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Cheng-Huai Ruan, M.D.
Hey everyone, I have my really good friend here, Dr. Hammad Qureshi and let me tell you, we became friends a few years ago. He started his practice shortly after I started mine, and so we kinda grew up together if you will, and learned a lot of lessons and Dr.Qureshi and I have talked through so many different things in private practice and growth and in stages. So it became a very synergistic friendship, but at the same time, I wish that everyone knew what we went through, and I feel like a lot of practices don’t but I think that’s why we are kinda where we are today, so. But Dr.Qureshi, welcome to the show.
Hammad Qureshi M.D.
Thank you. Thank you so much. I’m excited to be here.
Cheng-Huai Ruan, M.D.
Yeah. So let’s talk about your origin story, if you will, right? But you started at University of Texas Medical Branch, more in the academic setting and primary care, right? So can you kinda walk us through, how did you go from there to where you are today?
Hammad Qureshi M.D.
Absolutely yes, so Chang first of all, thank you for this opportunity, I’m excited to be here and I just kinda just share my two cents and my experience with everybody. So yeah, I started at UTMB, I actually did residency at UTMB, in family medicine. And then after residency just stayed on as faculty. And so I was an assistant professor there for a period of about four years where, my principal role was basically taking care of their inpatient side of medicine. So I was the medical director for the hospital service. So we used to admit the patients that saw family medicine clinics and the outpatient, and admitted them and ran the inpatient service and did the side of, some resident preceptorship in the outpatient setting. So that was what my primary role was. And I did that for about three and a half years, but continuing to during that time period always felt that, would love for someday to work for myself.
And there were certain things in the academic world, and don’t get me wrong, I loved academics. I love teaching, I love, I continue to teach. I continue to have medical students, PA students, MP students, that come and rotate with me till this day. So that is a big piece, that part I really did enjoy it, but I felt like there was a ceiling, there was a limitation to some of the things that you could do, some of the things that you could not do, the bureaucracy of working for the big hospital system organization. And those were the things that planted that seed in my brain that, hey, someday I would want to kind of break away from this and just not be bound to anybody and basically work for myself. And so that was the feeling. It took a few years, but it finally came into fruition August 1st, 2018.
Cheng-Huai Ruan, M.D.
Oh, that’s great. And this is why I want people to understand that, the things that you value, which is teaching, you didn’t give it up. You still had it in private practice, right?
Hammad Qureshi M.D.
Absolutely. No, I actually, I loved that aspect of academics, I love teaching, I love preparing for the lecture, giving back to students, and this is something that I’ve continued to do till this day, when I have students and we have a topic like thyroid or diabetes management and to teach them what I learned, what I know, that’s one way of giving back, that I feel like it’s important in our profession and yeah I enjoy that immensely and continue to do that to this day and hopefully would be able to continue doing that in the future.
Cheng-Huai Ruan, M.D.
Yeah. So, me too, actually. So, we have students that rotate through and I’m clinical faculty as well, University of Texas at Arlington. There’s gotta be something that hit around the three and a half year mark for you, to make you wanna take that risk because it’s not an easy step because there’s a lot of uncertainties there. What do you think was that trigger that was there?
Hammad Qureshi M.D.
Yeah. I think that a couple of things, one thing was that I was an assistant professor and I’d been doing the same thing for about two and a half, three years. I was the medical director of the inpatient service, that was the height of my growth at that department. I mean, unless I wanted to turn into, becoming an associate program director and program director of the residency program, there wasn’t a whole lot more growth for me to do. So that got me thinking that, I’m young, I was in my mid thirties, I’ve had an easier lifestyle and that was time to work hard, and so I kept that really, that thinking was always burning at the back of my mind that I should be working harder for myself. And enough time lapsed when I think a year before I opened, I said, you know what? I think this is enough time, and that’s when I really started to plan ahead and look, trying to formulate a plan to give myself about a year before I actually took the plunge.
Cheng-Huai Ruan, M.D.
All right, so, academia allows you to accelerate to a point, but then after a while, you’re like, well, this may not serve me anymore because of the person I am right now. And therefore I changed and it is okay to change your mind people.
Hammad Qureshi M.D.
It absolutely is. That’s a very good point that you bring up is that, you become comfortable in the role initially and it’s fantastic, and then you grow, you mature, you learn different things and then a decision that was good, maybe two three years ago might not be the best decision anymore. And that’s like you said, that’s okay and it’s okay to evolve as you evolve.
Cheng-Huai Ruan, M.D.
Absolutely, and let’s take, let’s break it down it’s a psychology for a little bit, because I think this is really important for people to know if we look at the six human needs, and this is talked about by Tony Robbins, it’s actually adapted from a psychologist, Maslow’s hierarchy, which is a pyramid way of understanding what your basic needs are, your psychological needs are, emotional needs are and stuff like that. But I think Tony Robbins has a very much clear cut way of describing this. So the six human needs are the following. You have certainty, variety, significance, love, or connection, growth and contribution. So I think what’s going through residency at UTMB, you felt that you have room to grow at UTMB, right? University of Texas Medical Branch. And once you hit the apex of your growth, that growth is now crossed out no longer serves you, right? But yeah, and so you hit significance once again, you cross it out because I feel significant, because I’m program director and all this stuff like that.
