moneys have to be set aside in a disciplined fashion, or borrowed and repaid, to fund new projects such as installing an electronic medical record or a practice management software system.

The concierge practice business model differs substantially in a number of ways:

1. The per-physician patient roster drops, usually to between 400 and 700 patients.
   
   
2. Each patient is charged an annual fee of between $1,000 and $3,500 (some practices offer "family rates"). In exchange for this fee, the patient can expect 24-7 physician availability by phone or pager, substantially longer appointment times, appropriate health education and recommendations for evidence-based screening tests, physician guidance and support through surgeries and other health crises, and personalized attention.
   This fee usually does not cover billable services like lab tests, procedures, X-rays etc, or approved Medicare services. In some instances, the office will help the patient submit claims to his or her insurance - in others, the patient has to go it alone.
   
   
3. The annual fees provide a substantial one-time cash flow into a practice. This can be both a blessing and a bane. The blessing is having so much cash available at one time for capital improvements. A 600-patient practice with an average annual individual fee of $2,000 would produce a January income of $1.2 million, assuming everyone was billed (and they paid up) at the beginning of the year!
   The challenge is to forecast accurately the monthly cash flow needs through the remainder of the year to cover expenses, including a physician's salary. This would require a practice to invest and manage the cash very prudently.
   An alternative billing practice is to charge the patients a monthly fee e.g. $750 a month, which ensures a steady monthly income.
   
   
4. Most physicians drop out of their health insurance contracts. This appears to be mainly due to the fact that health insurance companies are not yet ardent fans of this model. According to a well-written article by healthcare attorney Thomas B. Shapira:

..........few third-party payors have been receptive to the concept. ....Most managed care companies contractually prohibit providers from charging "access fees" to enrollees. Accordingly, many concierge practices voluntarily terminate their contracts with third-party payors and function as out-of-network providers. Because this scenario leaves patients responsible for a greater portion of office charges, some concierge practices have reduced their office fee schedules. For the physician, this accommodation rarely results in a significant loss of revenue. As a service to its patients, the practice can offer to bill insurance, or patients can submit claims directly. Nevertheless, before converting to a concierge model, physicians should consider whether their patients will be willing to see an out-of-network provider.

Another potential area of concern for concierge physicians is the Medicare program. The Department of Health and Human Services has reviewed the concierge model and determined that, if structured properly, this type of practice does not generally violate current Medicare regulations.

To avoid potential violations, a concierge practice must carefully structure its benefits so that the annual fee does not cover services that are already reimbursed by Medicare. For example, Medicare now pays for a comprehensive physical examination for first-time enrollees. As a result, most concierge practices exclude the exam from the annual fee for first-time Medicare enrollees but offer a corresponding discount to the annual fee. Additional items eligible for Medicare reimbursement that should not be covered by the annual fee include coordinating consultations with other physicians and writing prescriptions. Although current Medicare laws are generally favorable to the concierge model, the risk remains that Congress will pass future legislation that adversely affects the viability of these types of medical practices. 

Depending on which actual model of "concierge" medicine is being used, patients can rely on having enhanced  access to their physicians without any change in medical services, or they may have both enhanced access and enhanced services. In order to provide the latter legally, it appears that a physician may not be a part of the Medicare program or a contracted provider for an insurance company. Healthcare attorney, John Marquis, discusses this in greater depth and describes three different business models in a March 2005 article, entitled Legal Issues Involved in Concierge Medical Practices.

It seems sensible to consult a healthcare lawyer familiar with these practice models, to understand all the ins and outs and implications of a decision to move to this medical practice model. 

For entrepreneurial physicians committed to staying in clinical practice, the first challenge is to recognize when your current business model is not serving you any longer. It won't take much to drive you out of practice altogether, if you hate going to work.

The second is to become truly entrepreneurial and creative --- to spend the time configuring the practice model that best meets your income and lifestyle needs, while permitting you to continue serving the many patients who need your care. Including folks like me!

I'd love to hear your thoughts about these practices. Care to share in the comment section up above? 

I will be a panelist at the Consumer Health World Conference

It came as a pleasant surprise to be invited a couple of weeks ago to participate in a panel discussion at the Healthcare Blogging Summit portion of Consumer Health World Conference at the end of April 2007.

Our panel topic is: "Creating a Presence - Plan and Develop Your Blog Strategy & Tactics on Establishing Your Social Media Presence" and we'll be focusing on the role that blogging is playing in business development and marketing.

I've only been blogging for six months, so I hardly qualify as a major expert in this area, but I do know that I can comment on the impact of blogging on my business.

For me, blogging has meant:

• The ability to have a conversation. Although my readers do not comment much on my blogs, seldom a week goes by without emails from readers, providing feedback, insights and other resources.
  
