My Practice, My Way

Healthcare is filled with people who feel bullied by forces beyond their control. Physicians and staff look at the chaos in their clinics and their plummeting reimbursement and they throw up their hands in defeat.

But some don't fit that mold. Instead of waiting for a revolution, they've set out on their own. They've created careers that make them feel energized and empowered. Instead of feeling defeated, they delight in going to work every day.

Physicians Practice introduces you to three physicians who refused to sit back and complain about the problems in healthcare. Their individual answers may not work for everyone -- and won't fix the system overall. But we cheer their entrepreneurial optimism. Here's to the rebels. May they inspire the rest of us.

Michael Janssen, DO 
Building a Dream

Michael Janssen, DO, had a vision. He dreamed of a state-of-the-art medical facility where he could treat and teach about complex spinal disorders using cutting-edge procedures developed onsite.
He wasn't satisfied with what he'd found in academic hospitals. The surgical staff he had to count on was sometimes only marginally familiar with spine surgery. Physician education came in the form of dry lectures, not trial and error in cadaver labs -- the practical training Janssen thought crucial for delicate work on the spine. No one was inspired. Medicine felt stale and haphazard.
Janssen decided he could do better himself. "I think in medicine you can always control your own destiny," he says. "It's about pursuing a passion."

To follow his dream, he bought some land and built his own medical campus just north of Denver. The Center for Spinal Disorders is a palatial, four-physician orthopaedic clinic with 16 exam and procedure rooms organized into pods where midlevel clinicians, nurses, and physicians work in efficient teams.
For surgery, they stroll to The Musculoskeletal Surgery Center that Janssen built under the same roof. Surgeons in multiple specialties work in the center on all kinds of musculoskeletal disorders, not just spine problems. The surgery center includes six patient suites accommodating recovery for up to 72 hours after surgery.

New vision for research

But what really sets the campus apart is The Spine Education and Research Institute (SERI). Janssen didn't just build a clinic and ambulatory surgery center; he built his own place to do research and educate other physicians.

At the heart of the not-for-profit center is a fully automated amphitheater. Lights and blinds can be manipulated from the podium. Every seat has a link to the Internet and a microphone so physician audience members can ask questions of other surgeons as they perform procedures in the nearby surgery center or cadaver lab. Cameras embedded in the surgical lights send live images of the procedures to the amphitheater, allowing observers to see right into the wound -- a better view than if a visiting surgeon were standing next to the patient. Physicians in the lab can also see their audience. Once surgeons have watched a new procedure, they are invited back to the cadaver lab to try it for themselves.

"Most surgeons don't get a chance to go back to a cadaver lab after medical school, and it's impractical to bring lots of people into the operating room all the time," says Janssen. Teaching by demonstration "takes the learning curve to a much different level," and the teaching facility lets him do it.

Surgeons from all over the world visit SERI to share treatment techniques. The Institute hosts a full-time fellow each year as well as 12 to 15 international students who visit for a month or two. SERI also conducts clinical trials and is one of 20 sites in the U.S. experimenting with the use of artificial spinal disks.

Three staff members coordinate events and research and do fundraising. In the summers, they help organize science camps for children in local junior and high schools. An educational grant from the Weiss Medical Foundation lets them include underprivileged students. The kids dissect frogs -- or even human hands -- in the cadaver lab and hear speakers from all aspects of the scientific world, not just the medical. For example, they might learn about animal behavior from an expert at The Denver Zoo.

'Fun to be here'

Of his clinical staff, Janssen says, "These people are happy. They used to be depressed and cynical." Gen Smith, RN, director of surgical services at The Musculoskeletal Surgery Center, isn't shy about sharing her enthusiasm for her job. Staff and physicians "share a vision," she says when asked to describe what sets this job apart. "Everyone has buy-in and gets emotionally rewarded ... It's so fun to be here at 7 in the morning -- usually my least favorite time of day -- and start a case. Anesthesia is on time, the doc is in a good mood, the nurses are in a good mood ... and the patients pick up on it ... .

