Solo Practice Amidst A Huge Team

Whether you are in solo or group practice, you work as part of a large team.  You rely on yourself and your employees to get stuff done, but you also rely on other people who you may never have met to act on your behalf and that of your patients'.  When I schedule a surgery in the OR, for example a penile implant, at least 7 people are involved in the process, not including the patient.  If anyone of them fails to do their little-but-critical part, the process comes to a halt, or worse.

It is a wonder that the system ever works at all.

Here are some things that we do so that we can trace the course of an order through the multiple levels that have become our health care system.

• Save fax confirmations
• E-prescribe
• Take notes
  
• Send letters by certified mail
• Document, document, document
  

. . .and really we question everything and take it to the next level when something is not quite right. 

Modern medicine is a team endeavor whether you are solo or not.  Anything you can do to make it easier for someone else to do their job will ultimately make it easier for you and your patient.

Who else is listening?

Have you ever had the nagging feeling that your words are being recorded?

Recording a phone conversation in which you are not taking part, ie between 2 other people, is wiretapping. This is illegal without a court order. Recording your own conversation, even without the other conversant's consent, is legal and done frequently.

Sometimes, I get the feeling that I am being recorded. I don't mind when this happens, because I tell the truth in the presence or absence of any recording devices, but I do question the motives of the person who records me surreptitiously. Are they building a case against me?

Here are some tell-tale signs that you are being recorded by an amateur on the QT.

• They keep on asking you to repeat yourself.
• They really try to pin you down to a guarantee on success or a particular outcome.
• The caller seems preoccupied with some of the technical aspects of the call.
• The caller says they just want someone else to listen in, yet there is no one there.
• The caller tries to manipulate the conversation so that you say something they may want to hear.

Of course, an expert can record your conversation without you ever knowing or suspecting it. But most people are amateurs.

And also, most of the time any recordings will pnly go in your favor in the case of a civil action since it will support you in the typical he-said-she-said game.

Good luck.

Is it time for a contrarian approach?

I spent last week in Florida. One fine day on the beach, I witnessed an interesting natural event. Some beach goers began to toss bread into the air and immediately 30 to 40 seagulls flew over to get some food. It was a frenzy and the birds seemed to be fighting each other over food. It reminded me of life as a doctor in NY.

Then I saw something amazing.

One bird--and only one bird--stopped participating in the melee and instead flew in the opposite direction toward the sea. Once there, beyond the cresting waves, this bird hovered and then made several dives and pulled out a fish. While his competitors were fighting over crumbs and hand-outs, this contrarian bird went solo and came out ahead.

It got me thinking. Do I fly with the other birds and fight like mad for some scraps. Or do I go the other way, beyond the cresting waves, so I can feed in the blue waters of no competition.

It was a nice day on the beach!

To send to collections or not, that is the question.

The decision to send people to collections or to simply write off bad debt is a difficult one to make and should not be taken lightly.  You and your managers need to balance the difficult economic times that we all face with the business's own needs for cash flow.  In addition, sending people into collections is unpleasant and I think it just feels wrong.  As a human being, I can understand that difficult choices that many people face in deciding where to spend their hard earned yet meager wages.

Despite these challenging times, most people pay their bills conscientiously and feel ashamed at not
having the ability to do so.  Even people who can not pay the bill in full are eager to pay in installments, even if it is a small amount per month and others are happy to accept a settled amount and pay it on the spot.  Most people just don't like to "stiff" another person. 

However, there are others, a very few, who brazenly withhold
payment as if they can do it with impunity.  They answer their phones and simply refuse to pay or they say they'll call back some other time and then never do.  Others say that the check is in the mail when it is not.  A very few even write bad checks.

They are the deadbeats and
these type of people plague every business, even
medicine.

I recently, 2 years and 9 months into my own practice, have decided to outsource my deadbeat accounts to a collection agency.  This was prompted by several events:

• I have been seeing a patient I know to be a deadbeat around town, eating out in restaurants and having Starbucks coffee.
• I have had several people simply refuse to pay their co-insurance because I did not "do anything"--other than provide them with information and advice.
• I've had a few people become very belligerent to my staff as they tried to collect moneys.

In my practice, deadbeats owe me in excess of $10,000 dollars.  That is a lot of money.  I need that money to pay my staff and my vendors and my bills.  Though I only came to this decision after several years and some glaring examples of "how not to act when you owe money", I have finally come to grips with the notion that sometimes you just need to resort to a collection agency.

I just never thought I'd have to do so.

Dr S

A new blog.

I just started a new blog at WordPress on andrology. I want to see how long it takes me to get it noticed by the organic search engines.

