By Brian Blank
After a summer spent shadowing three primary care docs in three very different practice models, this medical student was pleased to learn that private primary care practice is still alive and well.
This probably sounds crazy, but I am keenly interested in one day owning my own private primary care practice. The problem is I don’t really know what style of practice I might like to run. This past summer, after my first year of medical school, I had the wonderful opportunity to shadow three different family medicine doctors working in three very different models: a successful solo practice, a recently-converted concierge practice, and a very successful cash-only practice. I did this through a program organized by the North Carolina Academy of Family Physicians and funded in part by Blue Cross and Blue Shield of North Carolina. I was able not only to learn about different primary care models, but I was also able to see that despite what I’ve heard, private primary care practice is alive and well.
The first thing that struck me about the solo practice doc was that, hey, it’s still possible to own a successful solo practice in America! Who knew? By “solo,” I mean a practice with one doctor; there are still nurses, office staff and an office manager. This bustling practice saw patients from nine to noon Monday through Friday and two to five three days a week. One of those “free” afternoons was dedicated to administrative work. Everybody in the practice seemed happy and functioned well as a team. I was surprised by one thing in particular: the office still uses paper records, not an electronic one, and that seemed much easier and more efficient than the offices I had previously seen with electronic medical records. The doctor wasn’t constantly tapping away at a computer screen, and he didn’t spend most of the visit with his back to the patient. One of the downsides to that paper model, though, is that everybody has to be very on top of filing claims. It seemed to me that a lot of brain space was necessarily dedicated to billing codes, and a copy of the latest codes was displayed prominently at the office.
The second doctor I spent time with had recently converted to a concierge style practice, which means he keeps his patient pool small at about 500 or so, compared to the 1,500 to 2,500 that some doctors manage. His patients pay $1,500 a year in exchange for anytime access, hour-long appointments and robust yearly physicals. His office still files insurance but with the smaller patient pool, that did not seem as onerous as in other offices I’ve visited. While concierge practices have gotten a lot of criticism for turning away patients and charging an annual fee that may be a burden to some, the alternative in this doctor’s case was to burnout and retire, thereby turning all of his patients away. Switching to a concierge model, by his count, lengthened his career by at least five years. He is able to focus on quality appointments instead of quantity. His patients seem to appreciate the time and attention, and it seemed to me that the model better suited him to deal with patients who had more complex medical problems - he simply had the time to deal with them!
The third practice I shadowed was perhaps the most eye-opening. It was a cash-only, no-insurance practice. The patients spanned the insurance gamut from Medicare to Blue Cross to no insurance. In fact, when the doctor started his practice about 10 years ago (intentionally not signing contracts with any insurance company or Medicare), he estimated the majority of his patients would be uninsured; it’s now about a 50-50 mix. It turns out many savvy people with insurance are able to get cheaper care at his clinic than elsewhere – even those who would normally file with Medicare. Visits are $59, or patients can buy an Access Card for around $200 per year, which cuts the visit fee to $20. So how does this model work – and thrive? Three ways, as far as I can tell:
The simple act of collecting payments upfront significantly increases overall revenue. The doctor estimates that the average practice, by the time all of the necessary paperwork is filed, only brings home about 70 cents for every dollar claimed. By collecting upfront, he brings home more than 99 cents for every dollar.
Keeping overhead insanely low. This doctor does his own blood draws. He takes out his own garbage. And he now owns the building he practices in so that rent doesn’t get passed on to his patients.
Because he, like his patients, pays in cash, he is able to negotiate rock-bottom prices from lab and imaging companies for his customers. Tests that might ordinarily get charged to insurance for $100 only cost this doctor $2-$4. He is able to pass those savings directly to his customers.
And this doctor is able to do that while maintaining a full (average-sized) patient panel and giving folks hour-long appointments. Is this the holy grail of practice models? Seems like it to me.
Maybe it still sounds crazy, but I have been greatly encouraged by what I saw this summer. I have certainly glossed over a lot of important details about each practice model here, but I hope this highlights some of the unconventional – and maybe even counter-intuitive – strategies at play in primary care practices that are somehow still making it work.
Brian Blank is a second-year medical student at UNC-Chapel Hill. Before going to medical school, he was director of communications at Primary Care Progress.