PookieMD's Blog: Where Physicians Learn About the Business of Medicine

It may seem crazy, but now is the time to start planning for the economic recovery. There are bargains to be had, talent to be found and the sun will be coming out soon!  (I hope!)

So, a few tips on what to do now, to make tomorrow rosier:

• Invest in technology.  This may be the time to get serious about an EMR, especially with the government mandate and “reward” system.  (See previous posts.)  This is also a great time to launch or update your website, improve your billing software, etc.  (My company, ExtraMD is upgrading our computerizedreservation system so clients can get faster reservations and confirmation when booking one of our “local locums” doctors.)
• Get good help, cheap.  There are lots of  job seekers out there.  Make sure you take the time to search for the diamonds that are sitting in that resume pile.  Now’s your chance to get some great employees!  Don’t simply hire the first person that comes along–do your homework!!
• Train like an Olympian–invest resources in training employees(and physicians!) on that new EMR.  And for pity’s sake if everybody needs ACLS, or BLS, now is the time to get it done!
• Analyze cost cutting. You may have made across the board cuts, and it’s a perfect time to review  them. Continue to reduce spending, but not in ways that limit growth.  Look for ways to permanently cut costs. It’s easy to ignore costs in good times, but smarter to make long lasting cuts that will continue even in better economic times.
• Fix the bottle necks.  Analyze your work flow, and see what needs to be done to improve through put.  Would another copier help? An office redesign, another computer?  Seize the moment to bargain hunt for items that will have big impact in improving your practice. 

If you can afford it, now is the time to invest in your practice!

For those of you who insist that medicine is not about making a living, is not a business, and has nothing to do with money, please stop reading.  Immediately go and volunteer at a free clinic, go in to your lab and develop  a vaccine against tobacco addiction, and a pill to cure obesity.  For the rest of you, who realize that you can’t keep the doors open to see patients unless revenues equal expenses, read on.

Medicine, like it or not, is a business.  If you don’t like that fact, you should consider moving to Japan, where physicians are accorded great respect, and little money.  If you decide to stay here in the U.S., here are a couple of ways to look at your medical practice, ahem, business.

In general, there are  two mind sets in setting up and running a medical practice.  There are practices that focus on making money, and practices that are focused on saving money, I don’t care which model your practice falls in to, as long as your realize which is which, and are content with that choice.

Money making practices are focused on…making money.  (Orthopedic practices come to mind.) Key characteristics:

• Seeking profitable sales and loyal patients (customers).
• Developing and training employees.  (This is where orthopedic offices, in general, have it dialed.  The orthopods, do what they do best–surgery.  Their assistants, PAs, secretaries do the rest.  My orthopod has a secretary type his notes as he sees the patients.)
• Spending money where it gets the greatest returns.  Yup, orthopods have EMRS, comprehensive websites, and lots of assistants–all of which are designed to increase efficiency and through put.
• investing in the future of their practice.  Orthopods, and their savvy office managers got the EMRs and websites because they need to constantly feed the pipeline of patients.  Most patients are there for a single episode, so orthopods need to keep the pipeline of patients full–hence investing in the future of the practice.

Money saving practices are focused on….saving money.  (Primary care practices come to mind.)  Key characteristics:

• Getting the work done for the lowest or cheapest price.  (Yes, I know ALL about how little primary care is reimbursed, especially compared to our example above, the orthopod.)
• Maximizing employee and office efficiency.
• Constantly reducing costs through out the business, and looking for ways to save money.
• Providing acceptable service, but not a usually stellar knock your socks off service.  (There isn’t time, energy or money to provide consistently amazing customer service in this model.)

Okay, don’t get all upset with me.  I didn’t make the rules on reimbursement.  I would encourage you to look seriously at how your practice runs and make sure you are comfortable with that choice.  And, just so there are no misunderstandings, if  you find yourself in a practice that is too focused on maximizing revenues, and not enough about time with patients, or if you are struggling to make ends meet, then it’s time for a change either way.   The New Year is coming around, and this may be just the time to reprioritize and grow.  Just make sure YOU chose the direction!

See bookstore page for Get Your Business to Work, by George Hedley.

The following cases are true, but the names have been changed to protect the innocent.  You may recognize your practice here, and if so, shame, shame, shame!

Case 1: The Absentee Owner. At this practice, the physician owner  (in solo practice) never reviews the books.  The book keeper goes in once per year and balances the books.  The physician never looks at anyreports to see where his money comes from or where it goes.  “I have plenty of money, so I don’t really care,” he says.

Case 2: Irreconcilable Differences. At this practice nothing is ever reconciled.  There are over two years worth of bank statements, credit card statements and random receipts that have never been entered in to the books.  The physician owner, again in solo practice, wonders if a  book keeper and/or a practice manager would be helpful.  Time will tell if the practice keeps it’s doors open!

