How A Nano Firm Is National : Alice G. Gosfield, Esq.
In the summer of 1972, health law was not a recognized legal discipline. A law school roommate looking for a job through her college alma mater, found a mention of an office in Philadelphia where I live, looking for summer students to work at a War on Poverty funded program: the Health Law Project. I said, “That’s interesting, since there is no such thing as ‘health law.’” That said, I had grown up working in my cardiologist father’s office, as well as at the hospital, from being a candy striper, to working in the laboratory. I knew much more about medicine and health care than I did the practice of law.
The War on Poverty and Beyond
As it turned out, the Project was funded to develop health law as a discipline to help poor people in their interactions with the health care system. One of my first tasks was to analyze a law just passed in 1972 to develop a program of nationwide organizations to review the quality and medical necessity of health care delivered to Medicare patients. I enjoyed it so much, and the staff liked me enough, that they hired me as a staff attorney after I graduated. As I came to learn later, one of the things that makes it possible to become an expert in these types of programs is that the statute is enacted, but it takes time for regulations to be published. During that time, you can analyze the statutory provisions up and down. Final regulations are published with prefatory comments explaining why the regulators have done what they propose, and responding to comments received from stakeholders. With no pressure to do work for paying clients, I was able to take full advantage of all of this.
After 1972, the War on Poverty funding dried up and the Project was funded by the Department of Health, Education and Welfare. The Project continued through 1973, but by 1974 there was no more money. My analysis of the law, however, was a book length manuscript. I found a publisher that published high-end policy analyses as books, and they accepted what I had written. My first book was published in 1975 from the work I had done at the Project. At the same time, I had married one of the staff attorneys and we needed something to do. Because we were known for policy work we had done, the new administration of the Department of Health in Pennsylvania under a reform-minded governor, wanted to rewrite their hospital licensing regulations. They convened a group of stakeholders to advise, and we were the drafters. This was a project of more than a year, but it led to other work, resulting in us writing hospital licensing regulations in West Virginia, Medicaid regulations in Wisconsin, and I wrote HMO regulations for Pennsylvania, among others. Interestingly the hospital licensing regulations have been changed very little since the years we wrote them.
The Real Practice of Law
By 1978, I paid the first premium for professional lability insurance, ordered stationary and business cards, and we were off in a real law practice. My husband had experience with compliance with certificate of need regulations and got hired by an entrepreneur who ended up creating 7 hospitals in Pennsylvania and others in Florida. By contrast, I wanted to represent physicians, whom I knew so well from growing up around them. The Pennsylvania professional corporation law for physicians had been enacted recently and there were several lawyers focusing there. In particular, I wanted to help physicians deal with federal regulations for payment under Medicare. The problem was the physicians didn’t know they needed legal help in this regard. First, I had to build my market; then I had to market to my market.
I began with writing articles in small, local medical journals. That also led to opportunities to speak before physician groups. Each presentation led to other ones and sometimes I was even paid a small honorarium, but I still had almost no paying clients. Because I also spoke to the local Bar Association on what health law was, one of my first clients was sent to me by a litigator who didn’t know the relevant regulations. That client referred others, and very slowly my practice began to build.
Public Service and Marketing
Around the same time in 1974, I had attended my first meeting of the National Health Lawyers Association. By 1978, I was speaking for them. The law that was the subject of my first book, was obscure and complex; so I got an audience from speaking about it. I got involved with the organization and worked my way up from merely speaking, to organizing programs for them, and eventually became president in 1992. Two things which were critical in my career emerged from that:
(1) Two audience participants there invited me to participate in one of what eventually became four committees of the Institute of Medicine of the National Academy of Sciences, working on policy issues related to utilization review (a process akin to the statute on which I had written ) to control excessive heath care spending. Those interdisciplinary connections with national expert committee members led me to the National Committee for Quality Assurance, the organization that accredits managed care companies. I served on that board for twelve years and was chairman for five of those years. Through those connections, I also ended up spending thirteen years working with another group of pro bono experts to develop a new payment model for health care: PROMETHEUS Payment.
