April 2012
Not enough hours in the day? Small changes make a big difference.
in practice: ACOs: A Guide for Physicians technology: Coordinating Care with Mobile Tools The List: 10 Easy Patient Pleasers
C1_APR12.indd 1
3/20/12 12:57 PM
The Bigger Picture
Bob Keaveney
Does Medicaid Hurt the Poor?
One of the most powerful arguments in favor of the Affordable Care Act is a moral one. The reform law expands access to Medicaid by increasing its income limits. In so doing, goes the thinking, it extends access to life-saving care to millions of people. But will it, indeed, expand access to care? Or will it merely prove the axiom that access to insurance is not the same thing as access to healthcare? In 1997, Congress expanded Medicaid’s State Children’s Health Insurance Program (S-CHIP) to cover more children of the working poor. Researchers with the Center for Study Health System Change (HSC) compared states that had undergone large S-CHIP expansions to states with smaller expansions. Reporting its results last month, HSC found that physician utilization was lower in states with larger expansions — that is, with more kids newly covered by Medicaid. How can this be? The main problem is Medicaid’s obscenely low pay rates to doctors. Consider that the average national Medicaid payment for an office visit for a child is $47, compared to $81 for privately insured children, according to a survey by Ingenix Consulting. In most states, Medicaid is also a notoriously slow and unresponsive payer. There was no rational business case for accepting Medicaid even before the Great Recession devastated state budgets. But now, accepting Medicaid is utterly untenable. You need not imagine how this affects Medicaid patients trying to get appointments for care: In June, The New England Journal of Medicine reported on a next-available-appointment study that had researchers call doctors’ offices, as parents of children with medical complications. Those who identified as Medicaid enrollees were denied appointments two out of three times, compared with 11 percent for those who claimed private insurance. The Medicaid folks able to make appointment at all found their wait times about three weeks longer than for the privately insured patients. Still, can Medicaid coverage, lousy though it may be, actually be worse than no coverage at all? That’s hard to believe. Yet how many physicians would sooner accept uninsured patients who will pay a reduced rate out of their own pockets, even if it’s on an installment plan of some kind, than take Medicaid? Of course, many Medicaid recipients could not make those installment payments. But is that true, really, of the higher-income people who’ll be newly eligible for Medicaid under the coming expansion? Many ideas for expanding access to private insurance have been floated: replacing Medicaid with block grants to let states experiment with healthcare for the poor; incentives to increase adoption of health savings accounts; expanded use of high-deductible catastrophic insurance plans. Or, some combination thereof. Meanwhile, separate research is raising questions about the quality of care Medicaid recipients get. A University of Virginia study found that post-surgical Medicaid patients were almost twice as likely to die in the hospital as those with private insurance — and 13 percent more likely to die than even the uninsured. That study is controversial, but no one doubts that Medicaid produces far worse health outcomes than virtually any other kind of insurance. Given that, why would anyone want to expand Medicaid, as the the reform law does, rather than look for ways to expand access to private insurance? Bob Keaveney is the editorial director of Physicians Practice. What’s your
experience with Medicaid? Tell us about it at bob.keaveney@ubm.com. Unless you say otherwise, we’ll assume that we’re free to publish your comments in upcoming issues of Physicians Practice, in print and online. www.physicianspractice.com
PPJ_04012012.indd 1
Our Mission: Helping physicians manage their practices more effectively, leading to improved patient care.
P ub l ishin g S ta ff Senior vice president, Content & Strategy Pamela Moore, PhD pam.moore@ubm.com
E d ito r ia l Editorial Director Bob Keaveney bob.keaveney@ubm.com MAnaging Editor Keith L. Martin keith.martin@ubm.com Associate Editor Marisa Torrieri, MS marisa.torrieri@ubm.com Associate Editor Aubrey Westgate aubrey.westgate@ubm.com assistant managing editor Erica Sprey erica.sprey@ubm.com Contributing Writers Bill Dacey, Kate DeBevois, George Ferenczi, MD, Sue Jacques, Rosemarie Nelson, Shelly Schwartz project manager Amanda Rombach amanda.rombach@ubm.com
Desig n Group Creative Director Nancy Bitteker Art Director Bill Ellis
ho sp ita l str ate g ie s Group Director, Hospital Business Development steven.gottshall@ubm.com
Steve Gottshall 847 242 9552
HOSPITAL ACCOUNT MANAGER lindsay.moe@ubm.com
Lindsay Moe 410 818 2713
CLIENT RELATIONS STRATEGIST taylor.hine@ubm.com
Taylor L. Hine 203 523 7024
B usin e ss A d ve r tisin g S tr ate g i e s Group Director, Business Development eric.temple-morris@ubm.com
Eric Temple-Morris 503 203 1060
National Sales Manager pamela.peterson@ubm.com
Pamela Peterson 201 984 6246
National Sales Manager seth.geller@ubm.com
Seth Geller 410 818 2716
National Sales Manager david.gordon@ubm.com
David Gordon 201 984 6270
p ha r ma c e utic a l A d ve r tisin g S a l e s Group Director, Business Development eric.temple-morris@ubm.com
Eric Temple-Morris 503 203 1060
B usin e ss se r vic e s Director — Marketing, Research, and Circulation Amy Erdman amy.erdman@ubm.com Senior marketing Manager Amy Caswell amy.caswell@ubm.com Group Director of manufacturing and production Steve Sanborn steve.sanborn@ubm.com Group Production manager Carlos Yanez carlos.yanez@ubm.com
c l a ssifie d a d ve r tisin g sa l e s Heather Koitzsch | KERH Group LLC | 888 537 4858 hbk@kerhgroup.com
he a d q ua r te r s 5523 Research Park Drive, Suite 220 Baltimore, Maryland 21228 Phone: 800 781 2211 Fax: 443 543 5170 Web: www.PhysiciansPractice.com
sub sc r ip tio n se r vic e s ppsubs@masub.com UBM Medica journals include Consultant, Consultant for Pediatricians, The Journal of Musculoskeletal Medicine, Oncology, Psychiatric Times and Physicians Practice. Physicians Practice® (ISSN 1072-2912), published by UBM Medica, LLC, is distributed to nearly 200,000 U.S. physicians. Copyright © 2011 by UBM Medica, LLC, is distributed to nearly 150,000 U.S. physicians. Single copies $10; annual subscription $56. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. Send address changes to: Physicians Practice, c/o UBM Medica, 535 Connecticut Avenue, Suite 300, Norwalk, CT 06854, or visit www.surveymonkey.com/s/subscriptions.
April 2012 | Physicians Practice |
1
3/20/12 1:04 PM
April www.PhysiciansPractice.com
12 28
cover Story Finding More Time
Not enough hours in the day? Small changes can have a big impact on your practice efficiency — and your life.
IN PRACTICE
ACOs: A Guide for Physicians
Should you join an accountable care organization? It’s important for physicians in community-based practices. Here’s what you need to know about this emerging care-delivery model.
4
the inbox
What you’re saying: Three important questions; do EHRs interfere with patient engagement?
8
Physicians practice pearls
Stopping Gossip A four-step guide to ending the “trash talk.”
10
noteworthy
Luring docs with unusual incentives … what’s your signature worth? … overweight omissions.
19
Physician writer search
‘I Feel I Am Successful When…’ Gastroenterologist George Ferenczi escaped the Iron Curtain as a boy. Now he tries to justify his luck, and life.
Volume 22 | Number 4
31
TECHNOLOGY
Coordinating Care with Mobile Technology Thanks to new federal initiatives and the increased use of smartphones and tablets, more physicians are communicating with each other while on the go.
columns 21
STARTING OUT
Taking Leave the Right Way Planning a break from your practice for a while? Here are some tips to help you work with your partners and patients for a meaningful long-term absence.
24
The Administrator’s Desk
6 Ways to Get Organized Tired of decreased productivity? Here’s how to get organized and whip your practice back into shape.
26
36
Coding
Coding Questions? We’ve Got the Answers Family planning modifier; NPP billing; coding concerned patients; modifiers and bundled codes
40
The List
10 Easy Patient Pleasers How can you ensure your patients leave your practice feeling healthier and happier? We asked 10 patients for their tips.
Physician Beware
Communication Breakdowns Are docs and staff just not on the same page? Here’s how to fix it. Cover illustration: Dave Plunkert
PPJ_04012012.indd 3
3/20/12 1:05 PM
the
in box
physi c i ans advi sory b oard
Three Difficult “I guarantee if you were in any other Questions industry, you would about Your not allow yourself Medical to be as little in Practice charge as you do Future Editor’s Note: Below is an excerpt
of a post by physician Craig Koniver on Practice Notes, Physicians Practice’s blog. The post has been edited for space and is followed by a selection of comments made by Practice Notes readers at Physicians Practice.com/blog. Why is a trip to the doctor’s office more like going to the DMV than going to Disney World? Both the DMV and Disney World involve waiting in long lines, but Disney has made the entire experience fun and exciting, while the DMV has made it cold and frustrating. “But medicine is different,” you may say. Seeing the doctor was never meant to be a fun or exciting experience, after all. When you’re sick, you go to the doctor to get well — no more, no less. …We need to be honest with ourselves here and note that medicine and healthcare are moving in a direction that promotes more of my experience at the DMV than a room that is quiet and relaxed with smiling people. …I think it is time you started being honest with yourself about your profession and your daily choices in your practice. I guarantee if you were in any other industry, you would not allow yourself to be as little in charge as you do in medicine. Here are three brutally honest questions I want you to ponder: On a daily basis, are you practicing medicine the way you truly want to be? … If you could change (and you can) one aspect of your career, what would it be? … Why do you allow “the system” to dictate to you the terms by which you make money, provide for yourself and your family, and tell you “how to” practice your trade? 4
| Physicians Practice | April 2012
PPJ_04012012.indd 4
in medicine.”
