Grow Midwives Webinar Follow-Up: Creating Your Dream Job as a Midwife

February 14, 2018

grow midwives create your dream job

 

Join Ginger Breedlove and Lesley Rathbun for an in-depth look at the business side of midwifery. Together, they share experiences collected first hand during 70+ combined years operating successful midwifery businesses. From starting an independent freestanding birth center, to working in partnership with large hospital organizations, Ginger and Lesley have navigated business relationships in a wide variety of practice structures. 

If you would like to talk with Ginger and Lesley about starting or growing a midwife business, or preparing for a job interview or contract negotiation make sure to contact us.

IF YOU WOULD LIKE TO FOLLOW ALONG AT YOUR OWN PACE, YOU CAN USE GINGER’S PREZI HERE.

Ginger: [00:00:00] All right. Well we're going to ask that tonight folks stay on mute. Until Lesley and I get to the end. You see a big blue circle for questions and answers, so there will be plenty of time for us to have conversation. And we'd like to assure you that that that's been the most fun part of these webinars is to be able to talk to people and answer questions and really engage with where you're at and what you want to learn more about.

Ginger: [00:00:33] Starting your own businesses is, you know, in 50 minutes is like getting a master's degree over many, many years of education. So we want to qualify this by saying we're giving you some general concepts that help you feel a little more prepared to even begin to think about this conversation. Some of us on the call have been around the midwifery block a very long time and have been educators as well and realize that taking an in-depth look at the business side of health care isn't what most health professions training programs does. You may have some experience, but it's very unlikely you go into a level that's required to be able to successfully run a business. So we're going to provide you what we think is helpful information an enormous number of really valuable and interpretable resources for you and share a little bit of our own stories and then go into some questions that you might have for us. So let's get started on making sure this thing works for me. Started it this way. Don't know why it brought me back to zero. Let's try this one. Alight. So we're going to talk first about kind of the concept of how do you assess if you're ready and how do you assess if you even know what risk you may be setting yourself up for. How do you figure it out? And this the slide about "Are you ready?" is probably one that you think there is an absolute answer for, but, quite frankly, starting a business is always about risk and whether you're ready for risk or not is the question, because being ready is nearly impossible. You can do the best you can, but there are things you learn along the way no matter what kind of business arrangement that you go into. So there are some wonderful tools to begin to think about readiness and to be able to assess. Kind of where you're at in the planning phase. So this two minute Eizenberg checklist, it's it's well validated. There are 18 questions and they ask you to answer these to the level of 16 or higher and if you score 16 or higher it suggests that you are, in fact, ready. I'm going to take you there right now. You can see the questions right here. And if you score 16 and take off, they encourage you to continue to look at this set of questions as just a constant evaluation process of your business.

Ginger: [00:03:46] So interesting questions like, "Does your business idea soothe someone's pain discomfort frustration or dissatisfaction?" For a midwife who's considering starting a business in today's world, I can't imagine we wouldn't all say yes. Are there lots of those people out there? That may depend on where you are geographically located, how you answered that question. These people governments or companies have money to pay for it? So it's really an interesting exercise in how you think about your readiness based on your business idea and where you want to go with it. So we would definitely encourage you to take a look at that Eizenberg checklist and see where you fall as you begin to take this journey.

Ginger: [00:04:38] A little bit of facts from the Small Business Association which is an incredible resource that some of the people we've been consulting with in the early phase of our company really have found on their own and taken time to talk to. I think the statistics are really fascinating.

Ginger: [00:04:57] The vast majority of startup funds. So 82 percent of new business comes from the entrepreneur themself, family, or friends. So now Lesley may have something to say about that from the birth center world in terms of for how many birth centers may actually find themselves starting through personal financing versus external financing. But if you think about 70 percent said that 77 percent rely on personal savings of their initial funds. That's a big financial risk that needs to be seriously considered. Lesley?

Lesley: [00:05:41] Yes, the majority of birth centers that are that are owned by midwives are financed from their personal savings or their equity is through a personal loan and they're taking a big risk.

