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

Buckle up, partner, it’s time for another PookieMD biz refresher course!  This time, it’s on unmistakable signs that your practice business is about to crash and burn!

Knuckle gripping sign number 1:  You have cash flow problems.  You can’t meet payroll because you don’t have enough cash on hand.  YOU MUST BUDGET FOR CASH FLOW!  (Which leads to my even more basic rule for doing business: you must BUDGET!)

Knuckle gripping sign number 2: Expenses are greater than revenues.  Whether it’s decreased productivity, or that @%*# insurance company that pays so late, the basic rules is that revenues must be greater than expenses.  You must figure out what is happening, and how to reverse the trend.

Knuckle gripping sign number 3: You’re borrowing more than Citibank.  If you are borrowing to meet expenses, you are in deep doo.  No, the feds aren’t going to bail physicians out.  Tighten the belt, sniff the smelling salts and make a plan .

Knuckle gripping sign number 4: You hide from the postman.  The overdue notices keep on coming.  You need to structure your own bail out!  Call in the experts, and swallow the medicine.  You wouldn’t encourage a patient to ignore a breast mass, so why are you ignoring your business?

Knuckle gripping sign number 5: No one looks at financial statements.  This is a variation on the ignore the breast mass and it will go away scheme.  To get an adequate idea of how your practice is doing, you need to look at budgets, budget variances, cash flow and accounts receivable monthly, at the minimum.  In tight times, you may need to budget WEEKLY for cash flow.

So, what to do?  Just like you would tell an alcoholic, first you must recognize that you have a problem.  Next you must review your financial statements to find out the depth of the problem.  Then you must develop a plan to get back in the black.  You must budget, analyze your cash flow issues, and tighten the belt.  Lastly, get help.  Would an internist do a cardiac cath in the office?  Of course not!  Why would you try to go the financial world alone?  Get referrals from friends on good accountants and bookkeepers, read all you can, consider educating yourself through seminars, and take it one day at a time.  If you actively follow your plan, your practice can become viable again!

I have been encouraging physicians to explore group visits for a while.  Group visits are especially suited for stable patients with chronic disease–think hypertension, diabetes, COPD. Patients with chronic diseases make up the majority of the primary care office visits, especially for internists.  Group visits can increase patient and physician satisfaction, and encourage healthier patients and lifestyles.

Following is a short primer on what must go into a group visit:

• Privacy issues must be addressed.  The patient must sign a confidentiality form, allowing their case do be discussed in a group, and also agreeing NOT to discuss other patients’ medical issues outside of the group appointment.
• The chronic disease addressed must NOT require the patient to disrobe.  (Duh.)
• A physical exam must be done.  In order to bill appropriately, a nurse should document vital signs for each patient, and the physician should document an appropriate exam for the problem.
• Patients should be encouraged to have questions formulated for the physician ahead of time.  These questions may be posted on white board and reviewed through out the meeting.
• Physicians should be prepared to answer questions as they examine each patient.  This is where the efficiency exists–many of the patients will have the same questions, and will be relieved that they are not the only one with questions/problems.
• Time should be available after the group appointment for individual questions ON THAT SPECIFIC DISEASE PROCESS.
• Schedule enough time and enough patients.  Eight or nine patients in one hour is a good number.  You may need to have the initial group visits be 2 hours and discuss how the group visit will run.  Realize that Seniors tend to have more flexibility as to scheduling an hour long visit, while working folks may require early morning, lunchtime or late afternoon appointments.
• Have enough support staff to take vital signs, sign privacy statements and get patients situated.
• Be prepared for emergencies–if Mr. Pickwick shows up for the group visit with a pulse ox of 70%, be prepared for how you will handle the emergency AND  the group meeting.

As to billing issues: each patient is billed as if seen individually, hence the emphasis above on vital signs, appropriate physical exam, lab tests, level of decision making etc.  Utilize E/M codes 99212-99215 as appropriate.  Documentation is key here.  Consider a check list form, or a template for your EMR, that patients fill in regarding symptoms and questions, and then a check off form for the physical examination.

So what do patients think of group visits?  About 75% of patients that have participated would do so again, and 5% would not. 