So that’s done. So that’s crossed out. And then now you have contribution, which is basically contributing back to the medical students, and you’re like hey, I don’t have to stop that in my own private practice. And I think where most people get burnt out, where they are, is that they feel guilty for already satisfying their original needs, but subconsciously they have different needs at the time with more growth and more contributions development that they feel guilty saying, I have to leave this nice comfortable system, until, something triggers you to do it. So from a psychological perspective, and you did something that the I did as well, is that, hey, this no longer serves me, and I feel like there’s another calling and this is what I want to do my practice. Now, if you’re the type of doctor that say, hey, I can stay at UPMB for at least 15 years and continue to feel more sense of growth and significance, that’s great. Before you in particular, you weren’t one of those people and when you were able to recognize it you did something about it and that’s, what’s truly great about the decision, right?
Hammad Qureshi M.D.
Absolutely. I think that you summarized it so well. I think that taking that decision was not an easy decision because it was a comfortable role that I had evolved into and I was comfortable with. I was happy there, we had just a young family, it was a stable job. It was not necessarily a very difficult job. So taking that plunge so to speak was difficult, and like I said, there are certain, there are some of my peers, colleagues, professors, mentors at UTMB who are extremely smart, way smarter than I am, who excel at continuing growth into becoming a better teacher, becoming a better mentor, becoming, in that academia path, which is amazing for them. It was just, I did not see myself following right into that trajectory, which is why I think at that time, that break was necessary. I think my time at UTMB was very valuable in my growth as both a physician, as a person, as just a community member. And I think that that experience put me in good stead to tackle the many challenges that I’ve later faced.
Cheng-Huai Ruan, M.D.
Yeah, and I think it’s really important too because you left the structure where you had a lot of mentors, right? And you go into a structure where you have none. And it could be very challenging, and not only did you have none, there’s other people in your shoes, but we don’t know who’s doing the right things in clinical practice where you wanna go, so it can become very lonely and cold, which I think for both of us, what’s the very beginning. And so how do you overcome that sort of mental barrier of taking that step to do the things and how do you find mentors? What did you do?
Hammad Qureshi M.D.
So that’s a great question. And I think that this is one of the most important questions of this conversation is to where to start, right? Where to look for. I don’t have a very good answer that, how do you find mentors? I just felt like I was just blessed and lucky that I had people, some people around me that had been doing this. And so I’ll mention a few names. I’ve come from a family that has a lot of extended family as physicians and a lot of them in private practice. So some of them had been pushing me that, hey, you need to open your own shop. You need to be working your own for yourself. You need to do private practice. So I had them kind of putting that in my ear for a few years. And then I’m gonna mention this other, a very good friend of mine who’s a dear friend, she’s a mentor, she’s a friend. Her name is Dr. Hussein.
She opened her practice a couple of like a year, a year and a half before I did. She was also a faculty member at UTMB, and seeing her do it about a year, year and a half before I did it, kind of gave me a lot of confidence. I used to go and shadow with her, just go and sit in our office, when I had some time off from work and just kind of learn how the business side of things ran. And so that is what is very important for people to realize is to identify people, and there are people all around who you just have to look right? You reach out to people there, and you’d be surprised that majority, most of the times, people are willing to help other people. I would want to help any other person that I come across, who in private practice, who I can delve something to that might benefit them, for them to survive, to thrive. Because I think that we’re up against big hospital systems. And people keep on reminding us we’re a dying breed or whatever the case may be, which I don’t typically believe in but, find a mentor and reach out, which I think that this forum is a great place for people who would want to, reach out and see other people who are doing it and learn from their experience.
Cheng-Huai Ruan, M.D.
Oh, absolutely. Now that you are in practice for a couple of years, I’m sure we’re gonna talk about some lessons learned. But let’s go into practice startup for a second. So the first question in practice startup that anyone has always, for me, startup costs, finances, businesses. How do you allocate that and what should you really be expecting?
Hammad Qureshi M.D.
So, I’m gonna tell you purely from my experience, because my experience was a little bit different than, for example, my mentor’s experience. So, she took out a loan, made a business plan, met with a banker that, hey, this is how much the cost, took out a loan, rented a place and started the build out, so that’s one way of doing it. I went a little bit of a different route in which I went through the route of an income guarantee. So what I did was that I got in touch with all the major hospital players in this area where I wanted to come and move to. And I said, hey, I’m a new PCP, I wanna come and serve here. I want an income guarantee for a year, and I went to Methodist, I went to Memorial Hermann. I went to HCA and HCA was, kind enough to give me that opportunity, and that’s how I started. So how that works is, for people who don’t know about income guarantees is that you sign a contract with a big hospital system that you are going to essentially serve the area for about three years, and then your loan gets repaid per month when you serve that area. So since I did not intend on moving, this was make it or break it for me, so I signed that contract and knock on wood, it has worked out well. And they give you money for a startup, I think I got about $50,000 for startup money, which gave me an opportunity to, buy computers and tables and what have you.
Cheng-Huai Ruan, M.D.
Yeah, and I wanna stress to people. An income guarantee is not necessarily a loan too, because there’s government incentives for underserved areas. And you’d be surprised what are actually underserved areas. Even Houston is major, really crowded places are actually underserved areas. There’s government incentives to hospitals, to allocate funding, to attract point of entry practitioners, as well as other specialists to the area. So they can either give you a loan or a hybrid, which is a loan and loan for forgiveness. So if you stay in the zip code for three years, then that loan, they give you is essentially forgiven. For example, I had 150 grand by the way. And the whole thing was forgiven.
