Janet Kidd Stewart

Harp music plays through the phone as patients hold for the office of internist Garrison Bliss, MD. Bliss is one of the nation's first physicians to practice in a membership model where patients pay for their care on a monthly retainer basis, widely known as direct primary care.

Visitors to his practice website are greeted by a graphic bearing just his last name, with the "i" in Bliss formed by drips that had fallen gently into rings of nearly-still waters.

This type of "bliss" isn't too common in practices nowadays, with the physician burnout rate rising to unforeseen levels. Nearly 63 percent of practice-owning physicians reported somewhat or very negative morale in a 

 by The Physicians Foundation. Overall, a majority, about 54 percent of all 17,236 physicians, reported negative morale.

Bliss, who studied philosophy and biology in college, and his staff saw their own stress levels going down when he first started using DPC in the late 1990s. Typically, DPC practices don't contract with insurers, but charge patients a flat monthly fee for most routine care.

"One of the first things we noticed when we started was how quiet the office was," Bliss recalls. "It went dead calm, and people weren't running up and down the halls. A lot of the stuff we used to spend time doing didn't need to happen anymore, such as prior authorizations."

Over the next couple of decades, Bliss built out the model, first in his own Seattle practice and then with venture capital partners, he spread it to other locations around the country. Today he cares for his own patient panel, about 400 people, most of them long-time patients.

"It's wonderfully comfortable. When I get called (after hours) it's often somebody I've known 30 years," he says, which alleviates the worry of dealing with new patients he has to screen as potential narcotics seekers.

With stress and burnout being a major concerns in practicing medicine, DPC is one option for physicians to change their day-to-day routine while reigniting their love for medicine.

And while the morale numbers are disturbing, they are actually better than in 2012, when more than 68 percent of all physicians reported negative morale, according to the same Physicians Foundation study.

Some DPC physicians do find that it replaces one stress with another, however. Internist Inaam Schneider, MD, based out of Raleigh, N.C., says the stress of running a private practice drove her out several years ago.

"I had up to 3,000 patients and seven employees and still found it difficult to make enough money to survive," she says. "I was extremely tired, maybe sleeping six hours a night."

Schneider also struggled to keep up with medical records and doing complete work-ups on patients in the allotted 15 minutes in her schedule. She says she had to see that many patients each day just to keep her office doors open. "You end up getting behind [on charting], tired and irritable," she says. "The physician is becoming just a referral specialist and there's no enjoyment in practicing."

Less than a year ago, however, Schneider opened a direct primary-care practice Raleigh and is working on a fellowship in integrative medicine, which she expects will help attract patients.

"You do replace it with another kind of stress in that you need to recruit patients, but this is much better," she says. "You have to put yourself ''out there,'' but that's my personality anyway."

Elise Fulsang, MD, also recently started up a DPC practice in Waikoloa, Hawaii after practicing as a hospitalist.

"I was coming up on 57 and the realization comes upon you that the 12-hour shifts aren't something that can be sustained long term," Fulsang says. While she now enjoys spending up to two hours with patients, she worries about whether she'll be able to build up enough of a patient panel to make a living. To set up her new practice, she has cut into her personal emergency fund. She also has the unique Hawaiian economy to contend with, including high prices for office furnishings and difficulty getting discounted labs and drugs for patients, she says.

"I'm no longer burned out, but I am scared," she says. To get the word out about her practice, she's given talks to a local rotary club and has made connections with vacation rental landlords about providing care for short-term guests.

For Lisa Larkin, MD, starting a DPC practice near her formerly long-time practice in Cincinnati, Ohio helped her get up and running quickly. After the first seven months, her practice was up to just under 800 patients in February for herself and two employed providers, a physician and a nurse practitioner. She's aiming to close the practice at about 1,200 patients.

"My two providers hands down will tell you the stress level is vastly better now," she says. Larkin originally sold her practice to an academic center, then continued working there until she tired of the bureaucracy.