I personally have done group visits with diabetics, and enjoyed it tremendously.   We served lunch at the first meeting, and had a nutritionist and pharmacist there as well.  The patients enjoyed it, and learned a lot.  I think group visits will go a long way towards easing the treadmill approach we employ in primary care medicine, and encourage physicians to try it.  Some practices delegate this to the “mid-level” providers, but I think patients get more out of the group visit when it is physician run.  I also believe that most physicians enjoy the interaction and ‘teaching moments.’

Let me know if you do this, and what works or doesn’t work.

For an overview of how Harvard Vanguard Medical Associates is doing group visits, see:  http://www.boston.com/news/local/massachusetts/articles/2008/11/30/the_doctor_will_see_all_of_you_now/?page=2

For more information, forms, and another in-the-trenches view point, see: www.aafp.org/fpm/20040900/39grou.html

All right, Dr. Practice Owner, here are more tips to keep you practice’s head above water in these turbulent times:

• Share staff.  If you have an excess of staff, could they be shared with another office rather than laid off?  You  get to retain a valued staff member, the staff member keeps their job, and everyone wins.
• Enlist your staff for help.  Everyone is anxious about keeping their jobs.  Set up a brain storming session for ways to save money, and ask your staff for input.  Once they realize they can directly impact how the practice runs, they will be diligent in finding ways to keep the doors open!
• Pay bills on line.  You can pay bills closer to the due date, and keep the money in your account longer.  (See “sweep account” in previous post.)
• Get a free energy audit.  Your local power company will do this for free, and can give you information on where the energy is going, and how to improve the leaks.
• Turn off your computer at night and on weekends.  Ditto the lights.  (Duh, but did I turn off my computer last night?!)
• Evaluate your payroll company.  Payroll companies must guarantee accuracy in withholding and tax filing.   (Penalties are huge for mess ups!)  However, make sure you are not paying for services you are not using–if there is just three of you, do you really need the Human Relations functions?  Also, examine direct deposit.  See if you can get your payroll service to do it for free.  Direct deposit saves the payroll company money–which should you be paying for it?
• Make sure you take all the tax deductions you are entitled to.  Keep receipts as if they were gold.  If you haven’t done this during 2008, make it a top priority for 2009.
• Tax tips continued: ( http://smallbusinessonlinecommunity.bankofamerica.com/blogs/Taxes/2008/03/20/five-tax-filing-mistakes-to-avoid)     

–If you started a qualified retirement plan, you can claim a credit of $500 per year for the first three years to offset the administrative start up costs (e.g., educating your employees about their participation in the plan).
–If you conducted scientific research, you may qualify for a 20% tax credit for these research activities.
–If you hired someone from certain targeted groups, such as a disabled veteran or long-time family assistance recipient, you can claim a credit for a portion of their wages.

• Choose the best business entity.  Partnerships, LLCs, and Corporations all have various tax benefits.  Talk to your accountant and then business attorney about what is right for your practice.  General rule: “Any business with the potential for claims against it, which includes most businesses with employees as well as those with customers who visit the business premises, should probably opt for an entity type that protects owners’ personal assets.”  (Barbara Weltman, contributing writer for Inc. magazine.)
• Cross train your employees.  Rather than laying off, see if they can do other functions.  Beware of the training costs, but it may just save you money.
• Don’t be Scrooge McDuck.  Get creative with perks.  Consider dress down Fridays, if appropriate, or Pizza Fridays.  Ask you staff if they want that Holiday Gala, or if they would prefer some decent lunches, or maybe just a bonus check.

My company, ExtraMD, does the following: we use a virtual assistant, we pay bills on line, we keep payroll in  house, and are looking at giving bonuses this year.  I look at our profit/loss and budget variances monthly.  We have an ace controller, and an amazing tax attorney.  Our accountant is appropriately pessimisic  (that’s what I am paying him for!)  And, yes, I print on both sides of the paper.  I promise to turn off my computer at night.

Good luck!   Keep the doors open, the employees EMPLOYED and your practice business in the black.  Remember, if you aren’t open, you can’t see patients!

So now that we are in the spend, spend, spend season, I thought I would round up some more ways to SAVE money in medical practices.  The following tips are from the mundane to the grandiose.

