Starting a practice in Shiloh, Illinois

Please note, this is a work in progress, started in June, 2007
Starting a Solo Practice in St. Clair County, Illinois

I started The Country Doctor in 2002. I chose Shiloh, Illinois, as I grew up in the area and wanted to be the first Board Certified Family Physician to start a practice in Shiloh, Illinois. I started the practice directly out of residency.

When I came back to the area after medical school and residency, I learned that it would be an uphill battle to start a solo practice. No other independent family physician started a solo practice in 2002, and no other family physician has started a solo practice in Shiloh, Belleville, O'Fallon, Swansea, or Fairview Heights since 2002 and stayed in the area. Some family doctors are listed as solo, but these doctors actually are part of a group, often based in Iowa or Missouri.

A reason that it is difficult to start a practice include extremely high malpractice premiums. Most insurance companies and all hospitals require doctors to have malpractice insurance prior to credentialing for insurance contracts and staff privileges. The malpractice premiums are based on family physicians in the area and the high risk of getting sued. Dr. Mitchell's premium for 2007-2008, despite never being sued, is $33,500. Back in 2002, it was about $8,000, with the discounts disappearing as the number of patients increased with the number of years in practice. The premiums also are based on other Family Doctors' loss risks in the area, with a 78% increase from 2002-2006 through ISMIE. These high premiums have caused doctors either to join a group for a fixed salary or to leave Illinois.

The health care companies do not make it easy to start a solo practice. Most new doctors bill under an established doctor, until the new doctor is credentialed. Solo doctors cannot do this. The health insurance companies take between 90-365 business days to credential new doctors. Once credentialed, it takes 1-2 years to make it to an insurance company's web site and printed insurance directories. Most patients do not want to see a doctor for more than the cost of copayment, which meant the first year in practice was slow. My first year out, I made less than my salary as a Chief Resident at SLU. Additionally, the health insurance companies keep fees low, which means they decline to negotiate with solo doctors. The health care companies have a take it or leave it attitude, with the exceptions of Medicare, Tricare Standard, and Blue Cross PPO, which pay fair fees.

For 2007, the health care companies continue to hammer the solo doctors. GHP pays me an average of $6 less per visit than what GHP pays group doctors. Healthlink now charges between $2.80 and $3.20 per submitted clean claim, regardless of electronic or paper, to simply process each office visit. Healthlink is the only management company to charge doctors to see patients. The Country Doctor provides a "clean" claim to the in network plans, and Healthlink skims money at the end of each month as a statement fee for useless statements that list payments that are not made. For the privilege of seeing Healthlink patients, The Country Doctor pays thousands annually in administrative fees to Healthlink. GHP and Healthlink share the bottom of the fee scale with Cigna and United Health Care, with each plan paying 23% to 35% less for a standard 15 minute established patient visit compared to the best PPO insurance plan. In addition, GHP, Healthlink, Cigna, and United Health Care cannot even meet Medicare office visits fees, often paying 10% to 25% less than Medicare. This is despite practicing in Tier 1, high risk St.Clair County, with some of the highest malpractice insurance premiums and property tax rates in the state.

Another reason that makes it difficult to go solo or to start a solo practice is that many new and established primary care doctors in St. Clair County are either part of the subsidized Southern Illinois Health Care Foundation, Saint Louis University Residency, SSM network, or are sponsored through a hospital with out of state corporations. The advantages of being sponsored include a guaranteed six digit salary starting in year one, often paid staff, paid malpractice insurance at reduced (read subsidized) rates, specially leased equipment, monthly office space rental assistance, and help with other expenses. The main disadvantages of being subsidized are that the doctor loses autonomy and cannot stay in the area outside of the system. Most subsidized groups have about a 25% or greater turnover every 2-4 years, either secondary to unhappy doctors or secondary to low production numbers. Most subsidizers put a no compete clause in the contract, meaning any doctor wanting to stay in the area cannot practice in the area for one year after leaving a group. This contributed to at least 1/3 of the exodus of local doctors in the last few years.