"Of course, [her employees] have the security and I have the debt. But if you take away the financial pressure, the truth is professionals are passionate about what they do and at the end of my day I feel like I'm doing a better job than I was before. Instead of seeing 26 patients a day, I'm seeing about 16. I would stop practicing altogether before I'd go back to doing it the old way."

Clint Flanagan, MD, founder and CEO of Nextera Healthcare, a DPC practice with several locations, still runs a Colorado fee-for-service practice in addition to Nextera. He says his worst days in the DPC practice are better than his best days in fee-for-service family medicine when it comes to stress and overall satisfaction.

"You enjoy relationships with your patients and you are not wasting your time, and wasting time leads to more burnout than anything," he says. "It puts the physician back in charge."

Articles

Feeling burnout symptoms, physicians nationwide are changing their practice models to subscription-based clinics.

Physicians Find Relief from Burnout in DPC

After 11 years as part of a group family practice, Michael Iannotti had earned top marks from payers for his ability to demonstrate quality measures, but was frustrated that not everyone in the group shared his zeal for documentation.

"Physicians don't like all these new quality metrics, and the hospitals and government agencies that hire the physicians aren't good at it, either, so they end up losing a lot of money on employed physicians," he says. "I decided to create my own practice and participate proactively to get my quality measures to where they needed to be," he says.

Iannotti also knew that eventually he wanted to own his own medical building and didn't particularly care for the one he was practicing in, so the Lafayette, Colo.-based family practitioner decided to go solo last year. Not only did he go solo, but this fall he's launching a concierge practice in addition to his separate fee-for-service aesthetics practice.

More and more physicians can relate to the need for reinventing the primary-care model. In the most recent Great American Physician (GAP) survey, more than two-thirds of the 1,314 physician respondents say they would consider switching to a direct-pay practice that doesn't accept insurance, they already have switched, or are planning to make the change.

A year earlier, responding to a similar but not identical question, 43.2 percent said they were considering a direct-pay practice and 10.3 percent said they were planning to switch or already had.

The surge is exacerbating an already serious shortage of primary-care physicians in employed situations and traditional fee-for-service practices, says Jim Stone, president of The Medicus Firm, a Dallas-based physician staffing and recruiting firm.

When a physician decides to open a concierge or direct-pay practice, it typically involves slicing off a small portion of patients, creating a service void that either a hospital or practice must back-fill, Stone says. He says his firm has also been hired directly by physicians transitioning to DPC to find physicians willing to take custody of medical records and bring in patients not coming to the new practice.

"In internal medicine we used to have a third of residents go on to specialize in pulmonology or other fields and two-thirds went into practice. Now, the reverse is true and we further slice up the primary-care area with hospitalist, concierge, or other non-traditional models, so it's gone from bad to worse [with regard to the shortage of primary-care physicians]," he says.

Physicians working in these new models, however, say they are thrilled to be more in control of their practices, are making more money than in their previous practice or expect to shortly, and are hearing from patients that they love the change.

"I'm no longer beholden to the 'meaningless abuse' model of checking boxes" to fill out payer codes, says Denver family physician Michael Keller, referring tongue-in-cheek to his thoughts on Meaningful Use standards. "It really frees you up again to enjoy the practice."

At a July conference in Kansas City on direct primary care, hosted by the American Academy of Family Physicians, keynote speaker and a DPC family practitioner Julie Gunther noticed many attendees were physicians still part of traditional practices and only beginning to contemplate making a change. Typically, DPC practices charge monthly fees that cover most primary-care services and they don't take insurance, as opposed to some concierge services that combine fees and third-party payments.

So, during some downtime the first night of the event, she grabbed a microphone and asked two other DPC doctors to join her for an informal Q&A session.

"We had 40 doctors sitting there for three hours," she says. "We finally had to cut it off. There are some hitches in the giddy-up, but what we do is so simple and sometimes [physicians] are made to think this is so complex. It's amazing what you can do with a stethoscope, an iPhone, and a brain. And it's neat to see these docs have micro-epiphanies, realizing they can be the kind of doctor they want to be."

