The underlying principle of concierge and direct-pay practices is that patients have greater access to their doctor and receive comprehensive outpatient care (usually excluding all but the most basic diagnostic testing) for a flat fee that’s paid either monthly or annually. Physicians who practice under these models typically offer same-day and longer appointments and make themselves readily available to their patients by phone, e-mail, text message and/or Skype. Practices benefit from more consistent cash flow and lower overhead because they’re not dealing with insurance billing and collections. A few doctors who practice concierge or direct care medicine give up their offices entirely and make house and workplace visits to care for patients. Most, however, maintain an office and venture out for house calls only when that’s necessary. 

The original concierge practices catered mostly to well-to-do patients who paid their primary care physician a flat annual fee (often in the thousands of dollars) to provide all of their routine, outpatient medical care. These practices are still around, along with others that charge a more modest annual fee coupled with small office visit co-pays, and still others that charge patients a monthly subscription fee.

Hybrid concierge practices have emerged in recent years. In this model, physicians continue to care for patients in the traditional way (including accepting insurance) and also offer a concierge or direct care model for patients who choose that option. This solution allows doctors to continue to care for long-time patients who are covered by insurance or Medicare while, at the same time, provide more personalized service for patients who wish to sign up and pay for the concierge service. Some patients who have insurance elect to pay the fee to be in the concierge pool so that they have more immediate access to their doctor. The downside of the hybrid model is that the office is still dealing with insurance billing and collection issues.

One important issue to consider if you’re transitioning to concierge medicine is whether to opt out of Medicare. This is not a decision to be taken lightly. Once you opt out you can’t submit claims to Medicare for two full years. You must formally inform Medicare (during a certain window of time) and give your Medicare-eligible patients plenty of advance notice about your plans to opt out. You must also have a written agreement with each patient who is eligible for Medicare confirming that you are entering into a private contracting arrangement for care and payment. The American Academy of Family Physicians has a nice summary about Medicare participation on their Web site (revised January, 2013) and sample notification forms.

There are a number of companies that help physicians make the transition to concierge medicine. Some of these are MDVIP, Concierge Choice Physicians and SignatureMD. Spend some time on these sites (keeping in mind that they want you to contact them to sign up) to learn more about how concierge medical practices work.

Office supplies. Some employees feel guilty if they arrive home to find a pen from the office in the bottom of their uniform pocket, while others view pens, Post-it® notes, postage stamps, reams of copy paper and even more expensive items like printer cartridges as community property. Naturally, you want to make it clear to all staff members that this is not the case and that office supplies are intended to stay in the office. One way to send that message is to set up a “free” box of items that are intended to be taken (i.e. this stuff is for the taking, but not anything else). Toss pens, notepads and other miscellaneous items that you accumulate from sales reps into the free box and allow employees to take them home for personal use. You can also offer, as an employee benefit, to buy commonly used home-office supplies at your bulk purchase price and allow employees to, in turn, buy them from the practice. This would require some bookkeeping, however, so think it through before putting the offer out there.

Drugs. If you keep anything stronger than Tylenol® in stock, either for direct dispensing or in the form of samples from pharmaceutical companies, it’s essential to have a system to keep track of medications. Too often, employees view samples provided by pharmaceutical reps as fair game for pilfering since they’re “free.” Unlike the case of the harmless rep-supplied office items mentioned above, medications of any kind should not–without a doctor’s prescription–be given to (or appropriated by) employees. Create a written policy stating that drug samples and other medications kept in the office are intended for patient use only. So that you have cross-checking and accountability, put two individuals in charge of inventory control and ensure that only authorized employees have access to drug storage areas. Keep all medications and prescription pads in locked cabinets and drawers when they are not immediately in use.