So when I did the startup, okay, that’s all it really took from me, right? So it wasn’t a huge deal. This is my first practice. And there’s also bonus incentives from, different county systems as well. So if you’re starting in private practice, before you rent a place, before you sign a contract with any lease, because if you do you no longer qualify for these, before you do any of that, you talk to the hospitals first. Hey, what is going on? Do you guys have an ACO, accreditation, and do you have funds that are dedicated to doctors. And all of a sudden, you’re finding yourself, having some cashflow there that you didn’t really have to work too hard for because there’s really government incentives that the hospital sometimes match one-to-one on, to get people within the zip code, to help funnel them into the hospital system.
So that becomes a really, really powerful tool, for practice startup. And then the other thing is, both of us are lucky because, we ended up in zip codes that were allowed to do this, and it’s not like we’re in a rural area, we’re not. Neither of us are. We’re in a very heavily populated area in the greater Houston areas. And so it’s really surprising what you’ll find, as long as you’ll talk to the hospitals. You said, you talked to three major hospital systems, right? And say, hey, HCA has this very funding, then it basically, it’s a system of de-risking, you wanna lower or eliminate any financial risks at the very beginning, and that’s the way to go, man. I wanna say kudos to you on that one.
Hammad Qureshi M.D.
And I think just one small important point to add to that is that a lot of times, I think that rule that you talk about is absolutely true, it’s a government rule and it has to go by a radius. So you have to come from a radius of more than 25 miles if I’m not mistaken side of 25 or 30 miles, outside the service area. So for example, this is for people who are listening, who might want to explore this, if you are, for example in Cyprus and you want to start a practice in League city, so that it’s very much possible for you to go, but you have to keep in mind that you want to be moving to an area, which is 25 miles out of your current practice area, for new physicians who are coming out of training or sort of coming out of residency, that really doesn’t matter much because I think that, they are considered regardless of where they come from. But for people who are already in practice or thinking of moving or starting out on their own, just keep that in mind that it has to be an area of about 25 miles out of your, of where you’re trying to get an income guarantee from. So that, kind of plays a role into your decision-making.
Cheng-Huai Ruan, M.D.
Yes, that’s very true. So that qualifies for a lot of the government incentives, but make sure that you guys know that it’s not from your home address is from the address that you currently practice at. Or if you’re a new physician, it’s not gonna matter. So if you wanna practice close to home and you’ve never been in within 25 miles of your home, then you’re kinda in luck there and just reach out to the hospital system. So you’re absolutely right. That’s, one critical move. But if you are moving from one place to another, believe it or not hospitals like to compete with each other. So if you are within the one hospital system, you say, hey I’m gonna jump to this hospital system, the hospital doesn’t even care about the government incentives they just want you in their network.
And so if you wanna just hop out to the network, then they also offer you incentives, to be in their network. It’s not as a big of a financial gain on that, but it’s still a sizeable amount. And all it takes is a phone call. And each hospital has a department called physician relations or physician accommodations. And so, if you just call the hospital, call the operator, do you have a physician relations department, specifically on new physicians wanting to the area? They always have someone there ’cause they have recruiters as well. You gotta take advantage of that because the last thing you wanna do is move into area, get everything’s set up and you realize, oh my gosh, you gotta have 150 grand forgiven by the hospital system with income guarantee, which yeah, which kinda blows my mind that some people do and not have an idea that’s actually exists.
Hammad Qureshi M.D.
100%, and Chang, one of the challenges is that we get such an negative feedback when you’re in second year, third year of residency, or even in practice, that, hey, this is something that cannot be done, right? It is nobody does private practice anymore at all. You’re thinking about doing solo practice. That’s a unheard of concept, that doesn’t happen anymore. So I think that a lot of people that drawn out or get scared away or get pushed away by this narrative that, it’s something that is impossible to do. Obviously it has its challenges like any other thing in life has its challenges, but I think it’s important to know what all the avenues that are available to us as physicians that we can explore because hospitals would want to compete and contrary to do what we think, primary care physicians hold a lot of power at the community level to kind of direct the flow of care. So hospitals are obviously interested in having a good relationship with you.
Cheng-Huai Ruan, M.D.
Oh, absolutely, absolutely. But let’s dive in a little more about startup costs because as you and I both know, when we first started the practice, we had estimations of what things would cost and they may not fit that picture. And not only that, learning the revenue cycle, that’s a whole other beast, learning about billing, collections, reimbursements, human resources, and all the stuff like that, right? And so it’s like drinking from a fire hose, you just kinda get sprayed with it, and see what sticks and I encourage people to kinda fail forward. I mean, be in hurry to fail and fail forward, meaning you learn from it, you pick yourself up, which both of us have done in the last few years. But sticking along the private practice and in startups, Okay, so you got the hospital to give you some money with an income guarantee and you allocated some of that money. What was your sort of like first, second, third steps in doing this? Did you find people to hire first? Did you do the location first? What did you actually do?
Hammad Qureshi M.D.
So actually, I kind of lucked out that HCA in the Tomboll area was, in the process of getting rid of a lot of their primary care employed officers. So, I forget the name, this office that I’m added was actually an employed PCP office that HCA owned. Which was not HCA it was Tomball regional, which was owned by somebody else at that time, in any case that was owned by somebody else. And they actually were looking for somebody to take over the lease. So I kind of lucked out that I walked into an office, which was–
Cheng-Huai Ruan, M.D.