Though Iannotti's model is more complex, combining some aspects of traditional insurance payers, concierge, and direct pay, the sentiment of finding a more fulfilling practice type reflects his professional and personal goals.

"First and foremost, I wasn't satisfied professionally with my income or my job," he says. "I wanted life for my kids, my patients, and me to be better. I wanted money to eventually be able to send my kids to college, time to play a round of golf twice a month, and a better environment for my practice and my patients. All of that played a role" in his decision to start a new practice, he says.

For Gunther, dissatisfaction and burnout also drove her decision to make a change two years ago. While employed, she recalls one particularly grueling day when she saw 17 new patients. There was also the day when a trusted, highly skilled nurse quit to join a much slower-paced practice, and was later replaced by a very inexperienced nurse.

Routinely, the practice ran out of supplies that weren't reordered until she made a fuss. She even changed a few light bulbs in the office. Finally, she decided that if she was going to have to do all this herself anyway, she should take charge. "When someone explained that if I would just take insurance out of the mix, then I was able to see a path where I believed I could do it," she says.

Before jumping ship like Gunther, however, physicians need to be aware of some barriers to entry and some significant risks:

While many legal experts today say non-compete agreements aren't holding up in court, it can still take resources to fight the battle, says Gunther, who had to give four months' notice when she left her traditional practice. So first, realize the process of shifting gears could take some time, during which you may need to moonlight or seek some other temporary income stream.

Walking away from a guaranteed or RVU-based salary takes some guts, so being at least a little risk tolerant is essential, experts say. At the time she launched her direct-pay practice two years ago, Gunther still had about $170,000 in medical school loans left to pay. Today, that's down to about $100,000.

On top of loans, there is the common need to borrow funds to start a practice. Gunther was able to secure a Small Business Administration loan to buy her office building, which she's partially renting out to other professionals while she builds out her practice.

To mitigate risk if funds are extremely tight, she says, consider starting out small by renting space in a medical complex and moonlighting to supplement income for a while.

While direct-pay practices typically reduce a physician's panel size, they don't necessarily create bankers' hours. Most DPC practices strive to offer same-day or nearly same-day appointments, and many offer weekend and evening hours.

Keller, who switched to a direct-pay practice, Summit Primary Care, in October 2015, says he's on call 24/7 and schedules patients six days a week, including two evenings.

"The difference today is that I'm seeing six to 12 patients a day, not 30," he says. "It's much more manageable." He also says his practice growth rate was roughly twice what he expected when he started it. About 10 months into the venture, he had more than 600 patients, but says non-emergency after-hours calls are rare because patients typically feel they are getting all their questions answered in their office visits. Keller charges $89 a month for adult patients that are 27 and older, and $59 a month for younger patients.

Unlike Iannotti, Keller focuses exclusively on the direct-pay model, so he doesn't have to pay for any staff time to work with insurance companies. His wife, Audrey, works for the practice as a part-time practice manager and he employs a medical assistant who helps him room patients, among other routine tasks. When not with a patient, however, it is typically Keller at the front desk greeting people who come into the office.

"I've found patients really like that," he says. "You have to keep overhead down."

Gunther bought her office building and employed a second physician for the practice before taking a salary for herself, but says both moves have already paid off because the building has appreciated and the other physician is picking up the patient load she can't handle right now.

Meanwhile, she watches the smaller expenses closely. She purchased office equipment at discount retailers, for example, and counsels physicians who can't afford to purchase their buildings to shorten their leases from three years to one or two.

"There are opportunities to just hemorrhage money doing this,'' Gunther says, so take a pass on equipment leases if it's something you can purchase cheaply at a warehouse store.

• Detailed charting won't be left behind. 

Despite the considerable reduction in staff time devoted to billing third-party payers for services, physicians can't throw away those EHRs, experts say.

"I'm meticulous about charting and want complete family histories in the record, both for medical and legal reasons," says Keller. "But without having to worry about checking boxes on ICD-10 codes, I get a thorough note that clearly says what is happening with the patient."

