There are varieties of group practice, the most prevalent one is the multidisciplinary group practice, the other one is a venture where an individual allows his colleagues of same discipline to use the facilities without any financial involvement or a say in the management.
The concept that I am writing in this article is a novel approach to group practice in as much as in this, a group of doctors of one discipline got together to develop a hospital dedicated to the same discipline, with finances involved and equal responsibility in the management.
Why the need?
After working in an individual small set up for 15 years, I increasingly realised the limitations of such a set up, mostly, in terms of restraints of financial resources and man power. Such a set up did not allow you the freedom of movement. Most often it had nothing to do with the volume of work. Even a single sick child in the premises restricted the movements and kept me terribly tied up. Even if not present physically in the premises, it was very hard to dissociate mentally from the premises.
The lack of availability of a genuine, unbiased second look in times of need also weighed very heavily on my mind. The stress of dealing with sick children all alone and the constant demand of their parents started having telling effect, amongst other things, most importantly on my disposition. An element of irritation started creeping surruptiously in to my behaviour. And the risk of stress related diseases escalated as the age advanced.
In a small close set up there is hardly any discussion and the academic ambience is just not there.
And, one more important factor which did apply to me, and I am sure must be applicable to many other colleagues is what happens if your children do not chose medicine as their career. What do you do with your edifice? (This may explain increased number of doctors’ unwilling children in private medical colleges)
And to survive in the present competitive world, specially if you do not “swim along the current”, you have to develop a model which will draw patients purely on its merit and people will send you cases only on this consideration and there will be no guiding forces which rule the “market” today. (Unfortunate but true!) And this is very difficult to accomplish in a smaller set up.
It is said that any chain is as strong as its weakest link. But reverse is also true and in a group you can harness the good quality of one individual and cover up the weakness of one with the strength of the other. One may be a good clinician, another may be good in public relation and the third may have good managerial skills. When you can combine all this in a group it is bound to deliver.
Selecting the members of the group
In various discussions on selection of the colleagues, the oft repeated argument is to have like minded people. This is the most desirable, yet nearly the impossible goal. There are very few like minded people who will be willing to work together. Most often, husbands and wives are not like minded in our country, yet they learn to get along for rest of their lives. I personally feel that like mindedness is an evolving process and as you get along, spend more time with each other and start understanding and respecting each others’ perspectives, the differences slowly start getting diminished and this paves way for becoming like minded.
The basic qualities which I was seeking in my colleagues were sincerity, honesty, transparency, sharpness and the capacity to invest. The mutual faith is the singular most important factor which keeps the group together. One of the group members has to take a lead role and has to truly live by example. The group members should have unshakeable faith in him and he should always strive to come true to their reposed faith.
The planning, the MOU (outlines sharing burden and the profit.)
I had a few colleagues whom I invited to discuss the concept. Some who did not like the idea got eliminated in the first meeting. Then began the long parley. A working model was evolved. I used to prepare a draft before the meetings, considering the financial and the working implications, used to give a printout to each colleague. They would discuss with their friends, family, lawyers and tax consultants and come back with their comments, criticism and suggestions and some of these would get incorporated after due discussions. After 6 long months of extensive discussions we formed a private limited company and an MOU was signed. The salient features of this MOU are:
1. Each member will invest certain amount in shares. Those of us who found it difficult at that time were allowed to do it in phases.
2. Each one of us will close down our individual indoor set up, admit all our patients exclusively to the new set up and will not get involved in the formation of any new paediatric set up. There was no restriction though, on visiting any other set up if called for consultation. The members could continue their outdoor clinics.
3. Each one of us, on a fixed day of the week will run the outdoor in the new premises, will remain there for 24 hours, attend all new admissions and attend all emergencies.
4. Each one was required to take at least two rounds of his patients.
5. The patients coming directly to the hospital without any tag would get admitted to the consultant on duty. Similarly, patients admitted by consultant from his OPD or getting referred to him by some one would be admitted under the concerned consultant.
6. The hospital charges would be collected under various heads, all but the visiting charges would go to the hospital pool. The visiting charges fixed on per day basis (not on per visit basis) would go to the concerned consultant. The profit would be shared in the form of dividends. The opd charges would go to respective consultant after deducting a nominal amount as registration fee. The charges on procedures would be split equally between the hospital and the consultant who did it. A fixed amount will be paid to each member per month as director’s salary.
7. A colleague may ask another to opine on a case only when asked for (by the consultant and not the relatives), without getting any charges for that.
8. As far as possible, it was thought prudent to not to transfer patient from one consultant to another, unless the parents( not any relative) of the patient so insisted.
9. A priority list of payments was drawn (This was essential in the beginning when the funds usually fall short).
10. As far as possible, the relatives of the members will not be employed in the setup and will not be given to run any services like canteen, STD booths and pharmacy etc.
11. No member of the group would indulge in giving or accepting commission.
12. If any member wishes to “divorce”, he/she will be able to do so only after all the loans have been paid by the hospital. The share of this doctor will be preferably sold to remaining directors and the money will be paid depending on the liquidity, in instalments at mutually agreed interest rate.
13. If any member is found to be harming the interests of the institute, the board by a majority decision may bar that doctor from duties and revoke his/her rights to admit patients to the hospital, the remuneration will be stopped and his/her share will be sold to remaining doctors.
Changes observed in practice and advantages to self and patients
• Variety and volume of cases increased. The hospital today is 85 bedded with PICU, NICU having facilities to ventilate and monitor. There is inhouse facility for radiology, pathology, microbiology, surgery and physiotherapy.
• With DNB accredition, academic ambience is there. Resident doctors available round the clock.
• In management of serious patients the risk of missing some thing is minimised because of more than one head applied.
• In terms of monetary gain, every body is earning more than in individual set up.
• Other than on duty day, one is not required to wake up in the nights. And when not in the premises, one need not worry about the patients. One can move out with impunity, go and attend conferences etc and the show goes on.
• All the transactions are in books, no sleepless nights over income tax issues.
• From the patients’ perspective, they are assured of quality care, and also availability of a qualified consultant in the premises. Patient has assurance that in times of dire need and seriousness of illness patient will not be shifted to other centre for lack of availability of facilities. What is heartening is that patient has accepted the fact that it is beyond individuals to provide round the clock services 24 hrs a day every day. The necessity of team work has been accepted well.
Any short coming?
• Even in a group people tend to adhere to individual approach to management plans. It is difficult to implement protocols of management. No individual can assume the role of correcting the prescribing habit of other.
• Every patient walking in is not aware how the model works. And patient may and does feel uncomfortable in continuing to be under care of one consultant. He does not voice firmly his choice for the change and his discomfort continues.
• With the personal incoming soaring, few become complacent and the vision and motivation for progress is impeded.