Disrupting the dermatology model

For about a decade, George Gulisano was the point man for a major U.S.-based insurance carrier working to transform the health care system in Argentina, only to watch deeply embedded corruption infiltrate the hybrid HMO model and undo years of work.

Knowing how to maneuver within the system since he created it, Gulisano then spent several years advising insurance companies about how to exit the country.

A CPA by training, his specialty is engineering efficiencies in the medical, hospitality and insurance industries by creating and implementing systems that simultaneously streamline operations while enhancing customer engagement. He had recently completed a six-year project with a hospitality client in 2016 when he received a call from Florida Skin Center founder Dr. Anais Badia, who found him while searching for a consultant on an online career board.

A physician and a self-taught businesswoman, she had reached a crossroads 15 years after founding the practice as a one-woman operation.

“I had been approached by many investment banking firms interested in acquiring my practice for the past several years before we met,” Badia says. “I was not interested in simply selling out and retiring a few years after the buyout. It was shortly after we began consulting that George and I began to discuss ways to improve our health care delivery system and ways to innovate each step of our patient process.”

The Fort Myers resident agreed to a six-month project to study Badia’s burgeoning practice and to provide recommendations for modifications, growth and positioning the practice for an eventual outside partnership. Three months later, in January 2017, he was named CEO.

In the two-and-a-half years since, he has helped the practice grow from two to four locations, has more than doubled its staff and is documenting a business model he hopes will lead to a collaboration that can take the model nationwide. Revenues, meanwhile, have grown 54.5% since 2016, from $4.79 million to $7.4 million in 2018. 

“In a very small way, this is the same kind of reengineering I did in Argentina — thankfully without the corruption and without people getting kidnapped," Gulisano says.

Through his efforts, the practice isn’t being held hostage by accepted industry standards. Gulisano is instead focused on incubating a disruptive medical services delivery model while growing the practice. “It is through George’s experience in health care consulting that we began to devise the plans and programs that we have implemented that may make us an attractive platform to the right outside investor,” Badia says.

Internal growth

In 2016, Florida Skin Center comprised two offices in Fort Myers and Cape Coral, with plans for a third office in Lehigh Acres. Badia was the only physician in the practice, which included three physician’s assistants and a total staff of 23.

In Gulisano's two years as CEO, the practice has grown to four offices, four doctors (two of them contract physicians), five physician assistants and a total staff of 54. Badia is the only pediatric dermatologist between Tampa and Miami, and the other staff physician, Dr. Chetan Vedvyas, is a fellowship trained Mohs surgeon who performs most of his procedures in the new Punta Gorda office that features six luxury Mohs surgery suites.

“In a very small way, this is the same kind of reengineering I did in Argentina, thankfully without the corruption and without people getting kidnapped.” George Gulisano, Florida Skin Center CEO

Growth, in revenue and new patients, Gulisano says, will take care of itself, providing Florida Skin Center continues on the course he and Badia have set: melding a personal, spa-like touch with a data-driven system that ensures efficiency and proactively engages patients to participate in their own skin health. All this set against the backdrop of an ever-evolving health care environment that works ever more against the patient.

“We see the changes that are emerging in health care,” Gulisano says. “We see how the insurance plans are covering less every day. We see how the patients are having tremendously expensive co-pays, the family out-of-pocket expenses are growing, the pharmaceutical companies are charging incredibly high prices, and it's kind of a perfect storm against the patient. So when we first met, we talked about what can we do to bring back that personal doctor-patient relationship.”

Infusing culture and tech

That relationship begins in the lobby, where “guests,” as the practice calls them, are offered hot towels infused with essential oils. There is a gourmet coffee and tea bar as well as cold bottled water, juice boxes and snacks for children. The intent is to set the tone for an experience more spa-like than medical and that reflects Badia’s desire to resurrect the doctor-patient relationship of decades past, when doctors knew their patients’ names, knew their families and asked about their kids.

