Making the Move into Private Practice
According to the American Academy of Neurology, the percentage of US AAN member neurologists in solo practice dropped from 23 percent in 2008 to 13 percent in 2018. Reasons for the decline are not surprising: everything from the complexity of billing to the increased costs of insurance to the rise of hospitals as employers has played a part in the career decisions made by individual doctors.
And yet, even with the evident decline in numbers, this glass is definitely half full. While fewer doctors are working on their own, another way of saying it is that nearly half of all doctors do, indeed, work in a practice where they have part or full ownership. This is a story that Jamie T. Krantz, MD, thinks residents and fellows may not be seeing fully. Currently practicing as a neurologist for The Health Center in Plainfield, Vermont, Krantz ran her own practice for 16 years, from 1994 to 2010. When she finished her training in the mid-1990s, she says, things felt different. “At that time, it was a mix in terms of what people were planning to do,” she says. “But today, it feels like everyone is focused on getting a job.”
Krantz believes that might be partly because those in training now may not be exposed to private practice. “I think a lot of people in training, all they see are people who are employed in hospitals or universities. My father was in private practice in New York State, so that was my model. It wasn’t scary to me.”
Susan P. Anzalone, MD, may be the exception to the pattern Dr. Krantz is seeing. Her first job after completing training in 2015 was in a private practice based in Denver. For her, it was the launch pad she needed to go forward on a plan to start her own practice. Set to open in April 2019, Colorado MS Center, Inc., will serve MS patients on an outpatient, hybrid model. According to Anzalone, they will contract with Medicare but no other commercial insurers, accepting self-pay for those patients not eligible for Medicare. A separate infusion center will contract with all insurers. Both the practice itself and the model she has chosen reflect Dr. Anzalone’s response to the current state of health care delivery. As she explains, “I want to really take care of my patients and help them live the life they want to live. I don’t like the idea of being rewarded for seeing a high volume of patients. My job as a doctor in the healing profession is to help patients get better.” As part of that focus, Anzalone says her patient care model includes spending at least 75 minutes on new patient visits, while striving to be a partner with patients in their health care journeys.
More than one way to start a practice
Although Krantz and Anzalone share the experience of opening a practice, their startup stories are as different as the generations in which they occurred. When Krantz completed her training in 1994, she already knew she wanted to live and practice in a rural area. She was married at the time to a newly-minted gastroenterologist who felt the same way, and they began a campaign of cold-calling around central Vermont. Eventually, they turned up a small community hospital supported by a loose group of local physicians. The couple went through an interview process and Krantz’ husband was selected for a staff position while she was approved for a different role—self-employed neurologist with an income loan guarantee. In essence, she was given a guaranteed monthly paycheck and an upfront loan for equipment (she bought a second-hand EEG machine) in return for practicing in the community. During the period she was receiving the steady pay, she turned over her collected receipts. After about a year, she was able to survive on her own and the financial support was no longer needed.
For Anzalone, the process of starting a practice has been very different, in part because of the current health care environment, which is largely influenced by insurance companies and hospital systems. She believes her model of offering self-pay concierge MS care on an outpatient basis will make sense to patients disillusioned by the other reality they may be experiencing: high insurance deductibles that make their care de facto self-pay anyway, with service delivered in short appointments. Not all of Anzalone’s services are designed to be self-pay. Most notably, insurance payments are needed for treatments from the infusion center, which are too expensive for individuals to pay on their own. Anzalone expects this secondary source of income will help balance her accounts, especially during the initial years of startup.
Although she also is jumping in very soon after her training, just as Krantz did, Anzalone is doing so without the backing of a larger institution or group of physicians. Instead, she’s spent the past year interviewing other doctors in private practice while also reading books on practice management and building a team of accountants, lawyers, and other professionals she will need as advisors. Having started in medicine after earlier careers in IT and advertising is also giving her a boost, both in confidence and in skills she will need as she builds her business.
While Anzalone has been planning very carefully to succeed in her new practice, she’s quick to point out that she wouldn’t be taking the chance if she hadn’t already experienced private practice challenges while working as an employee. “There’s no way that I would have started my practice without working for another practice first,” she says. “I got to see first-hand how a private practice is run, from the inside out. We don’t get that training in medical school. All of our training is in hospitals, so I had to learn what I needed to know as an employee.”