Physicians switching to a direct-pay model need to be aware that fast growth doesn't always occur, says Gunther. "I had a business person tell me half of all businesses fail in the first year and that if you make it through the third year, you'll probably make it," she says. "So I tell physicians to plan for three years how they are going to survive if the business isn't profitable. Having that in place decreases the startup stress and the likelihood you'll scalp your mission to make more money, which can compromise you."

. She may be reached at editor@physicianspractice.com

Direct primary care practices are growing in popularity, according to this year's GAP Survey. Why is that the case? 

Why Physicians Are Embracing DPC Practices 

When it comes to investing, doctors are notoriously active traders. Who among you doesn't know a day-trading radiologist or an orthopedic surgeon who speculates in farmland?

John Kidwell, a Dallas dentist, was no different.

By his own account, he fumbled around with various brokers and financial advisers over the years. There were limited partnerships. There were oil and gas deals. When the tech bubble burst at the end of the '90s, he lost half of his savings.

"It seemed like everybody but me made money," said Kidwell, 65, referring to the advisers he paid along the way. After the 2008 financial crisis, he quit working with investment managers altogether, but didn't love the idea of a completely do-it-yourself role.

If the new realities of physician compensation and the old ways of dealing with investment advisers and brokers have left you nervous about having enough for a comfortable future, it might be time to look for a new path.

First, some good news: Just as online trading and discount brokerages cut transaction fees more than a decade ago, costs for broader portfolio and financial planning advice are dropping, even as regulators beef up the standard of care many advisers must take with customers. And there are more options than ever for choosing the way you want to interact with an adviser, whether that's over filet mignon at the hottest restaurant in town or in your bunny slippers at 4 a.m.

The challenge is finding the right type of advice while staying aware of whatever caveats come with your choice.

Today, Kidwell's financial advice team includes an accountant who specializes in private practice issues, an investment adviser who recommends exchange-traded funds and index mutual funds with rock-bottom expenses in his IRA, and a so-called robo-adviser, Betterment, for managing his taxable savings account.

Digital investment managers - from independents like Wealthfront and Betterment to industry mainstays Charles Schwab and Vanguard - hold a portfolio of mutual funds or exchange-traded funds, rebalance it automatically without involving you, and typically charge much less than the standard industry practice of 1 percent of assets under management, plus investment costs for a face-to-face adviser. Wealthfront charges 0.25 percent of assets per year, and Betterment comes in at 0.15 percent for accounts above $100,000.

Schwab has a digital platform that charges no advisory fees at all, though the company makes money on customers' cash and underlying investments. Vanguard and other services, including Personal Capital, mix in live advisers, typically via phone.

Mainly targeted to younger investors with modest assets, the digital investment world is beginning to branch into higher net worth and older customers.

Betterment, for example, which says a significant number of its customer base is 50-plus years old, offers a draw-down strategy for retirement income as part of its service.

Kidwell happened to be the childhood dentist of Jon Stein, Betterment's founder, and chatted up the startup entrepreneur about the service before signing on.

"I've had [live advisers] who held my hand before, and they panicked, too in market downturns," Kidwell said. "What appealed to me was being able to pick the risk I wanted to take and then not think about it very often."

Robos don't pump and dump stocks, trade rapidly to run up commissions or, go on vacation just when you wanted to talk about your plan.

The autopilot approach isn't for everyone, however.

"I wonder about the [robo-adviser customer] when he logs in and sees the market down 30 percent," said Andrew Sloan, founder of Bluegrass Financial Planning, a Louisville, Ky.-based fee-only financial planner. "There's tremendous value in face-to-face communications, particularly when you're getting close to retirement."

Beyond the hand-holding issue are other shortcomings. Most online wealth managers ask fairly rudimentary questions about your risk tolerance, for example. Particularly for physicians, many of whom get a late start on saving and have atypical needs for asset protection, that could be a problem.