Herbert Drayton III suggests: If your questions correlate to physician satisfaction, I am not sure you are asking “all” the right questions. Try these as respective complements:
1. Does the first patient of the day and after lunch have a wait time (check-in to triage) greater than five minutes?
David Albenberg, MD Access Healthcare | Charleston, SC Frances Faro, MD Orthopaedics Physicians of Colorado, P.C. Englewood, CO Robert C. Goldszer, MD, MBA Mount Sinai Medical Center | Miami Beach, FL Melissa G. Young, MD Mid Atlantic DM & Endo Associates | Freehold, NJ b usi nes s advi sory b oard Rebecca A.H. Anwar, PhD The Sage Group | Philadelphia, PA V. Alin Botoman, MD Holy Cross Hospital | Fort Lauderdale, FL Jerry A. Bridgham, MD Wolfson Children’s Hospital | Jacksonville, FL Lee M. Duke II, MD Lancaster General Health | Lancaster, PA
2. If you could start your practice all over again, would you take all of your existing staff with you?
Francie Ekengren, MD Wesley Medical Center | Wichita, KS
3. Are you letting staff [who are] anchored in the past keep your business from moving forward?
Larry Hopperstead, MD Central Maine Medical Center | Lewiston, ME
Have you asked yourself the same questions? Tell us what you think; join the conversation at http://bit. ly/3-difficult-questions.
Balancing Patient Interaction, EHR Use Editor’s Note: Below is an excerpt of
a post by healthcare attorney Ericka Adler on Practice Notes, Physicians Practice’s blog. The post has been edited for space and is followed by a selection of comments made by Practice Notes readers at PhysiciansPractice.com/blog. I recently had opportunity to experience an EHR in a practice that had only recently integrated. My physician joined me in the examination room and sat down at a small desk and logged into a computer. She proceeded to ask me
Allen B. Hornell, MD ETMC Regional Healthcare System | Tyler, TX Leonard Lichtenfeld, MD American Cancer Society | Atlanta, GA Lorraine L. Manzella SUNY Upstate Medical University | Syracuse, NY Daniel M. Navin, MD Munson Healthcare | Traverse City, MI Harold Pillsbury III, MD UNC Hospitals | Chapel Hill, NC Brian Reardon St. John’s Hospital | Springfield, IL James A. Schell II, MD, MHA, FACP Saint Francis Medical Center | Cape Girardeau, MO Melissa Tizon Swedish Medical Center | Seattle, WA Doug Walta, MD Providence Health & Services | Portland, OR J. Stephen Wikle, MD, MPH Hoag Memorial Hospital Presbyterian Newport Beach, CA www.physicianspractice.com
3/20/12 1:05 PM
the
in box a variety of questions. …her back was to me during the time she asked these questions. When she began the physical examination, it was interspersed with visits to the terminal. … Not only did I feel the appointment was rushed (a separate issue), but the quality of the visit was diminished by the time my physician had spent at the terminal, turned away from me. After this experience, I wondered about whether providers are receiving the EHR training needed to properly integrate this technology into their practice. …When I left my physician, I was not thinking about the short wait time or how quickly I was able to schedule the appointment. I was feeling I had been neither seen nor heard by my doctor and the feeling was negative. Tariq Dastagir says: Very important point. In my practice I stand or sit on a stool facing the patient with my computer on my righthand side. I do minimal data entry in the computer during our visit, but use it to review charts, answer the patient’s questions, and share medical information with them on the screen. Sometimes I use it to show them images online which are relevant to their condition. John Ludlow writes: Healthcare is more of a service than a commodity but because of increasing overhead and decreasing reimbursements we’ll do whatever we can to push patients through our offices quickly while satisfying all of the “requirements” mandated by CMS and the insurance companies. It’s hard to develop relationships with patients when we’re worried about satisfying the payer and avoiding things like fraud and malpractice. Plus, with the impending change in reimbursement to ACOs (all physicians will be salaried employees) there will be even less urgency to “serve” the patient. Maybe medicine is a commodity. Do you worry that your EHR pulls your attention away from the patient? Tell us what you think; join the conversation at http://bit. ly/balance-patient-interaction. 6
| Physicians Practice | April 2012
PPJ_04012012.indd 6
The following institutions sponsor Physicians Practice in their geographic regions. Physicians Practice is mailed to practicing physicians within these geographic regions.
Advocate BroMenn Medical Center www.bromenn.org 309 454 1400
All Children’s Hospital www.allkids.org 727 898 7451
Bronson Battle Creek www.bronson battlecreek.com 245 966 8000
Central Maine Medical Center www.cmmc.org 207 795 0111
Christiana Care Health System www.christianacare.org 302 733 5339
Crozer-Keystone Health System www.crozer.org 800 CK HEALTH (254 3258)
Desert Regional Medical Center www.desertmedctr.com 760 323 6511
ETMC Regional Healthcare System www.etmc.org 800 648 8141
Hoag Hospital www.hoaghospital.org 949 764 HOAG (4624)
Holy Cross Hospital www.holy-cross.com 954 351 7844
Indiana University Health Physicians iuhealth.org/physicians 800 622 4989
Lancaster General Health www.Lancaster GeneralHealth.org 717 544 5511
Loma Linda University Health System www.lomalindahealth.org 877 LLUMC 4U (558 6248)
Maimonides Medical Center www.maimonidesmed.org 718 283 8227
Marshfield Clinic www.marshfieldclinic.org 877 647 3337
St. Francis Health Center www.stfrancistopeka.org 785 295 8000
St. John’s Hospital www.st-johns.org 217 544 6464
St. Luke’s Hospital www.stlukescr.org 319 369 7211
SUNY Upstate Medical University www.upstate.edu 800 544 1605
Swedish Medical Center www.swedish.org 800 SWEDISH (793 3474)
UNC Hospitals and the UNC School of Medicine at Chapel Hill www.unchealthcare.org 800 862 6264
Munson Healthcare www.munsonhealthcare.org 800 468 6766
University of Virginia Health System www.uvaphysiciandirect.com 800 552 3723
Providence Health & Services www.providence.org/oregon 503 574 7500
Wesley Medical Center www.wesleymc.com 316 962 2000
Saint Francis Medical Center www.sfmc.net 573 331 5877
Wolfson Children’s Hospital www.wolfsonchildrens.org 904 202 8000 www.physicianspractice.com
3/20/12 1:05 PM
Stopping Gossip at Your Medical Practice
contaminating your office or unit, you need to be bold enough to play a central role in creating a solution. That starts with a personal commitment to remain uninvolved in gossip, because being an audience to it is as detrimental as uttering the comments yourself.
A four-step guide to help your office ‘Stop Talking About Trash’
A: Ask for support. Can you imagine what would happen if you said, “Is anyone else tired of the way we’re communicating around here?” If you’re uncomfortable with the level of gossip at work, chances are some of your colleagues are as well. It’s common for people to suffer in silence. Don’t do that anymore. Take the lead by speaking up. Doing something like volunteering to lead a committee whose mission is to reverse rudeness at work will empower you to become an ambassador for civility. And if you’re a manager who is hearing about chronic gossip, listen to your staff and work with them to delete disharmony.
By Sue Jacques
edical practices, specialty clinics, hospitals, and hospices are fighting a pesky virus: gossip. Trash talk, potty-mouth, he said/ she said — these are only a few of the terms that are commonly used to describe plain old malevolence. If only there was a vaccine for vitriol. Like a bad flu, the bug of workplace disrespect can strike anyone in a moment of weakness, damaging professional relationships and patient care. No one is immune.
M
practice, your staff, and the patients who rely on them. Here’s a four-step guide to help your office Stop Talking About Trash — STAT: S: Step away from the conversation,
even if you can only do so in your mind. The second you hear someone speaking disrespectfully about someone else, take a mini-mental or physical break and quickly scrutinize your internal guiding principles to determine if this is the kind of dialogue you will allow yourself
The bug of workplace disrespect can strike anyone in a moment of weakness, damaging professional relationships and patient care. GONE VIRAL
It’s hard to place a concrete value on the benefit of professional civility; yet take one look at someone who’s been spoken to or about with condescension, and you’ll learn all you need to know about its worth. Healthcare professionals are pre-wired to focus on wellness, not weakness. Strong professional relationships are as vital to patient treatment as medication, because patients can sense when there’s an undercurrent of tension. And that’s the last thing a sick person needs. Put an end to gossip in your medical practice; doing so will improve the emotional health of your 8
| Physicians Practice | April 2012
PPJ_04012012.indd 8
to take part in. More often than not, when you really listen to your heart, the answer will be no. T: Triage your options. When you find yourself in the grip of gossip there are usually a few ways out. If it occurs in an informal group setting, the simplest thing to do may be to quietly leave the room without a fuss. In circumstances when gossip is one-on-one, it’s best to take a non-confrontational stand early in the conversation by saying something like, “I’d rather discuss this when Josh can be here to share the details from his perspective.” But if out-of-control gossip is
T: Turn it around. Your patients are your priority, and they need your full attention. Yet it’s hard to focus on listening to them when you’re worried about what others are saying about you. You can refresh your team’s spirit by taking steps to exclude gossip as an acceptable form of banter. Talk with colleagues about posting signs in meeting spaces, coffee rooms, and employee manuals that state, “We are proud of our gossip-free work zone.” Include a courtesy gauge in performance reviews, and inspire one another to focus on kindness rather than cattiness. You’ll be amazed at where that attitude shift will lead you. We change the world one action at a time. Here’s a simple way to begin: The word gossip begins with the letters GO. We can STOP gossip if we get up and GO when it starts. n Sue Jacques is The Civility CEO™, a veteran forensic medical investigator turned corporate civility consultant who helps individuals and businesses gain confidence, earn respect, and create courteous corporate cultures. www.TheCivilityCEO.com. www.physicianspractice.com
3/20/12 1:05 PM
Medicinal Microchip We’ve all heard of implanting GPS microchips in family pets, but what about implanting medicinal microchips in humans? That could soon be a very real possibility. Encouraging results of a human clinical trial with an implantable, wirelessly controlled and programmable microchip-based drug delivery device was recently published in Science Translational Medicine. MicroCHIPS, the company that created the device, hopes it will improve management of chronic diseases like osteoporosis, cardiovascular diseases, multiple sclerosis, and cancer. It plans to file for regulatory approval of the device in 2014, according to PhysBizTech.
Physicians who are overweight or obese are far less likely than their thinner counterparts to discuss weight-related issues with obese patients. That’s according to a nationwide survey of 500 physicians conducted by Johns Hopkins Bloomberg School of Public Health. The survey, published in the journal Obesity, also found that overweight physicians are less confident discussing diet and exercise with patients.
