Different concierge practices offer widely varying services. Where some practice owners view anything beyond core primary care services as a distraction, others see opportunity in expanding their offerings. 

There isn’t a right or wrong view. Choosing what’s best for your practice is more nuanced than that.

ROAMD has members across the spectrum. Some practices look more like first-class medical spas than typical primary care offices. Dr. Carrie Bordinko’s clinic Benessair Health in Scottsdale, Arizona, for example, houses a state-of-the-art Olympic gym and several hyperbaric oxygen chambers. Members receive primary care but can also get everything from personal training to physical therapy to rehab and more. It’s precisely what Dr. Bordinko wants her clinic to be — a destination for people seeking that type of treatment and therapy.

Other successful ROAMD members run straightforward primary care practices with a more traditional look and feel — exam rooms, a lab space, a physician’s office, a staff lounge, and a modestly sized reception area.

Is one of these right and the other wrong? Not at all. As business owners, you decide what sort of practice you want to run and what services you want to offer. 

In the spirit of learning and growing together, we simply want to share what’s possible and what kinds of services ROAMD members are offering. You can give it some critical thought as an exercise to consider whether you should or shouldn’t expand your scope. Is your practice still serving your members well? Would new offerings improve patient care? Would they improve the perceived value of membership, or generate new revenue?

The point is, you have options, and only you can decide what fits your patients and your practice. Let’s start by looking at some potential benefits of expanded offerings, which you can evaluate in the context of your unique situation.

Potential Benefits of Non-Core Services

There’s a lot of variation in what practices can offer as far as ancillary services. It’s important to note that many of these services don’t necessarily have to be carried out by the physician(s) of the practice. We’re not suggesting you get certified in massage therapy. But if massage is something a lot of your members use, or if you often refer patients for another service, perhaps you and your patients would benefit from bringing it in-house.

Enhance Member Experience

As a consumer, it’s always nice to have comprehensive services all under one roof.

Patients come to us because they trust us, feel comfortable with us, and prefer the concierge model of care. We understand them and know them better than anyone else. But often when they need additional services, we have to send them back out into the conventional, run-of-the-mill medical world.

If members are going to need additional services anyway, why not provide the opportunity to get those from us — in a space that’s comfortable with people they trust?

This creates a much better member experience and can even help retain members at renewal time, especially if you’re able to roll some services into their membership dues. The services become a really nice perk that creates some stickiness to your practice. For example, if a patient receives two free acupuncture treatments and a massage every few months, they’re perhaps more likely to renew.

Improve Impact on Health

Some extended offerings may seem to walk a fine line between primary care and specialized medicine. For example, is oncology screening part of primary care? We certainly perform some basic screening ourselves, and we recommend regular screenings like colonoscopies and mammograms. Does everyone go get them? It’s hard to say.

New technologies like the GRAIL Galleri Test offer an opportunity to screen for far more cancers and find them at very early stages. It’s not yet part of regular oncology diagnostics, but the potential health impact is astronomical.

The Galleri Test catches things like pancreatic cancer at stage 1. Traditional means normally catch pancreatic cancer at stage 4, after symptoms are present and it’s far too late. As a consumer, I would love my provider to offer me access to a test like that, even for an added fee. It could literally save my life.

Mental health care is another offering that could make a huge health impact. Many patients struggle to come forward with mental health issues due to their intensely personal nature and because of the social stigma. 

Bringing a mental health concern up with a trusted primary care physician is a big step, but then having to go see a stranger in an office with “psychiatrist” on the door can lead to patients not getting help at all. Offering this service in a place where they’re comfortable and in a practice they trust could make the difference.

Attract New Members

In concierge medicine, you may find that many members of your target audience are searching for something specific besides primary care. These ancillary or non-core services have the potential to become big attractors for your practice.

When you invest in a new technology or service and incorporate it into your marketing and SEO, there’s a good chance people will find your office when they search for that offering in your area. For example, someone might search for “BOTOX in Indianapolis.” They find your office and realize they also need a great primary care provider.

Ancillary services also set your practice apart from other primary care clinics because, depending on your geography, not many have offerings like in-office medical and cosmetic BOTOX treatments.

Raise Perception of Your Clinic 

Even if your clinic isn’t actively looking to add new members, it’s still good to be known in the community. No one talks about how their doctor weighed them and checked their cholesterol. But they will tell their friends about ice baths and hyperbaric chambers.

Just imagine someone on the golf course or at a cocktail party who mentions the steam room at your clinic. “Your primary care doctor offers what?” These kinds of conversations differentiate your practice from the traditional primary care model that has disappointed so many consumers. Members will spread the word about your practice if you’re impacting their health and improving their experience with non-core offerings.

