When he worked for a multi-specialty practice, Jonathan M. Greer, MD, FACR, FACP, president, Arthritis and Rheumatology Associates of Palm Beach, and affiliate clinical professor of medicine, Nova Southeastern University, Boynton Beach, Fla., found that there were too many restrictions and controls and no way to enhance the revenue stream for rheumatologists. So he moved on to a private rheumatology practice in 1997.
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Explore This IssueJune 2017
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When Elizabeth L. Perkins, MD, rheumatologist, Rheumatology Care Center, Birmingham, Ala., was interviewing for positions in 2009, she learned about a strong area need for additional rheumatologists. “The medical community, rheumatology colleagues in town and referring doctors supported my start up and growth,” she says. “I was excited to develop and brand a rheumatology practice.”
Working in a private practice allows you to control your own destiny. It’s perfect for entrepreneurial rheumatologists.
Having the ability to develop ancillary services that would give his patients better access to care was important to Robert L. DiGiovanni, DO, FACOI, FACR, Suncoast Internal Medicine Consultants, Largo, Fla., who became the eighth member and first rheumatologist of the small multi-specialty internal medicine group in 1987. “For us, that meant investing in plain radiography in 1988 and later upgrading to digital radiography,” he says.
“In 1993, we added dual-energy X-ray absorptiometry, and we have upgraded our instrument twice since then. We established a CLIA-certified laboratory on the premises and added low-field magnetic resonance imaging and two ultrasound units. We built an infusion center, which has allowed us to participate in Phase 3 studies.”
Dr. Greer finds that physicians in private practice can maintain their independence and integrity and, therefore, best serve their patients. This means they can order tests as they deem necessary, prescribe treatments as they see fit, decide which insurance plans to accept and collectively bargain with insurance companies. “We are able to control our own destiny,” he maintains.
Being in private practice also fosters entrepreneurship. “We can decide which revenue streams we want to incorporate, such as offering digital X-rays, having an infusion center and participating in clinical research trials,” Dr. Greer says.
Although the perks of owning your own practice are apparent, anyone who contemplates opening their own practice should consider the disadvantages, too.
For Dr. Greer, handling payments has spawned many headaches. “Private practices have much more administrative work (than hospital-owned practices),” he says. “We have to deal with every single contract with every single payer, as well as the daily operations of prior authorizations. We have to be advocates for our patients.”
Taking on risk, both individually and collectively, is necessary. “We have to ensure that the products and services we supply are reimbursed at appropriate rates that allow us to continue practicing,” Dr. Greer says. “For example, at our infusion center we have to make sure prior authorizations are complete and that copays, deductibles and co-insurances are met. If we don’t collect on just one infused product, we would have to see several hundred patients to break even.”
Given the challenges, Dr. Greer says it’s becoming increasing difficult to own your own practice, especially if you’re the lone practitioner. In fact, a 2015 report by Accenture suggested that only one in three doctors (33%) would remain in private practice by the end of 2016.1 By comparison, in 2000, 57% of doctors were independent.
Dr. Perkins says, “Reimbursement has not kept up with the times. Therefore, all of the joys of building a profitable business have been offset [by] concerns in how to cover rising expenses and stay viable in the marketplace. With the introduction of new healthcare benchmarks for quality and cost, owners will have to reinvent themselves in new payment models.”
Dr. DiGiovanni, who is also the program director of the rheumatology fellowship at Largo Medical Center at Nova Southeastern University College of Osteopathic Medicine, Largo, Fla., has found that you can never leave your work at the office.
Coping with Challenges
To handle challenges related to payments, administration at Dr. Greer’s practice monitors contracts and tracks monthly and quarterly reimbursement. “We look at every single profit and loss statement at every line, and make sure no discrepancies exist,” he says. “When one occurs, we find out why and make corrections. We constantly renegotiate contracts with various vendors to obtain the best rates possible. This includes insurers, pharmaceutical companies and even our landlords, if we are leasing property, or our utility companies.”
Dr. DiGiovanni has also found that expenses bring challenges. “If you don’t belong to a large group practice, you can’t spread out the costs of expensive equipment or submit a requisition for something,” he says. “You have to buy it yourself.”
Additionally, as healthcare enters an age of quality- and value-based reimbursement, clinicians will have to surround themselves with staff who have expertise in this area. “You need an office manager with a great deal of skill whom you can trust,” he says.
Another challenge is maintaining and keeping up with changing rules and regulations within the field and healthcare system.
Karen S. Kolba, MD, a rheumatologist at the Pacific Arthritis Center, Santa Maria, Calif., says her biggest challenge is having too much to do—including seeing patients, supervising employees, setting policy, managing a small business, staying current with rheumatology science and taking an active role in ACR leadership. “You need an office manager and nursing staff who can implement your ideas,” she says. With her busy schedule, it is sometimes difficult to attend educational and management seminars, but online offerings have made that easier. At one point, she employed a physician associate for nine months, but given their different goals, she decided it was easier to remain the lone practitioner.