That’s great. It was already built, right?
Hammad Qureshi M.D.
It had everything, it had computers, it had the EKG machine it had, so I ended up, I had still had to purchase everything. I had to buy everything, but I ended up buying those things at a discounted or a subsidized rate because it wasn’t new. So a lot of the things in my office that you see right now, even this desk that I’m sitting at, the painting behind me, I had to pay for each one of these things because legally you’re required to buy everything, but it came at a discounted rate. So that’s how I got started, And then I had in my interim guarantee contract an amount of money allocated for a startup cost, which was pretty significant, and it helped me purchase some of these things that I needed to at that point in time.
Cheng-Huai Ruan, M.D.
And that’s great. So as the startup costs, now, I know there’s some contracts out there that not only guarantees your salary, but your employee salaries as well. Is that part of your contract or was it just your contract?
Hammad Qureshi M.D.
So the way that my contract was is that the hospital said that, okay, we are going to give you, I forget what the dollar maybe it was. Okay, yeah, I think it was $20,000 per month, okay? So 20,000 or maybe it was 25. So we’re gonna give you a $25,000 per month, for a period of 12 months, okay? This is a part from the start-up cost. So 25 K per month, this includes your rent, your salary, your staff salary, however you wanna spend that money, but you have to show how you’re spending that money. So that’s number one and number two, so for example, you’re guaranteed to get 25,000 from the hospital and you bring in that month, 2000. So you get 25 minus two, 23,000.
So their hope is that you bring in one, 2000 first month, they give you 22, month two, you bring in five, they give you 20, month three, you bring in 15, they give you 10. And by six months or eight months, you’re on your own. So they don’t give you anything. And now you’re kind of locked in, not locked into, but you’re into this contract where you’re gonna be serving this area, and it’s a win-win situation for the hospital because with them spending 50,000 on a startup cost and 150 K on those six, seven eight, months, now they have a primary care physician who is not obligated to send them business or to use their facilities. but you kind of have like a soft corner for, I mean, obviously I’m gonna have a relationship within a hospital that helped me out when I was just starting out. So I think that those kinds of, it’s a smart move by the hospital settings, from the hospital.
Cheng-Huai Ruan, M.D.
That’s the thing. You are not obligated to send business that way, because it’s illegal. Otherwise it’d be considered a kickback and people can’t do that.
Hammad Qureshi M.D.
And they might do that in the contracts, that, hey, this is buy, in any way by doing that, you’re required to send us business or anything, but, it’s kind of like, I scratch your back, you scratch my back with an under tone. But, I admit, even after that I admit patients in HCA Tomball, I admit patients to Methodist or in Memorial Hermann. So, I’m not obligated to use any–
Cheng-Huai Ruan, M.D.
Right, right. Yeah, like you said, more of a soft, not really obligation, but it’s a relationship building process at the same time, you are free to do whatever you want, which is not really the same in the larger institution, which you’re kind of a, they can’t make you stay with a network, but it’s like, we really want you to do this, right? So I think that the important part is not only are you de-risking yourself and opening private practice, there’s all this found money. There is forgiveness if you stay within that zip code, you also don’t have to worry about what most businesses struggle with, which is startup costs and operational cashflow. And once you’re able to get a lot of the patients in, provide finances and get that in, you don’t really have a risk from the financial side of starting a private practice. And that’s why this is such an important tool. Now, here’s the thing. You didn’t go this route, but I did, banks.
So banks have a similar strategy, except there’s usually no forgiveness from the banking side. And then there’s also aside from banks, not many people know this, there’s private equity funds for physician startups as well. It’s pretty rare, but because it’s such low risk for physicians startups, to go belly up that it’s a very attractive fund, and a lot of them are actually by other physicians as well, and which you can find. And so, I think that nowadays, and I wish they told us this in residency right now. I wish they told us that, hey, it’s actually relatively easy to get to do a startup. But I think the language in training programs is that, hey, because you’re not an academic institution, then it’s probably not worth it.
But that’s come from a very biased point of view because you’re working with people within academia, who value academia at the highest level, right? That’s okay. If you’re not within academia, you’re crap or whatever it is, right? But then, right now you’re in such a good situation because you de-risk yourself in the startup cost, you continue to have that sense of contribution ’cause you have students still, right? And then you’re building your own equity at this time, within your own business, within to yourself, and that fulfills you from the growth side as well. And you still retain significance because you doing the things that you wanna do. And, also you’re probably making a whole lot more as well, right?
Hammad Qureshi M.D.
Absolutely. No, that’s so true. And the thing is, that whichever route you go, through the initial, my experience with the income guarantee was so good like you had actually stated. It took financial burden out of me, it was one less thing that I had to worry about because I knew that, hey, at the end of the month, if I’m bringing in only $1,000 or $2,000 per month, or for that month, I’m guaranteed a salary because the hospital is gonna pay me. So it, alleviates a little bit of that stress, but like you said, if banks do the same thing, but you have to pay them back. So the bottom line is that it can be done. And you just have to explore. You have to keep calling, you have to show up, and another thing that people don’t realize is that, when I was at UTMB, be the CEO of UTMB was a big shot that I never saw.
