How do you plan to find the capital for this? Do you have family members with serious cash who would lend it, do you have a home pretty much paid off you can harvest the equity out of?
If you are going to finance it yourself (which I strongly recommend - when you owe others you are their slave, and you don't want non-medical people - ESPECIALLY family members owning you) than I would recommend not going with PA's initially, not until you built it up. If being in control is really important to you than I would not have a partner either - I would bring them in later.
Everyone has slightly different ideas of a small to medium community - I am guessing you mean 80,000 give or take 20,000.
Rent : if you want a facility large enough to eventually house several FP's with 2 PA's each, than you will need at least 3,000 sq feet. With triple net this may run $4,000 to $6,000 a month - if you can hear a train from the office it may run less, if you can see a McDonalds from the door it will run more. If you start small , like 1000 sq feet planning on moving as the business grows (not as hard as it sounds) than you can plan on $1000 a month in a small town, and perhaps $2,000 in a mid sized town - more or less depending on train tracks or McDonalds.
Front desk - if they ONLY answer the phone and schedule patients, not other tasks you can get by paying them just a little over minimum wage to begin with (I am going to cover this under the thread of 16 years of practice tips), by hiring someone with lots of intelligence and ambition but no experience - with the promise of significant pay raises within the first year as they gain experience in your office. You will need to teach them scripts for what to say when answering the phone, when someone wants to cancel and appointment, when someone is going to be late, when a potential patient calls to ask about fees etc. So consider a 30-40 hour week paying $8.50 - 10 an hour or $270-400 a week.
You might want to put your wife at the front desk phone to save money, but unless she has had experience being a waitress and was good (often can be determined by how well she was tipped) or some other job that teaches people to really get strangers to like you - hire someone and not let your wife do it.
Fixed start up costs. Exam tables, EKG, spirometer, stethoscopes, reflex hammers, tape measures, pinwheels, cotton swabs, goniometers, manila files, copying machine, fax, urine dip sticks, toilet paper, computers, waiting room chairs, carpet, etc etc etc - You can figure $10,000 to $30,000 if you are not overly extravagant. This is assuming you have an office or house you can automatically use as a doctors office (front desk window and sinks built into patient rooms already) - if you have to build out the office, and you cannot install a sink - then you are also going to need to hire a carpenter.
make sure any office or house you buy is ADA ready - doors to bathrooms wide enough for wheelchairs, handicap rail in bathroom so people can get off toilet, backlit door exit signs at front and rear entrance etc - or that is more build out.
This is also if you want to paperchart your office visits. I am not familiar with the newest computerized medical computer SOAP notes etc - add that cost if you are going computerized notes from the beginning. Some MD friends of mine designed their own templates, with very routine visits so they can just use pulldown charts to write their notes - they did it on their own and never bought anyone elses software. However alot of software keeps track of procedures and services you sell - I had this in my chiropractic offices - the really nice thing is, you can hit a button and find out how much money you collected for everything you do. I found that although I offered a ton of various services, 80% of my money was generated by 4 things. Software that keeps track of things like that will tell you what services you do that are really unprofitable and which ones are really profitable.
Marketing in a town that size is important. A real small town (<20,000) is a cinch. Mid size to big cities require much more. The best marketing I ever did was talks. I will cover these but basically there are 2 types : one is talks you do - on various health topics. They can be done at libraries, rotary clubs, optimist clubs, PTA meetings, book clubs, outdoor clubs - any place people gather and will listen to you speak. The other is having other speakers come and give talks - the one I did that generated the most interest was having a psychologist talk about DEALING WITH YOUR TROUBLED TEEN. These talks you want to have in your office, and have enough seats for perhaps 20 people. By having them in your office, they come to hear these other speakers but new people will get familair with your office. Other topics are : losing weight, relationships, finding better employment. You do not even have to prepare a talk - you have other experts come and talk on these things, you just let them use your office. You can often get the local paper to run an ad for the talk for free in small to mid-size towns as a PSA - reads something like : Dr. Digitalnoize is sponsoring a free talk on growing a garden. The speaker is agriculture specialist, Tom Ato, from the University of SDN. The lecture is at Dr.Digitalnoiz' office Wednesday from 7-8 PM. RSVP to 477-777-7777 as seating is limited.
I think yellow page advertizing is always needed. Small town - a few hundred a year for a credit card sized ad that lists your name, location and special things that niche you from the other doctors in town. Medium sized town a couple thousand a year. Big city will cost several thousand a year or more depending on how big an ad.
If you are accepting insurance - that money won't be coming in for 3 to 4 months. So you need to plan on at least 6 months operating capital :
Rent X 6, your salary X 6, Staff salary X 6, Yellow pages X 6, fixed start up costs, plus an extra 20,000 for the crap you did not plan on. 1000 sq foot facility with only front desk help in small town : $60,000-90,000. But by month 6 you had better be bringing in the money - I did internal billing for 16 years in my office, and do not think I would want to tackle that again when/if I start a medical office. I am pretty sure I would outsource my billing for the first couple of years at least - although it is much cheaper to internal bill. Once you add other FP's - than its profitable to internal bill - you can bill for them and charge them, and get another slice of the pie that way. But if you have never billed - you cannot afford to make mistakes that delay your payments another 4 months - let someone who really knows billing to do it the first 6 months to year, so that it is billed correctly the first time, so that you are getting your money 3-4 months after you open your office.
If you are starting from scratch with no patients - do you really want a couple of PA's on salary when you are only going to have a trickle of patients - unless you are moving to your hometown, or have been doing lots of PR work months before you open your doors? And I myself would shudder at having another FP on salary from the get go - at first I want EVERY new patient who comes in the door. I would rather be tired from overwork than stressed from too little work (and money) for all the employees I have.
A massage therapist is a great addition from the first day. They bring in cash (no waiting for insurance) are happy to get paid per client (charge $60 an hour and give them $30). You can make money from day one, they generate their own salary and you do not have to be paying them out of your savings or loan money. Any cash service can help you through the first hump months of financial drought.