Generate Revenue

It can be tricky to decide which of these additional services should come as part of your core package, which to include in various membership tiers, and which warrant additional fees.

Some tests and services may not appreciably increase the demand on your time and resources, giving you more freedom with how you incorporate them. Maybe you simply roll them into membership dues or use them as the basis for creating membership tiers.

Other services, like interpreting a 20-page genomic test report, will require more. You should be compensated for your time spent reviewing and communicating complicated test results. Patients know this; they’ll even expect to pay for it.

Non-Core Services ROAMD Members Currently Offer 

To give you some ideas, below is a list of some non-core services ROAMD members offer in their practices right now. This isn’t a comprehensive list, and it’s not a recommendation to offer all of them. It’s just a list to show what’s possible:

• Hyperbaric chambers
• Photomodulator
• Physical therapy
• Personal training
• Massage therapy
• Acupuncture
• Cosmetic treatments
• Ozone therapy
• Standalone executive physicals  
• Surgical suites
• Branded and non-branded supplements
• Travel reciprocity / referrals / travel assurance
• Dietary services
• Psychiatry / psychology / counseling
• Advanced pharmacy offerings
• Advanced screenings and diagnostics
• Urgent care services
• FotoFinder (skin imaging)
• InBody (body composition)

Evaluate Patient Impact and Potential Revenue

As you contemplate what services you might offer, it can be helpful to build a matrix to evaluate the worth and feasibility of potential offerings. I love using a 2×2 grid with high versus low patient impact (quality of life, health outcomes, cost of care) on one side and high versus low revenue potential on the other side.

Some things might have a low patient impact, but won’t cost you much, so you make a judgment call based on that information. Other offerings might have low revenue potential but high patient impact, and you might decide to offer them regardless of direct revenue generation.

Thinking along this methodology can help you evaluate possible offerings in terms of both patient impact and revenue.

Evaluate the Impact on the Practice

Adding services will probably affect your staff in one way or another. They’re the ones who will be picking up the slack to facilitate these services, learning new technologies, scheduling appointments, and reconfiguring the space as needed.

Will you need to bring in someone who’s certified for dietary counseling or for staffing hyperbaric chambers? Or can you implement creative solutions to minimize impact on staff? 

Griffin Concierge Medical in Tampa, Florida, has an impressive setup for their InBody body composition testing. Members can come in through a side door to use the machine without ever talking to someone in the office. Their results automatically go into the EMR, the physician is notified, and everyone goes on with their day.

But in most cases, factors like increased foot traffic through the office, varying appointment lengths for different services, scheduling exam rooms, and even how many parking spots are available for your building need to be thought through carefully.

Will increased foot traffic put patient experience or patient privacy at risk? If so, some practices mitigate this by scheduling 45-minute visits on one-hour blocks to leave a 15-minute buffer for patients to come and go before the next person arrives.

Another big consideration is cost to the practice. Hyperbaric oxygen chambers, for example, come with an enormous price tag and the associated costs of finding the space to house them and operating them. But there is arguably no better way to become a true destination for care than adding such a service.

Consider What’s Right for Your Practice

All of these factors underscore the importance of evaluating what’s best for your practice. No two practices are alike. Certain non-core services might make sense for one, but not for another.

As we investigate new possibilities, it’s helpful to learn from one another’s experiences. Have you added ancillary services in your practice? Which ones, and what has your experience been?

At the 2021 ROAMD Annual Meeting, we conducted an extensive survey of members to assess a range of critical elements about their practices. One such item was to find out who had a succession plan in place.

There’s a reason HBO has an excellent (i.e. 9 Emmys and counting) series called Succession: The trials and tribulations of crafting and executing a succession strategy are dramatic to say the least.

Succession plans are important for any business, but succession planning in healthcare is especially important. It’s not the sort of business you can easily shut down and casually walk away from. You’re caring for patients who will expect and deserve continuity of care long after you decide to retire.

Our survey showed that the overwhelming majority of ROAMD members did not have a succession plan in place, or at least not one that gave them comfort or confidence.

What’s more surprising is that, on average, the respondents had been running their practices for 12 years. These practices weren’t newcomers to the industry.

Succession planning in healthcare is a serious issue that deserves time and attention, and it takes longer than most people think. So whether you’ve been around for a while or are just starting out, it’s never too early to consider what your succession plan might look like and start developing a strategy to put it in place.

