Choosing the right members for your practice

Not all members are a good fit for your practice!

The temptation to grow and accept all members is real — but it's not worth accepting members into your practice who aren't a good fit.

What's your ideal patient?

Take some time and think through your ideal patient and patient panel. If you could craft your perfect panel of patients, what would that look like? What kinds of patients would you not include in that panel?

Write out some of those characteristics in sentence form. Some of them might look like this:

• Mostly healthy individuals who are concerned about maintaining or improving their health.
• A mix of chronic-need individuals whose health I can help manage quarterly and healthy, independent families that I only see when they have an urgent need.
• Sports-focused families where I can help develop healthy routines for an active lifestyle without injury.
• Some drug-recovering adults who are willing to maintain a suboxone protocol and aren't pain-seeking.
• A mix of all types of individuals, with no more than 30 adults who need pain meds for truly chronic pain diseases.
• A large percentage of families with young to teenage children who need mostly urgent care.
• A large percentage of working-class employees who appreciate same- or next-day phone visits and occasional in-person appointments.

You get the picture. Write down your ideal mix of patients.

Where do you draw the line?

You've likely run into some patients during residency or your practice who you realized are not for you. And that's perfectly fine! It's your practice, so you get to have boundaries.

It's OK to filter out those patients and let them know they'll receive better care elsewhere.

You can steal one of my favorite lines:

"We want to make sure that whether you're a member of our practice or not, you receive the best care possible. Unfortunately, there are some health issues you need addressed that are outside of our scope and expertise, and we think it's best you find a better fit for those needs."

And if you can, recommend where you think they should go for great care. That's customer service!

How to filter patients who aren't a good fit

There are several ways to filter out patients. I can't list them all here, but here are a few ideas.

Pre-registration questionnaire

Have each potential member or family fill out a questionnaire prior to registering. Include areas where they can answer general medical questions, but also some specific questions if you want to filter out patients for certain things.

For example, if you do not want to take on chronic pain patients, ask whether they are on any current pain management medications, ask them to list those medications, and include a disclaimer that says something like, "We currently do not prescribe pain medications. Any chronic pain medications will need to be managed at the local pain clinic or by another physician."

Discovery call

Many DPC physicians start out with a decent amount of time, so instead of a questionnaire, they schedule a "discovery call" with each potential member or the head of household for families.

This allows you to hear more about their specific needs, how they heard about your clinic, and what they expect from you for their health needs.

Some potential questions to ask during a discovery call are:

• How did you hear about our clinic?
• How many times would you say you or your family visited your doctor in the past year?
• Do you see any specialists? For what?
• What medications are you currently taking?
• What are your overall health goals?
• What questions do you have about Direct Primary Care and how membership works?

Initial physical exam with a one-time charge

If you'd rather not deal with pre-screening members, you can offer a physical exam for everyone who signs up, with a flat fee charged (I'd recommend between $125 and $250).

You would then make it clear that the visit includes a 45- to 60-minute appointment where you'll go over health history, a general idea of health goals, and prescription history, plus perhaps a basic physical (without labs). This visit would not include prescribing any medications, nor would it assume that care is being established.

This is an evaluation of their health and whether you're a good fit for each other.

One caution: depending on your personality, it may be a lot harder to say "no" to a potential member in person versus over the phone or email.

The reality: some will slip through

Whatever system you implement to filter out patients, it's not going to be perfect. And that's OK.

Just realize that this is your practice, and it's OK to fire patients if they are being too stressful for you and/or your team.

It can be a good practice to evaluate every so often (once or twice a year) whether there are patients who bring you additional stress, and to consider firing them.

Policies exist to give you permission to fire patients

While I'm not a big believer in policies (I think they're overused, and they often prevent humans from using their creative problem-solving skills), putting a few in place can help protect you and your staff from stress-inducing members.

Here are some that should exist in all clinics. Violating any of these will result in immediate membership termination:

• Any form of sexual harassment
• Verbal or physical abuse of any of our staff or medical providers
• Stealing
• Unpaid membership dues

Some other policies that many clinics should consider, each of which could result in immediate termination, a three-strike rule, or similar:

• Requesting early refills of pain medication
• Requesting delayed membership dues
• Self-medicating with another person's prescription medication without consultation

It's OK to change your mind

There's nothing like time and experience as a teacher, so don't be afraid to change or alter your approach to patients over time.

You may discover that a patient you thought would be difficult actually brings you more joy than expected. Or maybe that you don't mind managing chronic issues, or even pain meds, as much as you thought.

The best thing you can do is move forward, realize that mistakes will happen, and take the chance to learn from them along the way.