Ginger: [00:05:56] Yeah I thought so. This next one is really interesting as well: 40 percent of small businesses are profitable 30 percent breakeven and 30 percent are continually losing money. Not taking a deep dive on how best explained You can find that information on the SBA website. But it is interesting to know that the chance of success is likely 40 percent with definitely an incentive if you want to consider breakeven for the greater good 70 percent doing good in their decision making. They also suggest that having two founders rather than one significantly increases your odds of success. And in fact you can raise 30 percent more capital when starting your business by doing that makes a lot of sense in terms of how you share the risk and what the collateral is on those loans that you may be taking out. So, again, what it what is the business risk? I love this statement. It's not about taking risks. It's about managing them.

Ginger: [00:07:08] So anyone who has been given a portfolio of money whether it's to start your own business or to manage a million and a half dollar grant you are taking on an immense amount of responsibility to manage those funds with fiduciary responsibility carefully and always with the intent of sustainability. So that means you need to be an expert. You need to start studying. We're going to give you some resources of where you can give that information.

Ginger: [00:07:42] The SBA says don't give up your day job yet. It's really important that you don't put added pressure on yourself by completely cutting off any revenue you have coming in. Until the business is launched. There is a strong bit of evidence about focus on building your client base. How are you going to find the people interested in your product or in the concept and are there networking opportunities that you can begin to build before that company or business is launched?

Ginger: [00:08:18] Learn how to read a balance sheet. Something few of us have had much exposure to unless you've been the chief midwife in a large midwife service. Maybe in a hospital practice the senior midwife gets to see a balance sheet. There may be other things you've done in your life where you've been exposed to financial sheets but it's important that you're able to understand how those function and get the help of experts people who can verify validate reassure and give you confidence that the steps that you're taking are are correct. Those all don't have to be experts that you pay. Many are out there in the world that work for free and I'm sure Leslie will talk to you a little bit about that later.

Ginger: [00:09:10] So as you become a student, we have some recommendations and more that will follow on on where do you find the resources instead of breaking up a 300 page textbook.

Ginger: [00:09:21] The Harvard Business Review is a phenomenal subscription. I would say anybody that's a midwife thinking about starting a business starting, a birth center, starting a hospital based practice, learning business only gives you more confidence sitting around a table with people who know business. You're less likely to be taken advantage of. Your voice is likely to be stronger at the table if you say things like a (crosstalk) and know what that means. There's a small business trends newsletter you can just google that. Also Harvard Business Review subscription is not free. The Small Business Trends newsletter is free and there is kind of like a free university online called Creative Live Online Learning which has a whole catalog of business courses from business 101 to financial spreadsheets and creating a proforma. So wanting to drop in just some ideas of where you can begin to find things that. Won't be real expensive. There's also associations that help with advice so Lesley you want to talk about this one.

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Lesley: [00:10:44] Sure, so SCORE is free and SCORE is a group of businessman, mainly required businessmen, who volunteer to give business advice to people looking at starting their own small business. Some of these guys run very large corporations. Some of were more entrepreneur type things. The input you get from somebody who's already been there and done that it's great and they will walk you through from very basic all the way through and there generally are SCORE groups throughout the United States. And this is the website. The gentleman that I was hooked up with had a fleet of gas station convenience stores, that type of a business and the best thing I got from him was when he'd gone through my business plan and everything and he said you're standing on the diving board with your toes hanging off the edge deciding if you're ready to jump or not and he said, "I just want you to consider yourself pushed." You know, that's the kind of thing you need to hear when you're figuring that out. Am I on the right track

Lesley: [00:12:09] So very valuable. The National Association of Women Business Owners is another really valuable resource as well as the women's business centers. They can state-to-state. Here, I'm in Charleston, South Carolina. So Charleston has the Charleston Women's Center and they were able to hook me up with an accountant, a female accountant who, for free, helped me do the spreadsheets, the budgeting, stuff that I was really uncomfortable with.

Lesley: [00:12:42] That is definitely, the accounting stuff, not in my forte. So, that was wonderful to have that help. So you just look and see what's available and there are lots of people who will help you.

Ginger: [00:12:59] Thank you. Lesley. So let's talk a little bit about how do you create a business plan and make the pitch? Part of this we've talked about in a previous webinar on community assessment. Gathering sort of the data that allows you to understand the demography of the area that you're considering starting the business in general ideas about healthcare competitors options that all really are different than a business plan.