Quotable:
Overweight Omissions
“Disgruntled is probably just too soft of a term for this. It’s really devastating to try to run an office in this environment.”
–Robert Wah, MD, speaking to NPR about Congress’ decision to implement a temporary Medicare “doc fix” rather than identifying a permanent solution to the flawed SGR formula. 10
| PHYSICIANS PRACTICE | APRIL 2012
PPJ_04012012.indd 10
WWW.PHYSICIANSPRACTICE.COM
3/20/12 1:05 PM
Stat:
Luring Docs with Unusual Incentives Forget higher salaries, fancy homes, and signing bonuses. A tiny hospital in southwest Kansas is trying a different route to attract physicians. Candidates are offered eight weeks off for missionary work overseas. The tactic has already lured at least one physician to the medical center, Ashland Health Clinic, according to NPR.
The percentage increase in the number of American medical students matching into primary-care residencies between 2009 and 2011. Source: Association of American Medical Colleges
What’s Your Signature Worth? In 2011, 88 percent of hospital-recruited physicians were paid an average bonus of more than $20,000 to sign their employment contracts. That’s according to The Medicus Firm, a national physician search firm, which compiled physician placement data from 103 U.S. healthcare systems ranging from rural community hospitals to large national healthcare systems.
Interaction Improvements How can you improve your exam-room interactions with patients? Here are 10 easy tips, courtesy of Practice Notes blogger George Taylor, president of Beyond Feedback, a firm that advises practices on patient experiences: 1. 2. 3. 4.
Minimize interruptions. Ask open-ended questions. Stand or sit at the patient’s eye level. Face the patient directly and maintain eye contact. 5. Always speak in the first person.
Telemedicine Crosses State Lines When it comes to practicing medicine remotely via telemedicine, the regular rules may not apply. A Utah senator hopes to promote telemedicine by introducing a bill this spring that would eliminate the requirement that physicians apply for separate medical licenses in each state where they practice, according to Government Health IT.
6. 7. 8. 9.
Describe clinical issues in nonclinical language. Use analogies to explain complex issues. Explain each step of the exam. Note when and how patients will hear about test results. 10. Encourage patients to call with questions.
Primary-care Makeover The Washington Post recently laid out two predictions for how primary care will change as the country addresses the looming doc shortage. In one scenario, the “traditional” primary-care work force would be bolstered by increased reimbursements, more residency openings, and additional scholarships to medical students. The other scenario would establish a “different” type of primary-care
work force. Requirements for foreign doctors to practice in the U.S. would ease, and other medical professionals — like nurse practitioners — would take on more responsibilities. Which scenario is most likely to occur? According to The Post, “a looming shortage of 30,000 primary-care physicians by 2015 leaves space to bump up the numbers of traditional and nontraditional providers.” APRIL 2012 | PHYSICIANS PRACTICE |
PPJ_04012012.indd 11
11
3/20/12 1:06 PM
illustration: Dave Plunkert
12
| Physicians Practice | April 2012
PPJ_04012012.indd 12
www.physicianspractice.com
3/20/12 1:06 PM
Not enough hours in the day? Small changes make a big difference. By Aubrey Westgate
n 2004, family physician Lynn Ho opened a medical practice in North Kingstown, R.I., and she decided to go it alone — completely alone. Though she outsources her billing, she employs no other staff members — no receptionist, no nurses, no administrator. During the first few years following the practice’s opening, Ho says she was completely “bombed” with work. “I would sometimes stay until 2 or 3 [a.m.] in the office once a week just trying to get the billing out.” Yet Ho’s office is thriving today because she has added tools that she says are vital to keeping her workday moving efficiently and productively. These tools — such as online appointment booking, e-mailing with patients, and having patients enter medical histories online — allow Ho to spend less time completing administrative tasks and more time seeing patients. “It’s extremely www.physicianspractice.com
PPJ_04012012.indd 13
important to be efficient,” Ho says of running her practice. “The less efficient I am, the later I go home. The more efficient I am, the less I work.” From technology additions (like those Ho put in place), to rearranging staff responsibilities, to cross-training employees, to benchmarking and goal setting — small changes at your practice can help you move forward more efficiently and productively. GETTING STARTED
If you think your practice is operating as efficiently as possible, think again, says practice management consultant Owen Dahl. “Regardless of specialty, regardless of size of a practice … everyone needs to recognize that they are not as efficient as they could be.” There is always room for improvement, and though it may be tempting to continue running your practice as usual — who really has extra time to seek out improvements when you’re already struggling to keep up with your daily workload? — Dahl says taking the time to look for inefficiencies will
pay off in the long run. Finding and eliminating one redundancy in the reception area for example, could reduce each patient visit by one minute. That could add up to an extra 20 minutes per day. “Well, that 20 minutes, that’s something you could do something with,” Dahl says. And small improvements beget bigger changes. “If we clean up the smaller issues — those that are easier to fix, those that bring a good change — that frees us up with more time available to really take a look at what we can do to improve in other areas,” he says. Practices should start the efficiency improvement process by asking: “What’s important to us?” he says. The answer could be reducing patient wait times, increasing the number of patient visits per week, or reducing the amount of time nurses spend on the phone each day. “Identify just one thing that needs to be fixed that you can fix,” Dahl says. “Don’t tackle the entire practice.” IDENTIFY TIME WASTERS April 2012 | Physicians Practice |
13
3/20/12 1:06 PM
Cover Story Not sure how to get started? Assessment tools can help. They provide a quick and easy way to look at your processes differently, and as a result, they shed new light on how things could be better handled. Benchmarks. When too many people share the same responsibilities, it wastes time and resources. On the other hand, when employees are stretched thin, tasks are not completed on time. Rob Culbert, president of Culbert Healthcare Solutions, a healthcare consulting firm in Woburn, Mass., recommends determining how your staffing compares to practices of similar sizes and specialties. That can help you “understand where [you] fall on the spectrum of being heavy on the staffing side or light on the staffing side or not having the right people in the right places,” he says. Consider using a benchmarking tool, such as the Medical Group Management Association (MGMA) Cost Survey report, available for purchase at MGMA.com. It provides average staffing ratios for practices of various sizes and specialties. Flow Charts. Creating a simple diagram of your office and the activities that take place in each area can help identify where, when, and why inefficiencies occur, Dahl says. Look at the flow chart and consider
in summary Small changes can create big efficiency improvements:
a patient portal or add soft• Implement ware applications to your website to reduce administrative responsibilities
paper trails, use flow • Document charts, and look at staffing benchmarks to identify inefficiencies
responsibilities to • Rethink maximize productivity
• Cross-train employees and implement a plan • Organize to stay organized •
Huddle to jumpstart each day effectively
• Establish a clear line of authority • Hold staff accountable for their actions goals to encourage teamwork • Set and productivity 14
| Physicians Practice | April 2012
PPJ_04012012.indd 14
how activities in each area of the office relate to and influence other areas. “When you start to draw some pictures of how things flow, you’ll begin to get a better understanding of ‘Oh, that doesn’t have to be done here,’ or ‘It can be done at a different time,’ or ‘Oh, that can be done by a different employee,’” he says. Paper trails. Work flow, the way in which patients or work tasks move through your office layout, is often a source of inefficiency issues. One way to identify problems is by following one piece of paper — for example, a patient’s bill — as it moves through the office. Document which employees handle the bill and when. For instance, the front desk, the doctor, the biller, and the coder all might interact with the bill at least once. “One has to ask, ‘Each time I touch that piece of paper, is it necessary?’” Dahl says. If the answer is no, determine how the process could be reduced. As practices acquire new technology, a paper flow assessment is especially timely, says Jeanne Smith, a CPA based in Fort Worth, Texas, who specializes in healthcare. Many practices have not yet fully adjusted their work flow processes to account for the new technology they have acquired, she says. When attempting to eliminate inefficiencies, consider how more “fully utilizing” your technology can help. For instance, if your practice has a scanner, place it next to the computer at the front desk. Encourage your staff to scan patient documents, such as driver’s licenses and insurance cards, right there at the desk, rather than getting up and walking to the copy machine to scan items. It keeps check-in moving faster, says Smith, and it also ensures that scanned information is quickly placed in electronic files. UTILIZE TECH TOOLS
Practices should also consider acquiring new technology to boost efficiencies, says MGMA consultant Rosemarie Nelson. For instance, if you are struggling to keep up with administrative responsibilities, as
Ho was, implementing a patient portal can help. Portals enable patients to do everything from updating insurance information to checking test results online. That means staff members no longer deal with those responsibilities, and have more time to complete other tasks, says Nelson. For instance, when patients input registration information online, data entry takes up less time in the office. And when patients book appointments online or send requests to the practice through a secure messaging system, staff members spend less time placing calls, taking calls, and playing phone tag with patients each day. “If we can reduce incoming calls, people will be more efficient,” Nelson says. Though implementing a portal can be a daunting task, especially if you’ve had a “tough go of it” with an EHR, keep in mind that portals are “fairly simple” to set up because a good vendor will help tailor it to your needs, says Nelson. And once the technology is in place, it’s easy to manage. Staff just needs to check it frequently for updates or inquiries (the same way they would check phone messages). If a portal isn’t the right fit for you, consider adding software tools that connect to your website and provide similar services. For instance, Ho uses an online appointment-booking database her patients can access through a link provided on her website. “It’s a lot cheaper for me to do it [that way], plus I can switch pieces out if I find things that work better,” says Ho. Some online tech tools you might consider adding are: • Appointment bookings • Lab or test result postings and/or notifications • Prescription renewal requests • Billing, insurance, and registration information updates • Medical history information forms • Secure messaging www.physicianspractice.com
3/20/12 1:27 PM
Cover Story New technology can be expensive, but if it will increase your efficiency, it’s likely to increase your revenue in the long run, says Smith. “Always think about how many more patients you are going to be able to see [by increasing efficiency]. Or sometimes it’s the reverse: How many [fewer] patients a day will I have to see to be able to make the same money.” MAXIMIZE STAFF PRODUCTIVITY