"The surroundings are so positive. When we get one little thing that goes wrong, it stands out like a sore thumb. Everyone strives for perfection, and everyone is oriented around that."

That's a far cry from the atmosphere at most practices or in a large hospital setting. Here, staff and physicians can quickly make improvements and see change. Physicians have literal ownership in the process -- that helps with attitude adjustment. But the pride and joy in North Denver goes a step further:  These are people who are bringing medicine a little bit closer to what they think it should be. Operating a comprehensive surgery and research center isn't in the cards for every physician, but the fact is that Janssen has succeeded in creating the kind of medical practice he wanted. He didn't give up.

His advice to other physicians? "Ask yourself what you expect for your career and focus there, then the whole cycle improves. Patients want to go to doctors who are happy and energetic."

Douglas Iliff, MD 
Going It Alone -- With Confidence

Douglas Iliff, MD, knew he didn't like the meeting, consensus-driven culture of group practice. So rather than suffer through it, the Topeka, Kan., family physician opened a solo practice - and has been at it successfully for nearly two decades. Iliff admits that solo practice isn't for everyone, but it may just be the answer for physicians who, like him, have "always had strong ideas about how I wanted to do things."

"It's not specialty; it's personality," he says of practicing solo. "You've got to have a lot of self-confidence and what [management theorist and author] Peter Drucker calls 'a bias toward action.'
"Everyone who is a solo practitioner bears the full burden of that business model," he adds. "There has to be a carrot, some reward for taking on that burden ... ." Which may explain why he was willing to take on all the demands of owning and managing a medical practice that includes obstetrics and delivery.

"I've worked in a group setting and you have committee meetings, and committee meetings lead to pontificating. People like to talk but I don't like to hear them talk - I don't even like to hear me talk. I just want to get something done," he says.

Iliff has been successful largely because he knows himself and found a path that makes him happy. Feeling stifled by group culture? Itching for independence? Here's what Iliff does to make it work.

A great support system

Iliff puts in a 40-hour week, which includes handling management duties and leadership of a practice with approximately 4,000 active patients. He sees an average of 125 patients a week assisted by 4.8 full-time-equivalent (FTE) staff.

That's slightly less than the median for family physicians -- 5.10 staff per full-time physician -- according to the Medical Group Management Association's (MGMA) 2003 Cost Survey. Iliff manages nonetheless because he invests well in his support system.
"My payroll is higher than the average physician's (24 percent higher, according to MGMA data) because I pay my employees well," says Iliff. "I hire RNs where other doctors [get] by with medical assistants. I want that higher level of decision-making because there's so much information that gets processed every day at a busy practice."

Iliff shares call duties with two other solo practitioners in town, but relies on a hospitalist for inpatient duties. To help keep the patient demand under control, he and another solo physician own an urgent care clinic staffed by an employed physician assistant.

Open access as always

The concept of open access scheduling -- holding open a portion of each day's appointments to meet daily demand - has been gaining popularity recently. But it isn't a new concept to Iliff -- he's been doing it for years. Doing anything else is just "bad medicine," he says.

"People get sick and they need to be seen promptly. That's part of taking good care of your patients."

Iliff speculates that insecurity and inefficiency may be why some doctors tolerate long waiting lists for appointments in their practices. "It has to do with self-assurance. An insecure person doesn't want the insecurity of seeing open spots on their schedule when they come in every morning," he says.

Experience has taught Iliff that a busy month will make up for a slow one, and that open access scheduling is the key to a more profitable practice. Yet, even as a solo physician who insists on meeting each day's demand for appointments, he rarely works late. "The only reason there's any discussion at all about open access scheduling is because there are so many physicians who have been seeing a patient too few each day for five or six years and now they won't take the time to dig out or make other changes to pick up the pace," Iliff says. "Seeing that long waiting list becomes an emotional security blanket for them, I guess."

Selective contracting

Common wisdom would say a solo family physician has to take any contract he can get; he can't very well negotiate. But Iliff contracts with only two carriers. (It helps that Blue Cross dominates the market in Topeka.)

