Get Big: Evolution of Success

March 1, 2006

Think your practice will always be small and struggling? That's what these practices used to think. But with hard work and innovation, they grew ... and grew ... and grew. Now they're frontrunners in their communities - and they have the power that goesalong with it.


George Bernard Shaw once said, "The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man."

Old George was right. So we thought we'd introduce you to some of healthcare's most unreasonable visionaries: Hal Teitelbaum didn't like the way physicians were being squeezed out of the equation in the new world of managed care, so 12 years ago he set out to build a new kind of healthcare delivery system. James Dove decided the best way to provide cardiac services in rural Illinois was to build one of the largest, and finest, heart care centers in the country. And Michael Janssen thought it would be fun, if revolutionary, to create a spinal care center that's a whole lot more.

Each concluded that in the new world of healthcare, the surest way to control your fate is to get big enough that you can't easily be pushed around. Each took big, but not foolish, risks, and each followed his passion.

Why tell you their stories? Because you could be next.

CRYSTAL RUN HEALTHCARE:
GROWING FOR SURVIVAL

When Hal Teitelbaum started his solo hematology and oncology practice in Middletown, N.Y., in 1982, he had to borrow $100,000 just to finish and furnish the office space he rented. "It literally had a dirt floor and no partitions," Teitelbaum remembers.

Hiring staff, buying equipment, and building a business all seemed like daunting tasks, and Teitelbaum worried about failing. "I asked my father what would happen if I didn't meet [my financial] projections, and he said, 'Well, you'll go bankrupt. But we won't let you starve.'"

Teitelbaum took the risk and didn't go bankrupt. In fact, his practice, Crystal Run Healthcare, grew - to seven offices with a total of more than 200,000 square feet to finish and furnish. "We are to my knowledge the fastest growing medical practice in New York state, and probably one of the fastest in the country," says Teitelbaum.

That wasn't the idea when he started. Having worked at Memorial Sloan-Kettering Cancer Center and Albert Einstein College of Medicine, Teitelbaum never thought he would end up working in a large practice. "I think that many physicians are sort of independent; they're not used to playing well in groups," says Teitelbaum. "The typical thing that you'll hear from physicians if they have a bias against larger group practices is, 'I want control.'"

Tired of the bureaucracy and worried that an academic setting wouldn't allow him as much freedom, Teitelbaum opened his own offices and was joined two years later by a former colleague from Sloan-Kettering. For the next decade they kept the practice small, with just two partners.

Ironically, the same desire for control pushed Teitelbaum to grow his practice. The rise of managed-care organizations and physician-management companies in the early 1990s convinced Teitelbaum that doctors were being squeezed out of medicine. External decision-makers were controlling how patients were treated, when they could be referred, and who they could be referred to.

Teitelbaum wanted to be able to refer his patients to competent physicians - but even when he found them, he still had trouble scheduling appointments. "Many physicians then, and some still today, measure their success by [how long] it takes to get an appointment with them. I would argue that's a measure of their failure."

NO MORE OUTSOURCING

With healthcare growing more bureaucratic and dominated by managed care, Teitelbaum felt he wasn't providing patients the best possible care. "It would be like BMW or Porsche saying, 'We build the best cars in the world - but, by the way, we outsource all the engine parts.' That's kind of what we were doing. We were outsourcing engine parts to the local cardiologist, the local gastroenterologist, the local everybody. The bottom line is you cannot provide your patients a quality experience if you do that."

Teitelbaum decided the only way to provide quality care was to expand from a two-person oncology practice to a larger practice with many subspecialties. He says his decision to grow was not financial but personal.


"This was not an issue of dollars and cents for us. At that time, in 1994, I was 42 years old, and I said, 'I have a long career ahead of me. Am I going to be happy being told how to see patients, who I can refer to, when I can refer, and dealing with these sorts of things?'"

Crystal Run Healthcare worked up projections and hired a practice management consultant, but few practices had ever done what they were imagining. "The consultant probably gave us more courage than knowledge," admits Teitelbaum. "We literally said, in 1994, that we thought that in the next 10 years we should certainly have more than 100 physicians in the practice."