As Culbert mentioned, assessing whether you have the right number of staff members in each area of your office is a great way to start identifying staffing inefficiencies. But you can also greatly improve efficiency by more fully utilizing staff members. Here’s how: Time checks. Consider whether tasks are conducted at the right time, says Nelson. For instance, if a nurse waits until the end of the day to separate the normal Pap smears from those that require the physician’s attention, the physician has to stay late to review those tests. If instead the nurse sets a few minutes aside throughout each day to sort the tests, the physician would be able to leave work earlier. “There’s always going to be some work on the table,” Nelson says. But you must consider “who does it, when they do it, what they are doing, and is it the right person.” Rethink responsibilities. Make sure that employee responsibilities match their skill levels, says Nelson. For instance, if a nurse is stocking rooms rather than completing her clinical tasks, that’s inefficient. Instead, assign that role to a lowerpaid staff member who can do it just as well. “Look at the level of license,” she urges. Cross-train. Have staff members spend time “shadowing” other employees as they complete their dayto-day responsibilities. That way, when an employee is absent, another can fill in quickly and easily, Smith says. “It doesn’t take much to break the link in a physician’s office by one person being gone, so if they’re cross-trained, someone else can fill in and keep things going for the day, or the couple of days, or the week.” 16
| Physicians Practice | April 2012
PPJ_04012012.indd 16
Eliminate redundancies. Use shadowing to identify inefficiencies and repetition in responsibilities. For instance, when one employee is observing another complete a task, she might recognize a more efficient way of doing it. In addition, she might realize she is tasked with a redundant responsibility. Add when necessary. More staff members might be just what your practice needs to improve efficiency and therefore revenue, says Nelson. A physician who is drowning in paperwork has less time to see patients. Additional administrative support could help reduce his administrative burden and allow him to spend more time in clinic, which should generate more revenue for the practice than the administrator would cost. Simplify layout. Make sure all exam rooms are organized the same way. “The prescription pads should be in the same drawer, the tongue depressors, the alcohol wipes, whatever it is, should all be located in the same place in each exam room,” Dahl says. That way, staff members always know where supplies are and they don’t waste time searching for them. He suggests designating an employee to check that all rooms are organized and stocked appropriately each morning. ANTICIPATE CHANGE
The most efficient practices anticipate change and adapt to it quickly. One way to better enable your employees to work productively despite unexpected day-to-day issues is by “huddling,” says Dahl. Have small groups of staff members meet briefly at the beginning of each day to discuss the schedule and identify what each can do to keep things running smoothly. “A huddle can be very simple, with the provider talking to the medical assistant and looking at the schedule and saying, ‘Oh, here comes this patient with this problem,’ or looking at this patient and saying, ‘Oh, here comes this patient and every time they come in they always have four, five,
six, or 10 complaints, so that one’s going to take me longer,’” he says. Receptionists should also participate in huddles so they can better prepare for patients in advance of appointments, Dahl says. Huddling can also help you continually identify efficiency improvements. During huddles, discuss what problems occurred the day before and identify what might resolve them more quickly in the future, he says. FOSTER GROWTH
When employees leave early, take breaks when they shouldn’t, and/ or skimp on responsibilities, efficiency suffers. If you’re facing such problems at your practice, hold a meeting with physicians and supervisors to make sure everyone is on the same page regarding the line of authority, says Nelson. “If a staff member makes a request and the manager says no, the physicians need to back up the manager,” she says. There needs to be a “well-defined process” in place. Then relay that process to employees and hold them accountable for their actions. If staff members continually fail to meet your expectations, staffing changes, rearranging supervisor roles, and/or linking raises to performance expectations could help turn things around, says Nelson. And, if your staff is simply failing to work well as a team and/or individual employees lack initiative, set practice-wide goals, says Smith. Goals could include anything from decreasing patient wait times to increasing yearly revenue. If the goal is monetary, Smith says, start with the end in mind. Determine how many more patients per day, per week, per year, you need to see to reach that revenue target. Then, relay the goal to the entire staff and provide frequent progress reports. “That way,” Smith says, “everyone in the office is working toward the same goal.” n Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey. westgate@ubm.com. www.physicianspractice.com
3/20/12 1:27 PM
Physician Writer Search
‘I Feel I Am Successful When…’ How I justify my life to the angels who’ve helped me live it By George Ferenczi, MD, MBA
I am most fortunate. I grew up with angels in my life. A doctor who took me into his overcrowded clinic when I was paralyzed for months with polio, and worked with me until I was able to walk without braces. A soldier who captured my father and me as we were fleeing in the night across the Iron Curtain,
their war-torn lives, and with love — their greatest gift to me. Their love enveloped me in a cloak that is with me to this day. She set me free, literally — sending me into the arms of a free world, knowing that she may never see me again, so that I could escape the tyranny that bound us all at the time. He worked tirelessly to make a new,
What my friends and I all shared was a sense of obligation to ourselves, and to the rest of the world, to give something back for our good fortune, to give meaning to being survivors. SURVIVORS’ CLUB
and instead of turning us into the authorities carried me on his back across a half-frozen river to freedom. A dentist who treated my teeth — much neglected by a system that didn’t have the resources for such niceties — free of charge. A parish priest who paid for a new immigrant’s education of out of his own pocket. A bespectacled YMCA staffer who gave me the skills and encouragement to survive as a stranger in a strange land. Angels all. Most importantly, though: my parents. I remember them with immense respect for who they managed to be, given the severe exigencies of www.physicianspractice.com
PPJ_04012012.indd 19
better life for us. She gave me humor and grace, the ability to love that which is beautiful, to sorrow over another’s pain. She taught me the importance of friendship and the need to help another whenever I could. He gave me determination and perseverance, showed me the satisfaction to be found in a job well done, and taught me that only my best effort was acceptable. Neither one was perfect, and as I grew up, I slowly learned to forgive them for that. And as I matured, and developed the ability to see people and the world from several perspectives, I came to realize that they were, indeed, extraordinary people.
When I was considerably younger, I had a circle of friends with whom I would get together monthly. We were all survivors of some calamity or tragedy, be it war, physical trauma, or a major illness. Each meeting would start off with a question: “How do you justify your life?” We would then go around the table, giving our answers, and receiving comments and questions in return. This exercise proved to be life-altering for many of us. It gave us a chance to acknowledge our good fortune and remind ourselves that our survival was not necessarily due to our own skills and preparation, but rather to random chance, fate, or God’s will. What we all shared was a sense of obligation to ourselves, and to the rest of the world, to give something back for our good fortune, to give meaning to being survivors. We were looking for a narrative to make sense of the randomness of life. Why are we here, when many others who were in similar situations are not? What we all shared was a sense that we had been given a gift, and we had the need to give back. I have been practicing medicine, as well as teaching medical students and house staff, for more than three decades. People bring me their health problems, some of which are curable, many of which are treatable, all of which need to be made endurable. There certainly is satisfaction in diagnosing a rare disorder, especially one with a potential cure, but April 2012 | Physicians Practice |
19
3/20/12 1:06 PM
Writer Search most medical practice deals with more pedestrian illnesses, such as arthritis, diabetes, psoriasis, and irritable bowel syndrome — conditions that are not likely to be cured, but can only be ameliorated. Every week I see someone in my office whose life plans are suddenly and drastically changed by a diagnosis of cancer or similar malady. It is with the chronic and the incurable that we physicians face our greatest challenge. It is then that we must help our patients develop a new narrative about life and its meaning. It is here that we can inform of that which is possible and that which is not in a manner that doesn’t destroy hope but also does not give false assurances. We can teach how to refocus on the things that are still possible rather than on what has been irretrievably lost. We can and should offer reassurance that we will never abandon a patient as “hopeless,” but will be at his side always doing the things that make medicine a noble profession — if not curing, then relieving pain, easing suffering, offering compassion. I think I’m successful when
I am achieving these goals at least in some measure, when I can sense that someone’s fear has been diminished or abolished, when a patient or family member says, “thanks for not making us feel alone.” In order to meet these goals, we need to have a better understanding of the human condition; of how individuals and cultures look differently upon health and disease in order to develop a dialogue that’s both meaningful and therapeutic. Sadly, our profession is being driven more and more by forces that do not value this goal, even interfering sometimes with the free flowing conversation required to achieve it. An EHR may capture a lot of a patient’s symptoms and demographics, but nothing of what makes him a unique person shaped by their upbringing and experience. I endeavor to teach my students the precepts by which I conduct my practice, and to give them an insight into the personal, medical, and societal forces that are likely to affect their lives. I try to teach them of the importance of balance and of friendships they will need in
BE PART OF OUR PHYSICIAN WRITER SEARCH FOR YOUR CHANCE TO SEE YOUR ARTICLE PUBLISHED NATIONALLY — AND BE PAID $250!
YOU HAVE THE
Welcome to our Physician Writer Search project! We’ll give you a topic, and you’ll tell us how your life and practice have been affected by it, or how you have affected it, or what it means to you, or, well, whatever you want to say about it that would be relevant to Physicians Practice readers. THIS MONTH’S TOPIC: How my EHR and I learned to get along. By submitting your work, you acknowledge that Physicians Practice retains all copyrights to any work it publishes. We will not publish your work without your permission. If we do publish your work, we will involve you in the editing process.
20
| Physicians Practice | April 2012
PPJ_04012012.indd 20
clinical professor of medicine at USC Keck School of Medicine while practicing gastroenterology in Glendora, Calif. In addition to teaching and private practice, he conducts seminars for physicians in financial management.
STUFF
Ready to get writing?
• Should be 1,000 to 1,250 words (not including your name, essay title, etc).
George Ferenczi, MD, MBA, is
DO WRITE
Each month, we’ll give you a theme and a deadline, and you give us 1,000 to 1,250 words. If we select your submission, we’ll publish your column in a future issue, to be seen by more than 150,000 of your colleagues, and you’ll get a check for $250. Only MDs and DOs are eligible.
submissions due by May 11, 2012.
order to survive in our demanding profession. My wife and I invite each student and their spouse or significant other for a dinner in our home, during which we discuss the personal challenges that medical marriages face. I love when I hear of their later accomplishments or receive notes from them attesting to the value of our endeavors. No matter how you envision your angel, in the end, I feel most successful when reaching out a hand to another, as, in the words of Luciano de Crescenzo, “We are each of us angels with only one wing, and we can only fly by embracing one another.” n
• Must be e-mailed as an attachment to writersearch@physicianspractice.com in an editable format (such as Microsoft Word). No PDFs, please.
?