(2) Attendees at one of the health lawyer sessions included representatives of the Medical Group Management Association, which is a national organization with affiliates in every state, of the people who manage physician practices. I ended up doing a series of national programs on managed care – a full day of me alone teaching non-lawyers how to handle managed care contracts. I also got invitations to speak at every MGMA affiliate in the country. All of this generated new clients; and since my work focused mostly on federal regulation, the fact that I was only admitted to practice in Pennsylvania was irrelevant. The other thing I learned was that these organizations were, among others, willing to pay me a decent amount of money for presentations that might be only an hour long. I never did a presentation during this time that I didn’t get a new client or an invitation for another presentation. Eventually the money from speaking was about a third of the firm’s income. The presentations were so successful that the national organization asked me to do a presentation – a full day of me – for which I would be at financial risk with them. I told them I would speak on fraud and abuse. They said, no one will come. I said, if you advertise it the way I say, they will. It was incredibly successful, I made a lot of money, and they ultimately decided they didn’t want to continue the at risk model and agreed to pay me a fixed rate. But new leadership came in and they changed their marketing. Eventually the audience dried up, and the programs I did were ended. By that time, my law practice had clients in every state.
Staying Nano
When my husband went off to join a big firm in 1986, I incorporated my practice and continued to search for work. By 1988 I had enough work to hire a part-time associate. After two years, she wanted another baby and I wanted a full-time associate. We parted ways and I hired someone else. At the same time, a legal publishing house approached me about creating a book that would be published annually consisting of articles from me and then other articles contributed by other lawyers. They had used this model with other areas of the law and thought it was time to launch into health law. In 1989 the first edition of the HEALTH LAW HANDBOOK was published and a new book has been published every year since. I write a major article every year for the book. The 2024 edition will be the 35th. A different publisher came to me in 1995 and asked me to write a book for non-lawyers on managed care contracting. I rejected them four times, but eventually agreed to do it. My second book was published in 1996. It got wonderful reviews in the trade press, but the marketing was terrible and the book sold very little. By 2003, the Handbook publisher came to me with another book they had published on Medicare and Medicaid fraud and abuse that was not selling. They said if my name were on the book, they thought it would sell. They sent the manuscript which had been written by two academics and had very little practical guidance. I took it over and we have updated that book every year since, after restructuring the contents and changing the style.
With my networking through the health lawyers, I was able to convince other lawyers to write substantive pieces for the Handbook. It is now considered prestigious to be invited to participate. Because I stayed focused on the areas on which I worked, I had the opportunity to refer clients to other high touch, high service firms for issues including corporate law, securities and litigation. Over the years, I have been asked many times if I would join a larger firm. My business model is not very compatible with theirs. In addition, I have run my own show for so long that I likely would not be a great team player. Since 1989, I have only had one attorney work with me. No one stayed more than four years and by 2003, I was looking for a lawyer to replace someone leaving because of the travel distance from his house to my office. At the same time my son had just graduated from law school and was looking for a job. I had never hired anyone so inexperienced. He hadn’t even passed the bar yet. It had never been the plan for him to work with me, and I was wary of parental-child dynamics in the workplace, among other things.
Daniel Shay has been practicing with me now for twenty years. We enjoy each other’s company. He has areas he works on which I do not do at all. As an example, he takes care of all issues involving technology, such as electronic medical record software licenses, social media liabilities, HIPAA, patient portal issues, and now artificial intelligence in health care. He also has written in every edition of the Handbook since 2003, and we co-author the fraud and abuse book. He is an excellent speaker and does a regular presentation for the county medical society, among others, to doctors coming out of training about their first employment contract, and he offers a discounted rate to review these agreements for new attending physicians.
Our Brand
We are known for representing physicians on transactional and regulatory issues. We also work with clients who want to do business with physicians – e.g., laboratories, hospitals, surgi-centers. Because we primarily focus on federal issues we can work all over. We do research on other state laws, but do not opine on them. We are a high touch, high service firm. The two things we hear most often from new clients are “thank you for getting back to me so quickly”; and, “thank you for getting this done so quickly.” Because we are highly focused, we can offer depth which is supported by our reading widely in the industry rather than just the law. We pride ourselves on real excellence and economical rates. Dan is married to a family physician and my father was a cardiologist, so our interest in the work we do is personal as well. We enjoy what we do, and try to help our clients feel the same way.