1. Get your printer cartridges refilled, rather than buying new ones.  And, hey it’s “green”!
2. Get free forms.  Visit www.entreprenuer.com/formnet.  They have forms for collections, credit cards etc.  Better than making ‘em yourself, or paying for them!
3. Use independent contractors.  ExtraMD (my company) is made up of independent contractor physicians.  We fill in locally around town, and cost less than the big locums  companies.  Practices save because we are independent contractors, and pay our own taxes/malpractice etc.  There may be similar groups in your location.  In addition, consider independent contractors for prn nursing, front desk help etc.  CAVEAT: check with your attorney/accountant to make sure the people you are using fit the stringent IRS definitions of independent contractors.
4. Shop around for over night mail couriers.  Boy was I shocked at the differences!  It cost about FIVE dollars less to use USPS over night versus another big company!
5. Make sure you plan for taxes appropriately so you don’t get soaked with penalties.  My bookkeeper calls this “tax anticipation.” 
6. Get the best credit card rates.  If you run balances, for pity’s sake get the lowest interest rates!
7. Look at a “sweep” account. If you run large balances for 2-3 weeks at a time, a sweep account allows you to move your money in and out of an interest bearing account easily, and earn interest, rather than having your money sit in a non-interest bearing account.
8. Ask suppliers if they will give discounts for early payments.  Hey, it doesn’t hurt to ask.
9. Make sure your billing company is a bull dog.  Don’t let them write off claims too easily.  I will post more on this later.
10. Get at least three bids on every purchase  (especially the big ones!)  When you DO finally purchase something, see if you can bargain, or quote a competitors price!
11. Reassess your phone plan and the number of lines you have.
12. Eliminate paper waste.  Copy on both sides of the page.  Why  add more to the land fill any way?
13. Use coupons.  Don’t laugh!  Get your medical assistants to find them.  Check out www.searchalldeals.com for lots of coupons on just about any purchase.
14. Sell equipment you aren’t using on Craigs List.  (www.craiglist.org )
15. Make sure you are getting the best rates on business/medical/malpractice insurance.

Just try doing one or two, and see where it gets you. I will search out more ideas in the next post.  As a reminder, try to have your staff look at this list and implement a few money saving practices.  Your time should not be spent clipping coupons!  I would love to hear YOUR tips!  Also would love to hear gripes/tips/info on coding in your practice.

For more info check out these on-line articles:

http://www.entrepreneur.com/money/howtoguide/article71318.html

http://www.insidecrm.com/features/78-ways-save-economy-101408/

As the ExtraMD, PookieMD has seen lots of practices.  I have also been asked to evaluate failing practices to see where they got off track.  There are some common themes amongst failing practices.  For once, I will NOT carry on about reimbursement, but rather focus on where the physician owners of these failing practices went wrong. Here are my top ten reasons primary care practices fail:

1. No budget.  With out fail, every time I have asked failing practices about a budget, I get a vague answer, along the lines of, “Well, we look at the numbers.”  NO!  A budget is not something your book keeper or office manager creates, and then places on a dusty shelf!  You need to look at it as a tool, and analyze where your practice’s money is going, where you want your practice to go, and why you are (or are not) getting there.  You must analyze variances and figure out why they are occurring.  When I say you, I mean YOU!  Yes, you must understand this process to guide your practice/business!
2. Serious lack of planning.  We physicians are masters at trying to anticipate and forecast what happens with patients.  This same skill MUST be applied to cash flow.  You must forecast your cash flow  so you can plan ahead.  Good examples of bad planning: not anticipating paying your staff for holidays/vacations, not planning for the lost revenues while YOU are on vacation, not planning on HOW you will pay your new partner before s/he is generating enough to cover her salary. 
3. Huge empty offices.  I worked at one office where one exam room was crammed with free give aways from drug reps.  You couldn’t even use the room.  Yup, pens, cute pedometers, plastic clip boards, heart shaped watches were stuffed into the exam room, rendering it unusable.  Yikes!  Who can afford that?
4. Top heavy staff.  If you are a small office, you really need to examine how much staff you have, and how much your really use and need.
5. Buying sprees.  Before you invest in what ever new gizmo you think will earn the big dollars, do a thorough market analysis and cash flow projection.  (Worst example I’ve seen: a gazillion dollar laser that a practice bought but never used!)  Don’t just believe what ever a vendor is telling you.
6. Investing in an EMR and not using it.   I have worked for 4 different practices that bought EMRs and were too busy to a) use them at all b) wrote notes and then typed them in later, c) persistently scanned notes in.  I’m not kidding.  If you are going to get an EMR, commit!  Realize it will take oodles of time to make it useful, but for Pete’s sake, don’t buy it and have it sit there!
7. Not putting in the hours.  All of the practices I have been asked to review had physicians that felt like they were working quite hard, but were only putting in 6 hours a day.  Many offices would open at 9:00 am, take a 1.5 hour lunch, and then the office would close at 4:30. 
8. This is not your father’s practice.  Back in the day, the “GP” hung out his shingle, saw 10  patients a day, gave a shot of penicillin in the behind for everything and perscribed milk for ulcers.  If you think the business of medicine is that simple you are in the wrong profession.  Physicians must understand the complexities of today’s medical/legal/business world.
9. Poor location/top heavy lease.  It’s tantalyzing to have the medical office suite with the fancy furniture and custom wall hangings etc., but get real.  See #1, BUDGET!
10. No advisors.  We physicians are smart, but not smart enough to know everything.  The practices I have evaluated typically had physician owners that were trying to do everything themselves, with out utilizing advisor such as bookkeepers, accountants and business attorneys.  You must know enough to understand your advisors, but you also need to trust them to guide you.

