Manage My Practice

It’s taken me a long time to realize that I’m part of a seriously small group that likes, or at least tolerates change well. People universally HATE change and will do most anything to avoid it. So what is a manager to do when charged with making change happen, or when leading your own change initiative?

Know the Change

Map out the change and do your best to understand every possible implication of the change. Have a trusted colleague or mentor review the map with you and see if you’ve neglected to consider any angle. For instance, if your plan is to offer Saturday clinic hours, make sure you’ve considered:

• A budget for the change – are all the stakeholders in agreement on the money that will be spent to make the change? Is this a pilot for a specific time period or will the Saturday hours be continued regardless of the patient volume?
• How will it be decided which staff will work Saturdays? Will working Saturdays be optional or mandatory? Will staff be allowed to earn overtime, or will they have to adjust their weekday schedule? Will there be a pay differential for Saturday hours? Will there be lots of staff wanting to work Saturdays or will there be no staff wanting to work Saturdays? Because they are so personal, staffing and payroll will always be the stickiest parts of making change happen, so assign them top priority!
• How will it be decided which physicians or mid-level providers will work on Saturdays? Have issues with pay, call, and time off been resolved?
• A marketing plan for the new Saturday hours. Letting people know that you will be open Saturdays is critical to the success of the plan.
• Will all services be offered on Saturdays, or will it be modeled after on an urgent care? If it is an urgent care model, will it be billed as an urgent care visit and will co-pays be collected for urgent care services? How will an urgent care model be communicated to patients so they are not surprised when there are different terms of service than they usually encounter?
• What, if any, changes will need to be made to forms, the computer system, HVAC, security, janitorial, lights, payroll system, etc. What workflows might need to be changed because the practice is not used to operating on Saturdays? Role play a patient coming for a Saturday appointment and map out all the possibilities.

Frame the Change Message

Let everyone know why the change is being considered/happening. Craft the change message into something repeatable. Everyone must understand the reason and must be able to attach the reason to a change message. It could be “We’re growing!” or “More service for our patients” or “We will thrive.” Whatever one or two messages you choose, repeat them in your Rule of Seven (see below) and throughout your change process. Explain that the change is coming because:

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Click here to go to Medsider to hear Scott Nelson interviewing me on ways sales reps can help physicians in new ways. When I consult with companies who want to understand new ways to work with medical practices, I advise them to consider more carefully the role the staff play in making practice services happen. It may be the physician’s name on the referral, but it’s probably the referral clerk who is pulling all the strings!

There is no one, and I do mean no one, in your medical practice who does not need to know the basics of coding. Here is why:

• Providing services to patients is the business of healthcare. Every person who relies on healthcare for their living should understand something about the business they are in. This should not outweigh the fact that we are privileged to care for patients, but as the saying goes “No money, no mission.”

• It takes a team to produce care. The silos of front desk, billing, nursing and scheduling must come together to share their knowledge and produce a high-quality, reimbursable patient visit. Here are the roles each member of the team plays:
  • The patient calls for an appointment and the scheduler matches the patients problem to an appropriate appointment type. The scheduler finds out if the patient is new or established and what the patient’s appointment is for.
  • The patient arrives for the appointment and the front desk assures that all current demographic and insurance information is collected.
  • The nurse rooms the patient, taking vitals, reviewing medications and reviewing the reason for the visit – the chief complaint.
  • The physician or mid-level provider cares for the patient, documenting the visit and choosing the appropriate service and diagnosis codes.
  • The patient completes the visit by paying any deductibles or co-insurance due and making any future appointments needed. The checkout staff enters the payments and/or charges if the service codes have not already been posted via the EMR.
  • The biller scrubs the claim, checking for any errors and electronically submits the claim to the payer. The hope is that the claim is clean and will be accepted and paid immediately (within 30 days.)

When staff understands how important their contribution is to the financial viability of the practice and how all the pieces fit together, they are more incentivized to perform.

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I had a great time recently when Joe Hage of Medical MarCom interviewed me during a Twitter Chat. The topic was how medical device reps could help specialty physicians market to primary care physicians. You can read the interview here at Joe’s blog.

So, what is a Twitter Chat? It’s a one-hour event that gathers together Twitter users with a specific interest to share a discussion 140 characters at a time.

Twitter chats are organized by hashtags, and in this case, the discussion was marked by the hashtag #MedDevice. #MedDevice is facilitated by Joe Hage (@MedicalMarCom is Joe’s Twitter name) who is the founder and CEO of a medical devices marketing consulting firm specializing in marketing communications, marketing strategy, lead generation, web development, and social media.