Why Succession Planning in Healthcare Is Serious Business

Very few businesses operate for 20 years, close up shop, and toss the keys to the landlord. Whether it’s an attorney’s office or a plumber, a restaurant or an electrician, a business is an asset the owner spent years building — and they plan to sell it, or arrange for it to endure.

We haven’t quite reached this mindset yet throughout private medical practices. Some physicians still picture themselves just shutting the doors when they retire. But what about all those patients? Do they simply have to return to a conventional office?

And what about your practice? The business you’ve spent years building has become an asset. What if it could continue to provide quality care for your community — and income to you — in other capable hands?

We need a shift in our thinking to start seeing succession planning as an aspect of quality of care. It means ensuring patients never have to go back to the old hamster-wheel model they left. Instead, they’ll have continuity of care without even having to look for a new practice.

What you’ve built isn’t easy. In fact, it’s nearly impossible for most people. But you’ve plowed the path of a new business in a relatively new model of medical practice — and you’ve done it well.

Few people have that level of risk tolerance, assertiveness, guts, and savvy. Newly graduating physicians may make great doctors, but it will always be a small number who start something from scratch. However, they may be fantastic at coming into an established practice, keeping it running, and producing consistent revenue for the retired founder. If you’re able to tap into this, you’ve provided an incredibly valuable stepping stone for other physicians to get into private medical practice.

That’s a ton of value that deserves serious contemplation — and remuneration.

Fortunately, there’s a market for a successful operation like yours, and shrewd suitors will line up to buy in. But if you haven’t thought about what your succession strategy is, you leave yourself vulnerable to being taken advantage of by people who are professionals at buying businesses like yours. So let’s get to work!

How Long It Takes to Plan an Exit

Most physicians I talk to operate on a three- to five-year outlook. They hit the tripwire of, “I think I’ve got another three years or so of practice in me,” and then start thinking about the need for a succession plan.

The reality is that three to five years is not nearly enough time to develop a good succession strategy. It doesn’t leave enough time to account for all the what ifs. You might be able to do it in five years if everything goes perfectly. But 10 years (at least) is a much more comfortable timeframe.

If you’re wondering why, consider what succession planning really entails.

Depending on your plan, you might decide to bring on a new physician to carry your panel. Hiring a new physician isn’t easy to do, but let’s say you find the right one quickly, maybe in six months. Now it takes another year or two for them to demonstrate their competence and prove that they can be your successor. On their side, they also need time to see if running this practice is what they want to do in the long term.

Assuming all goes well, let’s say you invite them to stay on to be your successor. But when they find out how much it’s going to cost for them to buy you out of the practice, they decide to walk away and start their own (after they sit out their non-compete clause), with everything you’ve taught them about finding patients and running a practice.

You’re now two to three years into your five-year plan and back at square one.

Or maybe you find the perfect successor by the end of five years, and they commit to taking over. Step one, find successor — check. Now it’s time for step two — plan and implement your segue out of the business, carefully transitioning your panel and offloading your extensive list of responsibilities in managing the practice. You undoubtedly underestimate all the things you do to keep the practice afloat. How many new hires will need to be made to truly fill your void? Rest assured, it’s not a quick process and could take an additional three to five years.

This is how retiring at 65 unfortunately turns into retiring at 70. Before long, the idea of selling your practice for what it’s worth fades. So you ultimately undervalue what you’ve built because you just want to get out.

When you start to unpack the caliber of human being(s) you need to bring in, the trust that needs to be built, and all the agreements that need to be in place, it’s hard to see any succession plan taking as little as five years.

Key Components of a Solid Healthcare Succession Plan

With enough time and a well-designed plan, your succession can go smoothly and provide the return on your investment you deserve. Below are some of the key components to consider.

Determine Your Role Going Forward

The first thing to determine is what your role will be. Will you sell outright or will you continue with the practice in some capacity? Are you going to stay on as an adviser? As a shareholder? 

Are you selling 90% of the business and retaining 10%? Do you plan to continue practicing medicine with a “smaller” patient panel? There are a lot of nuances and implications to unpack for yourself before you can answer other questions related to succession.

Determine Who Will Run the Business

The next thing to determine is who is going to run the business. Are you finding a physician to succeed you who’s capable of running both the business and the patient care? This is a true purple unicorn fighter pilot, and they’re rare.

Or, are you finding a physician who wants to focus only on the medical practice side while someone else runs the business? Now you’re not just looking for one person, but two — which might actually be easier.

Decide what you’re looking for up front to lend clarity to your search.

Determine How Compensation Will Work

Yours. As the founder of the business, you have a lot of valid options to choose from in approaches to compensation. Do you plan to take royalties or perpetual distributions? Will there be a buyout period where you continue as a shareholder for a period of time? Or will you only be paid if you see patients?