Time. This is a particularly insidious type of employee theft, and yet, in the moment, it can seem so innocent. Time theft occurs when staff members are not conscious of the clock or when they intentionally take their “little extra” in the form of minutes here and minutes there. They show up at 8:07 and mark their time card for 8:00, take 20 minutes for morning breaks instead of the allotted 15, or return from lunch 10 minutes late several days each week. It all adds up. If an employee is eking out an extra hour each week in this manner and they earn $12/hour, that’s $600/year, not taking into account payroll taxes. Keep this “time creep” situation under control by having arrival, break, lunch and departure times clearly spelled out in your employee manual and by investing in a time clock.

1. Determine when providers will be away. Knowing when each provider in your office plans to take their summer holiday or attend a continuing education course may help in terms of scheduling staff vacation time. While it’s not recommended to require that staff take their own vacation time when providers are away, if that can be worked out it makes sense to do so. With doctors out of the office patient volume will naturally be lower, so it’s a good time to reduce back office employees’ hours as well. If vacation weeks can’t be made to coincide, have special projects lined up for staff to work on while the office in quiet.

2. Coordinate staff requests for time off. Hopefully by now, you already know when everyone plans to be off for a few days, a week, or longer this summer. If so, great. If not, bring a calendar to your next staff meeting and map out who wants to be away when so that you’re not left short-staffed at any point. Some practices award vacation time according to tenure, while others just “work it out.” Whenever possible, try to take into account the needs of employees who want to be off to attend date-specific events such as weddings or family reunions.

3. Decide if you need temporary help. If one of your providers is planning an extended vacation (say, four to six weeks), determine whether that doctor’s patients can be cared for by other partners in the group or if you need to bring in a locum tenens to cover. If you’re in a one-provider practice, locum tenens may be the only option for coverage if the doctor is away for several weeks or longer. Likewise, if a staff member has accumulated a few weeks of vacation time and plans to use it all at once, decide if it makes sense to hire someone from a temporary agency to pick up the slack.

4. Keep in mind that patients will be vacationing, too. This can mean an increase in no-shows, particularly if you book appointments for routine care three, six or twelve months out. During the summer months, be especially diligent about making appointment reminder calls to patients, perhaps going so far as requesting that they return the call to confirm appointments. When you get a call back from someone saying, “Oh, I completely forgot . . . we’re at Disneyworld this week,” you can quickly fill the schedule with someone on your waiting list or keep that slot open for a patient who needs to be seen on short notice.

1. How many reminder calls do you make on an average day? If your office is the home of two neurosurgeons, patient volume is probably small enough that making reminder calls on a daily basis isn’t a burden. If your practice is made up of six busy pediatricians or family physicians, that’s a different story altogether. Count the number of calls you make each day, determine the average time for each call (factor in that some are quick messages and others turn into conversations), and then calculate how much making the calls costs in terms of payroll (don’t forget to include payroll taxes and benefits in this figure, not just the person’s hourly wage). Use this data to do a cost-benefit analysis of investing in an automated system.

2. Who are your patients? It may be a bit of a stereotype to assume that older patients are less tech-savvy than younger ones (there are plenty of grandparents on Facebook every day, to be sure), but if the majority of your patients are seniors they might be somewhat less receptive to receiving automated calls. This isn’t because they don’t understand or appreciate technology, but because they value human-to-human communication. Receiving a phone or text message from their doctor’s office just isn’t the same as hearing Sue’s reassuring voice.

3. What is your service philosophy? If highly personalized service is a hallmark of your practice, you may want to stick with having a staff member make reminder calls to patients. A friendly voice message or quick conversation is an additional point of contact that can help create an ongoing positive impression of your practice.

4. What about privacy? Some patients will balk at receiving automated calls, citing privacy as an issue. A computer leaving a message at someone’s home is, however, no different from a live person leaving the same message, so the concern on a patient’s behalf is likely that information is being stored electronically. Be prepared to respond to patients who raise this issue by explaining how data is maintained and used in a way that ensures their privacy.

As you read through this post, keep in mind that a patient can be subject to a medical error or  poor clinical outcome and not even think of blaming their doctor–if, that is, they feel they’ve been treated with respect and compassion. Another patient who experiences a similar untoward event may end up filing a malpractice claim as a result if they feel they’ve been “dismissed” or received poor service. This is where medical office staff comes in. The little things that both front and back office staff members do (or don’t do) can make the difference between “forgive and forget” and “I’m calling my lawyer.” Consider the following ways to reduce the risk of having your practice dragged through court.

