Written by Dr. Joel Warshaw | Published on Wednesday, August 19th, 2015

Adventuring into something new can be very scary, especially when it comes to career choices.  “Will I be happy? Will I be successful? Can I afford to make this decision? What if I fail?”.  I had these very same questions, in 2007, when I first decided to transition to a Direct Primary Care (DPC) practice.  Sure I had some bumps in the road, but I can tell you with much enthusiasm that I am happier now in my career than I’ve ever been before.  And certainly happier than I would have been had I stayed in the current “hamster wheel” traditional style of medicine that is our current healthcare system.  If you have any interest in starting a Concierge/DPC practice, but have reservations due to certain fears, then read on;

#1: “I worry I won’t have enough patients”

The number one concern you should have is whether or not you will have enough patients to sustain your business.  Your success could depend on the model you practice.

  • You could be like me and practice the DPC model, which means you completely opt out of insurance companies and become 100% supported by patient membership fees.
  • You could choose the Concierge model where you accept membership fees but also accept insurance reimbursements.
  • Or you could try a hybrid model, where you keep a portion of your practice as the traditional model and the rest as Concierge/DPC patients.  (I have a hard time appreciating the hybrid model, because it means you treat patients differently in the same practice, and that could be tricky.)

 Another factor will be your fee structure.  How much will you charge your members?  Is there a tier based on age, based on location, based on services used?  Do you offer discounts if patients pay for the entire year, if a spouse joins or if the entire family joins?  From the beginning, I decided to keep my rates lower than the national average because it was a new concept to Pittsburgh and I thought perhaps rates that were too high would frighten patients away.  Since 2008, I’ve raised my rates only once and my yearly renewal rate is greater than 95%.  In fact, patients often tell me I don’t charge enough!

If you have an existing practice, especially in an affluent area, your success will be much greater.  Typically, 5-10% of your existing patients will follow you, which creates a nice base to build from as you move forward.  If you are a physician early in your career, you will find membership to be a greater challenge, since you will not have a loyal patient base to draw from. However, you could consider exploring self-funded health insurance employers looking for better care for their employees while cutting costs.

#2: “I dread the thought of being on call 24/7 all year round”

This is a common question I get from physicians interested in starting a Concierge/DPC practice.  It’s certainly a reasonable concern since you promise constant availability to your patients, and they are paying you for this service.  If this is a big concern for you, then don’t worry!  The Concierge/DPC model allows only a limited number of patients into the practice, so caring for thousands of patients (which you may be used to) is no longer an issue.  By keeping the practice small, typically 400-600 patients, you’ll find that the phone calls after hours or weekends will be nothing like the traditional model physicians currently practice.  Patients are properly cared for throughout the regular work schedule, including refills on medications and answering quick questions.  Allowing the patients to access the office with simple emails or phone calls that get picked up right away, reduces problems after hours.  Plus, I’ve found that patients respect my time away from work and only call when they really need something.  In fact, patients have elected to go to an Urgent Care or Emergency Room for after hour issues, much to my discouragement unless directed by me.

Another question I get is how do I handle vacations or days out of the city.  I have staff that field all questions and resolve 90% of the issues while I’m away.  But when I am needed, I will handle all issues through cell phone, text or email.  If you are lucky enough to have another concierge practice in your area, you could cover each other, which is what I finally arranged after covering myself for seven years.  Which turned out not to be a “big deal”!

#3: “I’m not comfortable managing a practice by myself”

Some physicians enjoy the business aspect of medicine, while others run in the opposite direction as fast as possible!  If you are closer to the latter, then realize there are many options for you to assist you along the way.

  • If you are not good with banking then hiring an accountant can help you in this area.  But this will increase your overhead and divert funds you may find useful elsewhere.  I personally use the cloud based Quickbooks software to manage my practice.  They offer free telephone support to walk you through the software.  I find this extremely easy to use and quickly accessible anywhere I am located.  The software keeps track of my finances and membership in the practice.  I can easily use templates for membership fees and keep track of balances.  A very nice feature is the software syncs with my EMR (www.EmpyrealEMR.com) to allow myself or my patients, through an e-chart portal, how much might be owed.
  • Staffing will be one of your greatest overhead expenses and one of the most important decisions you’ll make.  With the right staff, your life will be less complicated, your patients will be happy and your business will be more likely to succeed.  Because of the lower volume of work, you won’t need many employees.  At a minimum, you’ll need two employees for the mornings to handle all the phone calls, blood draws and checking in/out patients.  The afternoon is typically quieter and you can work with one employee, so hiring 1.5 FTE per MD is ideal.  If you charge lower fees and therefore keep a larger practice, if you practice the Concierge model where you deal with insurance companies, or if you decide to go with the hybrid model, you’ll need to adjust your FTEs accordingly.
  • There are many other aspects to running a practice, such as contracting with companies to purchase medical supplies, laboratory certification and pickups, laundry for cloth gowns, tech support for office computers, etc.  None of this is more difficult than the challenges we faced going through Medical School!

The EMR technology that you choose for your practice can greatly improve workflow and efficiency.  EmpyrealEMR was built specifically for the Concierge/DPC practice, to help with all facets of the practice, from interactions with a patient including email/texting documentation, scheduling, intra-office workflow, patient monitoring using synced devices and much more!

Over the past few years, medicine has evolved, and in many ways not for the better for the physicians and patients.   More and more time is spent meeting insurance regulations and administrative burdens, while providing the highest level of medical care we can in an ever-growing complex medical world.  We all went to Medical School to learn medicine and care for our patients, but as the system evolves, so must we.  Practicing the Concierge/DPC model offers an excellent solution to those who wish for change.

Fear of the unknown is certainly understandable when it comes to changing a career choice, but learning from others who have traveled down this path offers a huge advantage and should allow one to make a more intelligent decision.  Don’t let fear stand in your way towards career happiness!

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