Thursday, March 27, 2008

The Value of a Slow Day

While busy is great, an occasional slow is ok too; as long as it is only every so often. Here's what to do on a slow day so that you can stay productive and proactive.

1: Do your bills—always important

2: Refine your processes—take the slow day to think about your inefficiencies, mistakes, and successes over the past few weeks and then refine your processes for the better. For example, you may find that patient flow improves simply by eliminating one form or another or use the time to record some new macros or templates

3: Pick-up a book—not Tom Clancy (who I love), but a business school book and use it to learn about marketing, business development, business strategy etc

4: Do some CME—perfect way to turn 2-3 slow hours into CME credits

5: Check your back-ups—use the time to make sure your back-ups are running as planned

6: Perform QA—run a random chart audit, check to may sure your insurance policies are in-force, make sure your reagents aren't expired, etc

7: Review your P&L statement—use the time to find areas in which to cut costs

8: Call your post-ops—where good doctoring and good business intersect

9: Market—an on-going process

10: Blog—of course


The IU

Wednesday, March 19, 2008

Now I've seen it all!

A hair salon for dolls. This is at the American Girl Doll Store in NYC. Upstairs, on the 3rd floor is "the hospital" where broken dolls can be fixed. And no, they don't take inurance.
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How to compete with the big boys

Just because you are new to the community does not mean you can't survive, even thrive. As a new entrant into the market place, you may have several advantages over the established practices.

1: Flexibility—you can be flexible, adaptive, and change-ready. These are important characteristics to possess in the face of shifting reimbursements schemes, regulations, and managed care rules on top of major advances in communications and health information technologies.

2: Cream-skimming—also known as cherry picking, this allows you to actively pursue more profitable diagnoses and treatments since you are not bogged down with a sicker, more labor-intensive, and—unfairly—less profitable patient base.

3: Tech-saavy—you'll have access to low cost, yet powerful technology that is designed for smaller operations. This technology will enable you to be efficient, more cheaply.

4: Alternative delivery methods—you'll be able to find new, creative ways to see patients and deliver care and also develop alternatives ways to get new patients. Just ask Jay Parkinson MD. IM, Video Chat, text messaging, e-mail, web-site; all this will allow you to capture a sizable segment of the patient base that other established groups are not reaching.

5: Patient preference—as a solo person or a small group, you'll find that patients will be choosing you preferentially over the faceless, big name group. Who'd you chose?: Suffolk Urology, North Suffolk Urology, Central Suffolk Urology, Western Suffolk Urology, or Richard A Schoor MD PC-Urologist.

6: Regulatory changes—No question that in this regard, the advantage tends to go to the new entrant. Inertia that is always present in established practices will make operational change slow in the face of mandates such as P4P-PQRI, HIPAA, etc. In addition, large groups will respond more slowly to changes in payer mix and ironically, can be less adept and handling cash paying patients.

On the balance, as a new entrant, immature, and upstart practice, you're not as disadvantaged as you may feel you are.


The IU.

Friday, March 14, 2008

Customer Service, Customer Service, Customer Service

I don't care what type of business you have, if you deal with people then customer service is important. This is what I like to see in a variety of businesses:

--Pizza place: have reading material for me, since I often eat lunch alone.

--Doctor's office: see me reasonably on time, be reachable & competent

--Contractors (all types): be honest, come in on budget, complete the job satisfactorily, and clean up after yourself

--Accountants: give me honest advice, be reachable

--Lawyer: see accountant

See, I don't expect much.

Monday, March 10, 2008

So much for NY Tort Reform

Our advocate has done what? See link.

Barriers to entry? Few.

Though the costs associated with starting and operating a medical practice have escalated rapidly over the years, in many ways the times and present environment have actually made it easier to start-up on your own. Why is this? The answer is that there are now fewer barriers to entrance into the market place.

Any industry has businesses that have been first to market, even Google within the search engine industry. Remember Netscape? In any marketplace, the established businesses will resist the newer ones from entering and competing. Medicine is no different. Since there is no longer a frontier, the possibility of being first in a community is essentially zero. Fortunately, in today's market, this is no longer as important as it once was. While far from being easy, a solo urologist or ENT or PMD can open a new office in an established, mature community and still survive and even thrive.

Patients come to doctors today by 4 ways: referrals from other providers, word of mouth referrals, insurance rosters, and external marketing efforts, such as advertising, yellowbook, etc. In the past, professional referrals were critical to a specialist's survival. Referring doctors had all the power and could make or break a new doctor. This is no longer the case. Insurance companies, whether intentionally or not, have made this happen.