Case 3: The IRS is on line 1. Here, mail is allowed to pile up, unopened, with the philosphy of “if I don’t open it, it can’t hurt me!”  Several of the envelopes contained inquiries into way ward payroll payments, from friendly IRS agents.

Case 4: No review of systems.  Here, there is absolutely no review of systems, actually no system at all!  Bills, payments, notices, and other random paperwork are placed in piles, with out any way to manage them.  There are no formalized ways of doing things,and so things just don’t get done, leading to financial meltdown.

If this is you and your practice–get help!  Stage an intervention! You work too hard to become another case in the PookieMD casebook of mismanaged practices.

I have decided to change the tone of the blog slightly–I want to post on where I’m going as a physician and a person.  The last four months have been especially challenging for me on a personal and professional level.  My husband, a high tech electrical engineer type, was laid off in May, and still doesn’t have a job.  I have taken extra shifts as a hospitalist and a primary care physician to try and make up the difference.

The result? A stressed, frazzled, and crabby PookieMD who misses her family and her time outdoors. Hubby and I had always chosen a simpler life–we have two cars with with over 100,000 miles on each, live in a very middle class neighborhood, and have consciously elected family time over money (and extra shifts!)  Our greatest pleasures have been bashing down black diamond ski slopes with our daughter and clinging to rock faces.  We have always chosen to earn less in favor of more time with each other and Tweenager Daughter.

So how did I end up working 50+ hour a week?

Fear.

Fear that Hubby would not find a job, fear that things would get worse, fear that we wouldn’t make it.

Well, I’m done with that.  I want myself back. So as I try to bring my life back in to balance, I will explore wins and losses with you, and continue to blog on the business of medicine.  So to that end, PookieMD’s blog will now be about managing your practice and your life.

I hope you will chime in frequently with suggestions, tips and criticisms as I bring my life back in to balance.

The utility of an EMR lies in it’s utility.  Today, I heard about yet another practice that had paid for an EMR, installed it, and yes, you guessed it, had never used it!  Even more horrifying was the fact that this is the THIRD case of this I have heard in the last year!!! So what went wrong with the groups that purchased these unused EMRS?

They were deemed too complicated for use by the endusers- the physicians.

So what is the moral of this story? Due dilligence! And just to be sure sure, here is a short (and probably incomplete!) check list of buyer beware items:

• Make sure your office can affrord a good EMR. There is no cash for clunkers for EMRs!  Take in to account the initial purchase of the software, the hard ware required, the cost of IT upkeep and maintenance, as well as training.
• Involve the physicians in the decision making process.  Physicians, don’t you DARE sign off on something that you haven’t completely, thorough, painstakingly reviewed and researched!
• Make sure your office can afford the time it takes to train the personnel involved. Realize that office flow WILL slow down dramatically, and time per patient will go up.  Most EMRs, no matter how good, have a stiff learning curve.  Plan accordingly.
• Make sure your users are aware and accept that things will be slower and infinitely frustrating.  Don’t believe the reps when they say things like “office ready” or “easy” or “turnkey.”  Be realistic.  It will be painful.
• Have a super user.  Have one staff member, preferably a physician, learn the system way before it goes live.  That “super user” can then help the other physicians with their head aches, belly aches and gripes.  Physicians seem to handle input better when it comes from a colleague, rather than a medical assistant who now appears much smarter than the physician.
• Have enough computers to work off of.  Not enough workstations=no implementation.
• Failure  is not an option.  Commit to using the EMR from the get go, and don’t let anyone weasel out.  If your practice is making this step, it’s like a Catholic marriage: divorce is not acceptable.

So, commit!  Life in medicine is hard enough without an expensive, useless purchase.

News flash: CMS proposes changes in payment to specialists, as well as primary care physicians.  See excerpts below from the press release!

“Based on current data, CMS is projecting a rate reduction of -21.5 percent for CY 2010. 

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services.   Practitioners will use existing E/M service codes when providing these services instead.  Resulting savings would be redistributed to increase payments for the existing E/M services.  

CMS is proposing to increase the payment rates for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit to be more in line with payment rates for higher complexity services.  The IPPE benefit was mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to pay for an initial assessment of key elements of a beneficiary’s health status within six months of the beneficiary’s enrollment in Medicare Part B.  Subsequently, Congress extended the time period for the IPPE benefit to within one year of the beneficiary’s enrollment in Part B.

In addition, CMS is proposing to refine how Medicare recognizes the cost of professional liability insurance in its payment system.  While these changes would have a modest impact, they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

 Taken together, refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule).”

Wow.  I foresee a big fight on our hands, but hopefully the “thinking” specialties will finally be rewarded as well as the “doing” specialties.  Stay tuned!

