Add concierge.
Keep every patient.
Your senior doctor goes concierge. Your team keeps the practice running.
Nobody gets cut loose. Your patients keep their doctors and their insurance. The few who want more of your senior doctor’s time pay a membership for it. And your senior doctor finally gets time to practice medicine, and to teach.
Most firms convert and cut.
We keep the practice.
The big concierge firms all sell the same plan. It fixes the senior doctor’s schedule by giving away most of the practice he spent his career building. There’s a better way, and doctors are already running it.
Convert and cut
- Write to all 2,000 or 3,000 of your patients and ask every one to pay a yearly fee.
- A few hundred say yes.
- Everyone else has to find a new doctor. The industry calls it “attrition.”
- Patients you’ve known for twenty years get a letter, and your team loses most of its work.
A smaller practice, and a lot of patients let go.
Keep them all
- Study your patient list together. Start with a few patients you’re sure will love it. You only get one first impression.
- Everyone else stays. Your team carries their everyday care, billed to insurance, the way it is now.
- When a patient needs the senior doctor, medically, he’s still there.
- As you get better at it, invite more. Add more membership levels when members ask for them. No hurry. Do it right.
The whole practice, plus a concierge tier at the top.
“You don’t throw away an asset to fix a schedule.”Adrian Keith Skane, CPA
Three layers. One practice.
The senior doctor’s time is the scarce thing. A strong team protects it, so he can give it to the patients who pay for it, and step in for everyone else when it matters.
The senior doctor
Members pay for more of his time.
- Sees two or three scheduled concierge members a day, with time to really talk.
- Does the thorough yearly physical with them.
- Pops in when the team hits something unusual: five minutes in the room with the patient and the clinician, sharing what he knows.
- The patient gets his experience. The clinician gets a lesson.
The rest of your team
Your associate physicians, nurse practitioners, physician assistants and nurses.
- Handle routine and follow-up visits for every patient.
- Billed to insurance: traditional Medicare and PPO plans.
- When a case stumps them, the senior doctor comes in and shows them what he’s doing, and why.
- Get more skilled and more sure of themselves every month.
- In time, can take concierge members of their own.
The next senior doctor
An associate physician, trained and mentored by the senior doctor.
- Takes on insurance patients the senior doctor used to carry.
- Learns the concierge side from the inside.
- When he’s ready, becomes a senior associate doctor with members of his own.
- Stays part of the practice and the team. The patients belong to the practice.
A day built around a few patients, and a team.
Here’s what a day can look like once the concierge tier is running. Every practice sets its own rhythm.
A long visit with a member
Forty-five minutes, an hour if it needs it. Results gone over line by line. Questions answered before they’re asked.
Pop-ins
A nurse practitioner has a patient whose numbers don’t add up. Five minutes in the room. The patient gets his experience; she gets the lesson.
Teaching
An hour with an associate physician on a hard case. Not four minutes in the hallway. An hour, with the door closed.
A yearly physical
The thorough one: a full blood panel and a plan for the years ahead, the kind insurance won’t pay for.
Calls back
Members who called today hear from their doctor today. Then he goes home on time.
An example, not a schedule. Your patients, your team and your state’s rules shape the real day.
Your senior doctor gets time to teach.
Next to keeping your best doctor in medicine, this may be the biggest win of all. A busy doctor does the work himself because it’s faster. A doctor with time teaches his team to do it.
“It’s quicker if I just do it myself.”
It saves five minutes today and costs years. The team never grows, and every hard case still lands on the senior doctor.
“Come in here. Let me show you what I’m doing, and why.”
He hands off everything he can. When the team gets stuck, he pops in for five minutes and turns it into a lesson. Every month they need him a little less.
I’ve run my firms this way for decades. Delegate everything you can, and use the time to develop your people. The good news is it works. The bad news is I kept growing people who wanted to buy me out of the practice. I’ll take that trade every time.
Adrian Keith Skane, CPAStart with the surest few. You only get one first impression.
There’s no hurry. The first members set the tone for everyone who follows, so we pick them with care and learn as we go.
Study the patient list
How long each patient has been with you, where they live, and how often they’re seen.
Ask the people who know them
Your doctors and your staff know who will say yes. Their judgment beats any spreadsheet.
Start small
A few personal letters, then a real conversation with each patient. Not a sales pitch. An invitation from their doctor.
Learn, then widen
Smooth out the rough spots with the first group. Then invite the next, and keep members up to date as you add new services.
For most of your patients, nothing changes.
That’s the point. The practice they trust is still there, and so is the senior doctor when they need him.
Two kinds of income.
One practice.
Keep billing insurance. Add a membership on top.
Your insurance patients keep paying the bills, the way they do now. Your members pay for something insurance never has: more of your senior doctor’s time. Here’s how the two fit together, the one rule that keeps it clean, and what it does to what your practice is worth.
Insurance pays for care. The membership pays for time.
They pay for different things, so they don’t compete. A member’s covered care is still billed to insurance. His membership pays for what insurance never covered.
The care you already bill
- Office visits and follow-ups, for every patient.
- Tests and procedures your practice already bills.
- The yearly wellness visit Medicare covers.
- Traditional Medicare and PPO plans.
What insurance never covered
- A direct line to the senior doctor.
- Long visits, as long as they need to be.
- The thorough yearly physical, with a full blood panel.
- A plan for health and the years ahead.
Medicare pays for a wellness visit. Not a real physical.
The most valuable visit of the year is the one insurance barely touches. That gap is what your members are paying to close.