“That environment generated a much more positive environment that led to a better medical outcome,” Gulisano says. “Now everybody is rushed, and everybody has a million things on their plate. So [what] we try to do here is simplify it. Let’s try to make their experience as positive as it can be.”

Simplifying can be complex, though. For one, in order to facilitate more time for doctors and physician assistants to spend with patients, seamless efficiencies must be implemented. The practice Badia had built over the prior 15 years, Gulisano says, provided a solid foundation. 

“It was a great story waiting to be told,” he says. “It was like an unknown gem of a dermatology practice. I came in and studied her operations over six years and compared it to national benchmarks. I spent six months studying every part of the company and prepared a report for her to understand how she stacked up. She is a very good business owner, and she wanted to know if it was possible for her to achieve those milestones.”

Culture in place, Gulisano turned his attention toward development of what is known in-house as “The Storybook,” an official documentation of the practice’s patient-centric approach to treatment. In order for doctors and physician assistants to create that old-school environment, new-school strategies were needed to enable them more patient-facing time while simultaneously growing the practice.

To accomplish those seemingly contradictory objectives, Gulisano developed a program that allows him to track, from check-in to check-out, the amount of time every patient spends in any of the four lobbies and all examining rooms. He employs time-and-motion data to determine the optimum number of patients who doctors and assistants should see in a given day, and he schedules them accordingly. This started with Gulisano putting on scrubs, conducting flow studies by mingling with the patients and observing the entire process from lobby to check-out. 

“When guest wait times are tracked and reduced significantly," Badia says, "our provider team can spend more time interviewing them about their condition or concerns to make their visit as medically effective as possible."

The goal is to maximize the capacity of the current physical space and staff before considering more locations. From his desk in the Fort Myers office, Gulisano can detect any anomalies in patient flow in all four clinics and, if necessary, make a phone call to address the situation. Often, he says, extended waiting time in the lobby is the result of the patient arriving too early.

After the visit, patient diagnosis codes are entered to the system, which allows automated delivery of personalized messages for appointment reminders and even best practice advice for skin health maintenance based on previous diagnoses and treatments. 

As he studied the practice, Gulisano noticed the positives: how appealing and non-threatening the offices are, again conveying more of a spa experience than a medical one.

“We started to consider how could we make this experience the best it can be and what can we use technology-wise to do it,” Gulisano says. “We are very respectful of our guests’ time. That is probably the single most common commodity people have the least of right now, so we want them to spend the least amount of time waiting and the most amount of time with our providers. We want them to have a great check-out experience, and we want them to have a great follow-up experience. We want no lapses in this start-to-finish concept.”

'The Storybook'

Florida Skin Center is documenting these strategies not only to consistently implement them internally but also to spread the business model. The goal is to attract a minority partner with the resources to take the model national. 

That’s a long-term objective. In the interim, Florida Skin Center is set to begin another service: an in-house pharmacy that will dispense about 50 of its most commonly prescribed medicines at a fraction of the cost of retail and, and in many cases, insurance co-payments. The practice will take a small mark-up on the cost of some medicines and even lose money on others. The goal is to average about a $10 mark-up on its wholesale cost.

One example is doxycycline, which is commonly prescribed for severe acne. The Medicare Part D co-pay for the antibiotic is $415, Gulisano says, and retails for as much as $748. Florida Skin Center will make it available for $55. It pays $34 for the drug. “I could sell it for $90 and make everybody happy,” Gulisano says. 

Another commonly prescribed medication, with an average insurance co-pay of $78 and an average retail price of $180, will be available to Florida Skin Center patients for $40. Wholesale cost is $25.

“When you start looking at these prices, you can see there is a tremendous opportunity for our guests to save money," Gulisano says. “We don't want to be that investment banker model. We want to find a partner that says they are happy making 10% and making the guest happier than anybody. Why can't we do that? That's Dr. Badia’s philosophy.”

And it’s the formula for what they both hope is a storybook ending.