And robot or no, some advisers won't or can't advise you on your total investment picture. If half of your savings is inside an active 401(k) plan, for example, a digital manager might not have the capacity to "see" inside your institutional investments in the plan. Or a live adviser might be unwilling to advise you on the 401(k) assets because he or she is only being paid a percentage of your investments outside the company plan.

So, how to find the adviser - human or otherwise - that's right for you?

Doctors rarely get too far along in their careers without being pitched or getting a recommendation for someone to manage their investments. Rather than hiring the first person who asks - even if you check the person's background - consider instead starting with creating a profile of the services you're trying to buy.

Are you looking primarily for investment management, or do you want comprehensive advice on tax planning? Are you getting close to retirement and wondering when to take Social Security benefits? Planning for your kids' college but still digging out of medical school debt and need help prioritizing?

For more comprehensive financial planning, a couple of websites have online directories of advisers, with either short biographical information or links to individual websites. Check out the National Association of Personal Financial Advisors (

Asking the same questions across a few different advisers will give you a sense not only of their communication skills, but also how their practice models work. Ask to see a sample client statement (names removed for privacy) for someone with a portfolio of a similar size and with goals similar to yours, such as saving for retirement.

As you review the alphabet soup of professional designations for each, be aware that some of them garner substantially more respect than others. Top designations include Certified Financial Planners, Personal Financial Specialists within the Certified Public Accountant community, and Chartered Financial Analysts.

Once you've narrowed the herd to a few top candidates, it's time to check out their backgrounds.

The Financial Industry Regulatory Agency (FINRA), an industry self regulator, earlier this year launched an advertising campaign urging more investors to use its BrokerCheck website (

). It also asked the Securities and Exchange Commission to require brokers to post a link to BrokerCheck on their websites.

While FINRA regulates broker/dealers, often called registered representatives, BrokerCheck automatically routes users who input financial advisers' names to the SEC's Investment Advisor Public Disclosure site. State securities and insurance regulators also maintain disciplinary records. Check out 

Make sure you understand the adviser's business model, advice offered and not offered, and payment schedule. Be aware that even comprehensive financial advisers can have subtle conflicts. Even with a fiduciary obligation, some industry observers have pointed out the potential for conflicts if, for example, an adviser who gets paid based on assets under management can be truly objective about advising clients whether to use those assets to pay off debt or purchase insurance.

That's why some advisers work solely on a retainer or hourly basis. If you're a higher net worth client considering working with an adviser who takes a percentage of assets every year for the same service he or she provides to clients with smaller portfolios, it's completely fair and appropriate to question the payment model and negotiate fees. Often, this conversation brings out the services your adviser truly provides - and the ones you're willing to pay for.

is a freelance writer based in Marshfield, Wis. She holds a bachelor

's degree from the Medill School of Journalism at Northwestern University. She can be reached at 

This article was originally published in the January 2016 issue of

Finding the right professional to guide your financial future can be tricky. Make it easier with these tips.

Select the Right Financial Adviser

Finding the right professional to guide your financial future can be tricky. Here are some ways to make it easier.

1. Don't search solely for an adviser who only works with physicians. You want someone familiar with clients like you, but you're more than just a physician. Say your spouse is a corporate executive with stock options or a defined benefit pension, or you want to blend your emotional values with your financial plan - there's an adviser for that. One example: Check out 

2. Ask to see a potential adviser's letter of engagement well before you intend to sign on the dotted line. Compare it with the other finalists. Does it acknowledge a fiduciary duty to put your interests ahead of the firm's?

3. If you're interviewing a financial adviser who is paid a percentage of portfolio assets annually, ask for a typical weighted expense ratio of the underlying mutual funds or exchange-traded funds used in portfolios. Then once you are a client and have designed a portfolio, ask again for your all-in fees and expenses in addition to the advice fees.

4. If you're within 10 years of retirement and envision working with this person ideally for the rest of your life, ask about his or her retirement income plans. Does he have one? Is it a ballpark rule of thumb, a robust decision-rules method or a computer algorithm-based strategy? The retirement of the baby boom generation has spurred a flurry of research on dynamic withdrawal strategies aimed to more surely survive even a very long lifespan. Make sure your adviser has a strategy for this.