• Should include your full name, contact information, and a short (30 words or less) bio. • Must be an original, previously unpublished, work produced by you.
www.physicianspractice.com
3/20/12 1:07 PM
Starting Out
Taking Leave the Right Way Planning a break from your practice for a while? Here are some tips to help you work with your partners and patients. By Kate DeBevois
Whether you’re a physician going on maternity leave, volunteering overseas, or taking a vacation, it’s important to plan ahead if you need to take an extended leave of absence. From communicating with colleagues and patients about care protocols to being sure you are easily available for emergency questions or concerns, there are a lot of first steps you need to take before you can walk away from your practice for an extended period of time. Susan Abkowitz, a hospitalist and veteran volunteer who has volunteered with Washington, D.C.-based Health Volunteers Overseas for nearly 28 years, says, “I joke and say, ‘I do this parttime hospitalist job to support my volunteer habit.’ While volunteering I am very cognizant about how lucky we are in this country with the freedom to choose a profession and access to great medical care. I feel very fortunate that we can volunteer and come back to a really comfortable life.” If you are thinking about taking some time away from your practice, our experts say a little planning and communication can help pave the way. Dedication Produces Results
A mother of three, Abkowitz worked part time as a primary-care physician in private practice before transitioning to her current role. How did she take a two-month leave of absence every year while working part time? Year-round dedication to her patients and to her practice meant that when it www.physicianspractice.com
PPJ_04012012.indd 21
was time to take leave, her colleagues were happy to cooperate. “I always worked harder than three days a week, and I was always there on my day off either doing paperwork or seeing patients I could not fit into the three days.” This dedication resulted in an easy transition to taking leave. “No one had any bad feelings about my taking off because they knew I was committed to my practice and throughout the year I did not take much in the way of vacation,” explains Abkowitz. Having chosen a practice that was open to her taking leave to volunteer, she chooses to save all of her vacation and use it annually, with her family accompanying her. “My [family] didn’t take any other vacations; we had fun on these trips … we love what we are doing, and we combine it with educational activities like an African safari,” she explains. The same dedication to her practice that allowed her annual volunteer leave to go smoothly also created a smooth transition to and from maternity leave for the births of her three children. “[Maternity leave] was a similar process … only I wasn’t leaving to volunteer, I was at home with an infant and later, my other children,” she says. “I told specific patients to follow up with specific partners. I wrote long notes explaining where we were in care, and I was accessible by phone for any questions.” Both types of leave provided her family with different, yet invaluable, experiences
and Abkowitz says she is thankful her practice was amenable to her taking both maternity and volunteer leave. Creating a Smooth Transition
Abkowitz says the keys to preparing for a leave of absence include making sure that: • Everyone knows when you are going to be around; •You let your patients know there will be cross-coverage; •You discuss the needs of any particular patients you are worried about with a colleague; and • The staff knows you are making arrangements as effectively as possible. “[This includes] seeing patients right up until you (leave) and making sure you have a plan for each person,” she emphasizes. When working in private practice, Abkowitz prepared her staff by choosing colleagues she thought would be a good fit for a particular patient based on personality and style, and by “writing out instructions for particularly vulnerable or complicated patients and making sure I told colleagues about my concerns.” Because it was standard practice in her office to cover for each other frequently, many of the physicians got to know the medical history of some of the more complicated patients. In addition, the nurse practitioners would assist with patients while Abkowitz was on leave, especially if they’d had previous experience with them. April 2012 | Physicians Practice |
21
3/20/12 1:07 PM
Starting Out Abkowitz also prepared her patients by giving them plenty of notice. She says, “I always got positive reactions from [the patients]. They thought it was really great that we were helping others with our time.” Just as important, Abkowitz says these patients didn’t feel abandoned. “I don’t feel like patients thought their care suffered at all. I would tell them, ‘I’m not going to be here for a month and I want you to see doctor so-and-so and they will know all your medical conditions and have your chart.’”
the time off. Personal leaves are often at the employer discretion.” She explains that it’s important to know job protections under federal and state law as well as company policies. “Being informed upfront will enable the physician/employee to ask clarifying questions should concerns arise,” she says. Jez adds that “with very few exceptions,” a leave of absence at a practice is unpaid. Also, unless the physician has a salary continuation program, like short- or long-term disability, the federal Family Medi-
“I always got positive reactions from [the patients]. They thought it was really great that we were helping others with our time.”
ENTHUSIASTIC RECEPTION
Susan Abkowitz, hospitalist
An unexpected extra benefit was an added dimension to the doctorpatient relationship due to her volunteer work. “When we returned, the patients would spend part of the time in the office visit asking how things went and wanting to see pictures …You would even overhear them in the grocery store sometimes, saying, ‘My doctor went to Africa,’” she says. Planning Ahead
For those who are thinking about taking a leave of absence for the first time, there are certain best practices to follow before having a formal discussion with management and/or colleagues, says Cheryl Jez, a national practice leader with Philadelphia-based Reliance Standard Life Insurance Company. In preparation for leave, Jez says, “The [individual] needs to know their entitlements. If your company allows for personal time off, know the rules and guidelines for taking 22
| Physicians Practice | April 2012
PPJ_04012012.indd 22
cal Leave Act (FMLA) is job-protected, unpaid leave. She also emphasizes the importance of understanding your rights for job protection and your responsibilities before taking a leave of absence. Jez says it’s essential to “determine if your company is required to provide job-protected, unpaid leave under the FMLA or state leave laws. Unless waived by the employer, federal guidelines only apply if the employer has ‘50 employees in a 75-mile radius before taking a leave of absence.’” She highly recommends doing some homework ahead of time, including: • Checking the practice handbook; • Investigating practice policies and federal and state laws on how long your job will be protected; • Tallying your paid time off, vacation, and sick days (otherwise, Jez says, your leave may be unpaid);
• Talking to other colleagues who have taken a leave of absence; and • Taking notes or typing an outline summary of your time away from the practice. Jez recommends physicians plan ahead and incorporate the above steps as part of their leave of absence preparation. Checking the practice handbook (if there is one) provides a starting point for discussions with colleagues and ensures all aspects of practice policy are addressed. Investigating federal and state laws ensures your practice remains compliant. Tallying your vacation and sick days ensures you are prepared to plan the details of your leave of absence while accounting for built-in travel time or time at home before returning to work. Including all these aspects in your discussions with colleagues as you plan your leave helps ensure the process goes smoothly. In addition, taking notes while on leave provides a way for you to share your experience with colleagues when you return. When it comes to job protection for maternity leave, Jez says it is defined by state and federal FMLA guidelines. In addition to state and federal FMLA job-protected leaves, many employers provide nonprotected leaves to their employers. Examples are bereavement and personal leaves, she says. During the discussion with colleagues/management, Jez also suggests you discuss your availability to answer questions during leave. Regardless of the specific approach, “maintaining an ongoing dialogue as you prepare to leave is essential,” she says. Preparing your Practice
Maintaining an open discourse has worked well for Abkowitz’s husband Glenn Crawford, an orthopedic surgeon with Sports Medicine Atlantic Orthopedics in Portsmouth, N.H., for 21 years. Crawford shares his wife’s passion for volunteering and makes time at his practice to join his family, volunteering overseas. www.physicianspractice.com
3/20/12 1:07 PM
When communicating with his colleagues and staff about taking a leave of absence, Crawford says, “It was generally perfectly fine; it didn’t put any extra onus on them. There were a few patients that needed follow up while we were gone, so before I left I would talk with the physician’s assistant or doctors and give them the patient’s file.” Otherwise, he didn’t perform any significant surgeries before he left, which he felt was important. The first time Crawford took a leave of absence after he joined the practice, he prepared other physicians and the administrative staff in three key ways:
• He maintained an open dialogue with patients who may have needed surgery during his absence.
• He talked to patients openly ahead of time to make sure they were clear about who would take care of them when he was gone;
Communication Throughout the Leave Process
• For surgeons, he stressed the importance of not scheduling complicated procedures before leaving to ensure that his colleagues didn’t have to attend to post-op visits while he was on leave; and
www.physicianspractice.com
PPJ_04012012.indd 23
“If you have patients who need an operation and you don’t have time to do it before you go, talk with the patient [to determine] if they want to wait until you come back or have a colleague do [the procedure] while you are gone,” he says. Crawford is often able to time his volunteer leave for the orthopedic “slow seasons” of November and December and March and April. He says, “My colleagues know that in the summer I’ll be there all the time. They can actually take more vacation in the summertime, so it actually works out very well that way.”
Initially, Crawford had concerns about how taking leave might affect his patients. “I thought I might lose patients, but it ended up being the opposite — patients wanted to know where I’d gone recently.” Crawford discovered that while on leave, his office is able to handle most of the questions that come up
without incident. This frees him to assist patients who may not otherwise receive medical care. “It’s interesting how unimportant that is. For example, when you are working at your practice and going full speed, you think you are very important. I found that when I go away and when I come back, it’s amazing how little I was missed,” he says. “Now, I can communicate via email if I need to. When I first started volunteering, there really wasn’t any way to communicate,” explains Crawford, who believes that’s one of the main reasons why people don’t participate in this type of volunteer work. “It’s amazing how many really pressing issues [the practice] is able to handle without communicating with you. I find that even when I am available by e-mail, most of the things they ask you really aren’t very important,” he says. n Kate DeBevois is a Philadelphia-based freelance writer. She has written for several healthcare and business publications. She can be reached at editor@ physicianspractice.com.
April 2012 | Physicians Practice |
23
3/20/12 1:07 PM
Administrator’s Desk
6 Ways to Get Organized Tired of decreased productivity? Here’s how to get organized and whip your practice back into shape. By Shelly K. Schwartz
You spent the last two hours trolling your file cabinet for a missing receipt. The staff keeps popping in with trivial questions. And it just dawned on you this morning that the monthly board meeting is on Friday, forcing you to cancel two appointments to prepare. Tired of spinning your wheels yet?
with Professional Management and Marketing in San Francisco, is to set priorities. “A basic rule of management is that there is never enough time to do everything,” he says. “You can’t do it all. You have to triage your workload, figure out what’s
“You have to be accessible to your staff, certainly, but you should set one-hour slots each day where you’re available to be seen and are able to accept interruptions.”
