How to Have Your Very Own Micropractice

Pediatrician and Air Force Captain Terence R. McAllister started to think about his post-military employment options in the summer of 2003. Although he still owed another three years to Uncle Sam, a strong desire to settle with his family in his home state of Massachusetts sparked some serious discussions with his wife (that would be me).

In 2000, when Terence proposed marriage to me, he changed not only my life, but my location and my career trajectory as well; all with a promise to both of us that we’d return to Massachusetts in 2006 when his military commitment ended.

In 2003, as we drove to our new assignment at Kirtland Air Force Base in Albuquerque, N.M., Terence turned to me, and asked: "Can you run a small practice for me?" And just like that, my husband changed my life yet again.

If we were going to do this, I laid out a few non-negotiable points (they are the same now as they were then):

1. As business partners, we must wear separate hats; as medical director, Terence takes the lead on all medical-related decisions. I, as administrative director, call the shots when it comes to business decisions.

2. Work-life balance is a must. While some nighttime and weekend call is expected, we set boundaries to make time for each other and our son.

3. Although we accepted that we’ll never earn enough to be in the top 1 percent, it is important to us that we earn as much as we could at our own business as we could employed by others.

As Terence military commitment kept him busy, I attended the University of New Mexico to obtain my master’s degree in business administration.

While there, most classes required small groups of students to work on a project. When my classmates looked at each other with a, "I dunno, what you want to work on?" expression, I’d ask, "How about a small primary-care pediatric practice?" And, with each class (operations, marketing, finance, and human resource), my business plan was created.

OPERATIONS

Like any business innovator, I did a lot of research and questioned everything from the role of traditional nurses in primary care to the positives and negatives of a cash-only practice. I took on consecutive part-time jobs, first as an entry-level medical records clerk at a traditional 11-provider practice and then as an office assistant in a small, home-based practice to observe what works (and what doesn’t) firsthand. In my research I learned of micropractices, two or three providers who work without medical assistants. The providers in micropractices see fewer patients a day than most doctors and spend more time with each patient. For Terence, practicing medicine in the gigantic bureaucracy of the U.S. military made him miserable. I knew he’d be happier at a small practice.

The key would be - and still is - to keep overhead low and profits high by limiting staff and utilizing technology to work efficiently. We started, from day one, as a paperless practice with an integrated practice management and EHR called Office Practicum. In 2010, we added the InstaMed clearinghouse because it integrated into our EHR system. Today, we feel we have the right technology tools working for us.

FINANCE

Like any good business plan, our pro forma numbers were well researched and conservative. Alas, like any startup, it only takes one or two bad assumptions to miss all financial targets. My one bad assumption: how long it would take to grow our practice to a stable size. I found a few statistics that said a typical new provider can grow a full panel within two years; it took us four. I believe it took us longer because most providers grow in partnership with an established provider feeding them new patients. Although today, nearly seven years into our practice, we are meeting our financial goals, the road to get here was long and, at times, financially scary. We were lucky early on to partner with a small, local bank; without their support, we may not have made it.

MARKETING

I started my career in public relations, so marketing is where I felt the most prepared. We named our practice Performance Pediatrics and we set both our mission and our vision statements to guide us in all decision-making tasks.

• Vision: To establish lifelong healthy habits in childhood.

• Mission: To support our patients as they fulfill their individual physical, developmental, and emotional health potential through medicine, education, and example.

To figure out where we should locate our practice, I researched where in Massachusetts there was the greatest need for pediatricians. Luckily for us, there was a shortage of pediatricians in the Plymouth area which happened to be near many of our friends and family members in the southeastern part of the state.

With vision and location set, the last major marketing piece was "price." I know I don’t need to tell you, my fellow practice administrators, just how overwhelming insurance contracting and fee setting is! In addition, keep in mind that we started in Massachusetts in 2006 at the same time that "Romneycare" was becoming the law of the land. As prepared as we thought we were, it didn’t take long for us to realize that we were on the losing end of negotiations with insurance companies.

Here is where fate lent a hand. I’d like to say that this was all my doing - that I cleverly figured out a solution - but the truth is that it was just plain luck that Terence happened to meet Gregory Young, MD, of the Pediatric Physicians’ Organization at Boston Children’s Hospital (PPOC), an independent physician’s association (IPA), in 2006. My usually shy husband struck up a meaningful conversation with Young who invited us to join the PPOC. We owe our success to our IPA and encourage other small practices to seek out IPAs as well.

Human Resources

The questions I get asked most often are, "How can you stand working with your husband?" which tells me more about the questioner’s personal life than I care to know, and, "But you wouldn’t work this hard if it wasn’t your husband’s practice, would you?" I’ve thought about this quite a bit and feel fairly certain that our model could work for other provider/administrator partnerships even if they weren’t life partners as well.

Sure, my job is challenging, but I’m well compensated (independent of what my husband earns) and I have flex time where I work from home one day a week and leave early for childcare when needed. I can’t imagine loving a job more!

I’ll close while stating that I recognize that the micropractice model is not for everyone. Providers in micropractices take the vitals, administer the shots, and even clean up the exam room. Still, for the benefits of getting more time with your patients and the opportunity of developing a more meaningful doctor-patient relationship, for us, far outweigh the negatives.

Yes, there are challenges, but if we can do it, so can you!