If you see your practice here, get busy making changes!  Today’s climate is tough, so we need to get tough in how we run our practices businesses.

Now that I have vented/ranted/opined on the demise of primary care, let’s move to some survival tips. Following are PookieMD’s two fundamental. most important, and most loathsome rules of survival in primary care medicine.

The money is in the numbers.

Time is money.

Yes, you have to see patients to  make money, and given today’s reimbursement you have to see a fair amount of them.  This is a given, a fact, a law.  If you don’t want to see 20 (or more) patients a day, go in to psychiatry.  If you are in primary care, you probably are looking for a way to make a dollar go a bit further.  Don’t laugh, you might spot something useful here!

1. Get a set back thermostat.  No, these aren’t just for home use.  If you are paying your utilities, why are you heating the office at night? 
2. Learn to be efficient.  I have previously blogged on being efficient.  Running yourself ragged to see more patients is a recipe for burn out (if you are not already there!)  Look for ways to become more efficient.
3. Use your EMR to the fullest.  For heaven’s sake, if you bought the thing, use it!  Learn every bell and whistle it has, every dot command, every work around, every reminder system. .  It will make you more efficient. Reminder: USE the perscribing feature (CMS will be rewarding this, and then penalizing you if you DON’T use it!
4. If you don’t have an EMR use preprinted check box forms when possible. Write in the extras but the check box forms will save you time, and are usually more legible.
5. Have your receptionist call and remind patients of their appointments.  An empty slot in your day doesn’t generate revenue.
6. Look at how you use your space.  Could you rent a spare exam room to a occupational or physical therapist?
7. Consider extended or weekend hours.  You are paying the rent whether you are open or not.  Consider opening a half day on Saturdays for urgent care appointments.  Don’t let Walmart take away YOUR business!
8. Consider using medical assistants during their internship.  Lots of local MA schools are looking for practices that will take on a student.  These students are usually in the later part of their training and can extend your man power for free!  Beware, your nurse or MA should supervise them.
9. Make sure you are billing for in-office procedures.  Train your staff to check off ua’s, strep tests, pregnancy tests etc.  You should then double check when you are filling out the superbill. You are doing ‘em, get paid for ‘em.
10. Shop at big ware houses, like Costco.  Get toilet paper, and office supplies at a discount.
11.  Make sure you charge for vaccination admission and the vaccine itself.
12.  Use those freebie exam table coverings.  (Yeah, I’m not fond of laying down on an exam table with a paper covered with Viagra logos, but hey, what a poor primary care doc to do?)
13. Don’t buy new–buy used equipment when possible.  (Checked Ebay lately?)
14. Consider remote deposit capture.  If you have a big enough volume of checks that come in, you can scan and electronically send the images to your bank to get instant deposits. Cash flow is king!
15. Consider ancillary services.  See previous post on ancillary services.  See what you can stomach.
16. Consider group appointments.
17. Utilize your staff to the fullest.  See previous rants.  Yes, I’m talking to you.

Look, this stuff isn’t fun.  However, if you want to survive, your business (note, I didn’t say PRACTICE), must have revenues greater than expenses.  This is the law of keeping the doors open.  Maybe things will change for the better.  Maybe not.  But if you are doing primary care, it’s up to you how you handle your BUSINESS, and how you keep the doors open so you can see patients.

