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

Thanks,

The IU

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.

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.

Thanks,

The IU.

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.

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.

QA,QC,TQM,6-sigma,IU

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
--e-prescribing
--fax-tracking
--electronic medical records
--A written QA plan

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

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!!

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!
Thanks,
The IU.

A Day Off

Took some time off today with the family.

More uses for technology in medicine

Today I:

• e-prescribed
• remotely completed medical records
• used a greenlight laser
• performed a TESE in conjunction with ICSI
• roasted a chicken
  

Good day

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My automated semen analyzer

I recently invested in a new and somewhat expensive technology to automate my semen analysis process. The instrument, called the Sperm Class Analyzer or SCA System is a very sophisticated software program that links by computer and camera set-up to my microscope in my in-office, COLA accredited andrology lab. The SCA System adapts to my methodology of semen analysis and quality assurance and is really a very useful adjunct to my lab. Aside for basic features such as concentration and motility analysis, the software can also analyze sperm velocity, progressive motility, morphology by Kruger and WHO criteria, and sperm DNA integrity. In fact, these cumbersome and complex analyses have become so easy that I have been able to train my MA to do them.

From a technology perspective, the system fits in well with my general electronic office design. I can access the system remotely and review the saved analyses from home, generate a report, and digitally sign it, all from the comfort of my home. I can even do it from the road via my lap top. If I have a doubts as to the accuracy of any particular report, I can even re-run the analyses, since the digital images and motion analysis data are archived.
I can then convert my reports to PDF files with a keystroke and fax them electronically to referring doctors.

Automated semen analysis has some advantages over manual analysis. Perhaps the biggest advantage is reproducibility of results and decreased inter-observer variability. Accuracy is not compromised in anyway, since the instrument is calibrated daily and verified manually for accuracy by a trained andrologist, a guy by the name of Dr Richard Schoor MD.

Apparently, I am the only lab in NY to have the system, though several of the largest IVF groups in the nation have recently adopted the technology for their own usage.

If you need a semen analyses, please contact me:

Thanks,

The IU.

My high tech snow day

Despite global warming, the weather brought snow today to Suffolk County Long Island, where I have my urology practice. Fortunately I had a slow day in the office and was not really disrupted much by the snow. My biller however, was unable to get into the office. No biggy. Here's what we did:

• Encounter forms were delivered to my biller by my MA, who lives in the same town as my biller. We could have faxed the biller the encounters or emailed them as well, though delivery was just as easy, and HIPAA compliant.
  
• My biller VPN'd into the network, entered the charges, and submitted the claims electronically, just as if she was at her post in the office.
• I left early as well and had phone calls forwarded to my cell phone.
• From my cell phone and blue tooth wireless, I called in a prescription for antibiotics while I drove and deposited checks in the Commerce Bank drive-through..
• When I arrived at home, I e-prescribed for another patient and electronically signed off on some labs via the VPN connection to the work station in my own office.
• At one point, I was on the phone with my biller, who was remotely accessing her workstation from her home while I was remotely on my work station from my own home.
• While I was at home, where I get little cell phone reception, I received a call from a local doctor's office. They called my office main line which forwarded to a VONAGE line in my home office. Had I been on the road, the VONAGE line would have simul-ringed on the cell phone. Since I was home, I simply picked up a cordless phone,and took down information on a new patient.
  
• I did miss one call, but the number was logged on VONAGE, and I easily returned the call.

Maybe mundane to you, but I think it is pretty cool.
Thanks.
The IU.

E-Rx: A Good Use for An i-Phone

I don't have an I-phone but I may get one soon since I just discovered a new use for it that would fit in well with my practice: e-prescribing. E-prescribing has some advantages over traditional paper prescription writing. To name a few such advantages, e-prescribing decreases Rx dosing errors and insurance formulary and tier-ing issues, not to mention handwriting problems. Though I'm still slow at it, I can see that e-prescribing willmake my practice more efficient.

In NY State at least—which is fast becoming the most physician unfriendly state in the nation—only licensed practitioners such as RNs and MD/Dos can call in prescriptions to a pharmacy on behalf of the doctor. As you might imagine, a busy doctor, especially a generalist, can easily become overwhelmed by prescription management. In comes e-prescribing. With this new high tech tool, my high school educated MA—or anyone else with no medical training for that matter--can queue up all the prescriptions and refills for me that come in throughout the day and then I can review, edit, and approve them with a simple keystrokes from anywhere. My MA does not need any specific training in prescription writing or drug-drug interactions and she really can't make a mistake that can get my patients and me into trouble. Yet she can do the lion's share of the work for me.

Beautiful and just what I need.

Here is where the i-Phone comes into play. I was in the OR today and forgot my Rx pads. I did several cases on patients, all of whom had different pharmacies and I had have to call in some scripts for them. Now with hold times and phone trees and formulary related call backs etc, calling in prescriptions to pharmacies can be a royal pain and not something that I relish. Instead, I asked to borrow my friend Mike's i-Phone. With it, I logged onto my e-RX network, located my patients' profiles, selected the meds and doses from drop down menus, selected their pharmacies, hit approve all and voila', done.