LIMIT ACCESS
Judy Capko, consultant
Office managers juggle a mindboggling number of tasks, from personnel problems and physician credentialing to budget planning and payroll. Without a strategy to stay organized, it’s easy to get lost in the minutia, creating higher stress levels for you and decreased productivity for the entire office. “A practice administrator not only has to wear a bunch of different hats, but he or she has to keep all things related to those hats in good order so you can put your hands on what you need quickly whenever you need it,” says Mary Pat Whaley, a practice administrator for 25 years and founder of the consulting firm Manage My Practice in Cary, N.C. PRIORITIZE
The first step to creating order from chaos, says Keith Borglum, a practice management consultant 24
| Physicians Practice | April 2012
PPJ_04012012.indd 24
most important, and do that.” A daily to-do list, whether electronic or handwritten, can help. “It’s easy to look at your list and do the most attractive thing first, but you’ll be able to see at a glance what’s more critical,” says Borglum, noting a written list also helps to identify priorities for the following day, which helps you hit the ground running when you walk in the door. Keep in mind that some of your lower-priority tasks may never get done, and some, like expansion plans or personal goals, will remain on the back burner for years. That’s OK, says Borglum. “I have things on my list that have been there for three to five years,” he says. “Long-range planning often evolves from daily to-do lists.” CALENDAR CONTROL
A carefully groomed calendar is also critical. Each month brings
with it a new set of deadlines — financial reports, profit sharing and 401(k) filings, training requirements, internal project milestones. Everything you can reasonably anticipate should be documented on your calendar. “We sit down at the beginning of the year and plan out each month, designating a specific month for OSHA and HIPAA training and another for the government programs we participate in, like e-prescribing and meaningful use,” says Susan Miller, administrator of Family Practice Associates of Lexington, in Lexington, Ky. “We always know what deadlines we’re working toward.” Her calendar also includes staff and board meetings, group gatherings for staff recognition, grand rounds for the physicians, and a series of reminders ahead of important deadlines to verify progress along the way. REVISIT OPEN-DOOR POLICIES
Though Miller is on top of her schedule, even the most organized manager can’t get down to business if she’s constantly being distracted, says Capko & Co.’s Judy Capko, a practice management consultant and author of “Take Back Time” for office managers. “Managers often brag about having an open-door policy with their staff, but that’s not something you should be bragging about,” she says. “You have to be accessible to your staff, certainly, but you should www.physicianspractice.com
3/20/12 1:07 PM
set one-hour slots each day where you’re available to be seen and are able to accept interruptions.” Even then, it should never be a free for all. “Put criteria on it,” says Capko. “Tell them if it’s something they can handle themselves, they should do that.” Make sure your team has the training and tools they need to solve their own problems. “A lot of times your employees come to you because it’s easier or faster, but that job should really fall to a lowerlevel person so you can spend your time doing things that require your level of expertise,” says Capko. OPEN MAIL ONCE
It pays, too, to establish a policy of not opening mail, electronic or otherwise, until you’re prepared to deal with it. That prevents the time suck of having to sort through bills and emails more than once. A three-part file system of “do now,” “do later,” and “file” can help you process the most pressing paperwork quickly as your work flow allows. Everything else should be trashed, which has the added benefit of helping to reduce clutter.
Borglum also suggests asking your team for ideas on ways to organize their own departments. Allowing them to implement their suggestions fosters a sense of ownership. ORDER ONLINE
You should also have a system in place to keep close tabs on office supplies, which prevents the mid-morning rush to the store for ink cartridges and helps control inventory. The Internet makes it easy, says Borglum. “It’s inefficient to be driving over to Office Depot or Staples every few weeks, when most suppliers these days offer online ordering,” he says. “That takes you [or a staff member] out of your seat, and interrupts efficiency.” Such vendors generally keep track of prior orders so you need not reinvent the wheel each time you go to order printer paper or new pens. You’ll also be better positioned to keep track of brand, model, and item numbers for all your office supplies and generate utilization reports. “That helps control embezzlement, and pilferage which is much more common,” says Borglum. “That happens when someone orders a case of tape for the office and brings half of it home with them.”
Thousands of Practices Saving Millions of Dollars! We are a nonprofit Group Purchasing Organization (GPO) serving practices of all specialties and sizes nationwide.
No Contract!
MAKE AN EMERGENCY PLAN
Finally, the organized administrator should always be prepared. The Medical Group Management Association recommends all practices have a secure back-up system in place to store duplicate personnel and financial records, in the event of a power outage or IT meltdown. You should also have a plan for fire emergencies, hazardous spills, and breaches of security that includes a grab-and-go bag that has important phone numbers for the building manager, fire department, employees’ home and cell phones, and insurance contacts. By putting your ducks in a row and setting priorities every day, you’ll be able to use your most limited resource — time — more effectively. An added perk: When you’re not playing catch up as a matter of course, you’re likely to sleep better, too. n Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.
We select and negotiate the best pricing/terms on products and services such as Vaccines, EHRs, Insurance, Pharmaceuticals, Medical and Office Supplies and much more! Members have free access to over 70 preferred pricing solutions!
PLUS...In addition to best pricing, our
Vaccines Rebate Program gives our members the opportunity to realize even more savings on vaccines!
Join Today And Save! www.physiciansalliance.com 866-348-9780
www.twitter.com/physall www.facebook.com/physiciansallianceofamerica
www.physicianspractice.com
PPJ_04012012.indd 25
April 2012 | Physicians Practice |
25
3/20/12 1:08 PM
Physician Beware
Communication Breakdowns Tips to improve employee interactions By Aubrey Westgate
About a decade ago, family physician Randall Rickard separated from a larger healthcare system in Murfreesboro, Tenn., to form Family Practice Partners, an independent four-physician, two-site practice. Unfortunately, breaking away from the larger healthcare system led to major communication breakdowns between staff members at the new practice, says Rickard. “We formed this group and we didn’t have much effort put into working together,” he says, noting that faulty communication arose within each practice site and between the two locations. Employees were failing to discuss their daily schedules and responsibilities with one another, and as a result, coordination and efficiency suffered. “To build teams you have to build communication,” says Rickard. To combat these types of breakdowns, Rickard and his colleagues began “huddling” with small groups of employees each morning to briefly discuss the day’s schedule and identify what each individual could do to keep things running smoothly. They also initiated full-staff meetings regularly to relay goals, policies, and upcoming changes to employees. That way, Rickard says, “We could all work toward the same point as opposed to just randomly establishing schedules without communicating with each other.” Today, Family Practice Partners is thriving. So much so that it’s even added a third practice site to its group. “We did a much better job once we started communicating,” Rickard says. “…In order to innovate we had to communicate a lot.” CHAIN REACTIONS
Often practices underestimate the importance of communication, says Barbara Stahura, a practice management consultant at PYA GatesMoore in Atlanta. 26
| Physicians Practice | April 2012
PPJ_04012012.indd 26
“A lot of times people see communication as a ‘soft skill,’” she says, noting that it’s not as “in the news” as say, coding changes, and it might not seem as measurable as accounts receivable. But, done poorly, it is very measurable in terms of the problems it creates, she says. As Rickard learned, the poor interchange of ideas can cause inefficiencies and disorganization. Worse, it can hinder quality of care, says Sherry Migliore, director of consulting at PMSCO Healthcare Consulting in Harrisburg, Pa. “If you have inherent issues in terms of how staff communicates with each other, you are going to have communication issues with patients as well,” she says. Of course, when quality of care is hindered by poor expression of information, both the patients and providers suffer negative results, says Miranda Felde, assistant vice president of patient safety at The Doctors Company, a nationwide malpractice insurer in Napa, Calif. “If there is a patient harmed and the patient decides to pursue litigation or file suit against the physician provider, the physician has to endure that,” she says, noting that 85 percent of medical malpractice cases result from communication failures. Making clear communication a top priority is the first step to improving it at any practice. If staff members don’t understand its importance, they don’t take the time to ensure they are articulating their ideas properly, says Migliore. Stahura says implementing formal communication policies is key. Leaders should “define their expectations” regarding verbal, written, and nonverbal communication skills and policies. But leaders also need to show staff members that they too are working to fulfill those expecta-
tions, she says. “You can’t expect your staff to communicate well and treat patients well if they’re not seeing it modeled at the top.” THE CRITICAL TOOL
Meetings provide an ideal opportunity for leadership to prioritize and address communication issues, says Migliore. Meetings can also (as Rickard learned) ensure your staff is working together to reach shared goals. • Staff meetings. Meryl Luallin, a healthcare marketing consultant with SullivanLuallin Healthcare Consulting in San Diego, advises weekly staff meetings to keep employees updated and connected. Meetings minimize confusion that might later lead to communication breakdowns, and they reinforce a constant flow of discourse between staff members. Migliore recommends making communication an agenda item at such meetings. This helps relay its importance, and it also provides an opportunity for staff members to continually discuss problems and identify ways to solve them. • Department meetings. For large medical practices, Stahura suggests short weekly meetings within each office area to discuss issues and keep staff informed. • One-on-ones. When employees continually communicate poorly with one another, a manager should step in to help facilitate a discussion and resolve the issues, says Migliore. www.physicianspractice.com
3/20/12 1:08 PM
Though meetings are “critical” to keeping communication flowing, Stahura says the frequency and type of meetings should vary depending on your practice’s size and current challenges faced. “You have to feel out what works based on the practice,” she says. THE VITAL ACTIVITY
As Migliore points out, medical practices are now more “hectic” than ever. Often staff members have less time to do the same, or more, amount of work. This leads to major communication breakdowns. “When you are rushing from one thing to the next and you don’t have a lot of time, you don’t communicate very well,” she says. Daily huddles can ensure your staff is prepared and ready to take on each day despite busy schedules, says Luallin. Each morning, small teams of staff members, for example, a doctor, nurse, and receptionist, should huddle briefly to discuss the day’s schedule, identify challenges that might crop up, and allocate tasks and responsibilities. Huddles can also solve communication breakdowns between departments, says Stahura. For instance, if your practice is encountering accounts receivable problems, the billing office and the front office should huddle each morning to review the schedule and determine what needs to be collected from patients, she says. “I think it’s a great way to understand what each other does, what your role is, and how they play into each other but also get the job done.” FURTHER COMPLICATONS
Often breakdowns are more prevalent at large multi-specialty practices and multi-site practices. One reason is it’s more difficult for staff members to become personally acquainted with each other, says Luallin. “You have to know who it is you are communicating with.” Leadership at these practices should foster social interaction by holding weekly or monthly staff gatherings, such as lunches or dinners. Quarterly “town hall” meetings can also ease breakdowns, says Luallin. The entire practice staff should meet www.physicianspractice.com
PPJ_04012012.indd 27
in one location to discuss goals, responsibilities, policy changes, etc. “It builds camaraderie,” she says. “That also improves communication.” Stahura suggests using Skype to hold remote practice-wide meetings when multi-site practices are separated by larger distances. She also says implementing practice-wide newsletters can help keep staff updated and connected. “The goal is to make everyone feel like we’re one practice as opposed to only identifying with the site.” HONING SKILLS
One of the most common sources of breakdowns is when staff members and physicians simply lack proper communication skills. Here are a few noteworthy one-on-one tips: • Respect. When providing feedback to others, never “crush” them, urges Luallin. And when criticized, don’t immediately become defensive. • Follow through. When discussing a new policy or responsibility, don’t assume colleagues immediately understand what you are saying. Check back in with them, says Migliore.
