A clinician founder opens a practice. The clinical program is designed the way clinical training teaches: evidence reviewed, protocols written, standards set before the first patient arrives. The business side comes together differently. A billing process borrowed from a former employer. A scheduling habit that began as a workaround. An org chart that reflects the order people were hired.
The clinical side
Evidence reviewed. Protocols written. Standards set before the first patient arrives. Designed.
The business side
A borrowed billing process. A scheduling habit. An org chart in hiring order. Accumulated.
This is not a criticism of founders. It is how training works. Clinicians are taught to design care and are then handed a business. The field itself took years to name the gap. The Triple Aim defined health system performance as better care, better population health, and lower cost.1 Six years later, a fourth aim was added: the work life of the people delivering care, because the first three depend on it.2
- Better care for each patient
- Better health for the population
- Lower cost sustained over time
- Team work life added 2014
Berwick, Nolan and Whittington, Health Affairs 2008 · Bodenheimer and Sinsky, Annals of Family Medicine 2014
Clinicians are taught to design care and are handed a business.
Business strategy from the beginning
- The revenue model, chosen on purpose: which payers, which services, and what visit mix sustains the practice.
- The staffing model, built from a coverage map rather than the last emergency.
- Compliance as architecture, written into workflows from day one, because building it in costs less than adding it after a survey.
- Documentation systems selected for the practice being built.
Who the practice answers to
Part of designing the business side is knowing, from day one, which bodies govern it. A California practice answers to more of them than many founders expect, and each reviews a written artifact that a designed operation produces naturally.3
| Body | What it governs | |
|---|---|---|
| Medical Board of California | Physician licensure, corporate practice of medicine, supervision of PAs and medical assistants | mbc.ca.gov |
| Board of Registered Nursing | RN and NP licensure, scope, standardized procedures | rn.ca.gov |
| CDPH Licensing and Certification | Licensed clinics and health facilities, Title 22 | cdph.ca.gov |
| Department of Health Care Services | Substance use and mental health program licensing, Medi-Cal, Title 9 | dhcs.ca.gov |
| Cal/OSHA | Injury and illness prevention, bloodborne pathogens, workplace violence prevention | dir.ca.gov/dosh |
| HHS Office for Civil Rights | HIPAA privacy and security; 42 CFR Part 2 | hhs.gov/ocr |
| CMS and HHS OIG | Medicare enrollment, billing rules, compliance guidance | cms.gov · oig.hhs.gov |
| DMHC and CDI | Health plan and insurer regulation | dmhc.ca.gov · insurance.ca.gov |
| Joint Commission, AAAHC, CARF | Voluntary accreditation that payers and referral sources increasingly expect |
Every row reviews a document · a designed operation produces it as a byproduct
Concierge, and the established practice
For concierge medicine, the case is especially clear. The product is the experience: access, continuity, attention, and time. Each of those is an operational property. When operations are designed to deliver them, the founder no longer has to personally underwrite the promise on evenings and weekends.
For an established practice, the same work applies in reverse. The practice succeeded, and the scaffolding that carried it here was built for a smaller version. The next step is to give the business side the design phase it never had: map what exists, decide what should exist, and close the distance deliberately.
The equation holds in every setting
A quality clinical team drives the care. Systems decide whether that quality reaches every patient, every day, at a margin that sustains it.
Starting points
Five ways to give the business side its design phase.
- Map the business side on one page. Revenue model, staffing model, key workflows, and who owns each.
- List your governing bodies. For each, note what document it would ask for and where that document lives today.
- Choose one design priority. Pick the area with the most rework or risk and give it a design phase.
- Review your payer and service mix. Confirm the mix you have is the mix you would choose.
- Add the fourth aim to your metrics. Track one measure of team work life, such as turnover or overtime, alongside clinical and financial results.
Resources
| Resource | What it offers | Website |
|---|---|---|
| IHI | Triple and Quadruple Aim resources | ihi.org |
| Medical Board of California | Practice ownership and supervision guidance | mbc.ca.gov |
| HHS Office of Inspector General | General Compliance Program Guidance | oig.hhs.gov |
| MGMA | Operational and financial benchmarks | mgma.com |
| AMA STEPS Forward | Practice management modules | edhub.ama-assn.org/steps-forward |
Sources
- Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Affairs. 2008;27(3):759-769.
- Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Annals of Family Medicine. 2014;12(6):573-576.
- California Business and Professions Code 2000 et seq. and 2700 et seq.; Health and Safety Code 1200 et seq. and 11834 et seq.; California Code of Regulations, Titles 8, 9, and 22; 45 CFR Parts 160 and 164; 42 CFR Part 2.
For educational purposes only. This is not legal advice.
Two sides.
One system.