Although he's seeking ways to increase his cash business, Iliff keeps his focus on partnering with patients. For example, he has a new program for overweight patients in which up to 30 patients ages 45 to 65 pay $500 - and get $400 of it refunded -- if they attend three group appointments (he calls them "lectures"), take part in 12 weekly, two-hour exercise sessions, and keep a daily exercise diary. If patients miss a session, Iliff prorates the refund. Talk about incentives.

Iliff takes just a few Medicare patients, billing them as a nonparticipating provider. He says that his decision five years ago to drop out of Medicare was a risk reduction strategy, not a financial tactic. A solo practitioner cannot take time to keep pace with the growing mountain of Medicare regulations and still run an efficient practice, he contends.

In fact, when Iliff -- now in his 50s -- runs through possible pre-retirement scenarios, seeing Medicare patients again almost makes working in a group again more palatable.

"There'd be a legal department, a compliance director, and all of those things you need with a program like Medicare that's just not possible for a solo physician," he says. But there'd still be those committee meetings.

In the meantime, Iliff stands by his approach to medicine. Solo practice - the self-discipline it requires and the choices it can offer to patients - is keeping alive the free-market approach that Iliff strongly advocates. "Patients will always be served best where the market is freest," he says. He lives his ideal.

Richard Goldman, MD
Concierge Practice: The Golden Ring

Miserable with job stress and desperate for a change, Massachusetts physician Richard Goldman figured he had two choices: he could get out of medicine altogether or he could do something truly radical. He could fundamentally change the way he practiced.

One thing he couldn't do -- wouldn't do -- was go on as he had. In his mid-40s at the time, Goldman couldn't imagine spending the next 20 years or so as unhappy and worn out as he'd spent the last 10. Yet having already tried working as a traditional solo doctor, in a group practice, and on staff at a hospital, he'd run out of ways to rearrange the deck chairs on the Titanic of his career.

"I just could not do it anymore," he says about his state of mind two years ago. "I'd been through all the different formats. And I hated it. I absolutely hated it. I was seeing 35 patients a day and was lucky to spend five minutes with any of them."

It was a choice between his head and his heart. A corporate job would have been the safer bet. He could have made a nice living, and no longer would he be zooming through patient encounters so he'd have enough time for paperwork. But he became a doctor to treat patients, and he was determined not to give it up without a fight. 

Promise and peril

For a primary-care physician, concierge medicine -- in which patients pay an annual membership fee in addition to paying for services through insurance or their own funds -- is alluring, no doubt about it. Imagine having just a few hundred patients instead of a few thousand. Of being guaranteed a baseline income. Of not having to fight with insurance companies -- at least, not as much as before, and not for the right to make a living. Perhaps best of all: being able to spend time with patients. To talk to them -- really talk to them. Listen to them. Get to know them. That's how medicine is supposed to be practiced, isn't it?

But concierge medicine is not a panacea, and physicians considering it should think carefully before proceeding, according to both Goldman and Allison McCarthy, managing consultant at Corporate Health Group in West Dennis, Mass., who helped Goldman set up his concierge practice.

The hardest part is finding enough patients who can afford, and are willing to pay, the thousands of dollars in annual membership fees that most require. As a percentage of the population at large, such patients are rare. Goldman's Access MD in Wellesley, Mass., charges $2,000 for an individual membership (or as little as $1,000 for patients under 30), $3,500 for a couple, and $4,000 for a family. Two years after launching the practice, Goldman has about 220 patients; about 100 came over from his old practice. He's still below the minimum of 250 to 275 he figures he needs to be profitable, but at the rate he's going he'll reach his minimum by the end of this year or early next year, well in advance of his four-year target. By 2007 he'll have reached his self-imposed 400-patient cap.

Still, it has not been easy. Like most physicians, Goldman is not by nature a self-promoter, so the marketing aspect of concierge practice - which is indispensable -- has been difficult.

"That's been the biggest challenge since we started -- the marketing. There's nothing that's clearly the way to go," Goldman says. "We've tried lots of different things. Word-of-mouth is the best marketing, but it's a struggle until you really get that going."

