Manage My Practice

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Ownership

Private practices are organized in a corporate model where the physicians are shareholders, or where one or more physicians own the practice and employ other physicians or providers. Private practices are almost exclusively for-profit. Physician practices are organized into corporations for the tax benefits as well as protecting the owners from liability judgments.

Hospitals can be for-profit, not-for-profit or government-owned. For-profit hospitals make up less than 20% of the total hospitals in the United States.

Financial Models

Private practice owners take a salary draw, split any receipts after all expenses are paid, and generally distribute receipts monthly or quarterly. This leaves very little at year end to be taxed through the corporation.

Hospitals that employ physicians typically guarantee a salary and offer an incentive plan where the physicians earn more for seeing more patients and/or being more productive based on work Relative Value Units (wRVUs). Hospitals may or may not use a practice expense and revenue model to measure the margin.

Benefits of Managing a Private Practice

1. You get to do everything, so if you like or want to learn about HR, marketing, finance, IT, contract negotiation, revenue cycle management, facility management, and lots of other stuff, you’ll get to do it in a private practice.
2. You are the top position in the practice, so you get to put your imprint on the practice. You can often be more creative.
3. Physicians can be very laid-back and practices can maintain a more relaxed, family-like atmosphere.
4. Decision-making can be straightforward and swift, so you can help your practice to be nimble in response to news events, trends and new ideas. If your practice decides to become a concierge practice or stop or start taking a particular payer, so be it!
5. You may find it easier to get a foot in the door and start your management career in a private practice as physicians don’t always hire managers using traditional means. A recommendation from another manager, a consultant or a physician may be enough to get you started.

Drawbacks of Managing a Private Practice

1. You report to the physicians who may not have business expertise and may fight you on your well-founded recommendations.
2. There is no internal career path – you’re at the top in the practice.
3. Physicians will make less money every time a new non-revenue generating position is added or any time equipment needs to be replaced – expect them to be generally slow to respond to capital expenditure needs, especially if they cannot see that any new revenue will come from the expense.
4. When physicians “eat what they kill”, taking home the dollars they personally earn less their expenses, they can be pitted against each other and have conflicting priorities.
5. Your practice could be purchased by a hospital and you could find yourself out of a job, or your job radically changed.

Benefits of Managing a Hospital-Owned Practice

1. You report to a management professional who should understand the business and be supportive of your well-founded recommendations.
2. You will receive support from other hospital departments: the Human Resources department will screen, orient and provide benefit support to your staff; the Information Systems department will provide and maintain your practice management system, EMR system and other hardware and software; and the Accounting department will pay the bills and write the payroll.
3. You may be able to climb the career ladder and manage multiple practices, or become the Vice President of Physician Practices, or the COO, CFO or CEO of the hospital.
4. You will get to interact with managers of other departments and broaden your hospital knowledge and understanding of the care continuum.
5. You can learn a lot from the process of preparing for and living through a JCAHO (a.k.a. “The Joint Commission”) visit.

Drawbacks of Managing a Hospital-Owned Practice

1. Hospitals use different terminology for charges, adjustments and receipts and work on the accrual system instead of the cash system, which most private practices use. It takes time to understand and distinguishes the terminology and process differences.
2. The entire system will be in a tizzy on a regular basis getting ready for a JCAHO (a.k.a. “The Joint Commission”) visit.
3. You can expect to have much less autonomy in a hospital system and there may be more red tape involved in getting even simple requests filled.
4. Hospital administration may find it difficult to relate to the perspective of the hourly staff and it could be frustrating to balance the needs of the staff and the needs of the organization.
5. Because the hospital is the big-dollar earner, the needs of the clinics may be second, third or fourth down the line in importance.

What do you see as the benefits or drawbacks of your private practice or hospital practice job?

Many practices and providers take their patient schedule for granted. They overlook the opportunity to improve both productivity and effectiveness by managing their schedule. Here are ten tips for office managers to make sure that the patient schedule works for you and for your practice.

1. Evaluate the schedule template with the providers and nurse manager quarterly.

By using actual issues from the previous period, discuss what has worked and what has not. Have providers share their concerns and

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discuss their recommendations for change. Nursing often has many ideas to improve the flow of patients through the practice and is a valuable source of information. Keep track of changes made and evaluate their effectiveness at the following meeting.

2. Standardize visits types.

There are many reasons an individual provider likes their own schedule. As managers, we know that this makes it very difficult for the front desk staff to do their jobs. Standardization reduces the potential for errors and disruption that proprietary schedules may cause. Your role in the discussion with providers will be that of facilitator, staff advocate, and coach.