Check it out: The Andrology Blog.

My New Years Business Resolution

Someone in the Enteprenwur Group ask the question about business plans for next year. Here is my answer.

• reviewed and revised my business plan for 09.
• upgraded to EMR-PM system
• Hired coding consultant
• Hired lab consultant
• Plan to expand lab test menu
• Improve marketing: email, direct mail, targeted mail, blogging, adwords, twitter
• Increase referral base
• Outsource collections for deadbeats
• Improve collections: check scan, cc's, EMR-PM, cash
• Answering phones 24/7
• Making it easy for new patients to book and be seen

Anything else that I'm missing?

Dr S

Disney's use of technology and what a doctor can learn from it.

I spent the past few days at Disney World and among other things, I was amazed at how they have improved their technology usage since my last visit, only 3 years ago. While I have no doubt these improvements did not come cheap, I also know they enable Disney to make money more easily and efficiently. Here are just a few that come to mind immediately.

• Smart room keys: your room key doubles as a charge card and park entrance pass
• Biometric scanning: upon entrance, adults have to scan their index fingers which get matched to the park pass and to the kid's entrance passes
• Photopasses: photographers line Main Street and Hollywood and Sunset taking pictures of guests. Image numbers are infrared scanned onto cards which can be usd by guests to purchase the pictures on line
• Ride-photography: at the end of roller coasters and flumes, guests are shown pictures of themselves during the "big drop" and the pictures can be purchased right there
• Remote card processors: all vendors, even the portable street ones, accept credit cards, room keys, or any sort of electronic form of commerce, as payment

So how can doctors learn from this. Technology that enables more efficient billing, verification, and documentation will help you save money and make money.

Good technology can well worth the cost of implementation.

Dr S.

The 5 Key Elements of Any Business Plan

Whether you plan to open a bagel shop or a solo medical practice or to attempt to advance your own career while an employee within an established group, you must develop a business plan.  Here are the key elements to a good business plan:

Revenue Sources
Operational Costs
Capital Requirements for Start-up
Critical Success Factors
Key Risk Factors



Think about each of these 5 elements and brainstorm as much about them as possible.  You'll find that with this disciplined approach, you'll avoid making some costly mistakes and maximize your chances for success in the venture.

If you don't understand or have the time to make a plan yourself, you can use a number of resources, such as The Entrepreneurial MD, et.al. 

Good luck,

The IU.

Size Does Matter: Go Small

Everyone wants a large office.  I think that is an ego thing.  For me, I'll take too small rather than too large anytime.  Larger offices, like larger houses, have costs that smaller spaces just don't have. 

• Rent--most of us pay per square foot.  Obviously, the more square footage, the more you pay.
• Cleaning--larger offices cost more to clean that smaller ones.
• Heat--see cleaning
• Cool--see cleaning and heat
• Wallpaper--see above
• Carpet--see above
• Clutter--more space = more clutter = decreased efficiency

The only exception to this rule is if the office does not have sufficient working space to maximize patient flow.

If in doubt, in my opinion, go smaller rather than larger.

Dr S

Going Solo? The Turnkey Medical Practice: 2.0 Style

I know I have written previously about how to start a practice from the embryo stage on up, but here it is again, parred down to its bare essentials:

1. Get or develop a detailed business plan that will serve as a blueprint.
2. Get a mentor or coach or other such trusted adviser.
   
3. Get credentialed with insurances, hospitals, et al.
4. Get professional liability insurance.
   
5. Get a phone number.
6. Get a web-presence.
7. Get office-space; sublease, lease, or purchase depending on your unique situation.
   
8. Get a good EMR-PM system.
9. Get a payroll service (also does statutory insurances for small businesses).
10. Get an employee.

That is the list. Easier said than done and each step has many and multiple sub-parts. Still, just 10 steps.

Good luck.

Dr S

A New Car--A Vas Reversal

I recently traded in my Honda Accord with 114,000 miles for a used, mint condition, 2005 Accord with 26,000 miles. What could have been a difficult and cumbersome transaction was smooth and pleasant because all parties involved assisted each other and were motivated to make it happen.

My experience int the car dealership got me thinking about the differences between exceptional medical practices and typical ones.

• In a typical practice, staff is harried and just wants to push you through the system with as little effort as possible.
• Exceptional practices provide assistance and encouragement with all aspects of the experience and go the "extra mile".
• The typical practice just wants patients with good insurance; i.e. insurance plans without much hassle factor.
• Exceptional practices want cash paying paying patients.
• The typical practice is not equipped, psychologically or operationally, to handle cash pay patients and the challenges that this type of patient brings to the business.
• The exceptional practice has developed the skills, techniques, and mechanisms that make it easier for patients to WANT to pay out of pocket.
• The typical practice adds little added value to the encounter.
• The exceptional practice does little things that add value for the patient, and in turn the patients--or their insurance carriers--are willing to pay extra for them.

