Too big? Too small? How to get your general practice scale just right.
What do you get when you cross a hardcore commercial analyst with a passion for community health? A blueprint for financially viable general practices.
Speaking to The Tea Room podcast, health economist Tracey Johnson shared how the right economy of scale can make money for a practice.
You’re CEO at Inala Primary Care – tell us a bit about it.
I have an extraordinary team of nearly 48 people and we’re here to change healthcare and make it better. It’s a general practice and does the things that every other GP practice does – baby immunisations, caring for women during pregnancy, all the normal stuff – we’re just probably a bit larger than most clinics.
Who are your customers?
What makes us special is that we work in Queensland’s largest housing commission suburb with the highest rate of disability pensioners and five jails just down the road. We specialise in complex, chronic comorbidity and I’ve spent the last decade looking at what I can bring out of hospitals and into the hands of patients and primary care providers. The goal is to deliver care where people want it, which is near to home. Nobody wants to go to hospital.
Is there also an economy of scale that works best for clinics?
Yes. One sweet point is four to five GPs. Most of those small practices will also have a treatment room nurse and a couple of receptionists who might be part-time and/or a practice manager. So, it’s quite a lean team. And if you’re managing up to about seven to 10 people, research shows that an average manager can do a reasonable enough job of keeping order in an environment of that scale.
Given the price of commercial rents it will be incredibly hard for you to survive if you don’t sub-lease to on-site pathology or pharmacy. Your other option is to charge full out-of-pocket expenses to around two thirds of your patients.
The next tipping point in scale seems to sit at around nine to 12 doctors. And then the next tipping point is around 20 doctors. These seem to be a natural loci for practice size in this country. If you’re going for that mega scale of doctors you absolutely must have pathology and pharmacy and you must rent out some rooms to allied health and other specialty providers. To do it at this scale you need really professional management systems.
Tell us about those systems.
You need to systematise everything: standing orders, protocols and internal pathways that guide how you work with your nursing team and your allied health providers so that everyone knows what their role is in that patient journey. You’ll need many templates and checklists for your nursing and administration team so that doctors can be very confident that, for example, recalls and reminders are being done in a certain way. No matter who is away on the day, there’s policy and procedures so that anyone can step into the role and complete the required tasks.
How can general practices generate more revenue?
Room utilisation. If you’re running a practice with nine doctors, and you’ve got the capacity to move up to 12 doctors, you might consider opening from 7:00am to 7:00pm. It’s surprising how many doctors or allied health professionals are happy to do those piecemeal hours. Some practices are starting to have two shifts of doctors. First shift starts at 7:00am and works until 1:30pm. The second shift starts at 1:00pm and works until 7:00pm. Many doctors are enjoying their work more by reducing the cognitive burden that happens from working those really long, gruelling days. You also get more room utilisation and generally things come together better for the patients. When we schedule our fees we consider that if a patient wants to come really early or late the chances are they’re employed.
How do you manage the incredibly complex patient group at Inala?
We use nurses more and have non-dispensing pharmacists on the team. It’s sometimes a struggle to pay for them but our doctors say that the nurses do much better care plans than they do. Our nurses generally get 45 to 60 minutes to do a care plan depending upon whether the person needs an interpreter. The doctor then spends 15 to 20 minutes with that patient, creates the scripts and and checks in with the patient about their goals. The nurse-led model for care planning picks up a whole range of preventative health areas that you can then make a separate appointment for.
What’s the bottom line?
It’s about creating a general practice environment where we’ve got the capacity to care and organising our resources around how to do that. For example, if you’re introducing a patient to bisphosphonates for their osteoporosis does the GP need to provide the education to the patient about calcium intake and lifestyle modification? No, nurses can do that sort of work. It’s all about how we use our time across the team to see more patients and make life better for everyone.
Listen to the full podcast interview with Tracey Johnson.
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