Here is how it works today. Many patients may feel, for example, that if they need to see an ENT specialist, and they can turn to their insurance company list first. Even those who do turn to their primary initially will then turn to the insurance list. It is the rare patient that will go with a professional recommendation without first verifying that the specialist is "in-network." In addition, patients feel that the insurance company has done the ground work in verifying the doctor's credentials and that if he is "on the list" he must be OK. And for the most part this is true.

What this means is that essentially, a new entrant into the marketplace can have the same standing in the eyes of patients as an established doctor or group simply by being on the same insurance panel. The implications of this for the medical market place are nothing short of incredible—in both the good and bad sense of the word.

To a new doctor in a community, it means they can make a living--not a great one but a good one—simply by contracting with insurance plans.

To an established doctor or group, it means that there is little they can do to prevent competition and an erosion of their own advantages.

To an insurance company, this means that few doctors can ever become so powerful that they can increase their fees unilaterally.

Perhaps this is another paradigm shift in the business of medicine.

Again, just my observation.

The IU.

Friday, March 07, 2008


They say that a chain is only as strong as the weakest link. Medical practice is no different. The best surgical care can be undermined by an overlooked laboratory value and perfect outcome ruined by a mis-filed lab. I’ve learned over the years quality assurance and total quality management are every bit as important as is history taking and the physical exam. Here are some of the things I do routinely in the realm of QA:

--Outbound test and study tracking
--Re-call lists
--No-show lists
--Equipment maintenance and mainetenance logs
--Random chart audits
--electronic medical records
--A written QA plan

My patients do well. I sleep well at night. Everybody wins.

Wednesday, March 05, 2008

The novice. . .the expert. . .the master.

The most incredible advances in medicine have not come out of cancer research or robotics or nanotechnology. No, instead, the greatest advances in modern medicine have been the creativeness in the stories told by drug seekers. There are 3 categories of drug seekers:

The novice: allergic to IV contrast, can't take toradol. Very easy to defeat these days due to non-contrast CT scans. Just send them to the ER or for a CT.

The expert: was in pain "while in Vegas", went to hospital, has no insurance, can't afford CT scan. More difficult here, but the trick is to pin the patient down on the exact name of the medical center, the dates of service, and demand a faxed report from the ER or treating physician. If they are unable or unwilling to provide you with that information, they are most likely drug seekers.

The master: Actually has a stone—even better if they have blood in the urine as well—but the stone is not obstructing and not causing their pain. These cases of tough ones and many-a-physician has been tricked into treating, even to the point of surgery, these patients. The key test here is to get either an IVP or a lasix renal scan to prove that there is no obstruction and then refer them to "the experts" at the university. Typically, these folks will get you for a couple narcotic scripts before you figure them out. They are THE MASTERS!!

Monday, March 03, 2008

Going solo? Use all your resources

This morning I was busy. I had 5 follow-ups, 1 scrotal sonogram, 1 penile duplex scan, and 3 semen analyses. The patients that I saw generated 3 new prescriptions and 2 refills. In addition, an established patient of mine moved and requested that her chart be sent to her new urologist.
In other words, a lot of grunt work.
Fortunately, my inexperienced staff can do the lion's share of it because of training and technology.
  • My MA electronically queued all the prescriptions while I was doing the duplex scan. She made 2 mistakes, but the system will not allow her to actually send the prescriptions, so patient safety was never compromised. When I had a break, I pulled up the queue, made corrections, hit approve, and the prescriptions were sent to the pharmacies.
  • My MA with no andrology lab experience was able to do the semen analyses for me on my automated system. I was able to verify their accuracies by reviewing the image and motility files. Plus, she calibrates the instrument daily and performs quality control on known samples. All this while I was doing a scrotal sonogram.
  • My receptionist printed out the chart of the patient that was leaving us and placed it on my desk. I reviewed it to make sure that she printed out everything--which she did not--and then I signed it. She then scanned the signed copies back into the patient's chart into a sub-folder named "record releases", dated the entry, and then faxed the paper copies to the new doctor. All this while I saw the follow-up patients.
By 10:15 AM I was finished and on-time and all grunt work was done with accuracy and completeness. I then logged onto my blog, The Independent Urologist, and wrote the above.
Good morning!
The IU.

Sunday, March 02, 2008

A Day Off

Took some time off today with the family.
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