Not all financial advisers are created the same. Make sure to do your due diligence before you commit to a working relationship.

Financial Advisers for Physicians: Select the Right Fit

By now, you've been told countless times to get tougher about patient collections. Are you doing it the right way?

U.S. Supreme Court decision upholding premium subsidies on Affordable Care Act health insurance plans alleviates some concerns about patients as payers, experts say, but high deductibles, larger copays, and mounting system costs are putting significant pressure on patients at a time when they are becoming a larger share of your payer mix.

"With average deductibles between $3,000 and $8,000, you have to change the dynamics of how you interact with patients and be aware that what used to work doesn't anymore," says Chuck Seviour, vice president of revenue cycle consulting with Array Services Group.

If the reform law's premium subsidies had been disallowed in certain states, experts feared system costs would have strained remaining participants even further and millions more would go uninsured. And the more stressed patients become, the less likely physicians are to receive their fees for service.

However, even before the reform law, workplace cost sharing, and the growth of high-deductible plans, internist/pulmonologist Thomas Horiagon regularly dealt with high rates of patient defaults on copays. Today, he operates a time-based, direct care practice, and says patients almost always pay the bill on the spot or within a few days.

"I have a very low overhead model, and everyone understands it is payment at the time of service," he says.

Setting patient expectations is more than half the battle, practice-management consultants say, but there also are a few intangibles to keep in mind.

Chief among them is the value created by support staff members who understand the importance of collections, but also how to deal with patients as customers, says Shep Hyken, a customer service expert and author.

Hiring generally positive people in roles that interact with patients is a given, but spelling out in detail the right words to use in a first encounter is critical in training new staff, he says.

Rather than bluntly asking a patient if her insurance is an exchange plan, for example, make sure that information is already included in her file. Then, the front-desk staffer can begin the conversation with "How would you like to take care of the bill today?" or, "Any changes in your insurance since last time?"

"The doctor's office needs to get paid, but the front-desk person needs to be trained in how to ask the question the right way," Hyken says. "If the questions you ask patients make them feel like second-class citizens, that's a problem."

Hyken once counseled a hospital chain client that was having problems finding nurses with a patient-focused attitude.

"They had made promises to patients and marketed themselves as an organization that was putting patients first, and they knew if they hired the wrong personalities it would erode everything they were working for," he says. "The outcome was they shut down a floor of the hospital for a short period while they waited for the right people. Now, that's extreme, but it showed they were serious about treating patients like people and not a number on an insurance form."

For jobs dealing directly with patients, Hyken advocates using behavioral-style assessment questions in the hiring process to identify candidates with more outgoing personalities.

Regularly talking about positive ways to talk with patients about their bills is also a must, he says.

"Take 15 minutes once a week and introduce, one at a time, a few things everyone is going to focus on that week," in terms of making patients feel good about their office experience, he says. Over time, those lessons get ingrained and become automatic to staffers, he says.

At Michiana Hematology Oncology, PC, in northern Indiana, financial counselors on staff are trained to approach patients with the mindset that efforts to more efficiently take care of payments is a benefit, not a negative, says central-billing office manager Lori Fleischauer.

"We don't want patients stuck with an ever-growing bill, so we approach this as a way to protect patients," she says. Knowing upfront that a patient might have difficulty paying can also alert staff to help direct him to possible community resources that can help with cancer care, she says.

Beyond the feel-good factor, practices need to also pay closer attention to the realities of increasing bad debt, notes Ron Calhoun, managing director for healthcare risk management consultant Aon Health. "Providers are having to shift their revenue cycle strategy from a payer-centric model to more of a consumer-centric one, and there are enormous structural challenges to that," he says. "Practices never really had to present an accurate payment methodology on the front end because the percentage of the bill consumers had to pay has historically been very low."

