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CLINICAL COMMENTARY
Moving A Community-Based University Medical Practice To The Medical Center Campus
Anita Y. Agzarian, M. D. and Alice E. Agzarian, M. D.
\"Even if you\'re on the right track, you\'ll get run over if you just sit there.\"
-Will Rogers 1
We have been practicing Internal Medicine at the same freestanding office location for more than 23
years. The first 15 years we followed the traditional style of medicine of private practice in a small group
of physicians. Eight years ago we joined the Department of Medicine at UCLA, and our office was
integrated into the university practice. We have been able to continue to provide good medical care to our
patients with the additional advantage of being asso-ciated with a major medical center. All of its clinical
resources are immediately available to us. In addition, our teaching of doctors in training has kept
us familiar with the latest academic and practical techniques.
However, after an assessment of the changing economic environment of the business side of
medicine, evaluation of our own personal goals and to help ensure the future viability of the practice, we
decided to relocate the office to a site on the main campus near the hospital. One of the physicians who
had worked with us had already moved away, and a senior physician, our father, had recently died, leaving
us with reduced doctor power and some daily feeling of sadness and loss in the old location. It was time to
reinvent our situation. 2,3
After deciding to make this transition, we held several informal meetings with the new office manager and
some of the physicians with whom we would be working. We discussed the logistics of the planned
move, similarities in practice style and differences we might expect. We were pleased to get new ideas on
how to improve efficiency, and we were able to share our experiences.
Maintaining Adequate Practice Size
It is clear, of course, that a worrisome cost of moving
one\'s practice location is the potential loss of existing patients. \"It is five times more expensive to attract a
new customer than to keep an existing one.\" 4 We tried to inform our patients of the plan as soon as we
had enough details and facts for an integrated presen-tation. A few months before our move we started to
notify our patients as we saw them in the office of the general need to relocate. In-office discussions by our
support staff and us later included specific informa-tion about our new address and phone number. Six
weeks before the move, we sent letters to the home. The letter expressed our very genuine appreciation for
their patronage and thanks for the wonderful relation-ships we have enjoyed over the years. 1,5
The fact that our existing space will no longer be available as a medical office for patient care is an
advantage in the transfer of our existing patients. Patients do understand that the practice is really
leaving and was not taken over by a new doctor. This should help prevent the loss of some patients who
might just return to the same facility to see a new doctor out of habit.
We emphasized the benefits of being closer to a major medical center-a brand new hospital!-with an array of
subspecialists, diagnostic facilities and opportunities to share in scientific and technologic advancements
just next door. We frankly were pleased to report that we all would be in a nice, comfortable facility instead
of an out-dated environment. We pointed out that the move would be an \"upgrade\" not only for the doctors
but also for the patients.
Additionally, we discussed our plans to move with some of our longstanding patients. We asked what
concerns they might have about the transition. Some of our patients\' concerns were very similar to those
they had when we initially had left private practice and joined UCLA. These were their major questions:
Will the same staff be at the new office?
Will there be any change or increase in fees?
How to get there-maybe it\'s too far?
How much does parking cost?
Will you still be my doctor?
Will you still notify me of my test results?
Will you be too busy for your patients?
Who will be on call when the office is closed? 6,7
We tried to address these and other issues/ questions during office visits and phone conversations for a
couple months before leaving the previous location.
The large medical support staff with which we have worked for months (and in some cases, years) is
familiar with most of our patients and their personal-ities and needs. They understand our practice style,
are attuned to the demands for complete documenta-tion, and can facilitate patient flow. We want the
employees to have a sense of personal growth and professional advancement. The new space, however,
is much smaller (fewer doctors), and some office staff is already working there. We were able to have some
of our existing staff come to the new facility and feel this will be a benefit to us and to our patients with
whom they already have friendly rapport. 8
Patients were told that the same insurance plans would be accepted and that we would continue to \"take assignment\" for Medicare for our office visits. There would be no changes in copays or out of pocket
costs just based on our move.