A different patient dynamic

And when each patient matters so much to a practice's survival, a physician must often rethink his attitude about customer service.
"This is not the way you practiced medicine before," explains McCarthy. Of course, that's the point, but not every physician is cut out for all the changes that come with a concierge practice, she says: "In this model, you have to exceed their every expectation. It's not 10 minutes, write a prescription, and they're out the door."

A successful concierge practice is a total customer-service-driven enterprise. Patients have access to you 24 hours a day, seven days a week (except perhaps for vacations and holidays, and even then concierge physicians need to make accommodations), in person, on the phone, and via e-mail. You might very well spend an hour or longer discussing any medical issue under the sun, from the latest in prostate research to a pharmaceutical commercial. 

In other words, the difference between concierge medicine and traditional practice is like the difference between a fine steakhouse and fast food -- at least from a customer service standpoint. So if you feel like you've been flipping burgers your whole career, you'll need to think about how well you'll adjust to a new kind of physician-patient relationship -- one in which the power dynamic has shifted.

You're still the doctor, but your patients are, in many cases, influential executives, well-to-do professionals, and their families. They're accustomed to being treated with a certain level of respect, even deference, and they're not used to being spoken down to. You are also, in a sense, the patient's employee, and some of them might treat you like one.

Moreover, patients who chose concierge programs are different from the typical patient -- many are older and often have various chronic illnesses. Some are younger and relatively healthy, but might be described as either strongly engaged in their healthcare, or the "worried well," depending on your point of view. It can be a tough crowd. 

Goldman, though, says that has not been his experience. "Lifestyle-wise, it's fabulous," he raves. "It's really not an imposition. I've had people say to me, 'Oh God, they must drive you crazy,' but they don't. They're respectful of your time. They really do hate to bother you. The calls are miniscule, and when they do come, the calls are legit."

In his previous practice, many of Goldman's so-called patients were people he'd never met; they had just written his name on an insurance form. Perhaps Goldman feels less imposed-upon because he knows each one of his patients now. They have accepted his invitation to be part of a different kind of healthcare model, and so he feels bonded to them in a way he couldn't have before. They're in something together.

"I can spend 90 minutes with a 38-year-old talking about lifestyle issues, dietary habits, exercise, and preventive medicine," he says. He loves that, but "the regular healthcare system would never pay for it."

Careful planning a must

If you're thinking seriously of launching a concierge practice, McCarthy suggests you prepare a detailed business plan first. (See page 69 for more information on how.) Among the questions you'll have to answer: How many patients will I need to be profitable? How long will it take to get that many? Will any of my current patients follow me into my concierge practice? How many? How much of a membership fee will I charge?

To answer those questions, you'll need to conduct a careful analysis of both your practice's finances and the demographics of your patients and community. Goldman realized a concierge practice wouldn't succeed in the blue-collar neighborhood where he'd been practicing, so he opened his office in a well-heeled Boston suburb.

There are other considerations, too, like whether you need as many staff as you have, and whether the staff you keep will be able to transition to the kind of customer service-oriented practice you're planning to run. And, assuming you'll continue to accept insurance, you must scrutinize each of your contracts carefully because some of them forbid physicians in their plans to charge patients fees beyond what's spelled out.

How will you inform your existing patients of the switch? Are you prepared for the inevitable complaints, the allegations of elitism?
More significantly, are you prepared for the likely drop in your practice's revenue, at least in the early going? Remember, Goldman expected to lose money for as long as four years.

What about costs? Overhead could be significant if you're leaving a group practice and opening a new facility. Many concierge physicians remain affiliated with their old groups, continuing to share space and back-office staff, for instance, while setting up a separate area just for their patients and receptionist.

"We just haven't been doing this long enough to really know how much demand there is for these services," says McCarthy, referring to concierge medicine generally.

While the demand among patients may be a mystery, the desire among physicians appears to be strong. And physicians like Goldman aren't afraid to try to grab for the golden ring - a living wage and a true physician-patient relationship.

This article originally appeared in the September 2004 issue of Physicians Practice.