Failed Private practice

[Random1]

What kind of characteristics such an area should have in your opinion

You need to go to an area of the country , doctors don't want to go to , and has a relatively good economy. Sorry I can't be more specific but I have looked in many years. If you go to small town USA , you will be stuck with a large amount of Medicare / MA / no insurance. You may do well there but it will be more difficult financially. Go to where people are moving too, that are not over saturated with doctors and health systems. This means you may not be living in your most ideal situation.

Call small health systems in the area you pick and speak with them directly to see if they are willing to help you set up shop.

[Jaqen Haghar MD]

I had a PP for many years, that I would consider successful. A few years ago I joined a private group.

In my area, which I suspect is like the rest of the country , corporate medicine took over and squashed most everyone else. The market dynamics are quite different now than they were 20 years ago. Hospitals would help get you up and running, now if they see if you are successful , the put up an office across the street. Also, Obamacare, with the explosion of managed MA plans was the nail in the coffin for me.

I used to work in a small city. On the outskirts of the city, in a smaller rural town, the people had drive 20-30 miles to get to the nearest urgent care/family med office. So someone opened an urgent care there and it started doing well. This pissed off the main hospital system in the city.

So the hospital system built a brand new, shiny building across the street for that urgent care, and opened their own. They operated it at a massive loss, and siphoned patients from the other place until it went out of business and was forced to close.

Right after that, the hospital system locked the doors on the shiny new building and shut down their operation there too. They spent a lot of money to make sure the first urgent care went down in flames.

So, now the patients have to drive the 20-30 miles to get care again.

[nastle]

I used to work in a small city. On the outskirts of the city, in a smaller rural town, the people had drive 20-30 miles to get to the nearest urgent care/family med office. So someone opened an urgent care there and it started doing well. This pissed off the main hospital system in the city.

So the hospital system built a brand new, shiny building across the street for that urgent care, and opened their own. They operated it at a massive loss, and siphoned patients from the other place until it went out of business and was forced to close.

Right after that, the hospital system locked the doors on the shiny new building and shut down their operation there too. They spent a lot of money to make sure the first urgent care went down in flames.

So, now the patients have to drive the 20-30 miles to get care again.

That is about as evil as it can get
esp since for many people gas money is a big issue

[nastle]

What kind of characteristics such an area should have in your opinion

You need to go to an area of the country , doctors don't want to go to , and has a relatively good economy. Sorry I can't be more specific but I have looked in many years. If you go to small town USA , you will be stuck with a large amount of Medicare / MA / no insurance. You may do well there but it will be more difficult financially. Go to where people are moving too, that are not over saturated with doctors and health systems. This means you may not be living in your most ideal situation.

Call small health systems in the area you pick and speak with them directly to see if they are willing to help you set up shop.

What is your opinion of cash only practices ? I feel like that’s not for the faint hearted

[Kamban]

Your position is far better than an average FP IM who goes into PP usually straight out of training
Again specialty practice is much different than Primary care , you were smart enough to know better early in your life

A PCP does not depend on the hospital. He can attract patients directly.

I on the other hand usually need referrals from not only PCP but surgeons, GI and pulm. The hospital system has bought out everyone and uses the EMR to prevent outside referrals.

The worst disaster - I get referral from PCP and am forced to send to the hospital employed surgeons. In spite of my best efforts, the hospital swallows them and before I know it the oncologist there has put in a LifePort and started chemotherapy. But miraculously if the patient does not require chemotherapy or is on Medicaid, they manage to refer it back to me. :-(

There are no independent surgical groups in town.

[Tim]

Kamban
There are no independent surgical groups in town.

So I guess that means a brand new fellowship trained surgeon of any type might have a few problems opening a solo private practice. Would it even be possible to get privileges and OR time?
Question, would you still relocate to the same location?
Question, would you still go into PP or would you work for a hospital system?

[StateOfMyHead]

What is your opinion of cash only practices ? I feel like that’s not for the faint hearted

My guess is that it would be difficult to fill a concierge practice in primary care unless in a really affluent are. Psychiatry seems to be an exception and even then can take a while before full.