Ginger: [00:13:37] So the community assessment will feed into it. Some will be copy and paste, but not all. So I love this little info graphic about 8 simple steps to an awesome business plan also known as the investor pitch. So creating an executive summary sort of the quick and dirty couple page discussion of the idea. What is the compelling story that you're trying to convey and how can you do that in a concise way that synthesizes sort of maybe what the problem statement is and the aim. What is it that you're trying to do that you think is unique and important

Ginger: [00:14:20] You're going to have to talk about the market and that will all come from your community assessment investigation. You know what's out there. How many how many women live in the area that you could provide services to or that you're interested in providing services to What's the unique selling proposition the USP that you have that's different than your competitors? So I'll just use Lesley for an example. She has water birth, I believe nitrous also in her birth center. If there are no other locations in Charleston that offers those options for women you have a very unique selling proposition that can help make the argument of why you're different and why you could in fact bear part of the market that other people would not get.

Ginger: [00:15:11] What's your attraction and and how do you forecast your progress? You know, from from where you're going to sort of land your feet and start your business and what do you anticipate your progress being over a particular period of time, especially for banks and investors wanting to be assured there's going to be some kind of good enough guarantee that their financial investment isn't a total risk.

Ginger: [00:15:43] Identifying your team. You can't do this by yourself, even if you're the only midwife in your business for a while, you're still going to need other people to help you run the business and who is that team, what are their jobs, their roles,their responsibilities, and what is the culture of this team

Ginger: [00:16:02] What are the foundational values and purposes that assure that you have a team dedicated to the same pathway.

Ginger: [00:16:12] The financials. So what does that business plan look like in detail. Things that Lesley just mentioned in terms of how do you create the spreadsheet for your costs, for your anticipated revenue generation, for your expenses in great great detail. And finally, what's the deal? You know, how do you come to an agreement that's a win-win for both, if you are seeking funding or partnership with others, what are the principles that help solidify that deal? You can see this info graphic looks pretty short and sweet, but it takes a fair amount of time. So we actually work with a couple people that have been working on their idea for a year and are getting very close to starting their businesses. So a lot to think about, and yet, if you can configure this in a real organized way, not quite so overwhelming.

Ginger: [00:17:22] And the piece that I think is true no matter what you're doing as a presenter is, "How do you tell the story?" What is the compelling reason that someone wants to believe you? And that often comes not from facts and numbers, but really the emotional side of the story. Lesley, do you want to you want to share how you approach that with the Charleston Birth Place?

Lesley: [00:17:57] Sure. I was told they were having trouble hearing me, is that better? I've switched my mic. OK. So I went back to Midwife school, grad school, thinking I had a job because I was working at a birth center and it was the physician that was running the birth center that talked me into going back to midwife school and then the malpractice crisis hit and he was a family medicine physician and he was not able to get malpractice insurance. And at the same time about 30 experienced CMs in the Cleveland area were laid off. So it became really clear pretty quickly that I wasn't going to get a job where I live, so we were moving. So there was a large physician-midwife practice here in Charleston that contacted me because they knew I had some interest in birth centers and they had an interest in opening a birth center.

Lesley: [00:18:58] Working in that environment was very difficult. The midwives did not receive much respect from the physicians. We were treated as we were physician extenders where physicians would dictate exactly what we were to do with patients and we were just to be the person that was actually breaking the water and starting the pit that they were running the whole show.

Lesley: [00:19:21] So there's a lot of dissatisfaction. The practice went through kind of practice divorce the end the founding physician left and I got very angry and very upset with the way we were being treated and the way I saw the practice going and so, instead of doing a birth center with them, I decided to just do it on my own. And a lot of things have to do with luck and timing and that was 2007. It was just befor the economy became a real problem with recession and getting loans, so I was able to slide it right before that happened. We were able to get loans that we personally backed and opened the birth center within a little under a year from the time we decided to do it. And I did not have trouble getting physicians to work with me or the hospital to agree to be a transport. I was already on staff there. The practice I was with, I was able to keep my job while I opened the birth center and I saw my patients through their process with the intent that they knew when I did open the center that the patients were going to come with me. Initially they were our consulting physicians, but being a large practice and there were personalities that were hard to deal with we did eventually go with a solo practitioner.

Lesley: [00:20:52] It was actually easier than I anticipated and more successful from the actual opening of the practice part. What became overwhelming very quickly. I think it's something typically with birth centers that people don't put into the equation is rapid growth and with rapid growth brings along its own problems.

