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Medscape Business of Medicine, “A Small Practice’s Fight to Stay Independent: Can It Work?”

In a May 2014 Medscape interview, Concierge Medicine Today and the Direct Primary Care Journal, said that there were nearly 4000 physicians “who are verifiably, actively practicing concierge medicine or direct primary care across the United States, with probably another 8000 practicing under the radar.”)

By Neil Versel, MedScape

A Valiant Fight for Independence

OCTOBER 17, 2014 – A six-physician primary care practice in Chicago would rather fight than join.

Subscribe-to-our-NewsletterPrimary Care Medical Associates (PCMA), serving the city’s North Side, decided to buck the trend toward consolidation of medical groups and the urge to sell to a large health system. Their strategy is gutsy, and it entailed some trial and error — but it has been working out for them and could possibly work for you too.

“We were really losing business to urgent care and walk-in clinics,” says internist and PCMA founder Robert G. Perlmuter, MD. “We would rarely see people with a cold or a rash or an acute ankle sprain.”

Four years ago, in response to the proliferation of convenience clinics at retail pharmacies and urgent care centers, the practice switched the early part of the workday to walk-in service five days a week. On weekdays from 8:00 to 8:45 AM, established patients can come in without an appointment for treatment of specific acute conditions, such as cold and flu symptoms, rashes, urinary tract infections, and sprained ankles. Appointments start at 9 AM Monday-Saturday.

PCMA started the walk-in program with a physician assistant, who then left shortly thereafter. Still, the practice kept the early-morning window free of appointments, despite reservations from some of the physicians.

“A lot of my doctors don’t really like doing walk-ins,” according to Perlmuter, who says they worry about getting a late start with patients scheduled for the 9-AM hour if walk-in business is heavy.

“The younger doctors like it. I like it.” Perlmuter himself had training in urgent care at a walk-in clinic during his residency at Northwestern University Feinberg School of Medicine.

Getting More Patients to Come

But the practice knew that you can’t rely on “build it, and they will come.” During winter 2013, when traffic was lagging during the first hour of the workday, the practice sent out a mailing to all of its established patients touting the walk-in hours, hoping to reinforce the value of having a regular primary care physician. Business for minor, emergent issues picked up almost immediately. On Mondays and days after holidays, the practice gets about eight walk-ins in that 45-minute period, Perlmuter reports. Other days, it varies between two and five patients.

start_up_hub_pan1Perlmuter says the practice may expand walk-in hours soon, though it will continue to limit this service to patients with whom the physicians already have a relationship. He says feedback has been “excellent” from walk-in patients, many of whom express a preference for seeing their own doctors to being treated by a nurse practitioner at a convenience clinic. However, Perlmuter is unsure whether the walk-in service has added much revenue.

What PCMA is doing apparently is not common among small, independent primary care practices. The Convenient Care Association (CCA), a Philadelphia-based trade group for retail clinics, says that there are more than 1800 retail convenience clinics nationwide, and that does not even count stand-alone urgent care centers.

“We are seeing more and more health systems partnerships and collaborations with physician practices,” CCA Executive Director Tine Hansen-Turton says. About 40% of patients seen at convenience clinics do not have a “medical home” or regular primary care physician, according to Hansen-Turton. “We are strong referral partners for physician practices who want to build their practices but also have an off-hours retail clinic partner.”

PCMA does not have a partnership with any walk-in retail clinic. “I have not heard of many practices doing their own walk-ins, except community health centers,” Hansen-Turton says.

For its part, the Urgent Care Association of America, based in Naperville, Illinois, reports that there are about 9000 facilities in the United States that provide urgent care. About 35% are owned by physicians or physician groups. Nearly one half focus on family medicine, and 94% have at least one full-time employed physician.

The organization does not have any data on how many small, independent practices have added walk-in hours as an alternative to opening a full-scale urgent care clinic. However, three quarters of the nation’s urgent care centers are located in suburban areas; just 15% are in big cities.

A Bold Tactic to Remain Independent

In another move intended to offer better customer service and more personalized care, Perlmuter added a concierge option in November 2012. About 70 people now pay $1800 annually ($150 a month) for immediate access to Perlmuter by cell phone or in the office during business hours, as well as an annual physical examination. (Additional visits are billed to insurance like any other patient encounter.)

Concierge members get a minimum of 30 minutes with the doctor. “It’s what you want to do for everybody if you had the time,” Perlmuter says.

Indeed, patients do respond to convenience and quick access. The Medical Group Management Association reported last year that “better-performing” physician practices on average see 10% of their patients during same-day appointments or as walk-ins — twice as many as those not considered better performers.

Having the concierge option has benefited the practice — even though Perlmuter is the only one of the six physicians participating and the service has been revenue-neutral for Primary Care Medical Associates, because the concierge visits take extra time when he could be seeing a higher volume of patients.

“It establishes loyalty among our own patients,” he says. The up-front fee also eliminates the administrative hassle of billing insurance for routine visits and assures that the practice won’t have to chase small receivables once the patient walks out the door.

Perlmuter is the only one of the six physicians offering concierge care, because all five others are mothers of young children. “They do not want to be available 24 hours per day, every day, like I am,” Perlmuter says. The other physicians have expressed an interest in concierge service when their children are older, he adds.

“It’s really convenient [offering medical advice to patients] on the cell phone,” Perlmuter says, adding that people are not abusing the privilege of having his personal number. “The concierge patients for the most part are very respectful.”