What are some examples of subsidized and sponsored practices near Shiloh with a high doctor turnover? O'Fallon has at least three family practices, that are receiving financial help to stay in business. One larger practice was founded in the late 1990s with only one original doctor left from the 1990s, in that outpatient only practice that advertises being open seven days a week. Another large healthcare group placed an outpatient only doctor in O'Fallon recently with frequent newspaper advertisements for new patients but forgets to tell patients that outpatient care means a lack of inpatient care. A third practice is down the street from me on Greenmount Road. The doctor turnover at that practice includes working on the third set of doctors to be in the practice across the last five years. All three of these O'Fallon practices' doctors do not see any inpatients. The high doctor turnover and lack of inpatient care causes many patients to switch their care to The Country Doctor.

Most of the sponsored doctors use the hospital-backed hospitalists. Hospitalists are inpatient only physicians who do not see patients in the outpatient setting. The majority of the outpatient only physicians, which includes a large group in O'Fallon and a large area multispecialty group, forget to tell their patients that they will not see these patients when they are admitted to Belleville Hospitals. Being on staff at a hospital does not mean that a physician will take the time to see his or her own patient in the hospital. The outpatient only doctors find that the efficiency increases with early AM and late PM hours, as they have no responsibility to their own patients who become inpatients. In turn, the hospitalists have no responsibility to the patient, once they are discharged with a limited supply of medication for follow up with the outpatient doctor. Unfortunately for the the inpatient, the patient learns his or her regular physician, meaning the physician who should be most familiar with a patient's care, will not see the inpatient at either Belleville Hospital at the time of the admission when a stranger sees the patient. The Country Doctor gladly sees inpatients at both Belleville Hospitals and outpatients in his office.

From 2002-2004 the out of state universities and hospital systems, such as SLU and SSM, along with the local hospitals acquired many practices at fire sale prices. As malpractice premiums went up over 70% in five years, many doctors would not stay in the area and were desperate to sell their practices. Hospitals bought solo primary practices for around $100,000 each, which often was less than the outstanding accounts receivable. Most of these doctors left for Indiana, Missouri, Texas, or counties in Illinois outside of St. Clair and Madison. Madison and St. Clair Counties, despite not being anywhere near the size of Cook County, have the exact same malpractice premiums as Cook County. Other doctors found it enticing to join a hospital or out-of-state medical system, as someone else could worry about paying employees and malpractice premiums. Currently in Belleville, Shiloh, O'Fallon, Swansea, and Fairview Heights, no independent, solo family practitioners exist outside of The Country Doctor. A few independent groups still exist, but many of these groups are struggling to stay in business.

The advantages to the university or hospital sponsoring system vary. The St. Louis based sponsors often get referrals to St. Louis specialty physicians. The Iowa and Illinois sponsors keep the patients within the system. When a new specialist comes in, a referral base already exists, which allows the specialist to rapidly build a practice, as long as that specialist does not leave the sponsor. If a sponsor opens up an urgent care center or new office space, the sponsor can order the sponsored doctors to go to other locations. In the past, this has meant family doctors rotating in urgent care centers and fast track clinics. The advantages to the sponsors also include a double digit percentage of the profits from each doctor and maintaining admissions/testing numbers at the hospitals. An extreme example is a recent neurosurgeon, who was sponsored at an estimated cost of $1,000,000 the first year, with paid staff, paid malpractice insurance, and a guaranteed annual physician salary of $600,000. The advantage to the sponsor is that the high profit procedures boost profits for the hospital. An empty operating room or hospital bed makes no money for the hospital. Other hospitals give $75,000 a year to orthopedic doctors to help them pay their malpractice insurance or pay them an hourly fee to be on call, whereas most doctors are expected to be on call for free. A 24 hour call at $80 an hour, whether or not you see a patient, is the going rate for one orthopedic group in Belleville. Most of these subsidized doctors keep privileges only at the hospital that sponsors them, meaning the profits stay at the hospital.