Last night I ditched my tennis team practice and instead went to the Colorado Foundation for Medical Care “Launch of A Community Health Endeavor” meeting on how the community can/should reduce re-admissions to the hospital.  As you are hopefully aware, the CMS (Centers for Medicare and Medicaid Services) has mandated that the amount of re-admissions of medicare/medicaid patients must go down–approximately 20% of these patients are readmitted in the 30 days following their hospitalizations.  One of the hospitals I work at has been chosen to be part of a pilot study on decreasing re-admissions; CMS has picked 14 areas with in the country to take part in the initiative which CMS is funding.

There was a fair amount of finger pointing by some parties, a lot of talk, some power points, brochures and introductions, but not a lot of concrete planning.  I suppose it is early yet, but I was hoping we could get down to concrete tasks rather than the usual “it’s broken and has to be fixed.”  There was a panel discussion which contained the chief medical officers of the two hospitals involved, the director of the Center to Improve Care of the Dying from GW Medical School in Washington, D.C., a professor of medicine from the U–an expert on “care transition intervention”, two state representatives, a community liaison, and the chief medical officer of the Colorado Foundation for Medical Care.  There were no hospitalists on the panel.  The physicians on the panel were not “in the trench” physicians, but rather CMOs or University Professors.

Here are the general points that were made:

• Medication reconciliation is onerous to all, and the primary care physician doesn’t enough time to reconcile a med rec from a discharged patient.
• There needs to be a standardized form for all transfers.
• Hospitalists don’t pay for themselves, and make transfers even harder and more complicated.  They have some value however in that they are “enthusiastic” about making changes.
• Patients should have a Personal Health Record, (PHR), whether it is paper or electronic.  (No word on how we will access this–?from a memory stick?  Do I hear “computer virus”?)
• Nursing homes receive patients from hospitals/hospitalists “all the time” with out receiving proper discharge paperwork and medical reconciliation.
• Hospitals/hospitalists do not prepare patients for “the next care situation.”  One physician panelist asserted that hospitals and hospitalists “lie” to patients about nursing homes to get them out of the hospital.
• The way to fix all of this is by “Care Transition Coaches.”  These are non medical coaches are charged with visiting the patient in the home or nursing home.  They are to make sure the correct medications are being taken, and incorrect medications are NOT being taken, check that the patient knows who to call for problems (not necessarily the PCP), and that follow up appointments are made and that the patient has a way to get to them.  Additionally, Care Transition Coaches are to role play with patients so they know when to ask questions or bring up concerns at the follow up doctor visit.  (Example given: when following up with the cardiologist, the patient should not wait until “the door handle moment “to tell the doctor they are short of  breath when they lay down.)
• “Care Transition Coaches save $300,000 per coach.”  (Please do not ask me for the data on this number as I don’t have it!)

Hmm. The take away for me:

1. Transfers do indeed need to be standardized.  (I have ranted on this before.)
2. Medical reconciliation is paramount.  (I have ranted to hospital administrators on this, and am told it costs too much to do it effectively!)
3. We have got to do better at calling PCPs and SNIFs.  (And vice versa!)

As to the health transition coach: I’m not so sure.  I think the better solution is SLOWING DOWN HEALTH CARE.  Make it so we have time to contact each other, explain things to the patients, and review with the family what is next.  I don’t know that introducing yet another person into the mix –the “coach” is the answer.  I do believe that having the time to effectively communicate with patients, families and other care givers is!

And you? What do you think we should do to fix this problem?

The hospitalist groups I work for are both trying to cut costs as hospitals are clamping down on the payment to hospital owned groups. Both groups are stretched thin, and rely heavily on locums to fill the gaps. Here are some ideas on how hospitalist groups can save some mula as we continue to weather the economic storm. I admit some are ridiculous, but others should have happened long ago.

• Wash own coats. (I already take mine home because I don’t like the starch!)
• Print on white paper (for some reason the administrative staff prints our patient lists on blue paper-more expensive then recycled white!)
• Cut CME money-go ahead and give the time off, but reduce the amount for educational expense.
• Cheaper business cards-go cheap on the ones we give out to  patients.
• Cut excess staff. The two groups I work for have way too many administrative staff.
• Avoid locums staff-this may sound downright stupid coming from the owner of a locums staffing service, but here is my point: all my docs (including me) are local and more reasonably priced then the big companies. See if you can find physicians like me who fill in for less, live in your area and provide great patient care. (A little shameless self promotion,eh?)
• Buy cheaper pens.
• Cut down on computers. One office I work in has way too many computers for the EMR-the computers seldom get used to capacity.
• Consider ER hospitalists. Let me explain myself. Many of our admission are the so called “garbage” admissions-those patients that are admitted for social reasons, or because the ED is too busy to work them up fully. Admissions cost money. Why not have an ED Hospitalist that does the “borderline” or “garbage” admissions and tries to get those home that don’t belong in the hospital? This would cut back on physician staffing requirements, and heck, would even save health care dollars!
• No more free food. Sorry, don’t kill the messenger.
• Look for cheaper phone systems and pager systems.
• Up staff during day to take the 2 pm ED patient bolus. Evening and night time physician coverage is usually more expensive than day time coverage. Up staff the rounders during the day, with the expectation that with fewer patients to see rounders will also do 2 or 3 admits. This will help take care of the 2:00 pm patient bolus most hospitalists get from the ED. (There are usually two bolus times: 11:00 and 2:00 pm-with the 2 pm bolus being the biggie.)

