Mike,
These are very tough questions with no absolutely correct answers.
I am an FP and have been in private practice for 17 years.
Prior to that I did Emergency Medicine, worked 12 shifts/month and took a 10-12 day block off each month AND earned a boat load of money. I loved the simplicity, no responsibilities, loved the excitement of the ER and always learning. I also, like you, eventually wanted a 'small' family practice office.
I started a small mom and pop FP in the USVI in '91. Until about 6 years ago, we did not take any insurance, opted out of Medicare, did high quality work and had a very elite, financially successful practice. It was too elite -- only rich folks could afford us. It was labor intensive as most mom and pop operations can be and reduced my ability to take time off.
Over the years we have expanded considerably -- I now have 3 offices on 2 islands, we have 7 providers (peds, FP, IM) and about 35 total staff. We formed a PPO with most of the other docs in the USVI and started taking insurance about 6 years ago. We only accept those companies that agree to pay our fee 'insurance/PPO' fee schedule and agree to pay within 15 days. We still do NOT accept medicare but do see elderly people at reduced rates who do not have resources (i.e. $6-22/visit).
We have a very profitable model, where all my docs take home over 50% of what they bill out and are able to take up to 12 weeks off/year if they can afford to or want to. I personally take 6 months off a year to go mountain biking, hiking, and sailing as well as take CME courses.
The bad: having 35 employees and all the complications, going from mom and pop to having and administrator, IT person, operations manager, front desk supervisor, insurance biller, employee issues all the time.
IF I had to take reduced fees from insurance companies, deal with Medicare, and have to fight to get my money I do not think I would do it -- too costly, too aggravating, and I would not be having fun seeing patients. I would also be working too hard and for too little money.
On another note...we are using AC and my docs like it a lot for its flexibility and it increases our work load the least compared to dictation. Because we are using AC we have a separate medical billing / managment program to handle the finances, insurance, e claims, tracking, etc. So...if AC does not have an integrated module by the time you start you might want to look at some of the other programs like eMD's.
These are very tough choices and it is good that you are asking now. What are your priorities? If it is having fun practicing, earning good money and having time in your life for other activities and interests -- why change what you are doing? IF, on the other hand, you want to be a family doc in a community and have patients/families that are yours for the next 30 years and be of service as your primary motivating goal then a small FP Practice can be wonderfully rewarding. Just do it smart and right!
I hope this rant is helpful. If you would like to see our operation I would be glad to share whatever I can. If you need a job where you earn $xxx+/year, no hospital call, 12 weeks off a year then I know where such a place might be;-)
Best,
James P. Clayton, M.D.
www.redhookfamilypractice.comUS Virgin Islands