What are the 2007 hospital inpatient and emergency department/urgent care charges? The Belleville hospitals charge each patient for a basic private versus semi private room between $800-900 a day. For that same care the primary physician gets paid separately $80-$100 on the admission and discharge days, and between $38-$60 daily for daily hospital visits. Phone calls in the middle of the night and throughout the day are not paid. The local urgent care facilities and emergency departments charge between $180-$250 for a basic visit. Most primary care physician office visits are between $60-$110 for established patients, with higher fees for new patients. The outpatient only physician has no ER or inpatient call, no middle of the night phone calls from hospitals, and many holidays off. Outpatient only physicians learn to be efficient and see 2-4x as many outpatients as inpatients at a higher profit per patient with lower risk, compared to seeing inpatients. The hospital and university system has learned that inpatient only doctors can see inpatients in bulk to make up for the low inpatient physician fees, and the outpatient only physicians can run conveyer belt practices. Medicare and the AMA recommend 10-25 minutes for established patient visits, yet some doctors brag about seeing 8 patients an hour. In the end, the patient loses face to face time with the outpatient only and inpatient only physicians.

When an independent doctor starts a practice, there is minimal camaraderie or insight from established primary care doctors. 2002-2004 saw an exodus of primary care doctors from the area, with the remaining older doctors having overflowing practices. Instead of telling a new patient or established patient, who might have a 2-8 week wait to see a doctor about a new practice that can get someone in within a day or two, the local doctors attempted to keep new patients coming to their own practices. The exception was Dr. Fred Wallisch and his staff, who sent over hundreds of very nice patients, prior to leaving for Indiana. Throughout the rough years and currently during the good years, I have received thousands of referrals from the independent specialists, optometrist, chiropractors, nurse practitioners, PAs, and other health care professionals. The solo doctor takes a high risk in starting a practice, as dozens of solo doctors have left the area in the last five years with no referral base existing to help a doctor build a practice.

I joined the local/state medical society and both hospitals' medical staff. The local medical society only sent Medicaid, discharged, and self paying patients, who would not sustain a practice in the long term. Back in 02-04 the hospital medical staff offices did not send patients to me. Interestingly an informal listing of family doctors at each Belleville Hospital shows that 44%-50% of the doctors on staff are sponsored either through a university or out of state hospital-backed corporation. The subsidized multispecialty groups try to keep the patients within the group, as is apparent from the records that I review from patients of doctors who have left the area. With two of the large groups I can tell you exactly which cardiologists, gastroenterologists, pulmonologists, orthopedists, sports medicine doctors, and hospitalists will be listed in the old records. The Country Doctor is a locally-based, Illinois Corporation, that was founded by Dr. David Mitchell. Dr. David Mitchell works with the patients to choose specialists in Illinois and Missouri who will best help the patient.

I was contacted by phone and/or paged by some of the established doctors in the area in 2002 and 2003. They asked me if I would like to take the "no doc" ER call. A no doc patient is one that is assigned to the doctor on call. No doc patients usually use the ER for primary care, secondary to not paying bills, noncompliance with medications, having no insurance, or having Medicaid. It got so bad, that multiple primary care doctors switched to courtesy staff at the hospitals, to avoid no doc call. At one hospital, the residency takes care of the no doc patients. At the other hospital, hospitalists have been hired for the Medicaid/self charity care patients. Interestingly, the doctors who contacted me about the no doc call have left the area for greener pastures. No doc patients do not help establish a strong, sustainable practice.

The best ways to build a practice are through being listed by an insurance company in a book/web page and through satisfied patients with word of mouth. The insurance books took about two years to be listed in most plans, while the insurance company web pages did list me within a year of joining. A very special thank you goes out to all my patients who have helped and continue to help spread the word about my practice. I have patients, who take extra business cards, pens, and magnets, and who freely give them away to other potentially good patients. I have a group of very kind and loyal patients, who are part of the healthcare team. As a side note, my web page is the only form of advertising that I do, as it is a portal to new patient forms, a map to the practice, and a list of basic information about the practice. Finally, many good hospital and hospice employees have sent me hundreds of patients, as they also are looking for independent doctors, who still care about the patient.