Lesley: [00:21:19] And how do you rein that growth in, so that it's manageable. So some of the advice I was given by Kitty Ernst and some other iconic midwives in the birth center world was you're going to be surprised how successful you will be how quickly. So that's a piece that you need to keep in mind. How am I going to take on more midwives and how are we going to grow and how are we going to manage that?

Ginger: [00:21:51] Yeah and I think, Lesley that would be true for someone in a state where they can set up just a midwife practice on their own and deliver in the hospital or whether they're setting up a home birth practice and trying to figure out how are they going to be on 24/7 call, with or without a partner, and and share some of those responsibilities. There are still solo OBs out in the world. There aren't very many, but...

Lesley: [00:22:15] Right. Ten years ago there was a growing interest in midwives, in birth centers, but not what it is today. Kind of one of those build it and they will come whether you're they're talking about midwife practice in hospital or out of hospital. The consumer is more than welcomed to considering midwives, they're actually demanding it. So you're needed and you're wanted. You could be very successful with just some appropriate planning.

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Ginger: [00:22:56] Yeah. You can see me here on the bottom. Within the first two years of me becoming a midwife at the Topeka birth center. I helped open this birth center before I went to midwifery school. Think I hear your feedback, Leslie. I put that in because I'm going to share a little bit when we get to sort of our stories. But this birth center was opened by two physicians who at the time were married and was sustainable until last August. Forty years from its existence and had been reconfigured a variety of times with midwives who actually took over ownership of the birth center, but it was the training ground for me to believe that physiologic birth could indeed happen safely and more likely in a birth center than in a hospital environment. And I just threw the Austin area birth center picture in there because Lesley and I are actually going to the ACOG annual meeting in Austin. We are going to stop by and see them. And I thought it was an absolutely beautiful building. I don't know anything about it but pretty impressed. Texas is a tough place. But very exciting to see where they're going.

Ginger: [00:24:28] So I'll apologize for my dog barking in the background. A few more complicated, but I think important things to think about as you think about the front end of readiness and risk and assessment. Am I ready? You also have to be in this constant state of evaluating and perhaps evaluation of your business as well. And again those aren't things that were commonly used to thinking about. Usually we work for an entity, so we probably aren't evaluating the business side of the entity or even understanding evaluation of it. I would be surprised if midwifes had access to that information. So again Harvard Business Review suggests as you're planning your business to define your governing objectives.

Ginger: [00:25:20] What is it that is the governing model that's going to be used? So there is clarity with all the parties involved whether they're your partners or whether they are people that come to work for you. You need to identify and follow value-creating activities and some might call those value statements. What is it that are foundational that really will help guide and determine the value of this business and often times in healthcare it's patient satisfaction, lower costs, and improved outcomes, right? The Triple Aim. We're really looking at ways to be able to communicate that to parties of interests like your payers, your patients, partners that you might have in other institutions that interface with you and you need to follow the statistics, so how often you establish a evaluation of those activities becomes important to determine. Important to you and also to act on.

Ginger: [00:26:33] The other piece of evaluation is valuation. So what what does that mean? Well, what is the value of your of your business? I doubt you would have any kind of valuation until probably the second or third year. Although if for some reason something happened and the business had to be sold, there would be a valuation done for those parties who needed to have it done. Maybe the bank, maybe other owners. But it's really looking at a variety of things that actually is a mathematical calculation and formula that we don't get to play with very much, but it's been interesting to learn a little bit more about valuation. And there is a Web site here, again not to get lost in the weeds here too much but at least to let you know what this whole process is from conceptualizing to actually beginning the business and then knowing what your worth is. [INSERT] is an acronym for earnings before interest on debt, taxes, depreciation or amortization and basically it's a number that tells you how much your business is worth before all these other things are taken out and it is a number that's typically followed with some frequency as the business starts and continues, so you expect to see that Abena grow as the worth of your company gross.

Ginger: [00:28:14] So, again, another web site for people to learn a little bit more about that word as it's tossed around and how that is forecasted and anticipated with business. So the next part really is from Lesley and I to just take a few minutes to share any any highlights or challenges that we experienced in starting the entities or being involved in the entities that we worked around, because I think that storytelling is sometimes the best way to learn.

Ginger: [00:28:53] Lesley, do you want to throw out anything else or do you want me to star?

