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Solo Private Practice

Sylvia M. Ramos, MD, MS, FACS

Why Do It?

I have been in academic practice, group practice and solo practice over the space of my twenty-two years post surgery residency. In each of those settings I have found benefits and drawbacks. It may be that each of those areas is appropriate for different stages in one’s life. A solo practice is a very rewarding arrangement for the person who enjoys making her own decisions about how to practice her specialty. It provides the freedom to plan, organize, tinker with and carry out a practice based on one’s personal beliefs without the need to accommodate someone else’s ideas which may, in some cases, be contrary to one’s own.

However, being in solo practice, is challenging especially these days mainly because of the health-care reimbursement process that exists now in most states. To be successful, the surgeon needs to be interested, excited and knowledgeable about managing the practice, including the financial aspects. This is so even when one has an office or business manager. One can expect in solo practice to spend at least 10 percent of one’s time in management functions. A degree in management is not essential, although in my case, having a Master’s Degree in Health Services Management proved very useful.

Planning and Preparation

Once the surgeon has decided to go into a solo private practice, it’s important to decide in what state the practice will be located so that she can gear the planning to the requirements of the various institutions in that state.

There are several steps to be taken before embarking on a practice. Initially, reading some of the books that are available that deal with setting up and running a practice is essential. Obviously, speaking with people who are already in practice, especially those who are in solo practice, is a must. These are people whom one may already know because they practice in one’s hospital and who, in most cases, will be happy to speak about their practice. In my case, I also used the services of a consultant whose practice management column I had read for several years in one of the throwaway journals. A business plan must be written and presented to the bank if one seeks help with financing the practice at the beginning. It’s important to remember that when in solo practice, the surgeon is the only income generator unless she hires a physician extender for whose services she can bill. Therefore, the business plan must allow for times when the surgeon is out of the office on vacation or at continuing medical education conferences. The services of a lawyer and an accountant to help set up the Corporation and establish the chart of accounts for keeping track of expenses is very helpful and will be looked upon favorably by the bank from which you are requesting funds. Applying for malpractice insurance and for hospital privileges also comes into this planning stage, as both must be in place before the practice doors open. These can be lengthy processes and the earlier one starts the better. Most hospitals these days require that applicants to the medical staff be board eligible or board certified in their specialty. Aside from malpractice insurance, there are various other types of insurance that will be needed before the start of the practice. Among these are business insurance, umbrella liability insurance, and overhead insurance in case of disability. The decision whether to buy or lease an office and the location of that office requires quite a bit of thought. It really depends on what seems to be more feasible at the time and what seems consistent with the long-term goals of the practice.

The Practice

If one has decided to employ an office manager from the beginning of the practice, the person can be hired ahead and can conduct the interviewing and hiring process for the rest of the personnel. Otherwise it’s a task that one has to do. Policies and procedures manuals should be developed so that they can provide consistent guides when discussing the actual requirements and job descriptions with the applicants being considered. Additionally, these manuals provide the guidelines for the staff’s functions and behavior in the workplace and set up a system of checks and balances to avoid financial problems. By this point, one needs to have decided on what benefit package will be offered to the staff. Especially at the beginning, benefits may be quite limited and the staff to be hired will need to understand that. Schedules dealing with the surgeon’s time in the office seeing patients, in the office managing and doing paperwork, and out of the office in the operating room and at other practice related activities have to be developed carefully and followed quite strictly. Having a very predictable schedule will ensure that both the surgeon and the staff will be able to use time efficiently and productively without feeling that the practice is unmanageable. Staff must have a clear understanding of what is expected in terms of their behavior towards and management of patients during phone calls and office visits.

Equipping an office will involve buying furniture, office equipment such as computers, copiers and fax machines, medical supplies and medical equipment such as surgical tools, examining tables, and ultrasound machines. Again, this can be done by the surgeon or, if the office manager has a lot of experience, it can be delegated to that person but with supervision.

Coding of procedures and disease processes is probably the second most important function in the office, second only to the surgeon seeing the patients. The financial health of the practice depends on accurate coding, billing and collections procedures. Coding should be done by the physician. The billing and collections can be done either in house or contracted to outside companies. It is imperative to make sure that whoever is doing the billing and collections has a thorough knowledge of the proper procedures and can insure that those functions will go on even when they are out of the office.