And you could never go and meet the CEO, right? You can never meet the CEO of a big hospital system, but in smaller community hospitals, you can call and say, hey, I’m the primary care doctor, and I would like to schedule a meeting with the CEO, and you go and meet with the CEO and they will meet you and they will talk to you. And they will say that, hey, we will get back to you, which so, I had a competing offer from two different hospitals, very similar and I decided to go with one. And one Memorial Herman was the first one that offered me, and that offer actually helped me get a better offer from HCA. When I said that “Hey, I’ve already had an offer.” And they said, “No, no, no, don’t go with Memorial Hermann. “We really want you to go with us.” And that’s how this whole thing came about.
Cheng-Huai Ruan, M.D.
Now, that’s such a valuable lesson in the great lesson, because we as physicians actually have a huge leg up on this, because there’s, if you’re getting money the traditional way, which is basically getting your FICO scores and get all this stuff in order, there’s a whole other system out there for private practices that doesn’t really exist, but it’s not marketed that well or at all, actually. So I feel like if you’re getting Instagram ads, the targeted ads, via some algorithm, from YouTube or Google or whatever, then you’re gonna be wanting to, go with specific, loan structures. And there’s nothing wrong with loan structures, because not all zip codes qualify for what you and I had, right? Well, actually my new zip code didn’t. So I actually used a loan to start my new facility, ’cause that was not a zip code that, required or qualified for these things. So, these are all the great things. Let’s talk about the pain points for a while. ‘Cause there’s actually a lot. But can you go through some of the pain points that you had when you first started and how were you able to overcome those challenges?
Hammad Qureshi M.D.
Yep, absolutely. So I think that the big… So, one of the big challenges, when you transition from having an employed position to kind of starting something on your own is to learn man management. I think man management was the biggest surprise for me to learn how difficult, hiring, firing, keeping a staff, keeping happy. So that was, I actually maybe lost the medical assistant two weeks after opening the doors because of some issue and then lost another one then. So, there were a lot of issues initially. So it made me realize that, when you hire people, and I think that we had a conversation about this as well, where you told me how a streamlined process you had when you interview people through a process, and that really was, something that I took to heart and then you used it. You have to hire the right people. You have to keep your employees happy. You have to be a good, employer because you’re in the market, which is competitive. And, people are going to, salaries need to be competitive, benefits need to be competitive. So that was a big learning curve for me to how to man, how to do human resource management, because that’s, very, very difficult. And it’s a challenge to this day, right? It’s in private practice.
Cheng-Huai Ruan, M.D.
Always a challenge.
Hammad Qureshi M.D.
We don’t want it to be a revolving door. You want to build a stable core team that kind of grows with you, but sometimes people move away, people have family issues, different things like that. And you cannot compete with a big like Methodist system or an HCS system, or you’re a much smaller company. So we realize that. So that’s definitely something that you learn with time and you talk to mentors and see how they’re doing it. And what are some of the things that are working for them, so that you’re trying to incorporate some of that into your own practice.
Cheng-Huai Ruan, M.D.
Yeah, I’m gonna echo you on you here. Human resources and people management is the hardest thing to learn at the very beginning, ’cause you’re not used to it. ‘Cause you come from a situation where you are the person being managed, right? And then when you flip it, and then all of a sudden have to develop leadership skills, that’s far more robust than academia, right? Because if your a paycheck to them, is their livelihood and at the same time, you’re also spending money and your own resources taking time away from you and your family and training these people, so they leave the turnover is high, then it becomes an issue. Now we did talk about this before how there’s gotta be a streamlined way of interviewing. And there’s also has to be a streamline way of documenting your process. And we actually use a program that we use for all, it’s like an online training program. And the link is with the description in this video, guys, if you wanna know about it.
And that allows us to pre-train people. And now we pre-qualify people and say, hey, start this online university pre application processes. And we talk about what our core values of the company are, and basically it’s like, we’re trying to build tribe. And that’s what I want people to understand in private practice. And I’m sure, by now we both learned that it’s all about tribal building and tribal leadership. If, you are coming at a point or you’re okay, here’s the medical system, front office back office, and here’s the job requirements, and then you hire people into that, most likely you’re gonna have a relatively high turnover, versus if you come to the mindset of building a tribe.
So, I’m Chang Ruan, Texas Center for Lifestyle Medicine, our values are communication with our patients and utilizing food and lifestyle metrics to improve chronic health. Is this something that you’re interested in as being a part of, right? So that’s a different conversations than, hey, do you want to be my MA? And I think for you, you’re also integrative family physician too, so you have a very unique subset of over there as well. And I think that language is really needs to be spoken about, hey, what are the special, unique things about my practice, that I value? And I want the same things for my employees to value as well. Now, if they don’t value it or they de-value it, and you can tell during the interview or the interview questions, they may not be the best fit because that matters way more than the resume, ’cause we can train people to do anything. But you can’t train attitude and culture without spending an exorbitant amount of energy to do so, right? And it is about building that tribe man.
Hammad Qureshi M.D.
And you have to build that team setting. There was a saying that, take care of your employees and your employees are gonna take care of your business. So you have to have that mentality that mindset, that, and one thing that I’ve told my staff, for me, customer service is very important, right? So I pride myself in, hey, I’m available for my patients. If you call, you are seen today, if not today, tomorrow. And I expect them to, I expect my team to, echo the sentiment that, hey, we’re a place where you come in and you deserve, or get a level of service that you typically don’t get at other primary care offices, or that kind of sets us apart. And, so that is good for business growth. It brings in new patients. For example, I pay a lot of emphasis on online ratings and online reviews and.
