How Dr. Brian Gantwerker battled with insurance companies to build his spine practice

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Brian Gantwerker, MD, is a neurosurgeon specializing in the treatment of brain tumors, as well as degenerative diseases and injuries of the spinal cord.

Dr. Gantwerker graduated from Rush Medical College in Chicago, before completing a neurosurgical residency at University Hospitals in Cleveland and a complex spine fellowship at Barrow Neurological Institute in Phoenix.

He has been in private practice for nine years as president and CEO of The Craniospinal Center of Los Angeles in Santa Monica and Encino, Calif.

Here, Dr. Gantwerker discusses why he opted for private practice, how he navigated early remuneration challenges and why location matters.

Question: Was it always your goal to set up your own private practice? Where was your head at after your fellowship at Barrow?

Dr. Brian Gantwerker: Private practice was definitely in the front of my mind. I enjoyed the ability to practice medicine in a direct physician to patient relationship rather than having a system sitting between me and the patient. My first job was with a small practice in the north part of Los Angeles and after that I wanted to try and practice medicine more in an old fashioned way with very direct patient care. That's when my wife and I decided to start our own private practice.

Q: Was establishing your practice an arduous process? What were the major challenges along the way, and how did you tackle them?

BG: It's still an ongoing process. We started with a very modest number of patients; about 30. We signed a lot of contracts with payers and certain HMOs in the area. As we gained experience and began building our patient population, we started to scale back on the number of insurances we took. One of the reasons was we had difficulty getting paid, even if we were getting in-network patients and charging what we were supposed to. We were playing by the rules, but the carriers refused to. We learned a lot about how carriers operate and decided it wasn't worth the trouble to take all these insurances when they weren't going to be providing us with remuneration for our services. Eventually we had to scale back because we spent too many hours chasing payments. 

Building a private practice and having to whittle down the number of insurances you take gets very difficult. It makes it a very slow process but when you finally get to the point where patients are being referred to you by themselves and family members, and not just physicians, it's a great feeling. There's a big sense of satisfaction. We try to provide services to anybody that comes through the door, but we can't say the same about when we try to get paid for the services we're rendering. I think that's going to continue to be a hinderance for starting a private practice, but I would advise anyone who wants to start one to be ready for a long, drawn-out battle. It's a constant back and forth conflict with the payers. I'm afraid that a lot of physicians who want to remain independent will be forced to drop all but a couple of insurances and becoming hospital employed. 

Q: If you were coming out of your fellowship now, would you go down the same road in terms of setting up your own practice, or would you do anything differently?

BG: I think I would. There's a certain comfort and safety having a large umbrella organization over you. There's definitely benefits in terms of retirement and ancillary services you could use, but I don't think I would have the same sense of satisfaction as I do when I'm working through my own issues, both from a business and clinical standpoint. 

I have a great group of colleagues that I work with and here in L.A., you can throw a dime and hit a spine surgeon or neurosurgeon. I have great relationships where I can bounce ideas off people. I would probably change a few things in how I set up my office initially but for the most part I'm very happy with how I've been growing. There's always that idea joining a group practice that's contracted with a hospital and becoming directly employed, but I don't think my job satisfaction would be as great as it is right now.

Q: Did you ever consider setting up your practice at home in Chicago? 

BG: I love Chicago but it's very expensive to practice there. Malpractice premiums are out of control in Illinois and that's the fault of the lawmakers who haven't initiated tort reform. When you have a neurosurgeon having to pay $250,000 in malpractice premiums, that's completely untenable in any kind of situation starting up. Most neurosurgeons have to join larger group practices or become directly employed in order to have their malpractice premiums covered. To me the scale is totally outlandish, and the system is broken. You'd have a lot more individual practitioners there if they could afford it. It doesn't make sense to charge such a large amount of money to someone who has just gone through residency and fellowship to open a practice in Chicago. 

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