Not bad. I can see other nice uses for the i-Phone as well, but this one is among the best.

Now if I could only use an i-Phone to reach Governor Spitzer to beg him for relief from this ridiculous med-mal environment that Long Island's docs have entered.

As always, join me on legislative day in Albany, March 4^th.

The IU

Going Solo? Develop A Competitive Edge.

What makes you so special? Why would patients go to you over someone else? While it may be difficult to compete with an established group or a large group, you can try to level the playing field--or perhaps tilt it a bit in your own favor--by developing a competitive advantage the amplifies your strengths and exploits your competitors weaknesses. Having Saturday hours when others do not may represent one such competitive advantage. Here are some others:

• Have office hours others do not
  
• Offer a service others do not
  
• Learn a new procedure that others are not yet doing
  
• Treat diagnoses that others find undesirable or less profitable
• Answer your own phones, and do it 24/7

As you grow, you can adjust your practice's competitive advantages accordingly. That is the fun part of solo practice.
Good luck.

The IU.

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Tell me this is a joke, please.

From today's NYTimes: Congress is preparing for the switch, allocating money for 33.5 million $40 coupons to defray the cost of set-top converters, which retail for about $50-$70. Each U.S. household is entitled to request up to two coupons, redeemable at a certified retailer within 90 days.

 

Do the math: That is 2 billion dollars for health care—Oh I'm sorry, for digital TV.

Yeh, that is what we need in this country.

Am I nuts, or is that just bonkers? Someone, please tell, what am I missing.

The IU.

Where is Dr Carl?

Pillitieri Ob-Gyn has been delivering babies in Suffolk County NY for 50 years. The practice was started by Dr Pillitieri senior, and it was ultimately inherited by his sons, Carl and Mark, and his daughter Eileen, a nurse practitioner. I got to know Carl first, and then Mark, Mother's Day 2003, when I was on call for my urology group. Carl called me first and asked that I see his patient who was in pain from a kidney stone while pregnant. I said sure. About 30 minutes later, Mark called to ask where I was because his patient was in pain.

Who are these guys? And why do they torture me thus?

Several months later, when my wife became pregnant with our second child and we needed a new Ob-Gyn, the Pillitieri's were the first and only number that I called. I only knew them from that interaction and one or two more like it, but I could tell that these guys were patient advocates to the n'th degree. Their commitment to my wife and me from beginning to end confirmed my initial belief.

I have come to know Drs Mark and Carl, as they are called, and "Dr" Eileen, pretty well over the years. They send me patient referrals from time to time and in fact kind of supported me in my early years as a solo urologist in start-up. Their patients are nothing short of fanatical about them as doctors; almost cultish in their reverence for the 2 docs and nurse. On several occasions I have treated mother-daughter-baby combos all of whom were patients of Drs Mark and Carl. From an unassuming office, the Pillitieris practice outstanding patient care and safety combined with state of the art medical treatments. They are the real deal.

They are also dying.

Dr Pillitieri senior left practice in the 90's after being on the losing end of a multi-million dollar lawsuit. Dr Carl left practice after 15 flawless and lawsuit free years in practice to relocate to Maine, where his liability insurance premiums dropped by 66%. Dr Mark has remained behind in the Deer Park NY office, along with his sister Eileen. They are committed to the practice and the community that they love. Mark takes call everyday and has not had a single day off since Carl, left 2 years ago. Now that is devotion!

This year, Mark paid the standard rate for Ob-Gyns in Long Island, which happens to be $180,000. Unless legislative action in Albany intervenes, Dr Mark will be forced to pony-up another $56,000 in July 2008, in addition to his $180,000. If he cannot do afford the rate increase—and who really could—he will be forced to close his doors to new obstetrical patients.

There is a real human drama unfolding here on Long Island—a crisis in the making.

You have the ability to avert it. Contact your local state senator and assemblyman. Join me in Albany for legislative day on March 4^th.

What affects Dr Mark affects me and affects you.

Act Now!

The IU.

An Activist is Born

Liability rates in NY are rising dramatically. Many obstetricians in my own community, have already either given up OB or have left the state entirely. Who will deliver our children?

MLMIC, one of only 2 liability carriers in NY, paid $500 million dollars over a ten year period to defend claims that never resulted in a single payout to a plaintiff. The trial lawyers say that the defense bar is winning the war, but the cost of that war has been so high that the vitality of the entire health care system in NY State is in jeopardy. For the OB that delivered my Emma, legislative action that occurs in the next 6 months will determine whether or not he stays in business--and he is one of the good guys.

The trial lawyer lobby is strong, but ultimately they in are in-the-wrong. The citizens of NY need professionals that can provide obstetrical care, emergency cardiac and surgical care, and preventive medicine. I know personally several family practitioners in my community that subsidize their own practices with personal savings and debt just so that they may keep their doors open.