• Repeat back. When giving instructions to a colleague, ask him to repeat back his understanding of your directive, says Felde. That creates a “constant communication flow to and from so there isn’t any kind of misunderstanding — the communication is clear.” • Tone appropriately. When rushing to complete a task, watch your tone, says Migliore. It’s easy to come across as curt or rude. “How you say it is just as important as what you say.” If one-one-one communication problems are causing serious breakdowns at your practice, invest in skills training for staff and leadership, says Stahura. Though the initial price tag might be off-putting, she points out that not investing is likely costing you money. “Over and over again when we go into a practice we hear that communication is a problem,” she says. “… Training is well worth a practice’s time and expense.” n Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey. westgate@ubm.com.
Want to slow down? But your call program won't let you? Moonlighting Solutions can help. By providing high-quality BC/BE physicians to cover your night and weekend call shifts, we allow you to maintain a productive practice without staying up all night or having to negotiate with your partners. Moonlighting Solutions is a physician-run company that specializes in covering nights and weekends. Contact us today to see how we can prevent call from destroying your practice.
It’s the right answer for you, your practice and your patients.
For more information call (800) 807-7380 or visit www.moonlightingsolutions.com April 2012 | Physicians Practice |
27
3/20/12 1:08 PM
In Practice
ACOs
A Guide for
Physicians Should you join an accountable care organization? Here’s what you need to know about these emerging care-delivery models. By Rosemarie Nelson
Accountable care organizations have been described as unicorns, because none have been seen but everyone knows how to describe one.” So says Medical Group Management Association independent consultant Owen Dahl. Because we haven’t yet seen any ACOs in action, many practices have put off thinking about them. But ACOs are emerging, in more than just theoretical form, and understanding market changes just makes good business sense. Should you get involved with an ACO? The answer depends on your practice’s strategy, culture, and tolerance for risk. An ACO is an organization of healthcare providers that can receive additional funds from Medicare (and an increasing number of private payers) if it can demonstrate that it provides higher-quality care 28
| Physicians Practice | April 2012
PPJ_04012012.indd 28
at reduced costs to a defined group of patients. An ACO must measure quality, outcomes, patient satisfaction, and cost, for which it will need a sophisticated IT infrastructure, and it must form a legal organization to receive and distribute shared savings among its providers. The regulations governing Medicare’s new Shared Savings Program have formed the framework around which ACOs will organize. To participate in that program, an ACO must: • Define processes to promote care quality, report on costs, and coordinate care. • Develop a management and leadership structure for decision making. • Develop a formal legal structure that allows the organization to receive/distribute bonuses to participating providers.
• Include the primary-care physicians (PCPs) of at least 5,000 Medicare beneficiaries. • Provide CMS with a list of participating PCPs and specialists. • Have contracts in place with a core group of specialist physicians. • Participate for a minimum of three years. ACOs will be led, for the most part, by hospitals and regional health-delivery systems, since only such large organizations have the scale necessary to meet the government’s regulations, which are centered on managing the healthcare outcomes of large populations. But ACOs are going to need affiliated community clinics to deliver many actual services to patients, so practices will have an opportunity to join ACOs. www.physicianspractice.com
3/20/12 1:08 PM
Hospitals that are forming ACOs might offer to purchase your practice outright, or may propose (or be open to) some lesser form of formal affiliation. Such offers might be attractive, as declining reimbursement and increasing practice expenses have driven many physicians in recent years to consider paths that include hospital employment, hospital integration, and various other professional service arrangements. When affiliating with a hospital, you want to reduce the headaches of practice management, increase your access to capital, mitigate the risks of an uncertain future, and improve your income potential. But the flip side to all that is a loss of control. Entrepreneurial private-practice physicians tend to underestimate what it will mean to have the hospital as their “boss.” Before making any decisions about affiliating with a hospital, consider the nature of your current relationship with its administration. Bear in mind that a new kind of affiliation might bring with it additional bureaucracy and make it harder to do what you want to do. But it might bring benefits, too, like income stability and resources for new technologies. HOW’D WE GET HERE?
The trends shaping healthcare today are consumerism and patientcentered care; transparency in healthcare cost-effectiveness; value, as represented by quality and safety in relation to cost; metrics; and information technology that delivers real-time data on the patient, processes, and systems. As the population statistics change and baby boomers age, healthcare costs are rising. The growing rate of obesity adds to the number of Americans with other chronic conditions such as diabetes, CHF (congestive heart failure), and CAD (coronary artery disease). Employers understand the impact of health and wellness on the productivity of their work force, as well as the ever-increasing cost of insuring their employees. Consequently, employers continue to experiment with wellness programs such as smoking cessation, weight loss, and health coaching. www.physicianspractice.com
PPJ_04012012.indd 29
Change in the payment and delivery system is inevitable. Health reform will shortly deliver many newly insured patients to your office. Evidence-based medicine focused on outcomes and quality will be a central organizing principle for care delivery and payment. Cost management is a practical imperative for a sustainable delivery system. And information technology is essential plumbing to this increasingly sophisticated system. SHIFT TO THE ACO
ACOs represent less a paradigm shift in healthcare delivery than the coalescence of many tactics that have been tried at different times over the years to make providers accountable for their patients’ health status. For example, membership in HMOs increased in the 1990s as health plans, hospitals, and physicians sought to deliver more costeffective healthcare. More recently, medical homes have offered upfront payments to physicians to provide additional services, such as coordinating care with other providers. But these initiatives usually lack mechanisms to tie providers’ pay to their patients’ ongoing clinical outcomes — one of the hallmarks of the ACO model. Unlike previous iterations, moreover, ACOs will rely on providers to review their own work and set standards. Their success will depend on how well providers, payers, and patients navigate the challenges that limited the effectiveness of previous efforts. The core principle of accountable care is the alignment of payments, benefits, and other healthcare policies with measurable, meaningful progress in improving healthcare while lowering costs. Under Medicare’s Shared Savings program, an ACO that succeeds in both delivering high-quality care and reducing the cost of that care to a level below what would otherwise have been expected will share in the Medicare savings it achieves. Access to high-quality information systems, medical management protocols for monitoring patient adherence, and compliance with regulatory requirements are all essential to ACO development and management.
Clearly, the costs and effort associated with these activities are substantial. Having an enterprise-wide EHR is not enough. The capability to develop information from the data within the EHR to facilitate changes in the practice, and then demonstrate the results of those changes to payers, is essential to population health management, which is at the heart of the ACO model. Patient engagement requires secure messaging, patient portals, patient-maintained health records, and tools for patient self-care such as telemonitoring, mobile health applications, and telemedicine. Having knowledgeable managers with relevant experience will be important to effectively implementing and managing ACOs. In an ACO, providers are accountable for achieving better results for all of their patients at a lower cost. However, physician groups may resist policies that put them at risk. ACOs will have to offer incentives that make the risk worthwhile for practices. An ACO can be made up of a multispecialty group; an organization of individual practices (like an independent practice association, for example); partnerships or joint ventures between hospitals and medical practices, in addition to physicianhospital organizations and integrated delivery networks; or hospitals with their employed physicians. A functional ACO most likely needs to include primary-care physicians, specialists, and a hospital. It also needs to be able to administer payments, set benchmarks, measure performance, and distribute shared savings (or allocate losses). Implementation of the Shared Savings program began on January 1, with 32 “pioneer” organizations. Medicare’s Pioneer program is designed for healthcare organizations that are already experienced with coordinating care for patients across care settings, so they can move more rapidly from a shared-savings payment model to a population-based payment model as they demonstrate specified levels of savings during the first two years of the program. April 2012 | Physicians Practice |
29
3/20/12 1:08 PM
in practice
Most of the Pioneer ACOs are linked to integrated delivery networks, academic institutions, and independent physicians’ associations. The Renaissance Medical Management Co., for example, is an organization led by primary-care physicians in southeastern Pennsylvania that includes a network of approximately 200 family and internal medicine practices and an established relationship with a health plan. The initiative will test the effectiveness of several payment models and how they can help experienced organizations provide better care for beneficiaries, work in coordination with private payers, and reduce Medicare cost growth, according to HHS. The Pioneer ACOs are required to engage other payers in similar efforts to the Shared Savings program. Pioneer ACO payment models include the risk of financial penalties for providers should healthcare spending accelerate. The risk of financial loss is perhaps greatest for the option that pays providers under a capitated model starting in the third year. Eligible savings range from 50 percent to 75 percent of the amount providers save, depending on the level of risk the ACO accepts. SHOULD YOU PARTICIPATE?
