Written by: Jennifer Gruen MD
In today’s medical practice environment, many will argue that the bigger the practice the better. Better to pool resources, share call responsibilities, disperse the ever-increasing costs of technology and office staffing.
But what if you like small? What if you went into medicine dreaming of knowing all your patients by name, being a part of their lives beyond the few minutes of their yearly physical, having time to chat about those Yankees instead of rushing off to the next, and the next, room…
My business partner and I were those dreamers. We had each spent years at large pediatric practices- well run for sure, but not professionally satisfying for our personal needs. We met working as associates for a small “country doc”, who operated a low volume pediatric practice in the suburbs of Connecticut, making ends meet by working out of a home office, and pretty much operating in the red until the day he retired. Clearly not a business model we wanted to adopt.
Add the fact that we both wanted to work “part-time” (we each put in 3 office days a week- many more hours at night on the business, but at least we have daytime hours to spend on household needs and kids.)
We spent a long time debating how to set up our own practice, reading SOAPM posts religiously for any helpful hints. We debated becoming a concierge practice, fee-for-service/no-insurance or hybrid concierge model. What we settled on was a pleasing mix that has sustained a growing practice in the 2 ½ years we have been open.
We settled on a few basic ideas- first, we would limit insurance to a few select plans that paid appropriately for our services. Given our history with a variety of insurance companies, Oxford/United was never considered. We would rather see one better paying plan X patient for a relaxed visit, than jam in two patients with plans that paid half of X’s rate. Many of our patients on Oxford/United still elect to see us out of network for our service. Second, we agreed that we would accept a small number of managed medicaid patients- we had a dedicated group of wonderful patients with this plan, and we were willing to sacrifice some income to continue serving these families.
We started out as a 2 person partnership, with a goal of adding a third, but no more than that. This rubbed my business minded husband the wrong way- why not expand if you are growing and successful? For a few simple reasons- we never wanted to be so large that we couldn’t each know the majority of our families by name. We had also agreed not to use an after-hours telephone triage service, and that meant limiting patient number to limit phone calls to a reasonable amount. Three docs meant every third weekend on call- not so onerous if our small practice generated only a few weekend visits sandwiched between our kids’ soccer games and birthday parties. The stress of seeing 40-60 patients on a Saturday in my previous practice would ruin those weekends for me, even if I was on-call fewer weekends out of the year.
Most importantly, we decided early on to charge a mandatory “added benefits” fee- a modest per child charge to cover the many and varied uncovered costs of practicing medicine. This was a lesser voluntary fee initially- promoted to the patients as a way of prepaying for multiple school and camp forms, and helping subsidize our somewhat unique (for the area) practice of not using after-hours nurse triage. After a year, it became clear that we were providing these services for all patients though only a minority opted to prepay. Also, by now these patients were well-acqainted with our quality of service, and word was beginning to spread. We decided to limit our practice numbers, typically seeing 20-25 patients at most during an average day. To make this financially feasible, we instituted our mandatory benefits fee, careful to be clear that it was for “uncovered fees” such as ACCESS to the physicians after hours (not the phone calls themselves, which we could rarely charge for anyway as those were usually related to a past visit, or resulted in a visit the next day.) Also included are unlimited camp/school forms.
But underlying this charge was the emphasis on it allowing patients to experience convenient, personalized and unhurried medicine- something commercial insurance plans would never be able to cover. Note that we live in an upscale area of Connecticut, making this fee affordable to most. Our patients, in fact, draw from across the economic spectrum. Very few objected to the fee, even fewer left the practice because of it. Several have returned. Patients new to the practice accept the fee generally without question, often knowing what they will receive is priceless- that extra few minutes in the room with a physician, and many fewer minutes out in the waiting room with a sick child. Time is money to many.
We waive the fee for parents with significant financial difficulties. Because we tend to know our families well, we know when a parent has lost a job or is ill, placing financial strain on the family.
So is smaller better? No, just different. And better for me and my preferences. Better seeing those 60 weekend patients spread out over 10 weekends instead of just one, making weekend call a quick trip to the office between gymnastics drop off and grocery shopping, an evening on call a message or two between dinner and homework help instead of in my office on the phone continuously between 6 and 12 pm while my husband handles the kids on his own. And by charging the added benefits fee, I feel better knowing I am in some way compensated more appropriately for all the little extras I do for my patients day in and day out (and nights too….)
Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.