There is a misperception, perpetuated by the trial lawyer lobby, that there is no crisis looming; that the problem is the result of bad doctors, and that doctors and insurance companies are just greedy. This is simply not true. The overwhelming majority of doctors consistently do the right thing by way of their patients, and the days of the "country club life" for doctors has long since passed. From a financial perspective, most of us are simply trying to stay in business, provide for our families, and practice the professions that are our passions.

Help avert the impending crisis that WILL come in JULY 2008 unless legislative change happens immediately. Join us in Albany on March 4th for Legislative Day. Contact your local assemblyman and state Senator. Contact me, and I'll assist you in contacting your local reps.

Believe-you-me; when you or your child or your husband or wife or dad or mom is sick and in need of medical attention, you will turn first to your doctor and hospital, not to your trial attorney. You have the power to make sure that we are there for you.

Act now!

Thank you.

The IU.

Develop your long range plan

Medical practice is a business. Like any other business, a medical practice has 4 stages in its life cycle. Stage 1 is the embryonic stage. Like a developing embryo, the new business must develop the basic necessities of life, such as an office, a phone system, a computer system, etc. And like the wonder we feel towards our newborn infant, when we look at our new business, we feel awe and amazement over all that we've accomplished just so that we can open our doors on day 1.

Ultimately, the business will either die in the embryonic phase or will proceed to the next phase, the growth phase. The growth phase is like childhood. It starts out all fun and wonder, but becomes more challenging and stressful as maturity hits. The growth phase will morph imperceptibly into the next and longest phase of the life-cycle, the mature phase. It is during this cycle that the business continues to grow, but it grows at a more predictable level. Cash flow is somewhat stable and daily operations sort of take care of themselves but the stability is often interrupted by head-aches and fires that seem to sprout up out of nowhere. Finally, like life itself, all businesses ultimately die. Businesses end either in bankruptcy, or they get bought out, or they simply disband.

During each of these stages, you'll have outside forces that will push or pull your practice in one direction or another. The chance to make some "quick bucks" with some new equipment, the possibility of hiring a new associate, or perhaps the opportunity for a strategic merger with another group; these, and many more possibilities will avail themselves to you during your career. Since you will not have a crystal ball and will not truly know what to do when faced with these uncertainties, you will need something that can guide you in the right direction. And the only place that you can turn for guidance will be your long range plan.

The long range plan is your vision. It is where you see yourself in 10 years. It is your ultimate dream; the business or practice that you would want if nothing could ever get in your way. Your 10 year vision, or 20 year vision for that matter, is never too large or too ambitious. Nor should it be something that can be reached to soon, for then it would not be big enough.

Recently I have felt a strong pull towards a large group that has formed in my area. The temptation to reach out to them has been great. From all that I've heard, this group will achieve tremendous success and financial glory. They'll have their hands into everything and generate revenue hand over fist. Urologists around me are falling like dominoes and have been lining up—and paying handsomely—just to join. Should I try to get in as well.

My answer: no. To join that group right now would be incompatible with the long range vision that I formed for myself many years ago.

For now, I stay solo and grow on my own terms.

David vs Goliath.

Wish me luck.

The IU.

Business Acumen or Dumb Luck?

I am reading a terrific book now called, The Illusions of Entrepreneurship, by Scott Shane. I started it, and it has already inspired me to write this post. Rather than give advice that is based on anecdotal information, the author uses data to illustrate the differences that lead to success vs failure for a start-up. Here are some:

1. Stay in school: college grads do better that high-school grads. Education I have-a-plenty.
   
2. Don't start to soon: people who work for others, and learn on their employer's dimes, do better when they ultimately do go on their own and start-up. I did that.
   
3. Money matters: Having access to capital early on makes a huge difference. I had significant savings which I used a collateral to get loans.
   
4. Have a business plan. I did that, only I did not realize that I had.
5. Choose the right industry: urology is pretty good, infertility is even better. For me, pure dumb luck! In New York, a start-up OB would be almost doomed to fail. Derm is good!
   
6. Have the right motivation: are you doing it to make money or to have autonomy to "do what you want." If you goal is to generate revenue, you'll do what it takes--like answer the phones 24/7 or have evening and Saturday hours. I did those things because they seemed obvious to me. If your goal is to be able to take a vacation whenever you want, re-think your plan.
   
7. Buy someone else's business: I did not do this, but I guess you can't argue with the logic.
8. Focus on your strengths. I did this. Dumb luck.
9. Marketing: Successful entrepreneurs market their products or businesses early on. Caveat, do it smartly. I wasted a lot of money in my initial attempts.
10. Find unreached customers: I suppose that had I stayed in the same area as my former employers and tried to compete with them, I'd have lost. Dumb luck and restrictive covenant to thank here. If you are starting your own practice, try to identify patients that others are not seeing, such as patients who need weekend or evening hours or patients of certain ethnicities, disease states, insurance types, etc.
    

I'll keep you posted about others.

Thanks,

The IU.