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

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.

This is EMR week at the PookieMD blog.   I will give a short primer on some terms, and later in the week will have a guest post by a surgeon that loves her EMR.

Terms to know:

IT: Information technology.  (Hey, we’re starting from the ground up!)

EMR: Electronic medical record, used by health care professionals, replaces the paper chart.

PHR: Personal health record–a record, usually electronic, kept by an individualto keep track of his/her health.  May be presented to physicians/care givers, but does not take the place of the patient’s medical record.

Web Hosted EMR: in which the software for the EMR is web based, and the data base of patient records is stored on a server out side of the physician’s office.  Technical aspects of the server is managed by the company to which the practice pays a monthly fee.  (Think of it as leasing a car.)  This is also known as SaaS–software as a service.

Client/Server EMR: in which the practice buys a server (think of this as a computer where all the patient records are stored) , and buys a license to the EMR software.  The practice is in charge of maintaining and backing up the server, and updating the software, as well as fixing any bugs in the system.  In addition, the practice should keep back ups of data OFF SITE.  (Think of this option as  buying a car.) 

ASP: application service provider–the company that provides the physician office with the EMR software, server to hold the data base, and provides software upgrades, help desk support, daily database back ups and server maintenance. 

CCHIT:  Certified Commission for Healthcare Information Technology–”private nonprofit organization with the sole public mission of accelerating the adoption of robust, interoperable health information technology by creating a credible, efficient certification process.”

Work stations: the computer at which you, the care giver, will be entering your notes.  This could be a tablet PC, a notebook PC  or a traditional desk top.  Both Web hosted and Client/Server vendors require the practice to own their own workstations. 

Printers: duh.  The practice will still need printers, scanners and faxes hooked into the work stations.

e-Prescribing: in which a prescription is entered electronically to a pharmacy, rather than giving a patient a hand written copy.  Usually, a part of the EMR.  (Buyer beware: class II narcotics and certain other drugs can not be prescribed via e-prescribing!)

I poked around at a couple of sites, and was frustrated  that most required me to fill out a request for email/address/phone in order to try the demo.  I think that when looking for an EMR, I definitely want to be able to preview one before talking to a rep.  AND, I would NOT have an office manager or nurse make the decision as to which EMR to go with or even which one to demo!   As the chief user, I think this is a physician level decision, not an office manager decision.  Helpful website: Fierce Healthcare.  Lots of news here on health care management and IT.

Chart credit.

The following is a list of deadly sins that physicians commit in running their practice/business.  I have several friends, not physicians, who don’t believe me when I tell them about the business mistakes physicians make.  “But you are all so smart!”, is a common refrain.  It’s our very smartness that does us in.  We know a lot, but not a lot about business, and yes, medicine is a business!  Here are 1o deadly sins physicians make when running a practice:

1. Thinking they know it all.
2. Thinking a practice is not a business.
3. Hiring someone to “take care of all of it so I can just see patients.” 
4. Not knowing the business basics: budgeting, financial statements, and cash flow forecasting.
5. Ignoring financial reports about the practice.
6. Hiring before a practice can sustain another salary.
7. Using high interest debt as a way to finance the practice.
8. Not collecting what is owed to them.
9. Buying equipment they can’t afford. 
10. Not managaing the practice manager.

Confessing my sins: I personally have committed the following “sins”:  thinking I know it all, not collecting what is owed to me (“I don’t want them to think I’m mean!”), and not managing the practice manager.  What business mistakes have you made in your practice, and how have you recovered?

I’m going to be honest here.   Sometimes work is just no fun.  Sometimes it’s just darn right stressful and I can’t wait til the day is over.  Sometimes I wish I had gone ahead and opened a coffee shop, and the other day I was wondering how I could get a job testing Black Diamond climbing gear.  There are two trains of thought involving work: #1 it’s called work for a reason or #2 you spend most of your life doing it, so it should be fun.  I go back and forth between the two, depending on my mood, my caffeine level, and how much time I’ve spent outdoors recently.