There’s not a single right or wrong answer on how to arrange your compensation. The only absolute is that if you don’t consider it ahead of time, you will get taken.

Theirs. How will your successor(s) be compensated? Are they bringing their own panels on day one? Or are they taking care of your waitlist? When do they earn equity in the business? Is there a buy-in? A revenue split? How will all of that work? 

Have you thought about how to value your equity and when and how much to give away? Far too often, I see practices undervaluing equity as a lever. They give too much away too soon, and they undervalue what the practice is actually worth.

Determine What Will Happen to Your Team

Does the team that’s been with you for the last 12 years get guaranteed employment agreements? Do they get equity buyouts? Do non-competes have to come into place — for the new owner’s peace of mind — to ensure those folks don’t leave when you do? Is there a possibility they’ll lose their jobs the day you walk out the door?

Determine How to Handle Outside Capital

Let’s say you co-founded your practice in a 50/50 split with someone else. And let’s say your partner decides to cash out in three years, but you decide to practice for 10 more years. Are you in a position to buy out their shares? Do you even want to? If not, you have to find someone to buy them out.

When you find a new partner, what is their source of capital? What degree of control are they going to retain over the practice? How might the source of their capital begin to influence that new doctor in matters such as office culture or the direction of the business?

Finding suitors won’t be hard. Suitors know the value of a successful business like yours. But finding the right kind of suitors with the sort of capital you’re comfortable with, and who have interests that align with your vision, can be a monumental challenge. 

Conclusion: Start Planning Now

These questions don’t have easy answers, which is why you need so much time to think about and plan for them.

This isn’t even a complete list or guide to succession planning in healthcare. It’s just meant to illuminate how complex of a process it is and how time-consuming it can be.

Ultimately, you will need to answer these questions, and many more, based on your unique plans, goals, and situations. Don’t delay!

Concierge physicians shoulder a huge amount of responsibility. They bear the burden of caring for their patients’ health, for the success of their businesses, for their employees, and for their own lives outside the practice.

Is it reasonable to expect a human being to bear that sort of weight and be okay?

Why Work-Life Balance Is Elusive for Doctors

Private physicians running thriving membership-based medical practices aren’t just unicorns; they’re purple unicorn fighter pilots. And the success of every purple unicorn fighter pilot rests on a stool of three legs.

The first leg, of course, is having a firm grasp on the practice of medicine, which is no static thing. We all know learning isn’t over just because we’ve been doing this awhile. Every hour of every day, new information is emerging that physicians need to consume, understand, consider, and apply in practical ways to patient care.

The second leg of the stool is being an entrepreneur and running a business. This is a monumental weight of ensuring profits exceed expenses, paying bills, handling human resource issues, and more. It involves learning how to be the boss, the one who manages staff issues, real estate issues, and tax issues. So while as a physician you’re working in the business, as an entrepreneur you’re also working on the business; Michael Gerber’s The E-Myth Revisited eloquently differentiates those duties and explains why ignoring them kills most small businesses.

These alone are two very full-time jobs, and there’s still one leg to go: the “life” side of “work-life balance” for doctors.

The third leg of the stool is being a good human — being humble and always striving to learn more while also taking care of your physical and mental health, being a contributing member of your community, and caring for your family.

It reminds me of the ’90s comedy “Multiplicity” with Michael Keaton. In the movie, the main character Doug can’t keep up with work and family, so he creates a clone of himself. Then the clone gets too busy, so they create a third. Eventually, there are four “Dougs” running around and still nobody’s happy.

The point is, responsibilities will always devour as much time as they can get. Without boundaries and balance, even another “you” won’t solve the problem.

Negative Results of Unhealthy Work-Life Balance for Doctors

Zig Ziglar once said, “Lack of direction, not lack of time, is the problem. We all have twenty-four hour days.” When we don’t direct our time and energy in a balanced way, we have a problem. Let’s take a look first at how this affects four major areas of physician work-life balance, followed by what to do about it.

Patient Care

Patient care is the area where physicians usually invest most of their time. It’s the practice of medicine, after all — an understandable default for doctors. Consequently, this is the area most likely to overstep its boundaries and muscle out other aspects of life and business.

If physicians spread themselves too thin in patient care, burnout isn’t far behind. Physician burnout is a major problem in medicine today, and concierge doctors can face it too; we simply must be honest about that.