The yearly wellness visit
- A risk check and a prevention plan. No hands-on physical exam is required.
- Original Medicare doesn’t pay for a routine physical at all.
The physical patients really want
- A truly thorough physical when a member joins, with a full blood panel.
- A plan for health, healthspan and longevity, built from those results.
- Time to go over every result, line by line.
- A doctor who answers, all year.
Never charge twice for the same thing.
This is the line that keeps a practice like this clean. Get it right in writing before the first patient is invited, and it takes care of itself.
Start with one level. Raise it a little every year.
One membership level to start
Keep it simple while everyone learns. Add more levels later, when members ask for them, such as a level for a longevity plan or for a whole family.
Price it on value
The fee depends on what you include. Every practice sets its own, and fees vary widely. A patient whose first question is the lowest price is rarely the right first member.
Raise it every year
Tie a small yearly increase to the government’s cost-of-living adjustment, and write it into the agreement from day one. Members get used to it, and you never fall behind your own costs.
Keep every patient, and you keep what they’re worth.
Insurance-based practices sell, and they sell readily. Cutting most of your patients loose throws away a big part of what a buyer would pay for. Keeping them keeps it.
No practice value is promised. What a practice sells for depends on its numbers, its market and its buyer. Have your accountant and a practice broker value yours.
“Every year my costs go up and my payments go down.”
I’ve heard that from doctors for thirty years. A membership doesn’t change what insurance pays you. It gives you a second source of income that you set yourself, so the practice stops living on one number someone else controls.
Adrian Keith Skane, CPA
From the first talk to the first members.
A practice that already exists moves fast. Most of the work is paperwork, procedures and the right conversations, and we do it with you.
A conversation
You, me, and whoever you want in the room: your spouse, your partners, your practice manager.
The design
Who goes concierge, what members get, what the team does, and one membership level to start. Your attorney and accountant weigh in.
The setup
Agreements reviewed by a health care attorney, procedures, systems, and a website overhaul.
The first letters
A few personal letters to the patients most likely to say yes. Not a sales pitch. A real letter from their doctor.
The first members
Long visits and thorough physicals. Then we tell your town what changed, and invite the next group.
A typical plan, not a promise. State rules, your attorney’s review and your own pace set the real timeline.
We hold your hand the whole way.
You keep practicing medicine while the change happens. We do the rest with you.
The legal documents
Membership agreements and the paperwork behind them, set up with a health care attorney who has done this for years.
Who to invite first
We study your patient list with you: how long each patient has been with you, where they live, and who your doctors and staff think will say yes. Then we start with the surest few.
The conversations
The letters, what to say when a patient asks, and how to tell a patient who doesn’t join that nothing changes for him.
Procedures and systems
Scheduling, member billing kept apart from insurance billing, and the tools that run it day to day.
Your website
An overhaul, or a first website if you don’t have one, that explains the new tier in plain words.
Telling your town
A goodwill campaign that brings referrals from the patients you already have, and new patients when you want them.
Specialists can do this too.
Some of the most interesting concierge practices we saw this year belong to specialists. The same idea works: patients pay for time with the most experienced doctor in the practice, and the rest of the practice keeps billing insurance.
The radiology second opinion
For a patient worried about a scan, that time is the whole point.
Can’t afford it? Earn it.
Some patients need more of the senior doctor and can’t pay the full fee. Some practices let them earn part of it by doing good work in their town.
Set up the program with your health care attorney before you offer it, especially for patients on Medicare. It must follow a written policy and be offered the same way to everyone who qualifies.
The patient asks for help
The practice offers a community service scholarship under a written policy.
He volunteers in town
At a food bank, a school, a church, a shelter. The hours are verified.
The hours earn credit
Verified hours pay down part of his membership. Everyone wins.
Priced after the first conversation. In writing.
No two practices are the same size or need the same help, so we don’t post one price for everyone. You get the price in writing before you commit to anything.
- How many doctors and clinicians are in the practice.
- Which state, or states, you practice in.
- How much of the work you want us to do: documents, systems, your website, the goodwill campaign.
- Whether you’re adding one concierge doctor or several.
The questions I hear first.
Is it legal to bill insurance and charge a membership?
Many practices do both. The rule is the one on this page: the membership pays only for what insurance doesn’t cover, like access, time and the thorough yearly physical. It never pays for a visit you also bill. Rules differ by state and by insurance plan, so a health care attorney reviews your agreements before the first patient is invited.
I have partners. How does that work?
We design it with all of you at the table. Who goes concierge, how the membership income is shared, and what changes for each doctor are decided up front and written down with your attorney. Nobody’s pay changes without their agreement.
Will my staff resent it?
Bring them in early, and it becomes their change too. Their work gets more interesting, they learn from the senior doctor every week, and the best of them can take members of their own one day.
What if an associate physician leaves?
The patients belong to the practice. Your associates work under employment agreements, and your attorney makes sure those agreements fit the new tier.
How many patients will join?
Nobody can promise you a number, and you should be wary of anyone who does. It depends on your practice, your town and your patients. That’s why we start with the surest few and widen from there.
Do I need new software?
Often not. Member billing has to be kept apart from insurance billing, and some practices add a patient app. We look at what you already have before suggesting anything new.
What does this cost?
Every practice is different, so the price is set after our first conversation and given to you in writing before you commit to anything. More on what you pay us →
It’s your practice. Keep it all.
Read the report. Talk it over with your spouse, your partners, your attorney and your accountant. Then talk to me. If it isn’t a fit, you’ll hear that from me too.
Adrian Keith Skane, CPA