I need to bleach my coat, so I gotta go.

Intuit thinks that medical practices are high risk for non-payment of credit card debt.  Following is my encounter with Intuit, in which I try to set up a merchant account so my company can accept credit cards from our clients–medical practices.

My company, ExtraMD, is a “local” locums–there are several physicians in our group, we live in the Denver area, and we fill in at medical practices through out the area.  Our business model is simple, but effective: we act as subcontractors to the practices that use us to fill in.  Practices email or call our trusty assistant with shift requests, we fill the shifts, and the practice gets invoiced, and ExtraMD gets paid.

Pretty simple, huh?  Well, not according to Intuit.  We are in the process of converting to a credit card model to make invoicing and payment easier.  We are asking our clients to let us invoice their credit cards.  They have all agreed, and I, as the president, was in charge of finding a merchant account that would be affordable.

I looked at several, and settled on Intuit, partly because it would mesh with QuickBooks, our accounting software.  I filled out the application, and waited.  And then waited some more.  They sent an email requesting more information.  I complied instantly, and waited.  And waited.  They emailed me again, saying they needed more information (which was actually included in the FIRST email I sent.)  This time I called, and reviewed the account with the nice Intuit customer service agent.  They would process my request, they promised.

Two weeks went by. Nothing, not a peep, no email, no phone call, zippo! 

I called back. “I’m sorry,” said Intuit lady, “but medical practices and medical practice staffing are just too high risk.  We are worried we won’t get paid, due to the risk.”

“What?!”  I asked.  “I’ve been in business for 5 years, and our time in AR is probably one of the shortest in the business world!”

“Well, you are a service industry, and medical staffing is too risky.”

I asked to speak to a supervisor, which she wouldn’t let me do.  I sputtered along for a few more sentences and then finally hung up.

The take home: Intuit considers medical practices high risk for non-payment, or late payment.  That’s you,  my friend–hard working physician and practice owner.  This is the cold reality–and so much for loosening up credit with bank bail outs! 

Needless to say, we won’t be using Intuit.  If you have a vendor for a merchant account that you recommend, please feel free to comment.  I’m still looking!

Things have been in disarray at the PookieMD household–Hubby got laid off two days ago, and we are picking up the pieces.  As a wife of an engineer that loves working in small companies, you would think I would be used to this.  But I’m not.  I am trying to get better at it, looking at it constructively, asking what I can learn from it.

But it is still a really scary place to be.

I go through the seven stages of grief every time.  Warning–rest of post may be a bit whiney for those hard-core-stiff-upper-lip people!

Shock: yesterday I was shocked, but I think this wore off quickly as I have been worried that Hubby would be the next under the axe as 3 of the 15 people company had already received their walking papers.

Denial: Hubby is at this stage–”well what if I get a job next week?”, he asked.  What if, indeed!

Anger: for me, it is the turning upside down of my carefully crafted world, the helplessness I feel at not being able to control everything that is enraging.  It is tempting to blame someone, but I know there is no one to blame.  I spent a lot of time sitting on my front step the last two days so I wouldn’t yell at Hubby.  Helplessness makes me furious!

Bargaining: nah, I don’t bother with this stage.  What’s there to bargain about and who to bargain with?

Depression: not there yet.  I think this will depend on the length of the lay off.  We are bracing for at least 6 months, if not longer, given the economy.

Testing: I have already taken more shifts at the hospital, and Hubby has already found a some jobs to apply for.   I have always worked 2/3rds time as a hospitalist so I can spend more time with my daughter, but I will have to give up that for a while.  I know I am lucky I have this option, but I am also sad, because spending time with my daughter when she is out of school is one of the greatest joys of my life.  In addition, we went through our budget via an excel spread sheet, and know we can go a year on my salary as a physician and president of ExtraMD.

Acceptance: does any one ever accept bad news?  I don’t know if I will ever get to this stage–maybe more study of Eastern Religions would help.

All right, enough whining and tissue wringing!  If anyone needs an electrical engineer let me know, and if you want me to cover some shifts, I’m here for you!