Essentially, my experience a the dealership taught me that when all people involved are motivated to make the sale or provide the service, business gets done.

Kind of like when we see our vas reversal patients.

Dr S

December Goals

Thanksgiving is over and December is upon us.  December can be a slow month.  Do you have plans to turn it around?  Here are things you can try.

1. Send a mailing to all your existing patients, either as a holiday card or a flyer.
2. Make a newsletter and send that to your existing patients and referring docs.
3. Update your website.
4. Blog and then blog some more.
5. Review your online marketing campaigns.
6. Send "thank you baskets", etc, to your good referrers.
7. Invite your best referrers to dinner.
8. Send something useful to your referring docs, like an article or hyperlink.
9. Keep your phones on and manned.
10. Open extended hours.

Good luck and have a good December.

The IU.

Happy Thanksgiving!

From Portraits 11/27/08 1:02 PM

Selection Criteria for an EMR-PM Purchase

I suppose that these criteria--the ones that I used--are as good as any out there.

1. Listen over a 2 year period to see what others are using and what their experiences have been.
2. Check the KLAS reports.
3. Check the CCHIT lists
4. Check the state medical society lists.
5. Define your own needs.
   
6. Call the top 10 vendors and see who answers the phone.  If they don't even answer for a sales call or get back to you promptly, you can forget about customer service and support.
7. Set up appointments to demo the systems.
8. Get references.
9. Contact the references and ask what they don't like about the systems.
10. Pull the trigger and make the purchase or continue the search.

And then layout the big bucks!

Good luck.

How to Convert an EMR From A Cost into a Profit Center

Good EMRs are very expensive. I am about to upgrade my homegrown system into one of these very expensive yet equally powerful programs. In order to justify the expense, I've brainstormed some ways to convert the EMR from a cost center into a profit center. If I were to use the system in the following ways, I think I could actually increase my revenue in the coming years.

1. Increase contact with referring MDs and patient providers.
2. Use the system's data mining capabilities to augment marketing to specific patient groups.
3. Improve my practice's operational efficiency and then market that.
4. Automate time consuming and error prone processes and then free up staff time to market for me.
5. Use the software to more efficiently evaluate practice patterns and then transition into more profitable areas.

I'd love to hear from others about additional ways to make an EMR a profit center.



The IU

THE ANGRY JUROR

I had jury duty today. Essentially, it was easy and relaxing and a nice break from my otherwise very hectic schedule. If I was an employee of a big company or a school district or some public job, I'd have even loved to serve on a jury. However, in my case every day out of the office is lost income so I was a bit nervous at the possibility of having to serve on a 3 week trial. Knowing my luck, I'd be sequestered in some motel for 9 weeks.

Fortunately for me, I was excused relatively early in the process.

Every one seems to have advice about how to "get out" of jury duty. I was told everything from "tell the judge your a doctor" to "tell the judge your a racist." One guy seemed to have listened to some of this advice. Let me tell about him.

I first noticed him early in the day. He was in his mid-50's, gray haired, and he seemed very annoyed about having to serve in this way, on this day. For the entire 4 hours we were in the room, he was pacing and mumbling loudly. Apparently, he thought it was "bullshit" that we had to wait past noon only to be excused anyway. At 1:30PM, I overheard him telling some other men about his jury-dodging strategy. One or 2 hours later, I watched him try to pull it off.

And it was awesome!

About 100 of us prospective jurors were called into the court room at 2:30PM. This was a criminal case and present in the court were the judge, the prosecutor, the defense attorney and the accused. The judge thanked us for our time and then had us swear to be honest. Now here is where the angry juror's plan commenced.

"Your honor" he said with a very bold voice. "I do not swear to be honest." He was trembling imperceptibly, but I was so close to him I noticed it.

"Excuse me", the judge said. Then the judge added, "then we can have you affirm the oath." I guess "swearing" might somehow be religious while an affirmation is not and the judge was trying to assuage the man on these grounds.

"No" the angry man persisted "I will not be able to be honest." Then he added, to my utter amazement, "I just wanted to be honest with you, you honor."

My eyes were bulging out of my head: what gall! This guy was something else.

The judge seemed for a moment taken aback, but was not about to lose this argument. "Well then, sir, we just need you to sit with the court officer outside, and after these proceedings are finished, we will talk again. And then he added. "what is your name" and then the judge directed the stenographer to record it into the record.

