New Game Breakdown: A Health Care Clinic Seen from the Inside

This week I talked to an owner who runs a small dialysis clinic in south Florida serving 50 end-stage renal disease patients, each coming in three times a week for life-saving treatments. She built this clinic from the ground up—hiring staff (with her and her business partners’ own savings), securing her own facility, and navigating the complex world of insurance reimbursements. On the surface, the clinic looks healthy: full patient census, steady cash flow, and a committed team. But dig deeper, and you find systemic friction that limits capacity, undermines margins, and risks patient outcomes.

You don’t have to run a clinic to learn from this. If your business depends on humans showing up, getting paid, and staying organized—these lessons are for you.

In this issue, we dissect the owner’s clinic through the same four lenses as last week: Patient experience, digital experience, internal operations, and financial readiness. Every business has an optimal system, but it takes lots of hard work, persistence, and research to create and maintain it. Get your notebook (or your AI note-taker) ready and let’s take a look.

Patient Experience: What It Feels Like to Receive Care

How patients find the clinic
Most arrive through doctor referrals or word-of-mouth in tight-knit nephrology circles. There’s no online booking, map visibility, or clear digital presence—just trust and trial.

👉 Takeaway: Without a digital front door, your referral flow is fragile and invisible to new demand.

Booking treatments
Every appointment is scheduled by phone. Patients call ahead, leave voicemails, and hope for a callback. There’s no confirmation, no text reminders, no rebooking flow. Missed calls mean missed treatments—which, in dialysis, is dangerous.

👉 Takeaway: Manual booking systems are not just inefficient—they’re unsafe in care-critical businesses.

Getting there
Transportation is a constant stressor. Nearly all patients rely on the clinic’s private driver, who runs four daily routes at $2,000/week. Despite the investment, late arrivals are common—and anxiety runs high.

👉 Takeaway: Even expensive logistics break down without routing systems and backup planning.

During treatment
Each session lasts 4–5 hours. Nurses are focused, caring, and competent—but stretched thin. Non-medical touchpoints like emotional check-ins or progress updates often get skipped.

👉 Takeaway: When staff are at capacity, the human side of care is the first to disappear—without anyone intending it.

Main Takeaway: Introduce a simple SMS-based appointment system with confirmations, reminders, and auto-rebook links. This one upgrade reduces missed sessions, restores patient trust, and buys back hours of staff time.

Pattern: When scheduling and support rely on memory and muscle, critical care becomes a chain of fragile workarounds. One missed call can lead to a disaster

Digital experience: What It’s Like Online

No patient portal
In 2025, patients still can’t log in to check their schedule, view their lab reports, or download an invoice. Everything is manual—paper printouts, emailed PDFs, or verbal updates from the front desk. This adds friction, slows down administrative tasks, and leaves patients feeling uncertain and uninformed.

👉 Takeaway: No visibility means no peace of mind.

Billing and insurance workflow
Insurance claims are submitted once a month via a third-party billing portal. If a claim is denied—and many are—it’s tracked manually on a spreadsheet. There’s no automatic alert, no integration with patient records, and no clear timeline for resolution. One small error in a claim code can delay thousands of dollars for weeks, or even months.

👉 Takeaway: Slow billing is more than annoying—it’s a revenue trap.

Communication silos
Scheduling is done in a calendar tool. Billing is handled in a separate system. Patient treatment notes are handwritten or stored in shared documents. None of these tools talk to each other, and there’s no central dashboard. As a result, the owner becomes the go-between—re-explaining treatment plans to billers, forwarding appointment changes to nurses, and chasing down unpaid claims across disconnected systems.

👉 Takeaway: When tools don’t connect, people become the glue—and burn out fast.

Main Takeaway: Implement a unified electronic health record (EHR) or patient engagement platform—such as SimplePractice, Kareo, or PointClickCare—that combines scheduling, clinical notes, and billing into a single interface. These tools don’t just modernize a clinic—they free up hours per week, reduce claim errors, and give patients visibility into their care.

Pattern: When every system is separate, the human has to become the bridge—and burnout is inevitable.

Internal Operations: What It Takes to Run It

Staffing structure
The clinic employs 15 team members across clinical and admin roles—but many of them work second jobs to stay afloat. Burnout isn’t hypothetical here; it’s visible in missed messages, skipped small talk, and the invisible tension of doing more work with less structure. There are no written SOPs (standard operating procedures), which means every new hire must shadow another staffer and absorb knowledge informally. If someone leaves, they take critical know-how with them. There’s no system of continuity—only people doing their best.

👉 Takeaway: When nothing’s documented, everything depends on memory—and memory burns out.