Complicating the timeline for making those changes are a host of other requirements, such as meaningful use of an EHR, that are often taking precedence over billing system upgrades, he says.

Even so, there are some strategies you can implement in your practice now to increase patient receivables:

Bringing on a vendor who can take over or at least streamline the patient payment process might be worth considering, but understanding the responsibilities as well as the costs is a must, Calhoun says.

"Understand precisely what the [vendor's] business model is because the risk profile for the provider changes dramatically based on what kind of payer they are working with," he says.

Some firms, for example, buy patient debt completely, with no financial exposure remaining with the practice, he says.

Those can be expensive - in the form of heavy discounting on collections - and certain not-for-profit providers could find themselves in a position where their tax status is jeopardized because they didn't offer a wide variety of financial options, he says.

"I recommend providers have a very clear understanding of potential regulatory exposures" before choosing how to handle consumer credit in the office, Calhoun says.

Also verify if the terms are, indeed, beneficial for your patients, notes Elizabeth Woodcock, a medical practice consultant and author.

"Quite often the companies are reticent to work with patients who really need credit," she says. "Make sure it really is a solution" in the best interests of patients, she says.

 Getting your billing system to the point that you can reasonably estimate a patient's bill at the time of service is a must, says Woodcock, as is collecting copays. Higher performing practices go even further, she says, collecting coinsurance and charges due to unmet deductibles at the point of service.

Another must-do is verifying patient insurance coverage and benefits eligibility, Woodcock says, to avoid getting trapped in an insurer's grace period and having claims denied.

Woodcock believes claim denials by insurance payers will double in the fourth quarter amid ICD-10 implementation, particularly in imaging and ancillary services.

"More claims are going to be denied, and patients are going to experience the trickle-down," she says. "It's all the more reason to be transparent from the beginning and collect patients' payments at the time of service."

Woodcock also recommends meeting with malpractice insurers to understand clearly the protocol for terminating patients who fail to pay. Make sure the standards are applied uniformly across all patients and if you require minimum deposits, be sure those are the same for all patients, too, she says.

 Finally, don't forget some basic education regarding the terms of new insurance plans often falls to physicians and practice staff.

"You have to make sure patients understand they have an obligation to pay, but also that they understand in today's world what a deductible even means and how that's different from a copay," says Seviour.

is a freelance writer based in Marshfield, Wis. She holds a bachelor's degree and master's degree from the Medill School of Journalism at Northwestern University. She can be reached at editor@physicianspractice.com.

This article was originally published in the November/December 2015 issue of

Practices must explore new collection strategies for patients with high-deductible plans that require more financial responsibility.

Overcome Exchange Health Plan Payment Challenges 

In a broad survey of U.S. physicians by Merritt Hawkins in 2014, nearly 42 percent of those surveyed aged 46 and older said they plan to accelerate their retirement due to current changes in the healthcare industry. In the same survey, more than 55 percent of physicians reported their current morale as somewhat or very negative.

Numbers like those suggest some physicians could be rushing for the exits before their retirement ducks are in a row, which can lead to some regrettable outcomes, experts say. Among them: nest eggs that are too small or too heavily invested in risky assets, missed opportunities for disposing of practice assets, and depression resulting from a lack of purpose once work ends.

Ophthalmologist Arnold Pearlstone retired nearly five years ago at age 80, not because he failed to plan for retirement, but precisely because he planned so well for so long.

He and his practice partners started up a 401(k) plan decades ago when the concept was still new, and Pearlstone learned all he could about investments.

"We were all pretty conscientious about saving and we really had a pretty good amount put away, so we didn't have to worry," he says.

What did concern him was how he was going to spend his time in retirement. He loved practicing medicine and knew he wanted to do it as long as possible.

And so 23 years ago, about the time many people start retiring, Pearlstone and his wife, Marion (now deceased), established a foundation they called Eye Care for the Underprivileged. Through that foundation they received donations in addition to their own and established a clinic in Jamaica while Pearlstone was still actively practicing.