The most common cause of the loss of an existing patient after a move is commuting distance. The new
office location is less than 8 miles from our present space. We plan to provide a \"map\" and hints about the
bus schedules. One patient in Santa Monica was thrilled at our move-she told us that now she could
come for her doctor\'s appointment by taking one bus instead of three. Another patient pointed out that one
bus could take her from Culver City to Westwood. 6,9
Most patients who come by car will have to pay for parking. Our patients have been used to \"free
parking\" for 23 years (in fact, many of them are even in the habit of \"stealing\" a spot in our lot while in the
area patronizing other doctors\' offices and busi-nesses!). Many patients have told us they are happy
that the medical center has large parking lots-that they would rather have to pay a fee to park than run the risk
of not finding a spot when they arrive for their visit. We know that having to pay for parking is a reality in
virtually all other medical offices, whether general medical or subspecialty practices. We can honestly
say that the doctors and employees must pay too!
We reassured our patients that we would continue to be their family doctor and provide medical care as we
had for the past 23 years. We would still be seeing them personally in the office, answering their ques-tions,
planning their treatment, etc.
We also explained that we actually might become more available during the day for office visits. Due to
more flexible staffing in the new office, we would begin seeing patients up to an hour earlier. This
increased availability was welcomed, especially by those who had difficulty scheduling their appoint-ments
around their work hours or leaving their jobs during the day.
End of the year \"open enrollment month\" is obviously poor timing to pick for a major move and change of
address. The choices for patients who have health insurance offered at their work are already too
complicated. Reliance on the different insurance plans to provide correct phone back-up and written
information for patients is too risky. Therefore it was decided to make the transition in the spring.
As in any practice, it is always important to try to attract new patients. Since more than 65% of the
insured working population in our area belong to HMO plans, we decided to reopen our \"panel\" to
accepting new HMO patients for about 5 months before moving and to continue to do so afterwards
until we are assured of a full practice size. 10
The demand for more medical care is anticipated to increase with the aging of the \"baby boomer\" genera-tion.
We have had considerable experience with providing health presentations and lectures to a
variety of community religious organizations, service clubs, senior citizen centers, etc. These have been a
local source of motivated, health-conscious patients. We have some plans to continue this activity in the
future. 1
Patient Satisfaction
\"Each dissatisfied customer will tell at least nine other
people.\" 4 Professional and courteous attention by a smiling and cheerful staff always is of great impor-tance
for patient satisfaction. Focusing on providing
good access for appointments for new and follow up visits is a place to start. Nobody wants to wait a few
weeks to see a new doctor. Minimizing the complexity of the registration process is impor-tant.
4,11,12,13
It has been reported that patients feel the reception area and office environment are reflections on the
doctor\'s ability and interest. They expect it to be clean and orderly. We try to provide individual chairs so no
one is forced to share space next to another unknown person. In our experience, most people prefer having
television available and dislike \"fossil\" maga-zines. 14,15
We have always encouraged our patients to \"take charge\" of their health, make appropriate lifestyle
changes and become educated about their medical problems. Patients appreciate the explanation of
medical test results and future plans. They want their questions answered. We aim to stay involved in their
care after referral to specialists.
Promptness in obtaining test reports is of great personal concern to each individual. In most cases we
provide instructions in the office verbally and in writing. Results of diagnostic testing are usually
written and mailed unless an immediate intervention is required. We both have had new patients who told
us they came because their friends told them that we, their doctors, always send them letters and they
wanted the letters too. We have taught patients to create their own \"home file\" and \"take charge\" of their
records. It has been noted that patients forget as much as 75 % of what is imparted to them only verbally.
We have found that most of our patients have enjoyed their interaction with the medical students we teach.
They know that our practice is part of the medical school and that they are helping students become
future doctors. Most have readily agreed to being interviewed and examined by students, and they have
asked us if this will continue in the new office. We hope to have even more opportunity for teaching, as
we will be located on the main campus adjacent to the medical school.