The angry man was shaking, only now visibly. Seconds later, he as escorted out of the court room by an armed court officer.

10 minutes later, the judge excused about 50 of us for a variety of mundane reasons, no questions asked, and by 3:00PM I strolled past the angry man, who appeared to be in some kind of "jury-jail", and I received my certificate of appreciation and proof of service, and then I left the building.

I wonder what happened to this guy, the angry juror. Obviously he listened to some bad advice.

In any case, if you get called, don't sweat it. It is not painful. It is interesting. And it does make one feel good about our legal system.

And for Christ's sake, just take the oath.

The IU.

Pay Cuts, Again!

I am not happy either!

I just read this on KevinMD. I thought the cuts were tabled for 18 months. Wrong?

Physician reimbursement. Medicare is soon scheduled to cut physician payments in excess of 20 percent and cash-strapped states are slashing Medicaid reimbursements. At a time when the costs of running a practice are increasing, this blow would cripple many practices. Linking physician pay to patient outcomes, so-called pay for performance, is one often-discussed approach to mitigate the payment cuts. This has been controversial as the reward in payment is not commensurate with the costs of implementing the systems to measure performance.

Oh Oh!

In rough times, every little bit counts.

These are difficult economic times.  People are losing their jobs, their homes. . .everything.  For many others like me, "country club" dreams have vanished and mere survival has become the goal.  In times like this, times that I think are only going to get worse before they get better, every little bit counts.  As a solo physician, here are some things you can do to maximize your chances at surviving through the coming months.

1. Answer your phones 24/7.
2. Invest money or time in smart, cost effective marketing techniques.
3. Invest in technology that enables you and staff to work smarter and less.
4. Be in-network.  People just don't have the money now for out of network providers.
5. Focus on what you do best and refer out or outsource the rest.
6. Do CME, learn new things, and incorporate them into your practice.
7. Know your metrics inside and out.
8. Re-examine your long-range vision & refine your short term goals.
9. Back-word plan to achieve goals.
10. Keep staff happy and turnover low.

Good luck and let me know if you have any other suggestions.

The IU.

Some things I've been thinking about.

My mind has been full these days with lots of important decisions that must be made.

• I am in the final phase of a decision to go with a specific EMR vendor.
• I am combing through my P&L statement with a fine-toothed comb looking to cut any extraneous costs.
• I am looking at ways to partially outsource my phone systems during overflow periods.
• I am looking to hire a technical consultant to assist me with laboratory regulations and management.
• I am looking for more economical ways to spend marketing dollars.
• I am simultaneously shifting and tightening focus for my practice goals so that I can continue to thrive in a changing environment.

Exciting times, indeed.

The IU.

The Ultimate Low Cost Specialist Office

With costs rising for all of us physicians, cost containment has become more important than ever. I've been thinking about how to keep costs super-low without sacrificing services. I've brainstormed some solutions. Here they are:

• Sublease office space from another office.
• Share office personell. You can use someone else's front desk staff to check in your patients. Of course, you must provide this staff, which technically is not your own, with your own workstations with your own PM-EMR system and teach them how to enter data into the system accurately. And you probably ought to augment their salaries with your paychecks so that they work for you, rather than someone else, and are thus loyal to you. You can even share the other doctor's office manager and pay them, then make them oversee the front desk staff.
  
• Purchase a good EMR-PM system. You may wish to consider an ASP model--or internet based model. These have no upfront costs to you and are payed on a monthly basis. Plus, the vendor manages all the technical aspects of the technology, such as back-up, upgrades, and interfacing.
  
• Outsource your phones. Phone systems can get surprisingly expensive if one considers the cost of the systems themselves, the line-fees, maintenance, and the salaries + benefits of the people who answer the phones. Check out this site for an alternative approach to phone managememt.
  
• Outsource your billing & credentialing functions. Sure, there are pro's and con's to this approach, but with the right company and proper over site from you it could work. Alternatively, with some of the better EMR-PM systems, you can do your own billing.
  
• Use only automated laboratory equipment should you choose to provide some lab services in your office.
• Any imaging equipment, such as ultrasound units, and of course your workstations must be portable, lightweight, and networked to your central server.
• Outsource some marketing functions, like direct mail advertising or email advertising.
  
• Make your own basic website and do your own basic SEO.
• Outsource payrole services, pension fund management, accounting, and book keeping (make sure the book keeper is bonded).
  

With this approach, you can function quite well and grow significantly with only one employee, ie a medical assistant. Your costs can be half that of a tradiotional solo doctor's without much sacrifice. If planned correctly and executed well, this approach could work well for even a specialist.

If anyone has tried this approach, let me know.