Transportation logistics
In service businesses like this, logistics is care. A dedicated driver makes 15–20 patient trips a day. The clinic pays him over $2,000 a week—money pulled directly from revenue, not reimbursed by insurers. But the system has no route optimization, no backup driver, and no scheduling automation. Every minute of delay compounds patient stress and staff overtime.

👉 Takeaway: Every inefficiency hits twice—first in cost, then in care.

Insurance workflow
With 95% of patients covered by Medicare or commercial plans, insurance is the clinic’s main revenue stream. But every denied claim becomes a time-sink: appeal letters, resubmissions, and follow-ups land on the owner’s desk. It’s not just administrative—it’s existential. Without clear delegation, the owner becomes the safety net for every rejected dollar.

👉 Takeaway: If only one person understands the system, it’s not a system—it’s a liability.

📉 Data Point: The average appeal for a denied Medicare claim takes 30–60 minutes to prepare and submit, often more if documentation is incomplete (CMS, 2023). Multiply that by dozens of denials a month, and you're looking at a full-time job—unpaid.

Main Takeaways: 

• Build systems, not heroes. Document every recurring workflow: patient intake, insurance billing, transportation, payroll.

• Use simple SOP templates (or even recorded walkthroughs) so that any new staff member can step in without friction. This is how you create breathing room for yourself and capacity for your business.

Pattern: The owner has become the system—not by choice, but by necessity.

Financial Readiness: Lending and Investment Perspective

Owner dependence
The clinic has one operations manual: the owner’s brain. She handles intake, billing, insurance appeals, HR, supply orders, and strategic planning. If she takes a week off, the entire system pauses. Banks call this "key-person risk"—and they penalize it heavily. Even profitable businesses get turned down if too much depends on one person.

👉 Takeaway: If your absence breaks the business, you don’t own it—it owns you.

Cash flow consistency
The clinic sees steady revenue—but not steady cash. Most payments come from insurance, and they arrive 60–90 days after treatment. That delay turns predictable income into a cash-flow challenge. Each dialysis patient generates between $78,000 and $109,000 annually, but the money sits in limbo. Staff still need to be paid. Supplies still need to be ordered. Rent is still due. The result is a permanent working capital squeeze.

👉 Takeaway: Revenue is a promise—cash is survival.

Receivables aging
A 30-day payment cycle is healthy. A 90-day cycle is risky. Banks and investors look at aging receivables to understand how much cash a business is really sitting on—and how long it takes to access it. Long delays signal fragility and reduce the clinic’s borrowing power.

👉 Takeaway: The longer your money takes to arrive, the less valuable it becomes.

Collateral availability
The clinic owns its dialysis machines, a delivery truck, and has made improvements to its leased facility. These are valuable assets, but they’re not automatically bankable. To count as collateral, each one needs a clear title, a depreciation schedule, and a record of maintenance. Without documentation, the lender sees liability, not leverage.

👉 Takeaway: If you can’t prove it, you can’t borrow against it.

Debt service coverage
For loans above $250,000, lenders calculate a DSCR (Debt Service Coverage Ratio). It’s a simple test: does your net operating income comfortably exceed your annual loan payments? Most banks want to see at least 1.25× coverage. If your income barely covers your bills—or isn’t clearly documented—you fail the test.

👉 Takeaway: Lenders don’t fund hope. They fund cushion.

Profit visibility
The owner tracks money through a separate “business fund” account, logging income and expenses manually. There’s no connected billing system, no unified ledger, and no P&L reports. From a lender’s perspective, it’s like trying to read a novel with pages missing. Without visibility, there’s no confidence.

👉 Takeaway: You don’t get funded for what you earn—you get funded for what you can prove.

Main Takeaway: Build your financial system before you need the money. Start by:

• Implementing integrated billing and accounting software that tracks revenue, expenses, and DSCR in real time.

• Creating an asset register for equipment, with serial numbers, purchase dates, and maintenance logs.

• Transferring operational knowledge into SOPs that outlive any one person’s involvement.

This is what makes banks say yes. Not the mission, not the margin—the system.

Pattern: Profitability alone doesn’t make you fundable. Lenders invest in predictability, structure, and risk management—not good intentions.

Final Summary: A Clinic at Capacity

The owner’s dialysis center has everything you’d expect in successful service:

• A mission that keeps her staff committed

• Steady patient demand and solid payer coverage

• Skilled clinicians and a loyal patient base

But it’s missing:

• Automated patient engagement systems

• Documented, transferable workflows

• Real-time financial visibility

Without systems, even healthcare businesses hit invisible ceilings. The same fixes that work in food service—workflow documentation, digital tools, and clean financials—apply here too.

This is what service-business friction looks like in healthcare. If you’re studying service businesses, building one, or advising clients—this is your playbook!

As always, reply with your questions or suggest the next business you want dissected. See you next week!

— Elgin
Founder, New Game