Lesley: [00:28:56] Go ahead

Ginger: [00:28:59] I'll start with growing the midwife practice at St. Luke's Hospital on the Plaza in Kansas City, Missouri. This was a decision that was made by a philanthropic donor that gave about a million and a half dollars to the hospital to start a midwife service and by the time I got there which took about six months of negotiating, the anesthesia department had reared its head and said you know we're not going to support this and a lot of battles ensued and I wasn't really sure what was going to happen. And at some point the trust fund attorney said to this very large health system, "If you don't want to have nurse midwifery at the hospital, then I guess I'll withdraw all of my funds for all projects I have here." Which included cancer, heart, ortho. They were the major philanthropic donor to this extremely large health system and oh, by the way, won the first Malcolm Baldrige Award as a hospital in the nation a very prestigious business award.

Ginger: [00:30:12] So they found themselves in quite a conundrum and that was my entree into starting a midwife service in a hospital, with a great deal of anger from the medical staff and definitely support from maternal fetal medicine and neonatology. But in a city that had never had midwifery before, so one of the things that I think is really important is when you're doing your landscape of sort of. Were you want to start this, "What's the general tone around you?"

Ginger: [00:30:48] You know, are you going to are going to start a practice in a hospital where the labor and delivery nurses have no clue what a nurse midwife or a midwife is Are you going to start a birth center in an area where a birth center has never existed before or do home births where there have been some traumatic experiences recently and that may in some way have implications for first impressions about you? Because it's incredibly important that your business and ability to start on a positive note in your community is as framed as you can make it. And for me bout was a tremendous amount of education.

Ginger: [00:31:36] Before a baby was ever born in Kansas City by a midwife in a hospital lots and lots of time talking to various departments, to the nursing staff, to people who would draw our patients' blood having no idea what a nurse midwife was. So communication sometimes with people you don't think you need to waste your time on is critically important. Lesley, do you have something you want to share?

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Lesley: [00:32:11] Sure, so I told you a little bit of how and why I started a birth center and now I'll talk a little bit about unexpected challenges. It's been a very successful birth center and we were able to build the practice pretty quickly. We now have five full-time CNMs and another dozen support staff. We have a great reputation within the community, not just at our hospital, but all the hospitals. We were trucking along and everything was goign well and looking at moving into a bigger building where the health department that licenses us decided to reinterpret a rule regarding our physician consultation to where it required that our physician would sign a letter saying that he would physically come to the birth center and provide emergency care there in person. Which he could not do. For one thing, he wouldn't do that. Of course, mom and a baby need to go to the hospital for emergency care. You don't bring the c-section to the mother, you bring the mother to the c-section. Then also his malpractice insurance wouldn't allow him even to think he would do it, when in reality he would never.

Lesley: [00:33:30] So we became very public very quickly and one thing that I was very thankful for is that we had a strong social media following. And we've kind of done that as our way of doing free marketing from the very beginning with Facebook. So it didn't take 48 hours for over 300 of our families to show up down town with picket signs. Little two year old girls with pigtails that said, "Save My Midwife!" on their sign really get the attention of the media. We even had a brief mention on Steven Colbert. We blew up the governor's email. He had to get a new email. And suddenly everybody in the state suddenly knew who we were and what we were about and you just never really know what could be around the corner, so it's really important that you maintain a good source of mass communication with the people who follow you, whether that's on Facebook or now a lot of EMR systems have e-mail blasts that you can send out. You want to make sure that you keep your supporters current. Another thing that we do is we have an annual family picnic and it grows and grows and grows every year and there's several hundred people. The people who come to Midwives and birth centers really think of their midwife as an important part of their family and so some practices send birthday cards to the babies on their birthday, but just reminding those people that you still care about them, because, some day, you may need their support.

Lesley: [00:35:18] We were able to weather that storm and continue to grow and we're currently looking for a new building and so we're going to be needing a new hospital transport, because the hospital that we use now is stopping maternity services. But there are four hospital systems in our area and all four want us. So it put us in a position of negotiation to be able to pick and choose where we want to go and how we want to do all that.

Ginger: [00:35:57] That's a great. Thakls, Lesley. I'll add one more thing. And it's really more about my experience in helping start the birth center in Topeka, Kansas back in the late 70s, and was true really throughout the first 14 years it was open that I worked there. Networking is critically important. I think anything you can do to find your way into conversations about maternal health in your community or your state will be an advantage to you. Because often when midwives start their own business and whatever model that might look like, because it is still less traditional, it often comes with a lot of inaccuracy and in a way that integrating yourself and being part of the table, really does make a difference in your interest and investment in the community , your voice in terms of families that you serve, and volunteering, being part of a network of people who have a similar broad mission even if the route isn't always exactly the same.

