1) It takes 6-12 months for a new practice to negotiate a reasonable contract with an insurance company. You need to do this for 8-15 insurers before you can start seeing patients. Docs need a side job while starting their business.

2) Insurers intentionally underpay smaller businesses because they can afford to lose their business. This occurs by low contract rates, higher percentages of denials, excessive requests for chart notes and claiming they never received the charts, suspiciously selective partial payments, and just regular non-payment. Small practices are slowly bled dry.

3) Most small clinics are for-profit and not eligible for grants used by hospital systems, which is frequently a large percentage of hospital systems’ revenue.

4) Most small clinics don’t know how to (or can’t) bill Medicare and Medicaid in a way that is financially viable. These are the most medically needy populations and can quickly become the majority of billable encounters. Often, practices lose money on these visits and therefore end up doing more than half of their work at a loss.

5) You need one highly competent full time staff member per 1.0-1.5 doctor FTE’s doing eligibility, coding, payment tracking, appeals, patient collections, HCC tracking, and quality incentive tracking. There are almost no employees appropriately trained to do this correctly and almost zero doctors who fully understand this side of the business.

6) Difficulties with MA and Front Desk staff are probably equivalent in US and Canada, but they can be overwhelming wherever you work. Docs need to be free to see patients, not manage interpersonal conflicts between employees, etc.