  
• The ability to express myself. I have long fancied the idea of becoming a novelist, without any of the discipline or inspiration needed to succeed in getting published. Well, I have discovered that blogging comes a close second - I LOVE writing the blog posts.
  
  
• The ability to organize my thoughts. Closely related to the second point above is the idea that my thoughts and musings are all organized into categories, with dates and times, so that IF I ever get around to writing a book on physician entrepreneurship, the task will be much less onerous. Less writing, more cutting and pasting; less research, more searching my blog posts.
  
  
• The ability to develop a network. Part of my excitement at attending and participating in the conference is the potential that exists to meet and talk to many of my fellow bloggers, whom I have been admiring from a distance. Many of us are active bloggers at Trusted.MD, a network of healthcare bloggers run by the indomitable and energetic Dmitriy Kruglyak.
  
  In addition, I consider my "correspondence regulars" to be a part of my network, as is that group of non-healthcare bloggers whose inspiring posts I read daily. People like Pam Slim of Escape from Cubicle Nation, Kathy Sierra of Creating Passionate Users, Matthew Stibbe of Bad Language, Kristi T of Kristi T's Home Business Blog, Jeff Cornwall of The Entrepreneurial Mind, Ann Michael of Manage to Change and Leon Ho of LifeHack (to name just a few).
  
  
• The ability to be perceived as an expert. For those of us for whom this is an important part of our business strategy, this is a biggie. A study I heard about recently (can't find it on the Web at present - anyone know where I can find it?) revealed that about 79% of journalists and writers said that they turned first to the blogosphere to see who was an expert on a topic, and thus worthy of an interview.
  It was through my new blog that I was approached by a representative for Oakstone Medical Publishing late last year to be the guest faculty speaker for their audioconference for physicians on “Become a Physician Entrepreneur: Use Your Medical Know-How and Credibility to Launch a Lucrative Business”.
  
  
• The ability to brand myself. It is my fondest hope that, as I continue to develop my blogging writing "voice" that my readers will begin to sense who I am and what I stand for. In that way, those clients who I am meant to work with and serve will be drawn to The Entrepreneurial MD brand.
  
  
• And last but by no means least, the sudden appearance of my website and blog on Google's page number one. I'd planned my whole website and blog promotional strategy around the common wisdom that regular writing on your topic of expertise and incorporating keywords that your readers might use to find you, was the way to rise to the top of the search engines. So I was puzzled when I didn't see my name, or a Google Page rank, despite anxious scrutiny day after day.
  Well, last week, it happened! I guess I had been stuck in the notorious "Google sandbox" for almost 5 months, and was suddenly let out. I confess, it is very satisfying to see my hard work pay off, and have my site show up on page 1 for at least five of my keywords or phrases.

So, if you are wondering whether a blog might be good for your business, these are some of my observations. I look forward to hearing from my co-panelists, Dale Hunscher of Business Blogging for Healthcare Professionals and Mike Smith of Mike Smith Business Development, and sharing with you what more I discover.

What Happens When You Allow Yourself to Believe

I felt a warm rush of pleasure when I opened my email this morning and discovered a message from a client titled: "Success! I'm an artist!"

My client, Dr Ellen Penno of Western Laser Eye in Canada (she has given me permission to use her name), wrote:

The first of my applications to various shows/sales was accepted - 3 of my glass pieces will be exhibited with other "fine crafts" from March 2- March 30 in the Saskatoon Mendel Art Museum (Sasketchewan) as part of the Her-icane Women's Art Festival. That's a nice bit of validation for me!

Thanks to you for helping me jump off that cliff -  Ellen

What is so remarkable about this email is that a little over a year ago, when Ellen and I started working together, one of her written goals was the cryptic "Decide on a future part-time career". What she confessed to me was that she loved to sculpt, and that while she enjoyed her career as a successful ophthalmologist in Canada, she longed to express herself more creatively.

Her hesitation in pursuing a career as an artist was that she didn't feel she could accept "artist" as part of her identity - she was too closely tied to the identity of being a doctor, with all its attendant encumbrances.

Each of us is blessed at birth with an Essential Self (to use Martha Beck's terminology from her marvelous book Finding Your Own North Star). The Essential Self is that innate, intuitive and "uncontaminated" part of ourselves that has its own wisdom about our true needs, wishes and desires. Look at a 16 month old in action and you will see the Essential Self in all its glory.

However, family, society, and culture intervene, to mold each of us to "fit in" with their expectations of us, and to help us adapt, and avoid shame and embarrassment. Thus the Social Self is born! Which is a good thing in moderation, as the Social Self's job is to help us navigate an acceptable path through society. It is responsible for insuring that we develop and use our Emotional Intelligence to manage ourselves effectively and build successful relationships.