The Country Doctor would have to be unique, if not a bit eccentric. I am not a boutique practice, but I have been compared to the new style of practice that exists on the East and West coasts. The same day visit was almost nonexistent in 2002 in St. Clair County, but my residency trained me to try to get patients seen the same day or within 24 hours of the concern. Convenience and minimal wait times began to differentiate my practice. Patients were getting fed up with taking a half a day off from work to see a doctor. Most patients also appreciate follow up visits to review medications, labs, and studies. I was one of the first, if not the first, practice in the area to offer e-mail to patients for nonurgent questions. Currently only a handful of doctors want to take the time to do e mail. I also trust my patients to contact me only with urgent questions, as I do not use a formal exchange system but elected to have a system that gives out my pager number to patients directly.

Being solo has many advantages. I set my own hours, meaning I don't have to ask an office manager permission or a partner permission to change my hours. If I need to buy equipment, I make the decision. I don't have my mortgage/lease subsidized by an outside entity, with no ownership in the end. If there is a billing question, I don't have to give 7% of my profits to a billing agency and don't have to call up an outside service to see what is going on. When a utility or part of the office needs service or repair, I make the call. If I want to upgrade equipment or furniture in the office, I don't have to ask permission from my group or subsidizing entity. Interestingly the subsidizers buy up a doctor's equipment and then lease it back to each doctor, meaning the startup costs would be high for anyone attempting to leave most groups in town and who would attempt to go against the no compete clauses.

I attempt to provide the best possible care to each of my patients. This has paid off in the long run. I have many shelves of new patient records and of old records from doctors who have left the area or from practices where the doctors treated the patients poorly. Additionally, the closing of most of the primary care at Scott Air Force base, the commercial base contracts, and the high expansion in Shiloh of jobs has brought thousands of new patients to my practice. The Country Doctor can spend a reasonable amount of time with each patient. The AMA recommends between 20-40 minutes for new patients and 10-25 minutes for established patients. The patients are intelligent, and they figure out that two minutes a patient is not going to cut it in the long run.

The patients make the solo practice worthwhile. Thanks to my regular patients, I have grown by double digit annual percentages. The practice really started to take off in 2004 and continues to grow in 2007. For 2007, I am getting between 40-55 new patients a month, along with seeing my established patients. When I see a patient, at least 90% of the time I know what is going on with the patient, prior to reviewing the electronic records. When a patient calls me after hours, I know the regular patient well. I often get to know my patients better than the group doctor or subsidized doctor can. My patients are part of the healthcare team.

As part of the team, my patients have certain expectations. Many of the patients who transfer from other local practices and from Missouri practices join The Country Doctor for multiple reasons. The Country Doctor has a same day or 24 hour turnaround on paperwork, work notes, FMLA papers, prescription refills, appointment requests, email, and most other patient care activities. Preauthorizations for medications and radiology studies are done the same day or within 24 hours of the request at an office visit. Recently The Country Doctor added extended AM/PM hours and Saturdays to accommodate the influx of patients. The Country Doctor tries not to short change any patients and to spend a reasonable amount of time with each patient. When patients are treated well, the the patients return for future care and recommend the practice to other potential patients.

Since 2002, I have built a practice that has allowed me to have a higher income than most subsidized family medicine doctors without having to see an excessive number of patients each day. My regular patients are enjoyable to see, and it does not feel like work to see patients in my office. I continue to go to the the hospitals as a courtesy to my patients, but I find that I spend about 96% of my time in my private practice office. The majority of my time is spent with direct patient care, although I do spend about 1-2 hours a day doing paperwork, which may include preauthorizations for medications or radiology studies.