“It’s notable that growth in the DPC industry according to physician interviews across the U.S. throughout the past 18-month is largely supported by consumers motivated by price and transparency,” said Michael Tetreault, Editor-In-Chief of The DPC Journal. “Looking ahead, we’ve learned from investors analyzing this industry that DPC growth will primarily occur in metropolitan markets such as Dallas/Fort Worth, TX, Boston, MA, The Carolina’s and others. Individual physicians, however, in rural markets are also predicted to make more moves into this space over the next several years.”   Editor-In-Chief, Michael Tetreault | The DPC Journal, ConciergeMedicineToday.com

“It’s notable that growth in the DPC industry according to physician interviews across the U.S. throughout the past 18-month is largely supported by consumers motivated by price and transparency,” said Michael Tetreault, Editor-In-Chief of The DPC Journal. “Looking ahead, we’ve learned from investors analyzing this industry that DPC growth will primarily occur in metropolitan markets such as Dallas/Fort Worth, TX, Boston, MA, The Carolina’s and others. Individual physicians, however, in rural markets are also predicted to make more moves into this space over the next several years.”
Editor-In-Chief, Michael Tetreault | The DPC Journal, ConciergeMedicineToday.com

Perlmuter estimates that he receives about one call and three texts per week on his cell phone from his concierge patients, so they clearly are not abusing the privilege, and most are for questions that don’t entail a visit to the office.

In a May 2014 Medscape interview, Michael Tetreault, Editor-in-Chief of Concierge Medicine Today and the Direct Primary Care Journal, said that there were nearly 4000 physicians “who are verifiably, actively practicing concierge medicine or direct primary care across the United States, with probably another 8000 practicing under the radar.”)

PCMA, which Perlmuter started in 1988, has long been trying to innovate and stay on top of changes in the business of medicine. “We haven’t had pagers in years,” says Perlmuter.

Where Do EHRs Fit In?

The practice bought its first electronic health record (EHR) system in 1998 and achieved stage 1 meaningful use in 2011, the first year of the federal EHR incentive program — something few small primary care practices did. “It reduces time spent looking for charts, labs, x-ray reports, and other data,” Perlmuter says.

As PCMA, like so many other practices, struggles to meet stage 2 standards this year, Perlmuter says he is considering bringing in scribes to help physicians document patient encounters in the EHR. “I’m beginning to think that data entry is not the purview of the doctor.” (Through the end of June, a very small number of individual physicians nationwide had attested to stage 2, according to the Centers for Medicare & Medicaid Services, compared with more than 235,000 who had achieved stage 1.)

Stage 2, which started this year for those who reached stage 1 in 2011, requires that physicians offer at least one half their patient population access to their individual medical records through a secure, online portal. Plus, a minimum of 5% of patients must actually use a portal to download their records or securely communicate with their physicians — a difficult prospect known as “patient engagement.” For its part, PCMA has offered a portal since 2010.

The practice also has joined a Medicare accountable care organization (ACO) led by Presence Health, a 12-hospital, Chicago-based Catholic health system. “It’s complicated out there,” says Perlmuter, who is Section Chief of Internal Medicine at nearby Presence St. Joseph Hospital.

“I think that it helps to have this hybrid model to stay independent,” Perlmuter says. “It seems like everybody is trying to take our business.”

For physician practices similarly fighting to remain independent, Perlmuter recommends considering many different options. “Keep overhead low, maximally utilize space, make sure all the doctors are working to capacity, join an ACO, have early-morning and evening hours, utilize hospitalists, hire a nurse practitioner or physician assistant, have a medical assistant answer most of your telephone calls, and consider a hybrid concierge program,” he says.

Perlmuter also says it may be beneficial to be on staff at more than one hospital and to participate in quality initiatives that emphasize preventive care and health outcomes rather than simply patient volume.

Although there are no guarantees of success, for physicians who have a strong desire to remain independent, it can be well worth the effort.

SOURCE: http://www.medscape.com/features/content/6006315#vp_1

2 replies »

  1. This article is encouraging in that in validates what I have often talked about when it comes to the need primary care doctors doing a better job of being accessible to THEIR patients; if they don’t someone else will fill the need. Patients definitely like the convenience of Retail clinics and Urgent care, thus their success and subsequent growth. However, when given a choice, patients would much rather see their own doctor when acute issues or questions come up.

    Private practice primary care, especially DPC, is in a unique position to be able to offer more accessible, immediate care. The employed doctors in healthcare systems and those still using the claims-based revenue cycle will find it hard to make this transition quick enough to meet demand. If we do this right, the need for retail clinics and UC will diminish.

    Frankly, the existence of physician directed primary care depends on it. Good primary care has to include immediate care.

  2. Reblogged this on THE SOVEREIGN PATIENT and commented:
    This article is encouraging in that in validates what I have often talked about when it comes to the need primary care doctors doing a better job of being accessible to THEIR patients; if they don’t someone else will fill the need. Patients definitely like the convenience of Retail clinics and Urgent care, thus their success and subsequent growth. However, when given a choice, patients would much rather see their own doctor when acute issues or questions come up.

    Private practice primary care, especially DPC, is in a unique position to be able to offer more accessible, immediate care. The employed doctors in healthcare systems and those still using the claims-based revenue cycle will find it hard to make this transition quick enough to meet demand. If we do this right, the need for retail clinics and UC will diminish.

    Frankly, the existence of physician directed primary care depends on it. Good primary care has to include immediate care.

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