Much of the rest of our lives is spent under the rule of our Social Selves .... which is a problem when the gap between our social and essential selves is wide, and our social selves are, in effect, split off from our essential selves.

Let me put this in context with the example of Dr. Penno.

Her Social Self was a huge professional success. But, mid-career, her Essential Self was missing something - a creative outlet, in line with a wonderful talent that was hard for her to acknowledge. When she contemplated taking her art seriously, the initial response of her Social Self was to cringe with concern that her dreams were foolish. It told her she should stick with being a physician (Hint: you'll often recognize the presence of your Social Self when it uses the language of "Should, must, have to, can't, shouldn't").

Fortunately, she recognized her Essential Self's desire and acted on it by seeking encouragement from someone with no investment in having her maintain her identity solely as a physician. 

She started sculpting regularly, transitioning from "a bit of a hobby" to committed student, sometimes flying long distances to take classes working in different media. She experienced palpable joy. She began to believe that her dream was possible.

The contract her Social Self made with her Essential Self was that, as soon as she had some pieces accepted into an art show, she could claim her new and additional identity as an artist. She claimed it today, in her message to me. Her Social Self had achieved the goal, in alignment with her Essential Self's deepest needs!

What I love about this story is how well it illustrates what can be accomplished if:

1. 1. You acknowledge the existence of your own needs, wishes and desires - your Essential Self.
2. 2. You give yourself permission to expand your identity.
3. 3. You let your Essential Self set the goals for the Social Self to accomplish (as Martha Beck says: Your Essential Self wants passionately to become a doctor; your Social Self struggles through organic chemistry and applies to medical school).
4. You harness all the talent, training, skill and drive of your Social Self in service of the needs, wishes and desires of Essential Self.
5. You believe!

Ellen's last words express so much about her experience -- "jump off that cliff". That is how scary it can feel, permitting your Essential Self to express itself, and then set the goals.

My hat's off to her for having the courage to believe in herself!

And because I am so enchanted by her work, I have a second photo for you to enjoy (the one up top is her beautiful glass tree wrapping its roots around a smooth rock).

What entrepreneurial physicians should have in their libraries

I have a confession to make - I am a sucker for books! Sometimes it feels like an addiction - I get the "must haves" for a book and order it ASAP, only to have it sit unread on my book shelf for months and even years.

Some of my learning about business has come purely from books. More often than not, a book or magazine article has been the trigger for a deeper exploration - perhaps a conversation with an "expert", a phone call to a friend who works in the area, or retaining a professional service person to help me really grasp the knowledge! And then the books have been my faithful companions as I have been guided to solve business problems or develop my skills.

Some reading materials have been crucial to my development as an entrepreneur, and since I was asked the question today by an aspiring physician entrepreneur "Do you have any books you could recommend for getting started in business?", I thought I'd compile a quick list here to share with you all.

The reading that has had the greatest impact on my growth as a business person includes:

The E-Myth Revisited, by Michael Gerber. This book teaches business owners the skills of thinking not only like a Technician (someone with the "technical" skills to deliver a service), but also like an Entrepreneur working ON rather than IN a business, and like a Manager who is putting in place reliable and repeatable Systems and Processes for efficient and effective operations. It was an eye opener for me early on in business.
Gerber has two companion books that are relevant and helpful - "The E-Myth Physician: Why Most Medical Practices Don't Work and What To Do About It" and "E-Myth Mastery", a detailed workbook.

Flawless Consulting: A Guide to Getting Your Expertise Used, by Peter Block. This is a MUST READ for anyone who plans to offer consulting expertise. The take home message - your greatest value as a consultant to another business derives from the powerful combination of your expertise and your authenticity.

The One Page Business Plan, by Jim Horan. This high quality workbook engaged me right away with it's insightful questions about why I wanted to be in business, who I wanted to serve and how I wanted to serve them.
I have used this book over and over with my coaching clients, and when I wrote to the author Jim Horan hoping to have him be a guest interviewee at one of my monthly teleclasses, I was thrilled when he said "yes". Look out for the April teleclass in which I interview him - the class will be posted for your registration after March 21st.

StartUpNation, by Jeff Sloan and Rich Sloan. From their Life Plan to their completed Business Plan, the Sloan brothers offer a quick but detailed overview of the steps needed to go into business. They have a companion website at StartUpNation.com filled with free content about business.

Entrepreneur magazine and its companion website, Entrepreneur.com. This inexpensive monthly magazine is rich with tips, ideas and resources.

Fast Company magazine and its companion website, FastCompany.com. This subscription too is inexpensive and the monthly magazine profiles many different interesting companies, services and products.

There are many more books I could recommend for reading from cover to cover, but this is enough to get you thinking like a business person.