Bring forward options for standardized visit types. Many practices use a block template based on 10, 15 or 20-minute blocks of time. The number of blocks used per visit type are agreed to and used to fill the schedule. There may be additional restrictions placed on the schedule such as no more than one new patient per half-day session. Minimize the number of restrictions or ideally eliminate them to assure your days are as flexible as possible to meet your patient needs. You may also want to consider open access scheduling. Moving to this system often takes time and effort to eliminate the backlog of booked patients but once fully in place can be very successful.

3. Track scheduling errors and issues perceived to be scheduling errors monthly.

Errors in scheduling cause patient dissatisfaction, back up your waiting room, and lead to stress and possibly short tempers. Ask providers and staff to tell you when they think patients are scheduled incorrectly. Track this over time to determine if changes in the system are needed, how visit type use can be improved, and what training may be needed.

4. Know where scheduling bottlenecks are.

What is your average wait time in the office per provider? Do a time study on each provider and measure how long it actually takes for a patient to get through an office visit. Note the time they arrive for check in and registration functions, their time in the waiting room, when the nurse completes check in functions in the exam room, when the provider enters the exam room, when the provider leaves the exam room and when the patient exits the office. Overlay this on your schedule. The information you gather will help you identify bottlenecks and provide meaningful data to share with your providers when recommending a change in the schedule template.

5. Know how much a visit is worth in revenue.

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Adding one visit per day by addressing schedule gaps, clinical start times, no-show appointments or changing the length of visits will increase your revenue. If your provider works four days per week and 48 weeks per year at an average visit reimbursement of $75, one additional visit per day will add $14,400 in annual revenue to the bottom line!

6. Train your scheduling staff and update the training regularly.

Training a new staff member often brings up questions the entire staff can benefit from. Be sure to keep track of questions and include answers in future written training materials as well as in staff meeting discussions. Develop a training checklist for scheduling staff and have both the trainer and new employee initial when each area is mastered. This checklist can also be used for annual performance reviews. For current staff, take a look at their computer terminals and see what sticky notes are posted there, indicating areas that need special consideration or additional training.

7. Have the schedule be a frequent agenda item for staff meetings.

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Get the staff perspective on what is working and what is not on a regular basis. You may find that nursing can provide a great deal of information on how the schedule impacts patient flow from their perspective. Take time for staff to discuss what if scenarios and how they would handle a particularly difficult situation. The goal is to have a schedule that staff understands, is user friendly and is consistently used.

8. Have a policy on the number of providers out at one time for vacation or holidays and follow it.

Everyone deserves time off but having many providers out at once can lead to a very hectic week for those remaining. Plan as much in advance as possible for time away. If you do end up with a number of providers out at once, remember that the person remaining will also be responsible for reviewing lab and radiology results for their colleagues as well as answering questions regarding patients that they may not know. Allow extra time in the schedule for this.

9. Know what changes in demand to expect during the year and plan for it.

Do you have more requests for acute visits in January, camp physicals in April, or school sports physicals in August? Minimize last minute adjustments to your schedule by knowing any seasonal trends in scheduling. Take a look at the schedules from past years to predict when you need more or less acute slots and adjust your schedule template for this. Manage the time youve allotted by marketing efforts in the office and local papers reminding your patients to schedule in advance.

You may also want to consider adding additional clinical hours during this time to make sure you can meet demand. Consider asking part time providers for extra hours per week or using per diem staff.

10. Deal with your patient no-shows.

Consider writing a policy on no-shows if you do not have one. If you have one, follow it. Make sure that your policy follows any state regulations to avoid patient abandonment claims.

Educate your patients. Develop a set of professional communications about your visit cancellation and no-show policy that begin with your welcome to the practice letter. Post a notice of your policy in your waiting room. Send letters following each no-show and then the termination letter stating the reason for the termination and that the patient is still responsible for their account balance. Be the contact person on the letter so that if the patient calls with questions, they speak with you rather than take up provider time or that of your staff.

If you have a patient that consistently no-shows but the providers do not want to terminate them from the practice, determine what other help you can provide to get the patient to the visit on time. Consider additional reminder calls, assistance with other services such as transportation, or offering the ability to come in and wait without a scheduled time. Though this may take more staff time, the revenue from the appointment should make it worth your while.

Donna Izor, MS, FACMPE is founder of West Pinnacle Consulting, LLC. Her 20 years of experience as a medical practice executive lends her special expertise in the areas of primary care and specialty practices, employed inpatient physicians, regulatory oversight, facility design, physician compensation and relations, and new program development. She has worked with academic, community hospital, and private practices. You can contact Donna at donna.izor@gmail.com.