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Based on a great conversation I had on LinkedIn recently, I decided to write about physician productivity models and the hybrid model (encounters and work RVUs) I developed for a hospital-sponsored family practice program. This bonus model rewards providers seeing less patients with more acute needs as well as providers seeing more patients with less acute needs.

Here are the components of this model:

1. SCHEDULE: The providers are available (have an open schedule) four 8-hour days per week, or 32 face-to-face patient hours per week. Providers are expected to work four 10-hour days, with the additional 2 hours per day used for reviewing records, approving prescriptions, etc. This was pre-EMR for this group.
2. ENCOUNTERS: The providers have an agreed-upon schedule which averages 22 patients per 8-hour day. (In this model, new patient visits are 40 minutes and established patient visits are 20 minutes.) Subtracting the providers time off, the schedule works out to 3828 patients per year, or 957 patients per quarter. For every patient they see over 957 patients per quarter, they receive $10 per patient. The providers receive encounter credits for nursing home and indigent care clinic work during office hours.
3. WORK RVUs: Based on the encounters, work RVUs are calculated at 4073 per year, or 1018.25 per quarter. Every work RVU over 1018.25 per quarter receives a bonus of $10.
4. EXCLUSIONS: The providers did not get credit for anything they did not do personally – no credit for ear lavage, vaccines, allergy shots or laboratory tests. They did not get credit for any no charge visit, either as an encounter or as a work RVU.
5. VALIDATION: Both encounters and wRVUs were also matched up to physician productivity surveys to make sure the base salary was comparable to the base productivity.
6. EXAMPLE: A provider seeing the 23rd patient of the day – perhaps a 99214 (work RVU 1.50) will get $10 for the encounter and $15.00 for the wRVU for a total of $25.00. By seeing an additional 99214 every day during the quarter, the bonus would be $1600 for the quarter. Because the appointment times were generous, there was a high probability that additional patients could be worked in daily, allowing the providers to see more than 22 patients per day without killing themselves.

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Last week I had the pleasure of speaking with 50 employees of Intuit Health (live in Cary, NC and virtually in Menlo Park, CA) on the workflow of the medical practice and what makes medical practices unique from a marketing prospective.

Why is healthcare so very different from other markets and so often frustrating for medical salespeople?

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I’ve been working with physicians for the past eight years on career diversification, satisfaction and mitigation of stress and burnout and can relate some common themes on why physicians are angry.

Unrealistic expectations

Many doctors enter medical school with an idealistic idea about what being a doctor entails. Television shows like Marcus Welby, M.D. and ER dramatize a doctor’s life. Picture this: You are a smart individual who likes science and wants to learn more about how the human body works. Throw in a desire to help people improve their lives. Put all those ideas together and the profession of medicine may seem like a good fit. Add the additional perceived perks of job security, a high salary, professional and personal respect and medicine seems to be the perfect career. I remember riding up the elevator with one of my mentors, a trauma surgeon at the UTSA Health Center in San Antonio. He had all the elements I just described and was the picture of confidence and charisma. I wanted to be just like him. It was the logical deduction of a 21-year old college student that by becoming a doctor, I would be. Over the years, as I came to the realization that my deductions might be false, it made me angry.

Lack of business training

Healthcare reform and federal government indecision on physician payment and the SGR formula have issued in an era of uncertainty for the future of the medical profession. When most of us enter medical school, we don’t understand how heavily the external landscape will directly impact provision of patient care and our salaries. In order to get accepted to medical school and then make it through medical school, we don’t get the training in how to understand, approach and navigate the external business environment. Then, we are thrown into it and expected to survive, thrive and smile. This lack of understanding and then control over external circumstances made me (and makes others) angry.

Culture of medicine

Most specialties take their residents through a training process that is akin to the hazing process one undergoes to join a sorority or a fraternity. Certain specialties are worse than others. Sometimes it’s not the specialty but a particularly malignant residency program. All of us spend many years having our self-confidence squashed over and over again. Remember, we aren’t taught the coping mechanisms of conflict management or the business skills to negotiate and navigate our situations. All this can lead to low self-esteem and breed self defense mechanisms. Some of these self defense mechanisms can be perceived as displays of anger and some of them are actual displays of anger. Hitting walls in frustration or yelling at traffic so hard your throat aches (like I did) are definite displays of anger.