For valuable reference books, here are my top three:

Streetwise Small Business Book of Lists, edited by Gene Marks

The Entrepreneur's Desk Reference, by Jane Applegate

201 Great Ideas for Your Small Business, by Jane Applegate

Finally, for those of you who are Book Hogs like me, a terrific investment is Amazon Prime, if you like to purchase books frequently over the Internet. For an annual fee of $79, you can have all your books (and many non-book items, including grocery items, that qualify for Amazon Prime shipping) shipped f.ree with a two-day delivery time (or $3.99 for overnight delivery). It is a most satisfying experience ordering something and having it arrive two days later, with no shipping charges!

Please share your great resources here, if you have any. I'm always on the lookout for good stuff.

Raising your Resilience - A Success Secret for Physician Entrepreneurs

This is a philosophical blog post coming on the heels of a meeting I had today with my "Mastermind group". We talked at length about the topic of resiliency. It appears that many physicians are feeling less than hardy these days in the face of all their practice struggles! They are worn down by the endless "rules" and the relentless pressure to see more patients while taking home less money.

I also thought back on the many conversations with I've had with successful physician entrepreneurs and how they have resounded with one near-universal insight - almost everyone has remarked on how critical the traits of persistence and resilience have been to their success.

Seems kind of self-evident, doesn't it? But it's a lot easier to think and talk about resilience than it is to figure out how to develop it.

Several years ago, I was struck by a book I read that was authored by Dr. Martin Seligman, an esteemed psychologist and the so-called "Father of Positive Psychology". I was a fairly new and earnest parent at the time, and was drawn to his title of "The Optimistic Child".

Dr. Seligman's premise was that you can "immunize" child against depression by teaching them to observe, check for accuracy and then dispute many of the "automatic thoughts" that pop into their heads. His research proved him correct and he and a colleague developed the highly successful Penn Prevention Program for school kids.

Demonstrating to children that thoughts were both verifiable and changeable, and teaching them social problem-solving skills were at the core of his program. Children were taught how to catch their fleeting, automatic, self-critical thoughts, judge the accuracy of their pessimistic thoughts and self-accusations, and also handle interpersonal conflicts.

So what does this all mean for us as adults?

How many times a day do you put yourself down, believe yourself to be unworthy in some way, or distort a situation by imagining the worst outcome? My bet is that you're pretty hard on yourself. Without realizing it, you probably use your thoughts to hit yourself over the head repeatedly with a large hammer.

One of the best antidotes to pessimistic or judgmental thoughts is a dose of The Work - a tool I use on a regular basis with my clients to help them investigate their stressful thoughts.

The creator of the tool, Byron Katie (known familiarly as Katie), has a great tagline on her website that describes the potential impact of her tool: "I don't let go of stressful thoughts. I question them. Then they let go of me."  I love picturing a life in which my lousy thoughts just let go of me!

In fact, this tool is a very practical method for investigating your own thoughts and "fact-checking" for reality, versus what you have made up in your head. 

My slightly modified version of The Work is a six-step process that begins with you identifying the thought that is causing you to feel bad or stuck. You may have to even check in with your body - your breathing, your "abdominal sensations", your neck and jaw muscles, to figure out what that thought is. As a novice in this process, you will find it helpful to write the negative thought down.

And then do the following:

Step One: Ask yourself "Does this thought seem true to me?" Answer Yes or No. If your answer is "No", there is no need to go any further.

Step Two: Ask yourself "Can I be absolutely sure that this is true?" Again answer Yes or No.
If you answer "yes, I'm absolutely sure", you are confronting reality. You have to deal with that.

Step Three: Ask yourself "How do I react when I think and believe that thought? Specifically, how does this thought make me FEEL and how does it make me ACT?" 

Step Four: Ask yourself "Who would I be if I were no longer permitted to have this thought? What would my life be like?" Picture yourself living without this thought - how would you feel? What would you do, or not do, differently?

Step Five: Now turn your negative thought around 180 degrees. Try not to go to the extreme unlikely opposite but to find a thought that feels at least modestly comfortable!
So go from "I won't be able to start the business I want to, becasue I never have any spare time" to "If I pay attention to how I use my time, I likely to be able to find small blocks of time several times a week to work on my idea" (instead of the much less realistic "I'll be able to start a business because I really have plenty of time"!)

Step Six: Finally ask yourself "If I put that second thought up against the original thought, is the second thought at least as true as the original thought (if not more true than it)?"
In essence, you are comparing one "fiction" (the thought you proved in Step 2 was NOT true) with a second "fiction" (a new thought that you haven't yet proved true). You are seeing whether the second thought is a least as viable as the first. Now, if the second thought feels at least as true, choose to feel and act as if it WERE true, and see how that works for you.

Once you get this down pat, you will be surprised by how much more resilient your thinking becomes. Because most of what plagues us is self-created!

What helps you endure? Do you have any other suggestions to help your colleagues become more resilient? If so, please share here.