Dr. Perkins foresees her next big challenge as maintaining her practice’s branded excellence in a new system that will coordinate with larger groups (e.g., accountable care organizations and patient homes) while demonstrating its excellence as a high-quality, low-cost practice.
For Dr. DiGiovanni, the greatest reward of having his own practice is the satisfaction of designing his concept of a medical care delivery system for his patients. “A private practice rheumatologist becomes a true advocate for his patients and a problem solver for referring physicians,” he says. A private practice rheumatologist can still teach medical students, residents and even fellows. The opportunity for pharmaceutical studies is also available.
Dr. Greer has forged close relationships with partners and views them as extended family. “We can all practice rheumatology as we desire to individually,” he says. By being at the same practice for more almost 20 years, he has gotten to know his patients well and forged good relationships with them.
Dr. Kolba loves being queen. “I get to decide my office’s decor, how patients are greeted on the phone and in person, how forms, paperwork and collections are handled, and how much time I spend with patients,” she says. “I take vacations and leave the office early when I want to.”
Dr. Kolba also finds joy in bringing her two dogs to the office. “They greet patients in the lobby, follow the ones they like into exam rooms, hop onto laps when invited and seem to know who needs a gentle nudge or hug when they are sad or hurting,” she says. “My staff and I take turns walking them outside, which is a great break. I’m pretty sure the dogs earn their kibble daily by standing between me and burnout.”
Karen Appold is a medical writer in Pennsylvania.
- Accenture. Many U.S. doctors will leave private practice for hospital employment, Accenture reports. Press release. 2015 Jul 29.
Editor’s note: For another perspective, see “Rheumatologists Weigh Pros, Cons of Working in Academia.”
Want to Open Your Own Practice? Read This First
Thinking of going solo? If so, you may want to think again, says Karen S. Kolba, MD, rheumatologist, Pacific Arthritis Center, Santa Maria, Calif. “In today’s payment environment, it would be very difficult to start your own practice, especially a solo one,” she says. “The economies of scale are just not there.”
Dr. Kolba explains how expenses can pile up. She introduced an electronic medical record system in 2000, and now has 17 computers. “The acquisition was gradual, but my staff and I could not function with less,” she says. Since then, she has traded a minimum-wage medical record clerk for a $150-per-hour computer tech. She contracts with a local company for these services, as well other companies for billing, collections, cleaning, maintenance, hazardous waste disposal, shredding, off-site storage and a security system.
Presently, Dr. Kolba has an in-office infusion center for her patients’ use only. “But with new Medicare price changes, this may not remain viable,” she says. “I used to have dual-energy X-ray absorptiometry, but when payments dropped, I had to pay to have the machine carted away.”
The bottom line, Dr. Kolba says, is if you start a new practice—either solo or a small group—you will need significant financing to cover your own income for the first couple of years, even with a full schedule. “You must have the right people working for you and pay them well,” she says. “Good help is hard to find.”
Jonathan M. Greer, MD, FACR, FACP, president, Arthritis and Rheumatology Associates of Palm Beach, and affiliate clinical professor of medicine, Nova Southeastern University, Boynton Beach, Fla., would also frown on starting a practice on your own. “Instead, start a practice with others or join an existing practice,” he suggests.
Further, he advises that you know your tolerance for risk. “If Medicare changes MACRA reimbursement or reimbursement for our infusion services is cut, it could greatly impact us,” he says. “We are all worried about this; nothing stays the same in this business. In recent years, we’ve had multiple stressors to deal with, including changing to Meaningful Use for electronic health records, making changes to meet HIPAA compliance and adapting from ICD-9 to ICD-10 codes.”
Robert L. DiGiovanni, DO, FACOI, FACR, program director, Rheumatology Fellowship, Largo Medical Center, Nova Southeastern University College of Osteopathic Medicine, a rheumatologist at Suncoast Internal Medicine Consultants in Largo, Fla., says opening a rheumatology practice is not for the squeamish. “If you choose this path, surround yourself with excellent staff,” he advises. “Stay abreast of medical education to keep you on your toes. As your practice develops, don’t hesitate to bring on young physicians who have new ideas and techniques.”
Elizabeth L. Perkins, MD, rheumatologist, Rheumatology Care Center, Birmingham, Ala., would advise any new business owner to have their eyes wide open about the future of healthcare and be prepared to embrace change. “You’ll have to coordinate with other health partners, such as payers, government, industry, accountable care organizations, management service organizations and health systems to find solutions,” she says.
Dr. Perkins also recommends disciplining yourself to run a lean business and hiring and training people who will guard it as their own while you see patients.
Starting a practice is a big leap, but it is feasible in a series of smaller, successful steps. “My favorite advice about larger, difficult projects came from my dad: ‘The best way to eat an elephant is one bite at a time,’” Dr. Perkins concludes.