Be responsive to patients by communicating with them in a timely manner. No one wants to sit by their phone (even their cell phone) waiting for a physician, nurse or office staff member to get back to them about a prescription refill, appointment time, to schedule a diagnostic test, or with the results of a lab or radiology report. Remember, patients who are chronically irritated, frustrated and annoyed by the service they receive may be more apt to sue their doctors than those who are continually wowed by the responsiveness of the practice.

Don’t ignore patient complaints. If someone takes issue with how long they’ve been made to wait, over a billing error, about the fact that they’re not being communicated with, or any other matter regardless of how minor it may seem, take them seriously. Listen carefully, acknowledge the concern, take steps to rectify the situation, and keep the patient in the loop as to what’s being done to solve the problem. Unhappy patients often just want to be heard.

Be cognizant about working within the scope of what you are educated and trained to do. Medical assistants and front office staff alike accumulate a great deal of clinical knowledge over time, but casually or unintentionally dispensing medical advice to patients can create problems. Be careful not to accidently practice medicine by offering clinical advice that is beyond the scope of what you’ve been hired to do.

Thorough documentation in medical records is essential to good patient care, and also an important factor when it comes to staying out of legal hot water. Office staff can help ensure that patient records are complete by documenting missed and rescheduled appointments, prescription refills that are called in per a doctor’s order, and miscellaneous communications with patients.

Respect patient privacy. HIPAA regulations aside, it’s good business and good medicine to ensure that clinical information is safe within your office. Demonstrating this to patients can include simple actions such as keeping computer screens turned so that they cannot be seen by the public, turning paperwork face down when it’s on desks and countertops where patients stand or wait, using a low speaking voice when talking with patients, and being careful when using a patient’s name or discussing their care anywhere in the office or over the phone. Also, never reference patients on social media, even if your patient is an A-list celebrity.

The decision to add a highly paid member to your team is not one to be taken lightly. Before you go down the recruiting road, assess how you are currently scheduling appointments to make sure that the problem doesn’t lie there. Next, consider hiring a practice management consultant who is skilled in streamlining patient flow and working with providers to help them be more efficient with their time. Finally, find out if any of your current providers who work less than full-time are interested in increasing the number of hours or days that they are in the office.

If none of these three factors solve the problem of too many patients and too few appointment slots and it’s determined that an additional provider is justified, the next decision is whether that person should be a doctor or a mid-level provider. For example, if your practice is staffed by three family physicians, do you need another FP, or should you consider a nurse practitioner or physician assistant instead? If you have four dentists in the office, do you need a fifth, or would it make more sense to hire two dental assistants who could make the four dentists more efficient?

Recruiting is not an inexpensive proposition, so consider whether the practice has adequate cash on hand to bring in a new provider. Factor in paying a placement agency or advertising on your own to attract the right person, hiring an attorney to draft an employment agreement or associate contract, paying interview trip and relocation expenses, paying the salary of the new recruit during the early months while his or her practice is building up, and hiring extra support staff.

Another question to ponder is whether you have the space to add someone to the provider team. This might mean a private office plus two to four additional treatment rooms. No room in the inn? Consider extending office hours so the practice can accommodate more patients in the same amount of space by having some providers work from 7 a.m. until 3 p.m. while others work from 12:00 noon until 8 p.m. This will, of course, require additional support staff who are willing to work outside the usual 9 to 5 routine.

Once you’ve thoroughly evaluated each aspect of recruiting a new provider and the decision is made to move forward, put the wheels in motion as quickly as possible. Finding the right person–someone who is a fit both professionally and personally for your practice–will take, at minimum, several months. As soon as you have a signed agreement with the candidate of your choice, announce his or her arrival date to your patients so they’ll know that help is on the way and that getting on the appointment schedule will soon be quicker and easier.