Even excellent patient care still takes its toll if boundaries don’t protect a doctor’s work-life balance. Resentment can begin to creep in for anything that takes time away from patient care — like running the business that allows you to practice in the first place. Career longevity gets cut to a fraction, and eventually you can’t go on.

Business

If all your time and energy are absorbed in patient care, then you don’t have anything left to give your business. And businesses need care, too.

Part of running a business is looking beyond the day-to-day operations and thinking about strategy and long-term business development.

Managing the practice, hiring, marketing, new patient acquisition, and profitability constitute a huge job for anyone, let alone a practicing physician. Everything from growing the patient base at the outset to installing a succession plan down the road requires an investment in strategic thinking that takes time. Even office culture depends on the habits and work-life balance of the leader.

If the person steering the ship can’t pay attention to where the business is headed, sooner or later you’re going to run aground.

Family and Community

Given the demands of practicing medicine and running a business, it’s no wonder that the personal aspects of life tend to come last for too many physicians.

If you don’t intentionally budget your time and energy at the office, you end up bringing work and the stress of work home, and you can’t be present with your family and community. There’s just no gas left in the tank. With the people you care about most, you can’t be the best you.

But family and community are crucial. They’re the foundation that supports us to be really great at everything else. But if that foundation isn’t firm, strong, and well-cared for — if it’s quicksand — then everything else sinks with it.

An executive coach once told me I was great at my job, but I might be taking it too far. She was concerned that I didn’t have enough left after work to be my best self at home. I always thought, That’s who I am at work; I can’t give less 100%. But she suggested dialing it back to 70% for a week and seeing if anybody in the office noticed.

She was right. I ratcheted my effort down to 70% — and nobody said a word. Nobody even noticed.

But the change at home was huge. I had more energy and more of me available for my family. And the office was just as satisfied as it had always been.

That was a big lesson for me: Balance is possible, and I can control how much and to whom I give my finite time and energy.

Self

Self is the fourth item on the list, but it’s arguably the most essential. Unfortunately, it’s also the one that often gets cut first.

When flight attendants run through their safety instructions, they tell us to put our own oxygen mask on before we help someone else. It’s a great metaphor here. Physicians have to take care of themselves if they’re going to be able to care for everyone else.

This category is separate from family and community because it’s about caring for your physical and mental well-being. It’s about taking time to do the things that let you be your best self in all the other aspects of life and work.

Maybe this looks like setting aside time to read about parenting or business or relationships or time management. Maybe it looks like early morning meditation, perhaps related to your faith or just as a quiet time of reflection. I personally love a workout first thing in the morning, before the phone starts ringing and emails start coming in.

Determine what you need, and make an intentional move to reserve that time for yourself. Because if your self isn’t right, nothing else will be either — especially in the long term.

How to Restore a Healthy Physician Work-Life Balance

If you’re reading this post, chances are your work-life balance is skewed in favor of work at the expense of family, community, and yourself. The current will always drift in that direction. To help you row the other way, here we’re sharing what some ROAMD members are doing to stay balanced.

Follow a Passion

We’ve heard from several ROAMD members who balance the time they’re in the office by following their passions or hobbies outside of medicine and business.

For example, one member has a passion for international travel. He just loves to see this beautiful world of ours. To make it happen, he schedules it far in advance and looks forward to it. The travel then energizes him to give his best to his practice when he’s at home.

Another ROAMD physician has a passion for wine, so she decided to schedule time for classes to become a sommelier. Another doctor makes the time to do woodworking in his home, simply because he loves it.

Find your hobby — maybe even your passion — and give yourself the space and time to pursue it.

Schedule Counseling and/or Social Time

One ROAMD doctor schedules a personal visit with a mental health counselor every Friday afternoon and follows it up with an hour of social time with friends. That weekly counseling cares for his mental health, and he stays socially healthy by decompressing with a group of people he feels comfortable with. Those hours are off limits to the office.

Set Boundaries

ROAMD doctors also report setting firm boundaries in their calendars for things like morning workouts, designated lunchtimes, family functions, or kids’ sporting events. The key here is not just to schedule these activities, but to keep them sacred.

When you decide on one of these windows, make sure you set firm boundaries around it. The office should know not to schedule anything for you during those time slots.

How Are You Working Toward Work-Life Balance?

Not many people have already achieved a perfect work-life balance, especially as physicians. Most of us are works in progress.

Setting healthy boundaries and being intentional in how you budget your time and energy are two crucial components, but how you implement them looks different for everyone. That’s why we want to continue learning from one another and helping each other achieve balance in this demanding business.

What are some ways you strive for balance? How have you set healthy boundaries? What has worked, or maybe what hasn’t? We’d love to keep learning together.