Ah, yes, ICD-10 is coming!  Yes, the new coding system with 10 times more codes than the previous is slated to go live in 2011.  Much of the world now uses ICD-10 because it has more codes, as apparently, we are running out of codes.  You, my beloved provider, will be shouldering the burden of the cost to implement the system.   A few reasons why this has made my normally smiling face curdle with disgust:

1.  There are TEN times more codes– all codes will be 7 digits, and then, yes, oh yes! You can add a modifier.  Simple, huh? 

“We are just now beginning to learn the increased costs on physician practices associated with moving to the ICD-10 code set – and they are staggering,” said William F. Jessee, MD, FACMPE, Medical Group Management Association president and CEO.

2.   It ain’t cheap.  Implementing the new coding system is estimated to cost $83,290 for a THREE physician office.  (See http://www.aapc.com/news/index.php/2008/10/icd-10-cm-coalition-press-release/).  At an average reimbursement of $50 per patient visit, that’s an extra 555 visits per year, per physician.  If a physician works 5 days/week, 48 weeks per year, this makes an extra 2.3 patient visits PER DAY!  If patients already feel rushed during their visits, think of it now!  And you know what, there’s not a dang thing the physician can do about it!  (Well, I guess concierge medicine might look more attractive…)

3.   You will wait even longer to get paid.  CMS (Center for Medicare and Medicaid Services), which is the government agency behind this change, notes: “…putting in the new system could initially boost by 10% the percentage of claims insurers return to doctors because of coding errors.“   (See http://blogs.wsj.com/health/2008/11/11/look-out-docs-here-comes-icd-10/)

4.   It’s another blow to primary care.  Many primary care offices are solo practitioners, or small groups (three or less.)  These are the groups least able to shoulder the cost of another complex government regulation. 

5.   You won’t have time to implement it.  You will need to learn the new codes, educate your staff, update your super bills and then change over your billing software to accommodate these new codes.   Most importantly, you will need to do some major cash flow planning.  (Yup, adding in an extra 65,000 codes takes time and money!)  This will be tough to do given the time frame the CMS is proposing.  Even the insurers want more time.  (Who’d a thunk it—me agreeing with medical insurance companies!)

6.   Get ready to buy more computers.  If your practice wants to be efficient, you will need computers in each exam room to quickly file the charges.  This is on top of the mandate that medical practies move to an EMR.  (Who’s going to fund THAT?) (See: http://www.ama-assn.org/amednews/2008/09/08/gvsa0908.htm).

7.   Beef up your documentation.  You want to get paid?  Prepare to be exacting!  The reason for a medical chart has changed—it used to be so that we could develop a working diagnosis and plan, based on history and exam to treat a patient.  You poor dinosaur! A chart is a way to get paid! 

8.   It will drive up the cost of health care.  The cost of soft ware, computers, training, IT support and the like will first be passed to physicians, and then eventually to patients.  There is no such thing as a free lunch!

9.    Patient care will suffer.  As physicians, we are ever more focused on computers, documentation, crossing Ts and dotting I’s.  Who will focus on patients when we are focused on coding?

10.   We will lose more primary care physicians.  Small practices, in rural/underserved areas can not afford the implementation involved in transitioning to ICD-10.  Implementing  ICD-10 will be a nail in the coffin of areas that desperately need primary care physicians the most.

I was thinking about opening a coffee shop.  I could code and bill for beverages as follows: a small cappuccino would be a 99212(01), a medium 99213(02), and a large a 99214(03), and jumbo would be a 99215(04).  I could add modifiers to denote skim, 2% or whole milk.  Shots of flavoring would require modifiers as well. So, a medium, skinny cappuccino with a shot of hazelnut would be a 99213(02)-7-13  (taking into account the ‘skinny’ or -7 and the hazelnut -13.)  I would of course charge you, the customer, more for my nifty billing system.   I also could bill based on how LONG it takes to make the beverage.  I don’t know why Starbucks doesn’t do this.  It seems so efficient.

My trusty health insurance, for which I pay handsomely, (yes, I am self-insured) sent me an email titled, “Calls could cost you.” It states that calling your physician may cost you. I quote:

“Many times people call their doctor to ask a question, resolve a concern, or ask about a referral. Traditionally, doctors haven’t charged to answering these questions. In certain cases, that’s changed.