One of the more difficult but vital areas is negotiating with insurance companies in order to provide care to their patients. This only should be done with the advice of a lawyer who specializes in contracts. The medical societies have lawyers who can assist with this process. An accountant who understands medical services reimbursement and who can help one decide what level of reimbursement the practice will need to flourish is also important.

A trend that is becoming more and more important is the proliferation of rules and regulations that impact the provision of healthcare services in areas such as confidentiality, careful record keeping and documentation, and accurate coding and billing practices. Even if the office manager understands those well and keeps up with new ones, it’s still imperative for the surgeon to acquire that knowledge also. Remember, the buck stops with the person in charge!

Growing the Practice

Marketing a practice can be a lot of fun but also must be done in a very structured and diligent manner. Announcements in the press as well as mailings to the members of the local and state medical societies about the opening of the practice and practice services are essential. An open house for local physicians inviting them to come to the office to meet the surgeon and the staff can be a good way to have potential referring physicians see how the practice is envisioned. Both the surgeon and the staff will be on show. Seeking out the person in charge of the hospitals’ continuing education lectures and volunteering to present talks on medical topics to the local medical and surgical groups as well as to lay persons is a good way to get known in the community. Volunteering on hospital committees, especially those that have a variety of specialists represented, is very useful. Getting to know the other surgeons on staff will help both because they may provide coverage when the surgeon is off and also because they may refer some patients to her. This is a time when the surgeon will need to stretch herself even if she feels already too busy organizing the practice and, sometimes, even if she’d like to spend more time with her family. It’s essential to have all the family members committed to the success of the practice otherwise it will not work well and may fail. Later on, once the practice is well established, other activities may take precedence.

One thing I have tried to do during my years in private practice is to welcome any new physicians into the community, including those who may be my direct competitors.  Aside from the fact that it is the right thing to do, it helps to build their goodwill towards you and this can only help you in the long run. Those may be some of the surgeons with whom to share call. In addition, one of those new physicians may eventually become a partner if one decides to expand and share the practice.

Academic Life

If one is interested in pursuing research and teaching activities there is room in private practice to do that. It’s important to be affiliated with a medical school even as a volunteer on the clinical faculty. That affiliation helps to keep the surgeon abreast of new developments in the surgical community and can provide the opportunity for teaching both in the lecture hall and operating room.

These days, there are more and more opportunities to do office based research and to have it supported by many of the pharmaceutical and medical technology companies.  In my own case, coming from an academic background, I continued my interest in looking at the data on my patients. However, this was quite time-consuming and I was only able to publish one paper during my years in private practice, although I wrote several book reviews for JAMA. Additionally, I found it rewarding to present talks based on some of my findings. I still plan to look through the data on approximately 6000 patients with breast diseases to see what I can glean that may be interesting, unique or helpful to someone.

Physicians are committed to life long learning. Most of the time this involves attendance at continuing education seminars. One thing I enjoyed enormously as a surgeon already in practice was learning new techniques and procedures such as laparoscopic surgery and ultrasound guided biopsies. These classes can be costly but should be strongly considered even when finances are low. They will enhance the surgeon’s practice by adding new services for patients and by adding novelty, variety and fun to the surgeon’s repertoire.

Summary

I have tried to cover many of the major areas that need to be considered when going into a solo private practice. Several books and monographs  have been written on this so that I don’t feel I need to cover this topic exhaustively. The benefit of being a solo practitioner is that one is in complete control and can provide the kind of care that one wants to provide to patients in the setting that is the most comfortable for one’s needs. The drawbacks are that one is the only income generator, one may become isolated if not participating in the life of the medical community through committees, grand rounds and seminars, and one may become overwhelmed by the administrative responsibilities for the practice. Nevertheless, for the kind of person who likes to plan, develop, institute, troubleshoot and run her own show, a solo practice may be the only way.

References

1. Mart-Fox, Yvonne, How to manage the business called private practice, What they didn’t teach you in medical school, Yvonne Mart-Fox (Pub), 1994.

2. Mart-Fox, Yvonne and Levine, Brett. How to join, buy or merge a physician’s practice, Mosby-Year Book, Inc. (Pub), 1998.

3. American Medical Association, Medical Practice Series (10 books on topics including Starting a Medical Practice, Personnel Management and Managing a Medical Practice).

4. Mabry, Charles and Kron, Irving (eds), Practice management for the young surgeon, American College of Surgeons, 1995.

5. Cohn, Kenneth and Schwartz, Richard, Business Plan Writing for Physicians. American Journal of Surgery, 2002; 184:114-120