I think we in medicine have been regulated out of fun and in to seriousness.  Yes, health care is a serious business, but we are human beings, and enjoying ourselves is part of our make up. So to that end here are ways to make the day fun:

• Go outside at least once during the day and breathe.
• Joke with a coworker.
• Carry around a picture of your kid/dog/S.O./next vacation spot.
• Have something to look forward to.
• Treat yourself to a great cappuccino before work.  (Don’t forget the post coffee mint!)
• Look up something you don’t know. 
• Spend some time making light chit chat with a patient or family.
• Say hi to the house keeping staff.
• Have a pot luck, and PARTICIPATE.  C’mon, you can bring in a crock pot full of beans ‘n’ weenies!
• Keep the candy jar stocked in the lounge.
• Have a themed Friday, say Hawaiian, and wear that crazy shirt.  Let your staff play Hawaiian music, and decorate the lunch room.  Give  plastic leis to the patients.
• Have a barbecue at lunch and play basketball.  I love it when I see a bunch of people playing basketball in the parking lot where they work. Kids aren’t the only ones that need recess!
• Go to your hospital’s lunch ‘n’ learn and yuck it up with your colleagues.  Sometimes we are so locked in to our little routines we miss the importance of spending time with our friends.  Besides, you might learn something!

Get out there and have some fun! Leave your responses on how to have more fun and email pictures to blogatextramddotcom and we’ll see if we can up load ‘em!

Now, does anyone have an in with Yvon Chouinard?

I hope by now your practice has a website.  Americans are web savvy, and having a good website will insure fewer phone calls, a more efficient practice and happier patients. So, fire up the computer and make sure your website gets the PookieMD Website Seal of Approval!

• General design: leave out the fancy graphics, animation and clutter.
• Home page: include services provided, hours, location, phone/fax and a picture of the staff. Do not put hours on a different page!  Patients want to know when you are open, where you are located, what you treat, and how to book an appointment.  Also include what to do in case of emergency.
• Who We Are: yup, this is where you can proudly announce your medical school, residency, additional training etc.  Include pictures of the nurses, aides and office help.
• Insurance Page: list alphabetically the insurance plans you take.
• Contact Us Page: here is the place to list individual phone numbers/emails for staff and providers, billing office, refills, scheduling, referrals. If you allow patients to email providers, be sure you have clear guidelines for their use. (See previous post on “mouse calls.”)
• Forms Page: you will save your patients time if you have forms available for download as a pdf.  Include the patient information sheet, office policies, HIPAA forms, etc.
• Online appointment Page: this may be too big for the home page. Just for fun check out ReachMyDoctor. (No, I have no affiliation.)
• Directions Page: have a map on this page that is printable.
• Policies Page: this is where to put refill procedures, copay due at time of service, etc. Put your mission statement here, if you must. 

This is just the bare minimum. While poking around the web, I found some really great ideas which I will feature later. Send me your website url and we’ll post it for all to see and review!

PS: visit my website at www.extramd.com!

Just when you thought it couldn’t get worse, it just did.  I don’t know about you, but I went in to medicine to help people regain their health, and that vision  includes maintaining and increasing patients health and well being.  Unfortunately, Americans seem bent on eating, smoking and driving their way to chronic illness.  However, there is a movement afloat called “Health Coaching.”  What is a health coach?  Well, my intrepid reader, I went off to find out.

As far as I can tell, a health coach is someone, not necessarily a health professional, that will coach/mentor a client (not a patient) towards increased wellness.  Geez, I thought that was my job.  According to my research, Duke University offers some training in this and lists the following as an explanation of what a health coach does:

• Help people clarify their health goals, and implement and sustain behaviors, lifestyles, and attitudes that are conducive to optimal health.
• Guide people in their personal care and health-maintenance activities.
• Assist people in reducing the negative impact made on their lives by chronic conditions such as cardiovascular disease, cancer, and diabetes.

Hilarious.  Isn’t that the definition of what primary care is supposed to be about? But HOW on earth could you do that in 15 minutes?  Answer: You can’t.  And that is the crux of what is wrong with medicine.  We spent years learning about diseases process, pharmaceuticals, pathology and zebras, but we didn’t learn the basics of positive psychology, encouraging change and guiding patients towards optimal health.  Instead, this field will be taken over by ‘health coaches’ who have minimal training, little medical back ground, and no share in liability.

Here is what one be-a-health-coach website promotes:

1. …earn at least $121 per hour (with out having to leave your home).
2. how to find all the coaching clients you can handle.
3. How your life can take on new meaning as you begin making a HUGE difference in people’s lives and the Health Care industry in general.
4. …How you can immediately make money as a Professional Health Coach.

Now, I think we physicians SHOULD ALL BE HEALTH COACHES.  What I find so frustrating was that this is why I went in to medicine, and I can’t do it because I am constrained by the medical/legal/government/insurance bureaucracy that is today’s medicine.  Maybe I should forget that I am an MD, and focus on being a “Health Coach”.  I’d like to earn $121 per hour from home.  I think it would be invaluable to my patients to have me as a physician BE their health coach along with managing their medical problems.  Hmmm, do I smell “retainer 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!