Improved Efficiency
The business side of an internal medicine practice has
been adversely affected by low reimbursement from insurance plans and Medicare. The fees collected for
medical services have been \"ratcheted down\" by some managed care plans, and certainly the rest have not
been commensurate with cost increases. There is a real risk of becoming a high volume, low margin
business. 16,17
The plan is to increase efficiency by starting with improved office design to maximize patient flow
while improving eye appeal and giving an overall atmosphere of less congestion. Separation between
the check-in and checkout desks can help organize registration (including insurance verification) and
assure that patients have orderly written instructions and future appointment information to take home for
their file. 14
Having the \"nurses station\" located centrally with most exam and clerical rooms easily in the line of
sight can eliminate the need for the doctor to walk around in a circle looking for help and the temptation
for the employees to \"hide\" (consider the Circus Maximus in the movie Ben-Hur!).
We feel it is essential that the employees be willing and able to perform a variety of tasks as needed and
also be able to work with all the doctors in the group. For example, a medical assistant should be able to do
some phone calls and clerical support work as needed. This can obviously be very helpful to keeping the
office on track when employees call in sick or are missing for personal reasons. Also, it is imperative
that a female chaperone be available for some patient exams. 18
We hope to increase the efficient use of our time by having the bulk of insurance verification done before
the patient\'s arrival at the office. At the medical center, insurance verification is done the day before
the patient visit. At our old location, this was only done when the patient arrived at the office.
Frequently it would take the receptionist 20 to 30 minutes to finally get through to the insurance
company. This would cause a delay for us in seeing the patient and then also affected the rest of the
patients waiting. If the patient actually belonged to a different medical group, we could not see the patient
at all. That allotted time slot was then wasted, as it was too late to offer it to someone else.
By starting a patient visit on time and by not having to run the risk of being unable to see a patient due to assignment to another medical group, we increase not only our efficiency but also our availability to other
patients. We hope to identify the chronic \"no show\" patient, devise a plan for billing either that patient or
insurance company, educating that patient about wasted resources and time, consider a \"same day list\" designation, etc.
No one appreciates long waits in the reception area before seeing the doctor. However, we know from
discussions with our patients that waiting an hour or more in other specialists\' offices is very common. We
will continue to do our best to accommodate patients on time and always apologize when we are running
late. 16
Some Things to Remember
Even though we are still practicing medicine as
employees of the same university, because of our address change we had to be sure to notify the state
licensing board and the DEA of our new location and to apply for a change in provider status with MediCal
(Medicaid) and Medicare. We have been receiving several free journals providing valuable current
clinical medical information, with some of them including continuing education, and we notified them
of our change of address. We personally told local community physician colleagues of our move and
sent them a letter with our new information. Even though we are practicing at the medical center, we
still live in Culver City and are active in community service promoting healthy lifestyles. 19
New Policies and Procedures
A new location is a new start and an opportune time
to change some policies and procedures to improve the business. The added advantage of having face-to-face
communication with more colleagues is not possible in a small satellite office. We expect to learn
\"what works\" from our new associates. 1
We hope to initiate new approaches and procedures for tactfully handling these and other sensitive issues.
Some of them can be solved simply by not being located on the first floor of a free standing building in
the community with a convenient parking lot just outside the front door. We need to explain to our
patients that we have to follow new guidelines.
Some simple changes might include:
1) A patient restroom located off reception area can cut down on hallway traffic.
2) No specimen containers located in patient bathroom.
3) A written plan for handling prescriptions promi-nently displayed in the waiting room.
4) Patients can wait for their pick up rides outside the office in the main lobby of the building.
5) All lab work is drawn at a phlebotomy station nearby, but not within, the doctor\'s office.
The foregoing comments and suggestions offered are drawn from our experience and observations. Albeit,
we have truly enjoyed contributing to the excellent care given at UCLA Culver City. We are looking
forward to the coming move as a superb opportunity. We will continue to devote our talent and energies to
our patients with the added boost of the medical power of the outstanding UCLA facility.
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