The consultant thought it was an ambitious goal but a great idea. "It gave us hope - maybe false hope, but hope nonetheless," says Teitelbaum.

In 1994, the practice hired three physicians - two oncologists and a cardiologist - and quickly ran into a problem faced by many subspecialty groups that decide to grow locally: Referring practices began to boycott them. "[We] broke the first rule of medicine: you're competing with your fellow physicians outside your own specialty. Who knows what they'll do next?"

The practice's income dropped 50 percent in that first year, but this setback only spurred Teitelbaum forward. "Once we were being boycotted, the reality of having to bring primary care in was that much more obvious," he says. "If the referring physicians were no longer referring, then we clearly needed to have our own referring physicians."

Crystal Run aggressively sought primary-care physicians while continuing to grow its subspecialty base. The gamble paid off, and the group surpassed the goal it had set for itself a decade ago. Crystal Run now has about 130 physicians and another 15 to 20 midlevel providers. It is the largest primary-care provider in the region with services ranging from pediatrics to geriatrics. It is also the largest OB/GYN provider in the area and the largest provider of subspecialty care in internal medicine. It has more than 700,000 patient visits each year.

Still, the group continues to expand. Just last year it opened a new 81,000-square-foot office in nearby Rock Hill, and in the past 18 months it has started adding surgical specialties to the group, including orthopedics, general surgery, and ENT.

Although Teitelbaum no longer sees patients on a regular basis, he has no regrets about expanding the practice. "I look at it that I'm still practicing medicine, I'm just doing it on a much larger scale. With the physicians who work here, and the nurses and the midlevels and all the people who work here, I am practicing medicine on a much, much, much larger scale."

PRAIRIE CARDIOVASCULAR CONSULTANTS:
GROWING FOR QUALITY

It's been a year since James Dove stepped down from the nationally acclaimed heart care center he brought to life nearly three decades ago.

And now, as he pauses to reflect on the latest chapter of Prairie Cardiovascular Consultants, he is struck by an almost paternal sense of pride. The commitment to quality medicine and personalized care he fought so hard to establish at the Springfield, Ill.-based practice remain firmly in place, embraced and encouraged by the next generation of leaders he left behind.

It is Dove's legacy - and, perhaps, his greatest accomplishment so far.

"It was important to me personally that the practice continue to do extremely well after I retired," says Dove. "That was as much my responsibility as being involved in its growth and development. Our transition played out extremely well. Dr. Frank Mikell [the new president] is doing a superb job."

Indeed, Prairie Cardiovascular has become a well-oiled machine.

Now 280 employees strong (42 of them board-certified cardiologists), Prairie operates 28 clinics throughout central and southern Illinois and ranks among the most highly regarded cardiac centers in the country. The clinics, which include both fully equipped hub locations and smaller outpatient facilities, offer a range of treatment from basic consultation and diagnostic services to cardiac catheterization and stenting - treating nearly 100,000 patients per year.


Under the leadership of Mikell - a cardiologist groomed for the top spot for five years - Prairie continues to engage in cutting-edge research. And still today, the treatment of each patient is coordinated through a single physician and nurse who make it their mission to address both the medical and emotional challenges of heart disease.

"Jim Dove has provided excellent leadership over the years, and they have built a very strong model of cardiology in their community, with programs caring for folks in small-town Illinois outside their circle in Springfield," says Vincent Bufalino, president and CEO of Midwest Heart Specialists, a private practice cardiology group in Chicago. "They, like our group, have been aggressive with their electronic medical records and quality monitoring."

HUMBLE BEGINNING

Like any thriving business, however, success did not happen overnight. Motivated by the need for state-of-the-art medicine and compassionate, personal care in the rural Springfield suburbs, Dove opened his first office in 1979 with a secretary and longtime nurse Annie Alms. Through the local hospital, he was able to offer patients everything from cardiac catheterization to stress testing and open-heart surgery. (That was before the days of angioplasty, which dominates the business today.) It wasn't long, however, before Dove felt the itch to expand.

"When you start out practicing medicine you want to do good things for the patients you're seeing personally, and then you realize you could do more if you had additional partners who could help you do good work," he says. "Then, you realize with a larger organization you can offer a higher level of service, and then you realize it'd be nice to do research. It continues to grow as you develop manpower and capacity and there's a satisfaction with each new step."