"I didn't limit the foundation's scope to Jamaica, because I thought I might one day need it for other clinics I wanted to open," he says. "I didn't know what I was going to be doing, so when I set up the fund I left it open-ended in case later on I wanted to volunteer and needed to purchase equipment."

Sure enough, as Pearlstone finally started winding down his practice, he contacted AmeriCares, a humanitarian aid organization. He began working at an AmeriCares free clinic in Bridgeport, Conn., two weeks after he retired in 2010, taking most of his office equipment with him and donating it to the clinic. Later, he used money from his foundation to add equipment to other AmeriCares clinic locations. He keeps his Connecticut medical license current with 50 hours of continuing medical education every two years.

"My advice is to not just quit when you retire," he says. "Find someplace to use those skills where they can make a difference. It's good for you to keep the brain going."

As for the more practical aspects of retirement planning, getting going on those is equally important, experts say.

"Start early, because everything seems to take longer than you think it will," says Roy Bossen, a partner at Hinshaw & Culbertson LLP, with experience in medical office sales and acquisitions.

Increasingly, finding a junior partner willing to buy you out and continue the practice as it was is a rare find, Bossen says. Instead, you might have to consider a multi-year process where you join a hospital network for a few years at the end your career.

"If a hospital really wants a physician, it will often assume the lease or buy the building as part of the transaction," says Bossen. "They won't pay more than fair-market value," but having that obligation off your plate before you retire could be worth it if finding and keeping a tenant is difficult in your market, he says.

"These are issues you want to resolve going into a lease, not out, but if you're in a lease, for example, be aware that you may have to go to a condo board to get a tenant approved," he says, which can mean more delays and missed opportunities.

Near the end of his career, Pearlstone was the last of four partners in his office. He assumed the patient records of two colleagues who were retiring, closed down the office, and rented a new space from a friend who had another practice nearby for the last few years of practice. That doctor then paid Pearlstone a small fee for the patient records, which offset a portion of his rent, he says.

Preparing your nest egg to begin pumping out income at retirement is also a process that can take some time. A significant market correction in the first few years of retirement could doom an income system that relies on an initial withdrawal rate with automatic yearly increases - the oft-cited "4 percent" rule.

Be aware that because of stock market valuations and the low-yield bond market, projections for returns in coming years have market experts saying a more realistic safe withdrawal rate could be more like 2.5 percent to 3 percent.

If you're concerned you might not have saved enough to make it through retirement with just a systematic withdrawal plan, longevity insurance - or fixed deferred annuities - are beginning to be introduced for retirement accounts by insurers including The Principal and MetLife.

Recent federal regulations paved the way for these policies, called qualifying longevity annuity contracts (QLAC). Inside retirement accounts, the annuities allow owners to defer required minimum distributions on the amounts invested in the annuities.

Also, think strategically about how you want to receive Social Security income. You can now get an 8 percent bump-up in monthly benefits for every year you delay claiming benefits past full retirement age, up to 32 percent at age 70. Do this first before purchasing longevity annuities because it's the cheapest annuity available, many financial advisers say.

It's important to reconsider your risk tolerance now that retirement is looming. A decade before he retired, Pearlstone says he began shifting his savings to more fixed-income investments and away from stocks.

"Today I'm about two-thirds in income investments and one-third in equities," he says, noting that he spent considerable time throughout his career learning about financial planning and investments.

If you haven't put in that much time and don't expect to, at least thoroughly check out the financial adviser you plan to use to help tap your nest egg. Online financial management services such as Personal Capital and Betterment are beginning to offer retirement spend-down strategies.  They do so for a fraction of what traditional advisers charge - and they won't approach you with obscure land deals only available to "accredited" investors.

is a freelance writer based in Marshfield, Wis. She holds a bachelor's degree and master's degree from the Medill School of Journalism at Northwestern University. She can be reached at 

This article originally appeared in the October 2015 issue of 

With a large number of physicians planning to retire in the next few years, it will be important for them to plan ahead before hanging it up. 