New rules have been established that allow doctors to charge for telephone consultations in some circumstances. To be a billable call, the patient must not have been seen by the doctor for a week before the call or within 24 hours after the call. If the doctor provides services that could have happened at a regular office visit, then the doctor can submit a claim. The doctor must let the patient know the call isn’t free and that he or she intends to bill.

If the doctor does submit a claim to Humana, we’ll treat it as if the doctor filed a claim for an office visit. So if your benefits have co-payments for an office visit, you’d owe the doctor your co-payment for an office visit. If your Humana plan has a deductible, we’ll apply the allowable claims costs to your deductible. You’ll pay the allowed charges, unless you’ve met your deductible.

These rules don’t apply to most calls people make to their doctor. But Humana wants you to know that under current national rules, doctors can bill both Humana and their patients for some telephone visits.

It’s important to know that calling your doctor could cost you in some circumstances. If you’re aware of the rules, you could save yourself some money.”

Hmmm, this is interesting. What patients should you manage over the phone? What are the legal ramifications? Ethically, what is involved in charging for phone calls?  God forbid, are we behaving like lawyers? I don’t know about you, but I always prefer to see a patient rather than prescribe over the phone. I know some patients absolutely refuse to come in, “I don’t have time,” but I am loathe to diagnose and prescribe over the phone.    (And these are the patients I think are most likely to sue-they seem to be looking for a way to work around the system.)

My take-
If a patient is ill they need to be seen.
If you are going to bill for phone calls, and it is certainly justified in some cases, be impeccable in your documentation.
Establish criteria ahead of time of what sorts of phone calls you will bill for, and what cases ABSOLUTELY must be seen in the office.
Teach your staff how to triage calls.

Following are the codes for phone calls.  (From From the January ACP Internist, copyright © 2008 by the American College of Physicians.)  If anyone is doing this, I would love to hear back as to which insurers are reimbursing, and how you determine which patients are appropriate to be managed by phone–e.g.  coumadin management? 

99441: Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
99442: 11-20 minutes of medical discussion
99443: 21-30 minutes of medical discussion

As to liability, here are some guidelines from CRICO/RMF, the medical malpractice company for the Harvard Medical Community.  (http://www.rmf.harvard.edu/patient-safety-strategies/communication-teamwork/telephone-technology/faqs.aspx#Q31)

“Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient’s complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.”

Good luck with this!  I think that coding for phone calls has a lot of potential for good and bad, and would tread lightly.  And just to make you smile, I got an automated phone call from Humana while I was writing this, encouraging me to visit their web site, where I could get medical advice “tailored for me.”  Shoot, who needs an MD?  Just throw up a web site with generic advice and call it a day!

All right, pencils out, notebooks at the ready!  Quiz to follow!  Here is Part II of Resuscitating Primary Care.  At our last session, we noted the primary care was indeed a “code-blue/COR-0″.  As promised, I will apply my laser sharp focus to “fixing” this problem.

Buckle up!

You are a shrink. This is another unavoidable issue.  You must learn effective ways to help these patients, which make up a large part of medical practices.  In our medical school and residency programs there needs to be a greater emphasis on psychiatry, as mental illness is so pervasive.  As to your own practice, several things will help: learning and using the counseling codes, scheduling enough time for these patients, and having on hand the cards of your favorite psychiatrists, psychologists, and social workers.  Also, you must become well versed in the plethora of antidepressants out there.  Key point: you have limits too, and remember that most mental health professionals have the phrase down, “I’m sorry, but our time is up.  When should we schedule our next visit?”

Insurance companies make life miserable.  We must fight back!  As group, we physicians have laid down and played dead!  From a macro level, we physicians need to lobby for appropriate reimbursement and STOP accepting what ever insurance companies offer.  (See related post: “Entering the Lions Den”.)  At a practice level, your job is to ensure that your coding, billing and collections are top notch.  That means knowing which insurers are paying in a timely fashion, at an appropriate rate. It means dumping the ones that aren’t!  It also means negotiating for the reimbursement your work deserves. It means having a strong stomach, and realizing that this problem is not going to go away unless you make it go away! 