[jfoxcpacfp]

In my comparably limited experience, I have not worked with a PP that has failed but I have worked with clients who could make more as W2 and not have the employee headaches and went to W2 or joined another group (also for benefits). If by “failure” you mean lose money, I’m sure there are a few who fail to thrive b/c of bad decisions. A few I can think of that can haunt practices are:

• Avoidance of resolving employee issues
  • this covers such a broad spectrum such as theft, bad seed in the group, laziness, lack of respect for the owner, letting office manager handle all conflicts etc. The buck stops with you even when you stick your head in the ground. Very common in medical practices.
• Inability to delegate, burn-out
• Failure to get and follow good advice (attorney, CPA)
• Cash flow, not building a nest egg to support the 1st 6 mos - 1 year)
• Coding issues maybe
• Not planning ahead for sale of practice (this w/n/b failure to thrive but I hear of a lot)

Just off the top of my head.

Fwiw, WCI doctors (who make up 90%+ of our clients) are a very small subset of doctors and, therefore, the likelihood of “failure” is going to be significantly lower (IMPO) than the global pool of medical doctors. We can definitely tell a difference when a referral becomes a client and d/n come in as a WCI reader.

[cards67]

Are you asking about failure after starting a practice from scratch or failure after buying an established practice? I know someone who joined a single-owner practice, wasn't offered partnership and soon everything crumbled because of the owner's divorce. Both ended up getting an employed job elsewhere. Also plenty stories of practices selling to hospitals, not necessarily due to failure per se, but just a better deal for them.

[fire2026]

I used to work in a small city. On the outskirts of the city, in a smaller rural town, the people had drive 20-30 miles to get to the nearest urgent care/family med office. So someone opened an urgent care there and it started doing well. This pissed off the main hospital system in the city.

So the hospital system built a brand new, shiny building across the street for that urgent care, and opened their own. They operated it at a massive loss, and siphoned patients from the other place until it went out of business and was forced to close.

Right after that, the hospital system locked the doors on the shiny new building and shut down their operation there too. They spent a lot of money to make sure the first urgent care went down in flames.

So, now the patients have to drive the 20-30 miles to get care again.

That’s plain evil

[Kamban]

Kamban
There are no independent surgical groups in town.

So I guess that means a brand new fellowship trained surgeon of any type might have a few problems opening a solo private practice. Would it even be possible to get privileges and OR time?
Question, would you still relocate to the same location?
Question, would you still go into PP or would you work for a hospital system?

Tim

There is no brand new fellowship trainee surgeon in town who is not a part of one of the two health systems. The only independent surgeons are a couple of plastic surgeons who do more in office work than hospital OR work. I am not sure about getting hosp privileges if you are an independent surgeon but unless you can show call coverage you will not get it. Even med specialists in PP group who were swallowed up by one hospital system as employees had their privileges terminated by the other system soon after becoming employed.

From 2012 onwards, I would have not relocated to this town unless the hospital employed me with good salary and benefits. Love the town, hate the closed loop health systems.

With high acquisition costs for drugs, poor reimbursements and some patients just not paying their bills, I would never dream of starting PP in 2022. Geographic arbitrage does not work well in my field as the more rural you get, the more you get Medicare/Medicaid, Medicaid, Advantage plans etc where you cannot afford to stay afloat..You have to work for a system that gets drugs at 340b pricing.

[Tim]

Kamban ,
"From 2012 onwards, I would have not relocated to this town unless the hospital employed me with good salary and benefits. Love the town, hate the closed loop health systems."
There seems to be a pattern here. If you need hospital facilities, decent insurance reimbursements, or drugs one needs to be in a hospital system or a group to survive. Anecdotally, even a "rain maker" can run into problems changing hospital systems.
I am aware of one technique. The rural community hospitals can allow "sharing" of one or more physicians between two cities. Not enough for full time at either. Only game in town comes with it's own downsides.

Thank you for outlining how a private practice fails. Closed loop health systems, where ever that may be. Just a note, brand new fellowship trainees probably will not understand the economics to avoid getting crushed.

[nastle]

This is not true. You are better off PCP than specialty.

General question to all FP/IM
Can one open a FP/IM practice where you only see certain conditions NOT all diagnosis ( eg if you have syncope I cannot help you)
and decline older and more medically complicated patients ?
is that possible or legal ?

[AR]

General question to all FP/IM
Can one open a FP/IM practice where you only see certain conditions NOT all diagnosis ( eg if you have syncope I cannot help you)
and decline older and more medically complicated patients ?
is that possible or legal ?

I'm sure it's legal. And anything is possible.

Practical? That's another matter. Maybe someone doesn't sound medically complicated to your scheduler, but when they show up they have got a bunch of problems. Or maybe you have a healthy patient who develops complicated issues. You could, with adequate notice and following the proper procedures, transition their care to someone else. You might get dragged in yelp reviews, but I don't see why you couldn't at least severely minimize your exposure to certain things if you were determined.