Early on, he notes, the plan was to add one physician per year - a strategy predicated on manageable growth. But as the field of cardiology evolved, so, too, did Prairie Cardiovascular.

"In the late 1980s and early 1990s, cardiology transformed into a specialized field," Dove says. "We suddenly needed to recruit specific doctors, like electrophysiologists, heart failure specialists, those trained in echocardiology, and now peripheral vascular disease and angioplasty. We finally realized that adding one person each year was not going to be satisfactory. Our growth was much faster than we expected it to be."

The biggest challenge facing Prairie Cardiovascular today is recruitment. At a time when cardiologists are in short supply, the practice struggles to compete for top doctors with other cardiac centers in more glamorous locales. Yet, the reputation of the ever-growing practice and its patient-first philosophy resonates with many who are willing to forgo big-city culture and beachfront offices.

"Many trainees still want to go into an academic setting or stay at a training hospital where they can teach and do research," Mikell says. "The best way we are able to recruit is our strong reputation for quality, and because of our size we do have access to very high-quality state-of-the-art technology. We have that piece in place."

Prairie isn't the only cardiac center struggling to recruit.

Two years ago, a task force under the American College of Cardiology reported the nation is facing a critical shortage of cardiovascular specialists at a time when rising rates of obesity, type 2 diabetes, and a generally aging population are pushing demand for such care higher.

Prairie, named 2004 Practice of the Year by Physicians Practice, also is recognized for its efforts to comply with best-practice guidelines. Five years ago it implemented an electronic medical records (EMR) system to modernize record keeping, improve patient care, and publicize its performance.

"We take it a step further [than most in the industry] by linking into the EMR our quality initiative Web tool," Mikell says. "When we are finished seeing a patient, we go through a Web page that goes through all the guidelines applicable to that patient. It tells us if we have complied with the guideline, and if we haven't, we have an automatic point of reminder so we can address it while the patient is still there."

The system also allows Prairie Cardiovascular to profile the performance of its own physicians, something regulatory agencies and third-party payers will increasingly demand in the coming years.

What's next for Prairie Cardiovascular? Mikell says the practice will begin developing new hub locations, like its new ones in Carbondale and Decatur, with a network of smaller community-based clinics in the outlying rural areas. "We would like to see expansion," he says. "We already cover an extremely large geographic area because of the nature of downstate Illinois, but we are always looking for new opportunities in areas we feel are underserved."


The center also plans to open a new catheterization lab at the Prairie Heart Institute at St. John's Hospital this summer in Springfield, which will allow cardiologists to treat both heart and vascular disease in the same surgical suite.

At the end of the day, Dove says Prairie has developed its own recipe for success: equal parts competence and concern.

"It's really about the close connection with our patients and how their illness interacts with their family," he says. "Many times it's a life-threatening illness and the first time they have been seriously ill. We try to address that and put them at ease by talking to them in their language so they understand their illness. That's an important part of patient interaction."

CENTER FOR SPINAL DISORDERS:
GROWING FOR SUCCESS

At 6:30 one recent morning Michael Janssen, DO, was in one of the well-appointed conference rooms at his 50,000-square-foot private medical campus, noodling over a list of colleagues to help teach an upcoming course. Bantering with Monroe Levine, another surgeon at the facility, they settle on whom to ask, work out some curriculum language, decide they're finished, and move on to their next appointments.

For Janssen, it's a session to talk about how he found himself practicing in a bright, bustling, and prosperous "campus" instead of, say, in a typical three-exam-room suite in a medical office building next to a hospital.

His physical setting, in Denver, is less a campus than a modern, low-slung building of stone and glass. What makes it special is that it is occupied by an unusual, interrelated group of enterprises - a clinic, an outpatient surgery center, a nonprofit learning center, an imaging facility, a research center, and short-stay inpatient facilities - all devoted to spinal and musculoskeletal healthcare. Janssen owns all or part of each of them. Except for the imaging center, he also practices at each. A closed panel of 20 surgeons and a stable staff of specialized nurses, techs, and assistants tend to a steady flow of patients, a few of whom have already arrived at this early hour. Janssen and his partners, in fact, worry about becoming clinically full. There's talk about popping the top of the five-year-old building to make more room.