Joining a private practice as an employee
Indeed, working for a private practice as an employee is a time-honored way of launching into self-employment—either as an eventual partner with the practice you’ve joined, or by stepping out on your own. It’s also a very good way to test the theory, to learn if you really want to work for yourself, once you see what that might entail. Even so, the entry to this career path may not be self-evident, as private practices don’t always advertise their openings very broadly. Nor do they consistently work with recruiters, so potential candidates may miss these opportunities altogether if they’re not self-directed in finding them.
For physicians interested in this pathway, a good strategy would be to combine two approaches for the job search: Set up a Job Alert to capture appropriate postings on the AAN Career Center website, but also identify places you’d like to work and contact the practice manager or a partner directly.
For Anzalone, the experience of working in a private practice was rewarding in itself, and not just as a way to learn more about running her practice. “It was my first job in medicine, and it was really exciting,” she recalls. “I felt very autonomous. I was getting the word out around town that I was new and taking MS patients—it was great.”
Transitioning out of private practice
Besides the sense of risk and the feeling of unfamiliarity, another reason some physicians might hesitate to work in a private practice is a concern that they can’t easily shift to another setting later. But that wasn’t Krantz’ experience. As she notes, she operated her practice smoothly for 16 years before a hectic lifestyle with teenagers convinced her that being an employee of the hospital where she was affiliated would help her work-life balance. She also wanted to balance the pay fluctuations she was beginning to see, and a steady paycheck looked like a good alternative. To make the change even more compelling, the hospital worked hard to provide incentives to bring her on board, naming her director of neurology and offering positions to her staff while also purchasing her equipment and putting her in a new building. “I think they really wanted to keep me happy, and they did,” she notes. “I felt supported and it was very collegial.”
What You’ll Need If You Go Out On Your Own
If you decide to run your own practice, you’ll need a plan and some resources. Depending on what you already have in place, it could take a few years to get everything organized, even while you continue working elsewhere. Here’s a short list of things Krantz and Anzalone mentioned as part of their preparations.
- Books, references, and online support groups. Two resources that Anzalone can recommend from her own research are Secrets of the Best Run Practices by Judy Capko and Management Rx by Laurie Morgan.
- Space. Both doctors note that a practice needn’t require very much space. You need enough room to create distinct areas for reception, patient care, and administration, so perhaps 800 to 1,500 square feet.
- Furnishings and equipment. Office and reception furniture are relatively inexpensive and easy to find, while specialized medical equipment will take more planning. Purchasing used equipment could turn out to be very cost-efficient.
- Staff or contractors. In addition to yourself, you’ll need at least two other people—a nurse or advanced practice professional, and a biller. Most practices would add a scheduler or administrative assistant to that list, although it’s possible to adapt technology for some of those tasks.
- Advisory or support team. Mentors, bankers, attorneys, accountants...there’s a world of professionals standing by to assist as you determine the parameters and structure of your dream practice. Not to mention website builders, insurance agents, and practice consultants. Eventually, it will matter who you put on your team but at the beginning it may be more important just to be talking to others while you shape your ideas.
Even so, Krantz’ run as an employee only lasted seven years. When the hospital was taken over by a larger entity, it didn’t take long for her to realize she didn’t want to practice with the new policies they were using. After talking with her contacts, and at the age of 58, she entered her second stage of private practice—which she calls “self-employment lite.” In her new role as the neurologist at The Health Center in Vermont, she is again working in a type of supported private practice role. This time she is affiliated with a federally qualified health clinic that is part of a program designed to bring health care to indigent populations in rural or urban areas. Since their core services are primary care for adults and children, she isn’t on staff as an employee. Instead, she has a trade-off arrangement where they support her practice with scheduling and billing services, as well as malpractice insurance and office space, in exchange for her services as an on-site neurologist. She is given a steady paycheck with a built-in adjustment every three months as the actual receipts are reviewed.In reviewing both of her private practice experiences, Krantz is clear-eyed about the challenges. “I never really thought of myself as an entrepreneur,” she says, “but you have to be able to set yourself up and face the business side of it, as well as the patient side. That’s really the key. There’s a lot of downsides to consider, which I think are outweighed by the rewards. But you do have to put the work in.”
Anzalone agrees, saying, “You can’t just do this if you’re not passionate about it. You’ve got to really want it. But that’s true of anything in life. I know people who are overworked and they don’t have a zest for health care anymore. You can’t work like that and sustain it. You have to feel good about what you do.