Cheng-Huai Ruan, M.D.
Yeah, you kill it online reviews, man. You have 505 star reviews or something like that, it’s crazy.
Hammad Qureshi M.D.
So that is something that, all my staff knows that, hey, if there is a person who writes a one-star Google rating, it has to do with something other than myself, then there’s gonna be some explanation that’s gonna be called as to why that happened. Albeit you cannot keep everybody happy, but it’s something that I realized very early on that, for my patient population, which is a younger patient population that, every day, I hear a kid, you’re not that, how did you hear about us? Online reviews. So, it’s something that drives in business, and if it’s something that drives some business for the work that we’re doing, so we wanna continue doing that work, and we want a team that recognizes it and can build on those same principles. Something happened.
Cheng-Huai Ruan, M.D.
Yeah. I was all showing people that you have 471 Google reviews. And, you average on the five-star. I mean, that is so rare. I mean, it’s almost, not existing within medical practices. So good job for that man. I mean, this is just in a couple of years, bro. I mean, people are trying to get to this level, for multiple different things. But I think that, that’s the point about building the team, because if you think about it, a lot of people have a lot of gripes on social media and stuff like that because it’s usually the front desk or the back office or delays and refills and yada yada yada. So, I think that building that team that supports that customer service setting is gonna be crucial. I just did another part of the segment with Haley Fisher Wright. Dr. Fisher Wright, is the CEO of MGMA, Medical Group Management Association. And her and I agree on one thing, is that the mentality of a patient is that in addition to a patient, they’re also clients. And even though some people cringe at the aspect, we have to treat them that way ’cause that’s the mentality of over delivery. And that’s how you decrease burnout actually. People think, yeah, it’s the opposite, But that’s true, right?
Hammad Qureshi M.D.
There’s value in trying to get to that early on and understanding that it’s a very important in private practice that you know, that, hey, this is at the end of the day, you have to run a good business operation, right? It’s one thing being a very caring physician. If you’re a very caring physician, if you’re good at what you do, your business will grow. But unless you understand the dynamics of money in money out expenses, overheads, then, it’s not gonna work. So it’s very important that, hey, these are at the end of the day, they’re are clients that you need to keep satisfied, it’s a happy client because they’re gonna send their families. Or they’re only gonna tell 10 people that hey, never go there.
Cheng-Huai Ruan, M.D.
Right, and I think a lot of doctors also kinda fearing that with over delivery of this value, kinda burns them out. But honestly, if you look at the studies, the opposite is true. Is that, if you provide that sort of environment for your practice, for your patients, and then your staff reflects it, I mean, that’s how you get that 500, five star reviews over three and a half years, and that’s, but not only about the reviews, is that we have to think about here’s the thing. Here’s the thing that no one thinks about. What I just showed on the screen, which is basically your practice having, all those Google reviews, your great, great, great, great grandchildren are gonna see that. You’re developing your legacy, and those people have to understand that whenever you have a digital footprint, that’s on Google, by the way, Google actually owns the internet. When you have a digital footprint, that’s on Google, this is there forever.
And this is going to be the legacy that you have because you’re gonna be someone’s ancestor later on, and this is actually index, and they look back, and it’s like wow, you had all these great reviews and grandpa was such a great doctor and people loved him and that’s the thing. And this is called building digital equity. It’s not a concept people understand because we don’t experience in that. ‘Cause this is relatively new for us, but man, everything’s index right now. And then, now cryptocurrency is seen as hard currency, right? And so, we have to live in a digital age and understand that if you are one of those doctors right now and you have not so great reviews, I actually have online course, it’s free.
It’s actually with the description in this, video about how to get constant five star reviews and raving patient fans. And so let’s go ahead and check that out. It’s a very simple 30 minute mini course you go through. But that’s the thing, you gotta build a team. And the biggest pain point is always in human resources and understanding that. But it’s so worth it, when you are in a hurry to fail, you hire some people, okay this didn’t work out, but it’s so worth it to understand that you get what you tolerate, which means if you have someone that’s not doing what they’re supposed to do, or they’re not meeting expectations and outcomes, if you don’t let them go, you get what you tolerate. And I think a lot of practices do this and it’s really unnecessary and that’s a big problem as well.
Hammad Qureshi M.D.
A good fit with you and what is not, right? And one thing that I’m going to add to this whole reputation management, or just starting out their own businesses that you have to know what will work for you. So for example, when I started out my mentor, who is, I told you about earlier, there’s a service called Zoc doc. And a lot of people might be aware of that. It’s an online scheduling thing. So I signed up for Zoc doc initially when I first opened up and it was about $300 per month, that was a large amount of money at that time for me to spend on a subscription service. But it gave me a lot of patience and it was a good investment for me to make at that time, which my mentor did not seem to think that it was worth it because she already had a lot of patients. She opened in league city that a lot of patients followed up with her. So you will know what works for you, and you have to just kinda follow through with it. Get advice from a few different people, process that, digest that, and then act on what you think is gonna be good for your practice.
Cheng-Huai Ruan, M.D.