External forces and stresses

Acute and chronic stresses, inseparable in the life of a doctor by the nature of the profession, can be factors driving anger. Some of the external stresses include:

• family and friends who don’t understand the mental exhaustion that can result from daily pressures of patient demands and making sure a patient is diagnosed correctly and well taken care of;
• perceptions that doctors make millions of dollars (many doctors have trouble making payroll for their office staff each month);
• lack of respect for our time and decision making ability by the people we want to help;
• external healthcare environment entities (insurance companies, the government, etc.) without our training making medical decisions for us and then refusing to pay us for our expertise and the medical decision making skills we gave up years to attain; and
• expectations of perfection by everyone around us.

Many people forget that medicine is an art and diagnosing an individual isn’t like following a recipe for making cookies. Others want a prescription for the medicine they saw on television; still others expect to respond to treatment right away and express frustration when it doesn’t happen that way.

All of these things made me, and have been know to make other doctors, angry.

That being said, please don’t just assume all doctors are angry. There is an increasing tendency to classify all doctors as angry or unhappy. This can lead to perceptions and expectations about a doctor’s behavior that aren’t always true. Doctors, particularly ones in high stress specialties like OB-GYN, surgery and critical care, are required to make critical decisions in a critical time frame. There might not be time to say please, or thank you, or how are your kids doing, when orders need to be given and followed in order to save someone’s life.

And who isn’t angry about healthcare today? Who isn’t frustrated with the pace of change and the pressure to please the affiliates, the accreditors, the payers, the bank, and the patients?

Solution?

Is there a solution?

Some find the solution is leaving medicine, some find it is concierge medicine, some find it is becoming an employee instead an employer.

Approaching things as an opportunity and in a positive manner can make a tremendous difference in the outcome. There are basic steps you can take but the most important thing to remember is that each physician is unique and each situation is unique. There isn’t one black and white reason why a physician is angry or seems angry, nor is there one answer for every angry physician.

In this time of enormous healthcare upheaval and health reform policy decisions, there is an opportunity to create a vehicle, either for yourself or for your practice, that improves collaboration and communication. It’s possibly a time to set everyone up for future success in a soon-to-be-fully-defined accountable care organization (ACO) or medical home model. It’s a time for organizations and physicians to increase their commitment to supporting each other and building an environment that sees and treats doctors as a precious resource.

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DR. MUDGE-RILEY works with doctors and health systems as a business development and compliance consultant. She was recently called the Doctor’s Doctor in a 2010 book because she works to help physicians reduce or avoid burnout, optimize revenue and successful diversify their skill set. Dr. Mudge-Riley received her medical degree from Des Moines University Osteopathic Medical School and her Masters Degree in Health Administration from Virginia Commonwealth University. She completed a medical internship at Virginia Commonwealth University Hospital System (VCUHS) and a business residency under the CEO of the same hospital system. She has been directly responsible for planning, implementation, communication, and evaluation of programs involving healthcare wellness, change management, safety, and quality within a variety of industries. She has experience as a broker consultant within the health care industry and still advises employer groups on wellness and change management as a Senior Consultant at McCarthy Actuarial Consulting Firm. She can be contacted here.

Publications For Your Medicare Beneficiaries
New! The Medicare Learning Network (MLN) has released a new product titled Publications For Your Medicare Beneficiaries. This factsheet lists a variety of beneficiary-related publications available to assist providers in responding to patients questions related to Medicare, all of which can be printed and provided to patients. This product is available in downloadable format here. Check it out – links to more than 70 different publications!

The 2007 Physician Quality Reporting Initiative
New! Anew Medicare Learning Network publication titled The 2007 Physician Quality Reporting Initiative (PQRI) (November 2010) is now available in downloadable format here. This booklet is a compilation of CMSs various educational resources relevant to the 2007 Physician Quality Reporting Initiative.

Guidelines for Teaching Physicians, Interns, and Residents
The Guidelines for Teaching Physicians, Interns, and Residents (revised December 2010) is now available in downloadable format here. This factsheet provides information about payment for physician services in teaching settings, general documentation guidelines, and evaluation and management documentation guidelines.

HIPAA EDI Standards Web-Based Training
The Medicare Learning Network is now offering therevised HIPAA EDI Standards web-based training (revised January 2011) for CE credit. The goal of this activity is to provide information to physicians, suppliers, and healthcare professionals regarding electronic billing and other healthcare electronic transactions such as the Administrative Simplification provisions of HIPAA, electronic transaction standards and code sets required by HIPAA, and an overview of the steps involved in the Medicare electronic data interchange process. To take this training, go here and click on Web-Based Training Modules under Related Links Inside CMS. There are 15 other web-based training classes available on the same site.

Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers and Billers
The publication titled Understanding the Remittance Advice: A Guide forMedicare Providers, Physicians, Suppliers and Billers (revised October 2010) is designed to educate institutional and professional providers who bill Medicare with general remittance advice (RA) information. It includes instructions to help you interpret the RA received from Medicare and reconcile it against submitted claims and provides guidance on how to read Electronic Remittance Advices (ERAs) and Standard Paper Remittance Advices (SPRs), as well as information on balancing an RA. This publication may be downloaded here. If you are training an employee to be a biller or post payments, or if you want to understand more about your billing yourself, this is an excellent resource.

Evaluation and Management Services Guide
The publicationtitled Evaluation and Management Services Guide(revisedDecember 2010) is now available in downloadable format from the Medicare Learning Network here. This guideis designed to provide education on medical record documentation and evaluation and management billing and coding considerations. The 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services are included in this publication. This is another great resource that you can use to train staff, physicians, and other providers, or to get up to speed yourself if E & M codes are not part of your education or experience.

Image Credits:

Dancing Seniors: Image by StevenM_61 via Flickr

Money Rainbow: Image by TW Collins via Flickr

Patients want to know why they can’t get a return call from their doctor’s office – here are six reasons why the calls have increased and physician offices are having trouble meeting the needs of their patients.

1. Medication questions and requests for a prescriptions change. The average number of retail prescriptions per capita increased from 10.1 in 1999 to 12.6 in 2009. (Kaiser Family Foundation calculations using data from IMS Health, http://www.imshealth.com.) Because it is not easy to access prescription cost by payer in the exam room, medical practices get lots of callbacks from patients asking to change their prescriptions once they arrive at the pharmacy and find out how much the prescription costs. Related issue: Many national-chain pharmacies have electronic systems that automatically request a new prescription when the patient is out of refills. Also related: Patients calling to ask for additional medication samples.
2. Patients are delaying coming to the physician’s office by calling the practice with questions. Patients want to forestall paying their co-pay or their high-deductible by getting their care questions answered without coming to the doctor’s office.
3. Patients call back with questions about what they heard or didn’t hear in the exam room. They may not remember what the physician told them, they may not have understood the medical jargon, or they may have a hearing problem and were not comfortable asking the physician to repeat something.
4. Impatience: we live in an instant gratification world and patient expectations are not aligned with what physician offices can realistically provide.
5. Some patients will not leave voice mail messages and will call back multiple times until they get a live human being or will punch in options until they find someone to answer the phone.
6. Physician offices are often understaffed. Physicians find it untenable to add more staff to do more tasks for less money or no money at all.

And here are some possible solutions:

1. Have formularies for all major health plans on hand in the exam room. These could be paper lists, or electronic lists for the tablet or smartphone. (Note: Epocrates currently has a deal with Walgreen’s to support their discount program on the smartphone.) Don’t underestimate the patient satisfaction and reduction in callbacks for sending the patient out of the exam room with the right prescription. Automatic refills are not an appropriate function of pharmacies. Physicians should provide samples (check the formulary!) and a prescription to get filled if the samples do the job. If a patient can’t afford the brand name prescription, a prescription assistance program is the next step.
2. Patients need to be advised appropriately when they need to see the physician and when they don’t. Good triage nurses can be worth their weight in gold, but you can hold the costs down by hiring a triage nurse or several to work from their homes taking calls from your patients. The nurse will need to have access to your practice management system to schedule appointments and to document the conversation if the patient is given advice.
3. Provide patients with different modes of assimilating health information. Some patients are recording office visits via voice or video and one of the goals of meaningful use is providing patients with an office visit summary when they exit the practice. Websites should be loaded with educational information that physicians can “prescribe” to their patients. Some physicians help to cut down on return calls and improve understanding by asking the patient how they’ll describe the visit to a family member.
4. Give patients (on the web, in the practice, on your on-hold messages) realistic timelines for callbacks and make it so.
5. Yes, some patients will game the system to get their needs met ahead of others. Ask them to adhere to the practice guidelines. There will always be some cheaters, but most patients will respect you if you respond to them when you said you would.
6. The only answer to understaffing is technology. Use a patient portal to allow patients to request refills, schedule appointments and chat with billing staff or nurses. Replace paper charts with EMR. Use efaxing to eliminate paper faxes. Use the cloud to store information and collaborate.

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