Michael Janssen, in other words, is a happy man. His practice, his community involvement, even a new friendship with the medical establishment: "I get excited when I think about it. I didn't want to take the path of most physicians of complaining and adapting to the changes in healthcare, insurance, and regulation as they happened," he recalls. It was better "to be a part of (the changes), and help shape them."

In a large general surgery practice in the early '90s, he first broke away to pursue a subspecialty in spinal care. As his own patient base grew into a two-office practice, though, he found himself confronting the same frustrations that drove his peers crazy: Hospital surgical suites inefficiently configured for general, as opposed to spinal, procedures; grudging access to new technology and no chance to do research; ever-changing or unfamiliar teams of nurses and assistants; baffling and expensive bureaucracies; insurance complications; disconnection from the community and patients.

From those frustrations came his vision of an integrated, specialized facility that would let him offer top-tier, cost-efficient care for patients and, in the process, create a challenging and more satisfying professional life for himself.

At the time, in the late 1990s, few physicians would dream of creating a new practice model around a new subspecialty. "Physicians spend so much time learning their craft and their trade that they don't learn about shaping the economy of their environment. It's often said that physicians are the worst businesspeople in the world." Janssen, however, learned about business and risk from his father, "a very successful" retailer and real estate investor in Iowa. "He always said, 'Don't come to me with a complaint; come to me with a solution.'"

It disposed him, he says, to view his career in terms of market as well as scientific opportunities.

HURDLES TO CLEAR

Still, there were many obstacles. "It was a foreign concept," he allows. The city, which owned the land Janssen wanted to build on, feared he wanted just another medical office building or, perhaps, to just make money by later selling off parcels. Insurance carriers worried about patient safety in a privately held spinal surgery center. The hospital next door - called North Suburban, owned by HealthOne/ HCA - worried that Janssen and his new Center for Spinal Disorders would siphon off profitable patients. The relationship was "very adversarial." There were bills in the legislature to effectively ban private surgery centers.

Yet this, he explained, would be more than a clinic and a surgery center. It was to be "a true not-for-profit learning center" where both other surgeons and community groups came to evaluate new procedures, gauge new technology, and get hands-on experience with human tissue. Research would be at its center. "Most physicians," notes Chi Lam, who led the learning center's development, "never get to work with a cadaver after they're done with med school." There'd be classes and even summer camps for kids. There'd be an amphitheater for community groups to use.


And there'd be state-of-the-art, cost-efficient healthcare, provided by what Janssen foresaw as "the best operating room technicians and nurses who really specialized in one thing."

Most of the obstacles, of course, have been overcome, and the campus just celebrated its fifth anniversary. Its surgical procedures, Janssen proudly reports, are priced about 40 percent below those done in a general hospital setting. It is drawing patients from all over the country and, increasingly, the world. A new administrator at the hospital across the street has offered a much friendlier, cooperative relationship. There's even a sharing of technology, and rumors of closer financial ties. "Now it's an exciting venture. We both bring significant value to the community. Physicians bring the patients. Hospitals are good at managing facilities."

This, he believes, is the future: Hospitals not only making peace with surgery centers, but doing joint ventures with them. He sees hospitals concentrating on emergency and trauma care, complex and high-risk surgeries, and on managing patients with life-threatening conditions. Privately owned facilities like Janssen's will manage non-life-threatening illnesses and perform minor surgeries.

"Surgeons visit us from all over, from the U.K. and Asia, to see how to copy this, and I get questions about it on a weekly basis," he says. He also gets calls from "venture capitalists who want to purchase the entire real estate. And I've thought about it, about going back to being a tenant and taking it a little easier. But that wasn't my vision.

"Some things in life," he adds with a smile, "are not for sale."

Robert Anthony, Shelly K. Schwartz, and Bill Sonn are freelance writers. Each can be reached via editor@physicianspractice.com.

This article originally appeared in the March 2006 issue of Physicians Practice.