What a great talk we’re having right now, because I think that, these are general principles to kinda go on with private practice and even if you’re non private, even if you’re academia. What everyone should do right now, is go into Google and then Google your name, in Google Maps, not in regular Google, in Google Maps. And if you don’t have a location for your Google Maps, create a Google business profile with your actual name and then you can actually send that to, either patients or whoever it is that you take care of, even if you’re outside of a private practice institution, because you are, so what you wanna do is you can actually build your Five stars before you even go into private practice, right? I actually did that in New York. I transfer my stars in New York last year, and I’ll say, hey, I changed locations to Houston, Texas.
I actually carried a lot of that stuff with me. And right now the new thing with Google, especially with Google business, you can even create your own business website. It’s completely free. It’s called Google business. You can sign up. It’s completely free, you have your own thing. And then you can make sort of your, personal website and the account, right? And it’s totally cool, ’cause it’s just you. And then that’s how you sort of build that, brand equity of one being your own own brand, right? And I think that’s just, it’s a great accomplishment. Once again, you have more five stars than in our facility, which is awesome ’cause we actually have a bunch too. And then the here’s another pain point that I want you to talk about, is yes, we talked about, employees and building a culture of building a tribe, leadership, let’s talk about this. Let’s talk about the revenue cycle for a second. So how we get paid. I had no idea how freaking complex it was to get paid and how extraordinarily unnecessarily complex is to get paid till I went into private practice. You feel the same way?
Hammad Qureshi M.D.
Yeah, no, absolutely. So I think that one of the things that was very important to realize very quickly was that, you have to learn the revenue cycle very quickly, how important your CPT codes are, how important your, billing is, and then to have a good billing person, either dedicated that is dedicatedly looking at that, or somebody who can follow up on claims and denials and basically work with you to see why, what are some of the things that you’re missing out on revenue. So I realized that pretty quickly, and it was a painful process. I remember one thing that you told me initially, when this is one of our first conversations is, hey, money not spent is a money, a dollar not spent is a dollar saved, right? So important to realize that because there’ll be so many expenses and you have to make sure that your revenue is in a way that that can offset those expenses. Keep your overhead low and make sure that you are exploring all the avenues that bring in more revenue. And it’s important to understand that concept because every other specialty, be it cardiology, GI doctors, plastic surgeons, everybody’s, that’s how private practice thrives is to, figure out pockets of where that revenue cycle is and to tap into those.
Cheng-Huai Ruan, M.D.
Totally bright. I mean, this is a huge lesson too, because both of us went through a lot of those pain points and a lot of doctors is what most, I think most practices do. And even larger institutions go through the exact same pain points on revenue cycle collections, because here’s the thing, the insurance’s job is to make sure that it’s, relatively hard for us to get paid and if they can delay that, it could delay the reimbursement. The chances are a lot of the newer doctors don’t go after it. So there’s three whistleblowers within three different insurance networks in the last decade that talks about automatic claim denials. So this is big. So what happens is I’m not gonna name insurers, is that if you can think of the three largest insurance networks right now off the top of your head, it’s them.
So, one whistleblower was talking about, if you are a private practice under the age of three years old, you have 25% of your claims denied automatically. Why? Because the chances are you going after them is very minimal when you first start off, ’cause you know nothing, okay? And between five and seven years old in private practice, then it’s not one in four it’s about one in six or so. And if there’s any new code, if you’ve been in private practice and there’s any new codes that pop up, that is not built before, basically adding a service line of 50% of it, is requiring a lot more documentation and seeing that because it delays your revenue cycles. So insurance companies make money by, it’s not just not paying you, but it’s not paying you, but if they do pay you, they delay the payment. So money is calculated, not just in amount but amount over time. And we call that cashflow.
So a lot of private practice doctors are praised to this and the insurance company see that, oh my gosh, this guy has been like, just writing off claims for last six years would have continued to do one in four denials. They have artificial intelligence robots that risk stratify practices with this behavior. So if your revenue cycle, if you think you’re gonna be one submitting everything and not going after your claims, just for the first few years, know, that over a few years, that’s over a million dollars you’re probably gonna lose because of the habits of your actual billing. That pissed me off so much because of the fact that why is it so hard for private practice to start and be sustainable is because of actions like these as well. So, a lot of startups are like, okay, we’re going to get this billing company to do our billing service, or I’m gonna hire my own billers, but it’s not something that you should take lightly. And because you have to understand that your billing cycle revenue has to have a very consistent, I’m a go at it, go at it, go at it, especially if you’re starting out. And so that’s really important.
Hammad Qureshi M.D.
They, said that a good billing cycle or a billing revenue generation cycle is going to be the backbone that’s gonna make or break your practice. So this could be, not be further. I mean, closer to the truth, that it’s very, very important. And these are things that you learn on later on, I mean I’ve gone through. We’ve kind of talked about this ourselves. I started out as having an in-house biller, did not work well, then moved on to somebody else. You continuously learn and it’s a continuously evolving process. If you think that, happy and sad, and somebody has been working great for like 15 years, then kudos to you. And I would suggest that, you need to kind of take a look, a deeper look at your accounts receivable. And what is, because one of the challenges is, Chang is that we get so busy, we get so busy.