Ginger: [00:37:16] So I would really, really encourage all of you, despite the fact that you're always busy, find opportunities to volunteer and network in your community. We would love to hear any feedback you have. Short, little ad there. Post them on Facebook for us and we'd love to have to recommendations on topics you'd like to hear more about. The last thing I want to end with and then we'd love to take some questions from you. This is something I found today. Many of you know I'm a TED talk fan and this gentleman is a fairly young guy from Kenya who has about a 10-minute story to tell on TED talk that will. If it's as profound for you as it was for me, it's about why being an activist is so important. And the correlations between the devastation that happened to people dying in Kenya and the devastation of what we have really going on and maternal health crisis right now calls upon all of us to be an activist. And he finished the TED talk with this sentence which is that there are two most powerful days in your life, the day you're born and the day you discover why.

Ginger: [00:38:41] I really believe that much of what we do as midwives. Is driven by the advocacy that we have for the need for health care to be delivered in a way that's caring and compassionate, comprehensive, available to all. So really would encourage you to take a look at that TED talk, if you need to be inspired and think again about your dreams and how to be motivated. There's a why in there it'll come up pretty quickly. So let's try. Maybe audio one at a time, if some people have questions. You can also type them in. It's another way that we could definitely take your questions so let's see what happens here. Or wait a few minutes in case we've got some people typing. You can un-mute yourself right, Judy? I think we had you do that earlier.

Ginger: [00:40:15] Any thoughts, things that have resonated with you? Any questions

[00:40:27] Did you have a question from me, Ginger?

Ginger: [00:40:30] I wondered if you did.

Attendee: [00:40:36] I think, you know, the best advice I can give at this point. I'm thinking there's some of the persons on this call may be midwives who were just beginning their practice, just finishing school, is to actually get out into the community and see what the needs are, see what the opportunities are. And as you said, just start talking and talk to everybody everywhere to find out what's going on. What do people want? What do people need? Where are the needs?

Ginger: [00:41:22] Be curious if anyone on the call has thought about this from an independent perspective or if they're just wanting to learn more about the business of running a business. Anybody want to share? If you're looking for where to chat, at the bottom of your screen there's a little dialogue bubble. If you click on that the chat window will pop up.

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Attendee: [00:42:04] One of the things that I found kind of midway in my career as I was attempting to to open a practice is that of course most people are looking to see how they're going to make their money. And physicians particularly, even though they're wonderful people and provide really good care for people for our patients, many times the first thing they're thinking about is how is this going to benefit me and my bottom line. So I think you really need to be prepared particularly when you're out looking for those people who would be your consultants would be what you can do for their bottom line. I could tell a funny story when I was in the military. And that's when I went to school. There were residents who, before I went to school, thought that they would help me and let me catch babies, so that I wouldn't drop any when I got to school, in their words. So anyway we worked, I worked, with this one senior resident and we worked really well and about the time I was leaving to go to school he said Man Judy, he said I love this idea of midwives. He said, "This is great." He said, "I bet you would bring a hundred thousand dollars into my practice and, you know what, I think I'd pay you twenty." Of course, that was a few years ago and twenty thousand doallars was a lot lot less than what it is today. But that's just the concept.

Ginger: [00:43:31] Right.

Attendee: [00:43:31] Now you have to really need to be able to feed into that as you're talking about your new ideas.

Ginger: [00:43:36] Yeah. Yeah.

Lesley: [00:43:41] You have to think outside the box with your consulting physicians. Don't just assume we're going to pay them a flat rate. For one thing, there's some negatives in that are both of you. There's increased liability. [noise] because if there ever is a med-mal case they look at it as a prejudice if they're on your payroll. So other ways that we did to incentivize physicians to work with us was all of our anatomy scans and you need diagnostics [noise] Every patient has one consult visit with them that he bills for. Then if he steps in to deliver the baby, well, he'll bill for them back for the forceps or the c-section.