I also found that I have more time to spend with my patients by not accepting samples of the latest drugs, which only benefit drug company sales. Across the last few years patients and consumer groups are finally realizing that over 78% of the doctors in the U.S. take gifts from drug companies. The Country Doctor does not accept "free" meals and "free" gifts from drug companies, as the patients ultimately are paying the bill for these items. The next time you visit your primary care doctor, see how many pens, papers, stethoscopes, blood pressure cuffs, posters, paper, and other items are present with drug and lab advertisements. One local drug company has a $50,000 annual lunch bill at a large Belleville Family Practice, where it provides meals for its doctors and employees. The next time your doctor brags about doing research for a drug company, ask about the $50-$100 paid for each prescription that doctor is paid to write for the latest drug. Other doctors take research vacations, paid by the drug companies, to resorts that magically have a medical conference built into the drug symposium. Ultimately this costs millions to the patients nationwide.

A few additional things make my practice unique. I am one of a handful of physicians who is willing to see patients on a Saturday and who is willing to see established elderly patients in their homes. Most doctors find the profits are too low to do housecalls, as the backing entities want maximum return for the investment with maximum hourly production. The one or two other doctors who list housecalls as a service in their practice actually send out their nurse practitioners or PAs and do not personally see the patient in the home. I don't discharge my patients, once they become under hospice care. I try to keep each patient until the end and find it rewarding to care for my patients, both young and old.

By being solo and I can rapidly adapt to each patient's needs. In 2007, I decided to maintain my AAFP membership for board certification, but I have elected to redistribute some of my other membership funds to help my patients. I have found a $1,500 annual savings on my personal health insurance premium, by switching from the AMA health insurance to Blue Cross PPO. I decided to take some of the saved money and to use it to benefit my patients by having additional CLIA waived laboratory equipment, which includes full lipid panels, as most of the in store clinics and hospital health fairs simply provide a $20 total cholesterol without providing the HDL, LDL, and triglycerides. I have in office testing for HGA1C for long term sugar control of diabetics, fasting glucose for diabetes screening, mono, urinalysis for a variety of illnesses, urine pregnancy tests, Helicobacter pylori stomach bacteria blood tests, rapid pharyngitis strept tests currently available. In addition, a PT/INR machine was added to the practice on June 15, 2007. which is for patients on coumadin/warfarin. For July and August 2007, I added hemoglobin monitoring, mono screening, and thyroid screening (TSH is backordered). These tests provide same day results to my patients with same day treatment plans.

A hot topic is the in store clinics in Walgreens, Walmart, Schnucks, Target, CVS, and others. I have reviewed the EOBS/receipts for the acute care visits and have found that no savings exists for insured patients. The doctors who continue to book patients two weeks out for acute care and the ERs/Urgent cars that charge between $265-$500 just to walk in the door should be worried about the in store clinics. The price range for most in store clinic visits is $70-$90, on a first come, first served basis. The AMA also is worried about in store clinics, as the fees are competitive and the care usually is quite good for common illnesses. The AMA does question when retail clinicians give meds to be filled only at the sponsored retail clinic store, but this is no different from a doctor who accepts $50-$100 per prescription from the drug companies to write for the latest brand name drug. When a patient is booked 1-2 weeks out for a UTI or Sinus infection, that patient likely will not see the regular doctor for care. By offering additional CLIA waived labs, extended hours, and same day/next day visits, The Country Doctor feels no competition from the in store clinics.

Dr. David Mitchell started and built The Country Doctor from scratch. I was fortunate to have some patients follow me from my SLU residency in Missouri and to have thousands of quality new patients join the practice. I have extended the hours, to allow me to keep seeing new patients and to continue to not make established patients wait days for visits. I plan to retire in about 30-40 years from practice, but I will remain in Shiloh, Illinois.

Thank you to all my patients who have helped build my practice. I plan to continue to provide the best possible care to each of my patients.

Dr. David Mitchell

The Country Doctor

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Shiloh, IL 62221-2570
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