Hey, I have to see the patients. I have to do refills. I have to return phone calls. I have to get home to my family that. I can’t be bothered to, now when I have to go home, how do I need to, sit down and talk, look at ARs and what is happening. So I think that a lot of times billing companies, take advantage of that from the little guy that hey, he’s just so busy trying to make ends meet and try to get their revenue generated that they’re not probably gonna be bothered about, what are the claims that are denied, and why were they denied? That’s the severance that you provided? That it’s the same thing as having, going to a restaurant, eating a steak, walking away and not paying the bill, so.
Cheng-Huai Ruan, M.D.
Yeah, and believe it or not now, especially over since coronavirus, there are so many Silicon valley companies that actually have robots to fight the insurance company robots. And so what happens is a risk satisfy your claims for denial and gives you a pattern of coding to, sorry of submissions and resubmissions to utilize. So literally combats the enemy, like a robot versus robot war. That’s where we’re at right now. If you guys are interested in that there’s a company that I work with, and the link is with the description below this video. If you click on that, if you actually are in private practice, they would give you an entire lowdown of what you’re leaving on the table. The robot actually does a really good job. It’s a combination of robots and humans. And so, these are the lessons man. If people understand these main lessons, you should be pretty good to go. So once again, as a recap, find money where you can, talk to the major hospital systems, if you’re wanting to move into an area, if you haven’t started up yet, or if you did start up and you’re already in the way, find, this is something, we didn’t really touch a whole lot, but actually find more money than you need.
So there’s this book by Tillman Fertitta, which talks about, oh, the book is called “Shut Up and Listen.” And, I thought the book was about shut up and listen to Tillman, but it’s really shut up and listened to your clients, right? And in this book, he talks about listening to the clients, which are basically our patient, what do they really want? But another big lesson that I suffer, this painful in the very beginning is that I only got enough for what I think was needed to run a practice. And then six weeks later we had hurricane Harvey, where half the city or three fourth the city was flooded, right? And so I didn’t plan for catastrophes. And so that book actually taught me a valuable lesson is yeah have to have operating cash flow and reserves, so get more than you need, and then as you go along, keep that one year of operating cashflow there and then pay back the loan as you go, because that’s going to have a true dramatic improvement in longevity on whatever natural disaster come your way, whether it’s hurricane Harvey or coronavirus, right? And so get more than what you need.
And right now, honestly, if some, physicians don’t even have good credit, there’s companies out there that also have, career-based, a loan risk assessment if you’re a physician, even if you’re coming out of fellowship or residency, they risk stratify you based on your career trajectory. And you can actually get loans from that too. So there’s all sorts of things out right now. It’s just that it’s not marketed very well, I think to physicians and it’s relatively new, but right now we have to use every tool that we can, the other industries have already used in startup businesses to leverage that on our own. But that’s the whole reason why I created this summit. So, we grew a lot over the last few years and we’ll continue to grow and we’re always under a constant never ending cycle of improvement and that’s always gonna be true and that leads to our growth, and we really have to support each other as physicians and give each other resources. And that’s really the era of collaboration that we should really have.
Hammad Qureshi M.D.
No, I think that this is a great initiative by you and your team to kind of put this thing together. I wished that there, I had listened to, if I was starting back thinking back three years and if there was some resource like this, for somebody who is, on the fence or thinking of throwing their hat in the ring, or making the move, like I said, find people that you can talk to, that you can find that that can be your mentors, and then those will be absolute, valuable resources and look into avenues like these, where you can learn, learn from other people and learn from other people’s experiences. A lot of the things that we talked about are going to work for a lot of people. Some things might not. So you just have to kind of find your own path and your own journey, but the principles remain the same, that it can be done, there is a method to the madness. It’s a lot of hard work. So is anything else in life that is worth, anything worth doing is worth doing well, right? So, it absolutely can be done. You just have to learn and we continue to grow, continue to learn, have an open mind. And there is no reason why you cannot be successful doing it.
Cheng-Huai Ruan, M.D.
Yeah. And be unique and be true to yourself too. I think that’s the other thing. I was talking to both of our friends, Dr. Rada Tamorese, an integrative gastroenterologists on another segment of this, and we were just really talking about being authentic to ourselves and our uniqueness and having a lot of that creativity come out, right? And so you have your niche wishes, you have family practice and integrative health, and you also have an infusion center just like I do. So that’s very unique to a primary care practice. So there’s a lot of things that can be curated and generated as long as the foundations are set, right? And that’s the lesson here. Things are possible.
Hammad Qureshi M.D.
100%.
Cheng-Huai Ruan, M.D.
Yeah, so thanks a lot for coming on with me, man. It’s been such a wonderful time chatting with you and reconnecting again. I hope that doctors see this and get really inspired and take that step should they choose to, and some people will hear about this and say, no, you know what? It’s too complex for me. And that’s fine, at least we laid it out, and to know what you expect, ’cause the whole point of this is to do in what’s in your power for yourself to make yourself and your family happy and to put that value and growth and contribution within your heart. And that’s the most important thing for doctors,
Hammad Qureshi M.D.
No, 100%, like I said, it’s been a pleasure talking to you. I know we keep bouncing ideas from each other and that’s what we need. We need to inspire, other people to, have that hunger to do something on their own, that it can be done. And use absolutely all resources available at their disposal to make it happen.
Cheng-Huai Ruan, M.D.
Well great talk talking to you, and people take some action and be absolute critical that you just wanna be authentic for yourself. So I thank you for coming on. We’re signing off
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