Lesley: [00:44:33] Then there's also something called an OB stand-by fee and most insurance companies will pay that. Which is when you go [noise] and he needs to be more readily available than just., you know, by the phone

Ginger: [00:44:51] These are all great ideas. It is important as both you and Judy have said, "What's the win here in this relationship?" And if it's not going to be quality of life from them, because you're not working for them you're not doing their phone triage in the middle of the night or making their rounds. But if all of your patients are going there that need additional services, including your GYN patients. That's a big financial win.

Lesley: [00:45:22] Yeah, and another way we were able to help him that really isn't money was Tuesdays is his OR day over in the hospital, so that's the day the diagnostic ultrasounds are done in his office and my midwife is actually at his office. So when our patients get their ultrasound then they can come in and see the midwife right there [noise] OB patients right there for him. or his patients can also get their visit done while they're there for their ultrasound. Then there's also some ways that...

Ginger: [00:45:57] And you haven't stolen many of those patients, huh Lesley?

Lesley: [00:46:00] No, not too many. Some of our patients have chosen to go to him with their second baby maybe they were a c-section and they just chose to go with a repeat. It's like, "We know each other, don't we? You know, switching from his patients to my patients I always feel like we don't have enough to do with them, because his nurse does everything before we get in the room.

Ginger: [00:46:30] Wow. So we have a question here Lesley can you see it? Any tips about whether it's better to establish one service at a time? So I think the idea here from Lindsey is to start with a small hospital practice and then expand opening your birth center or just go big from the start

Lesley: [00:46:52] Well, that's a difficult question because, it's one of those where there's risks and benefits to doing both sides. So I think it's going to come down to really understanding your community, that community assessment that includes the hospitals the physicians. Are they going to look at a birth center as a bad thing from the get go or is a good thing? And if they're going to have a very strong negative reaction to it, then starting first in the hospital may be the best way to do it. Because, I had had a hospital practice, when I went to start the burn center, there wasn't much fear from the hospitals or the nurses. They all knew me. They all trusted me. They all worked well with me, so that part made it much easier.

Ginger: [00:47:41] You're also generating some income. So you've got some cash flow going while you're doing all of the homework and the development of the center.

Lesley: [00:47:53] Right and it gives you, you know, we opened, we got our license on January 7th. and had our first baby on the 10th. And the first month we were open we had 8 births. And by the time we were open six months, we were averaging 15 to 20 in a month at the birth center and that's pretty busy, so if you're already in a practice and you can see your patients there and then bring them with you, you can start off the births right away otherwise you're going to have a facility that you're going to have to pay a lot overhead for the birth center and there's no baby coming in.

Ginger: [00:48:32] For six nine months or?

Lesley: [00:48:35] Less, because the insurance companies take a long time to pay. It was three months from the date we opened until we get a check. [noise.

Ginger: [00:48:59] Other questions or thoughts Don't be afraid you can ask us anything. Everybody on this call's got some experience of some kind. I think one of the things that I would offer and we'll see if anybody's going to type and then we're getting close to the top of the hour is find people you trust. Find some key people, you know, maybe your partner or someone in your family or a close friend that you really are going to confide everything in. That you're going to be totally transparent and be able to have a dialogue about your fears, your excitement, your concerns, your own goals, what you want what you don't want and be able to freely express without fear of the conversation going anywhere else, because when a lot of people are approaching a development of a business whether it's because there may be competitors around the corner and you don't want them to know or just exposing your own vulnerability of starting up a business when you're still learning through that process. I really have found that being able to confide in someone, in addition to having a mentor, as Leslie mentioned earlier on whether that's someone who's been in business before. For me, mentors have have been based on the birth center and the hospital practice, physicians who had much more experience in managing a health practice than I did. Very, very helpful to be able to know that you can trust someone and not be judged for where you are in your own learning process. I don't see any more questions, so I think we'll go ahead and end. I hope some of these things are valuable to you as you think about starting your own business. [noise] Oh sorry, I didn't know if somebody said something or not. It can be very daunting, right? It's not quite the glitzy topic as how to get the salary that you should get and what you deserve, because oftentimes we're thinking of our salaries coming from other people rather than us being the one who provides salaries for those who work for us. You can just feel the energy of the difference of the conversation. We'd love for you, though, to not underestimate the power of your passion and what what can be a very attainable thing for midwives to do in our country. We really hope more midwives take on this call. And really thank you for being part of tonight.

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