A loved one was recently hospitalized for surgery in a nearby town. During the experience there were several moments when I had to decide whether or not I would say something to nurses about hand washing and cleanliness. To my great surprise, I was too intimidated to say anything! The one time I did speak up went something like this:

Hey, is that nurse filling my loved ones water pitcher?
Shes trying to make the water not too cold or hot, thats good.
Oh, no, she is letting the water run over her hands and into the pitcher! Should I say something?
Shes probably going to dump out that water and fill it up with water her hands havent been in.
Nope, shes turning off the water. Do I say something?
Me: Hey, that water ran over your hands!
Nurse: Dont worry, I wash my hands all the time.
Me: No, I dont think we should take that chance.
Nurse: Im really hurt that you would think Id do something like that.

This was a personal seminal moment. I could not believe that after working with physicians and nurses in healthcare for 25 years that I would be intimidated about saying something about cleanliness. I was worried about the potential impact that my questioning would have on the care of my loved one. That made me hesitate about saying something until a situation came up where I could not keep quiet. I could not suppress my concern based on the possible impact to my loved one.

What about the nurses reaction? It was defensive, and she was telling me in essence I cant believe youd question my decision-making. In discussing the situation later with my husband (not the patient), he assured me that I had done the right thing. He asked me if I saw the waiter in a restaurant washing his hands at my table, would I then let him dip his hands in my soup?

This hospital experience was 99% wonderful. I thought the hospital paid excellent attention to the needs of the patient and the family. I thought it was clean, the caregivers were very good, and I would recommend the hospital. But the wall is still up about questioning at this hospital and probably every hospital across the US. It is a hard call to tell the professionals that they are doing something wrong. A cleanliness episode can happen so fast that you dont have time to debate yourself about saying something.

How can we make it okay to question caregivers for the benefit of the patient?

Recent news stories about manager embezzlement give us all a black eye. What can managers do to limit their liability, and how can physicians protect the practice without managing the day-to-day operations themselves?

Here are nine suggestions:

1. Perform a thorough background check before hiring a manager, and have your manager bonded.
2. Have your bank statements sent to the physician’s home address and/or make sure the physician has the master access to the bank accounts online. Physicians, have a personal relationship with your practice banker and make time for a short meeting with them quarterly.
3. Have the physician sign your practice checks. Each check should be attached to an invoice that lists the goods or service purchased. Do not order a rubber stamp of the doctor’s signature.
4. Insist on a duplicate, numbered receipt book for staff to give receipts to patients for all over the counter payments.
5. Have your insurance and patient checks sent to a lockbox.
6. Make sure the manager takes time off at least several weeks a year. Managers who are too busy or cant ever get away are a red flag. The physician should review all mail during the managers vacation.
7. Check the monthly credit card statement carefully before making the payment. Keep the card restricted to a relatively low limit to manage your liability. Do not pay practice bills routinely on the card to build frequent flyer miles as this makes it much easier for an employee to hide non-approved expenditures.
8. Have a budget and make sure variances can be explained.
9. Hire a CPA to review the books quarterly. Even if you do not need the services of a CPA for your statement reconciliation, taxes or partners distribution, hire one to review the expenses and receipts, and ensure that the retirement plan is being funded appropriately.

A qualified, ethical manager has nothing to hide and will thank you for following these nine rules. The rules protect the manager as well as the practice.

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Generally, doctors either think it’s okay to be late (and usually are) OR they don’t think it’s okay to be late and only are in rare cases. That’s who they are as people, just like us, and it’s rare to be able to change them.

What I usually find is that certain patients are okay with doctors who are late, and will wait as long as it takes to see that doctor. Others will not wait, and therefore, will not return. I would let new patients know that the doctor takes his time with patients and that he often runs late and see if they can live with that. If that can’t, then they should be scheduled with another doctor or seek care elsewhere. If the doctor has a problem with that, he needs to know that a good practice manages patients’ expectations and that patients deserve to know that he typically does not run on time, and not have a surprise when they come to the practice.

One thing that is helpful is a very skilled nurse or assistant who keeps the doc on track so that he doesn’t run any later than necessary if he gets easily distracted.

I have seen some practices give patients beepers to page them when the doctor is ready so they don’t have to sit in the waiting room (especially with a sick child) any longer than necessary. You could also tell patients that someone will call them 20 minutes before their appointment – it’s hard to have someone keep track of this and do all the calling – but it might be worth it if it keeps the patients and the doctor happy.

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