It’s not good mind candy anymore.  Ahh, to find the random pheo and look like a hero!  The reality is we are managers of chronic disease, cheering patients on when they lose weight, lower their A1-C and actually exercise.  Yes, you will still make the occasional brilliant diagnosis, but your focus will be on medical coaching.  You need to learn how to coach, and find joy in it.  Another avenue to explore would be group sessions, which can be energizing and exciting.  Next, you could market your practice as “the practice for the seriously ill” — meaning you WANT complicated medical patients.  This has ramifications for billing/collections, but could be a viable model.  (Note: I haven’t run the numbers, but remember, you will code higher for more complicated patients.  If you really market your practice to get these patients, it may be fairly interesting. Any one out there have a practice like this?)  Lastly, consider leaving slots open for urgent care visits.  There is no reason to give this business away to Urgent Care clinics, and these visits can be fun and interesting.  (Yeah, I know, you will see a lot of URIs, but you will also see the occasional thyroid storm and aplastic anemia!  Been there, done that!)

The environment is hostile.  But you don’t have to be!  If you are on time, sit down, look AND listen to the patient a lot of hostility will vanish.  We have perpetrated some of this, and it is completely fixable by physicians!  Bedside manner, (Marcus Welby, not House!) is where it’s at.  Please, do not hide behind your computer.  Yes, use that high falutin’ super expensive EMR, but set it up so that you can look at the patient and type.  For pity’s sake DO NOT write notes and type them in later! Talking about a huge time waster!!!  Make your exam room and waiting room comfortable, and a friendly receptionist and nurse are a must.  Sourpusses need not apply!

Not everything is fixable.  Yup.  However, our mind set must be that our job is to guide patients toward health, and that there are no quick fixes.  Part of the job is to move patients towards this mind set as well.

Key point of this post:

Make it fun!

We spend too much of our time at work not to have fun. Have a good time with your patients and staff.  When the end of the day comes, I think the one that had the most fun, wins!  Hang in there, send comments on how to make it better, lobby for change, and keep doing the good work!

PS:  I will put up a page with a resource list in the next few days.

1.  The pay stinks. Yes it does.  Physicians do not get pay raises because they are more experienced or incredibly good.  The only way to increase the pay is to do one of three things: see more patients, add more services and globally lobby for getting paid for thinking (which is what primary care physicians do best).  At the practice level, you need to examine patient flow, appropriate billing for services rendered (example: are you billing/coding appropriately for immunizations?) and decide on an appropriate number of patients to see.  Calm down, I am NOT telling you to become a patient care mill, rather to be realistic and set a REASONABLE number of patients you could see.  Also realize that the pay is limited, and it will take a major change in reimbursement to get paid appropriately for what you do.  (Sorry, it is what it is.  Get out there and lobby for change!)

2.  You got an MD instead of an MBA.  I am addressing this early in the game because it is probably the most important.  In my neck of the woods, massage therapists, as part of their curriculum, learn marketing and accounting.  They are better equipped to set up a practice then a physician who has spent 4 years in medical school then 3 more in residency! (Academic medicine, are you listening?) Here is the big message of this post:

You must learn the business of medicine.

But how?  There are books on practice management, seminars on practice management, journals on practice management, and a good accountant and bookkeeper are essential.  But YOU must understand the financial underpinnings of your practice, even if you have God’s gift to office managers.  (For more on seminars, visit my website: www.extramd.com.)  Later this week, after I do my nights shifts, I will put up a page with a list of resources I found helpful.  C’mon, as a physician, you are used to soaking up knowledge like a sponge, you can do it!

 3.  Coding is really fun.  Sorry, but this is another one you MUST learn.  I don’t care that it is boring, picky and strong medicine even for the most confirmed of insomniacs.  Once again, avail yourself of every resource you can to learn it.  Think seminars, books, consultants.  No whining, just do it.  (And remember, ICD-10 is coming.  Sheesh.)

 4.  You are a hamster on a wheel.  You will have to weigh revenues vs. practice style here.  Of course, you will need to maximize revenues, billing and collections no matter what you do.  However, if you choose to see fewer patients per day, then you need to reconcile yourself to less revenues, and ultimately less income.  Your practice partners may have some input on this (!), but if you are solo, consider the micro practice model that is getting a fair amount of hype.  Whatever you do, be very clear in your mind what your expectations are.

All right, enough for today.  We will continue PookieMD’s crash course on primary care resuscitation in my next post.  Until then, keep the doors open, and get out and learn a little about the business of medicine!