All this leaves many providers with a decision to make: Should you jump into ACO participation? “A lot depends on the market and who the players are,” says Kim Harvey Looney, who leads the healthcare regulatory practice at Waller, Lansden, Dortch & Davis in Nashville. What is your relationship with the hospital — do you trust its management enough to be business partners going forward? “Rather than jumping on board, be a little wary and be thinking about doing something to align with other physicians,” suggests Looney. Pioneer ACOs will prospectively know who their included beneficiaries are, and will be able to contact them. But patients will continue to enjoy freedom when it comes to their healthcare choices — nice for them, but a challenge for the ACO, 30
| Physicians Practice | April 2012
PPJ_04012012.indd 30
u? o Y r fo nnaire
Questio Is aelnf-CACO heck
CO? n an A to joi ns: whether questio y-to-day wing decide ur da to ollo g uality? n to yo the f ill mea ve linked to q Tryin w O C A ti e n sider e th c f n no cialty an in Co d with our spe the visio
AS
of y hat lance willing ntative know w vity ba Do you s? Is producti represe nomy are you a r o u n o o to y ti u l a a il r h W ope nized? ble? How muc O orga rmathe ta the AC t a is r e w ew info k o a H adopt n nd support? ision-m c to e e d v a a be l you h lementation a quish? ne? Wil p to relin d the d timeli e plan for im n a s s e logy an e proc techno CO? hat is th th d W e is ? d t ls e a o e Wh y to quire n plement the A hnolog al to ac tion tec e capit xpertise to im s you th e v a ysician e h ese ph e ACO ational nd man r th th a e p s e re o e c A o an D ent and e ACO? govern m th e ir g in e a s th n ie ma t and is pecialt other s ith in the pas as well re the w a t s ts a r n h u e model o ? W red pati sistent with y elivery ation a d h ip d s c n ti e a r v n ha osophy ding pa medicine, tyle co il s lu h t c p n in e ’s agem e ACO gram — ence-based astructed to th id the pro commit y aspects of ata-driven, ev t and EHR infr t using u o y n e d k Are en r m to e e e g th c elopme a n as o col dev adhere practice man to d n ro a p in defined ipation in care use of ? tic nd par are standards a , ture rable c u s a e m
which is responsible for their health outcomes. Novant Health, owner of 13 hospitals and hundreds of clinics in states from Virginia to Georgia, considered joining the Pioneer ACO program. But Fred Hargett, Novant’s executive vice president and CFO, says he didn’t see enough in the regulations about the patient’s responsibility or accountability. “Their mobility is a question mark for us,” Hargett says, referring to patients’ ability to seek care outside of the ACO. Novant Health is working to develop ACO-like concepts with commercial payers, but is holding back on the government’s version. Reimbursement methods will continue to incorporate quality and outcome metrics, and affiliation with larger healthcare systems will provide physicians with a voice in the process of developing those metrics — as well as determinations of the incentives for meeting them. As opposed to direct employment, affiliation allows physicians to maintain some control in a time of transition. Affiliation with healthcare systems also provides support for physician participation in other delivery-reform efforts such as expanded use of
medical homes, bundled payments, value-based purchasing, adoption of information technology, and payment reforms. The decision to participate in an ACO is a serious and far-reaching decision. Rather than try to fit into a predetermined definition of accountable care, providers are exploring innovative approaches with commercial payers to reward quality and more closely align the pieces of the healthcare delivery chain as patients experience them. Have you explored your economic, political, and organizational options to maximize your chances of success? n Rosemarie Nelson is a principal with the MGMA healthcare consulting group. She conducts educational seminars and provides keynote speeches on a variety of healthcare-technology and operational topics. Drawing upon her diverse experience, Nelson provides practical solutions to help medical groups succeed in their practices. She may be reached at www.mgma. com/consulting/nelson. www.physicianspractice.com
3/20/12 1:08 PM
Technology
Thanks to new federal initiatives and the increased use of smartphones and tablets, more physicians are communicating on the go By Marisa Torrieri
For most physicians, coordinating care with other doctors and staff can be a time-consuming, backand-forth, error-prone process. But for pediatrician Wendell Wheeler of South Park Pediatrics in Chicago, an EHR user of nine years who purchased his iPad and iPhone in January 2011, it’s as easy as making a few taps with his finger. Armed with his mobile gear, Wheeler can open patient charts at any time, anywhere, and do everything from advising patients on medications and sending prescriptions to pharmacies, to communicating with outside physicians about specific patients. “It’s a nice extension [to the EHR],” says Wheeler. “I’ve been using Amazing Charts for nine years. I went into private practice and I wanted something that would make it easier for me to keep up with my patients and [my iPad and iPhone] have done that.”
initiatives under the Patient Protection and Affordable Care Act — including the muchpublicized accountable care organization (ACO) initiative that rolled out in April — call for greater communica-
Technology helps physicians make quick decisions anytime, anywhere. PLUGGED IN
Wheeler’s use of mobile technology to collaborate and communicate with his healthcare peers is representative of a shift in the way many physicians are practicing medicine. And it’s a shift that will only continue to expand. In addition to CMS’ meaningful use incentive for EHRs, new www.physicianspractice.com
PPJ_04012012.indd 31
tion between physicians. Additionally, a growing number of technology vendors are rolling out mobile versions of their EHRs that allow physicians to do everything from video chat with patients to send charts to hospitals utilizing different systems.
“If you think about healthcare IT, about a world where healthcare IT is being delivered in real time, you can see how mobile devices play a larger role, because physicians have a mobile device wherever they are,” says Albert Santalo, founder, president, and CEO of cloud EHR provider CareCloud. In the future, mobile collaboration between physicians is expected to deliver even more benefits, though it requires some considerations. Rise of the Mobile Physician
As with the general public, the use of electronic communications among physicians has picked up steam over the last several years. April 2012 | Physicians Practice |
31
3/20/12 1:08 PM
technology
For starters, the number of physicians who use the Internet has increased. According to our 2011 Technology Survey, 74 percent of hospital-owned and 66 percent of independent practices out of a pool of 1,013 respondents said their practice has a website. Nearly 40 percent of respondents said their practice uses e-mail to communicate with patients.
fully implemented EHR. That number jumped to 55 percent in 2011. The timing of CMS’ regulations couldn’t have been more serendipitous for the mobile electronics industry. In April 2010, Apple released the first version of the iPad tablet, which is still, to date, the most popular tablet brand among physicians. Per our technology survey, 20 percent of respondents (including
“If you think about healthcare IT, about a world where healthcare IT is being delivered in real time, you can see how mobile devices play a larger role, because physicians have a mobile device wherever they are.” THE MOBILE ROLE
Albert Santalo, health IT executive
But the biggest, most obvious catalyst for the growth of electronic communications in the practice is CMS’ incentive program for EHRs that launched in July 2010, offering providers who demonstrate “meaningful use” of an EHR up to $44,000 under Medicare, or up to $64,000 under Medicaid. In 2010, 48 percent of 597 respondents to our annual technology survey said their practice had a
in summary Here’s why mobile collaboration is the way of the future:
of technology is on the rise. • Use Twenty percent of practice professionals own a media tablet; 44 percent own a smartphone.
devices can eliminate • Mobile time-consuming communication by
•
physicians via faxes and phone calls.
New initiatives under the Affordable Care Act call for greater communication between physicians.
technology vendors are rolling • More out mobile versions of their EHRs, allowing functions like video chat.
www.physicianspractice.com
physicians and practice administrators) own a media tablet, and 54 percent own a smartphone. So it’s no surprise a growing number of EHR providers are offering mobile device access through these gadgets. For physicians, using mobile devices makes stuff such as e-prescribing and looking up medication information easier. “I’ve seen physicians go from Palm Pilots to having mobile phones, and vendors are making sure they have everything they need to treat a patient,” says Mary Griskewicz, the senior director of health information systems for Healthcare Information and Management Systems Society. “Many physicians have iPhones today, and many are moving toward Android [smartphones].” The Changing Face of Care Coordination
When physicians think of collaboration and coordinating care with their peers, many envision faxing April 2012 | Physicians Practice |
PhysiciansPractice_Apr2012-1-3P OL.indd 1 PPJ_04012012.indd 33
33
1/26/12 2:50 PM 3/20/12 1:08 PM
TECHNOLOGY
medical records back and forth and calling other doctors. Though this is still being done, a growing number of physicians are opting to coordinate care through electronic — as well as mobile — means. In addition to the increased use and sophistication of technology, there are a couple of other factors that are driving this shift. For starters, physicians are perhaps some of the busiest professionals on the planet. They’re often under tremendous cost pressure from their practices and payers to squeeze as many patients as possible into a day. But when the day ends for most people, it doesn’t end
one of the great things about it is its mobility,” says Corson. “I was … recently on an airplane from Salt Lake City to Newark, and I was communicating with my office, doing refills and such.” And thanks to the healthcare reform law, new regulations are also incentivizing physicians like Corson to embrace collaboration. In early 2011, under direction of this law, CMS called for the establishment of ACOs, organizations that share the responsibility for cost and quality care received by patients in exchange for a share of savings they achieve for the Medicare program. Corson expects to be coordinat-
“Physician-to-physician communication around a unified medical record, that’s the holy grail” STRIVING
Joel Andersen, health IT executive
for physicians. Using technology helps physicians make quick decisions anytime, anywhere about a patient’s care. Hillsborough, N.J.-based family physician Richard Corson obtained his Cerner EHR four years ago, and as the EHR vendor extended its access to mobile phones and cloud environments, he started taking advantage of the ability to access his data from any location. Though Corson only uses his Android smartphone to access his Cerner EHR when there is no laptop available, he likes having the option of always being near his data and able to manipulate it. “The EHR is going to be an integral part of how medicine will be practiced in the near future, and
more online To learn more about the pros and cons of coordinating care through mobile technology, watch our video interview with CareCloud’s Albert Santalo and physician/consultant David Lee Scher. Visit http://bit.ly/mobiletechvideo. 34
| PHYSICIANS PRACTICE | APRIL 2012
PPJ_04012012.indd 34
ing care outside of the office even more in 2012, as he recently applied to be part of the patient-centered medical home initiative led by the American Academy of Family Physicians, centered on collaboration between physicians to provide chronic disease management for specific patient populations. “That’s one of the main pillars of the patient-centered medical home: coordinating care with other physicians,” he says. WHAT’S NEXT
Physicians who’ve already hopped aboard the mobile collaboration bandwagon can’t say enough about the benefits they enjoy. “It’s been very nice,” says Wheeler, who uses his iPhone and/ or iPad at least twice a week to coordinate care. “I can pull up a patient’s notes, their allergies, their medications, and I can write a note and sync it up when I get back to the office. I can open it up in 15 seconds and it gives me full demographics including telephone
number and pharmacy number, and all of the notes from every visit.” Wheeler now has more time for patients and says he feels less stressed. Benefits like these are what Joel Andersen, chief marketing officer of Lumeris, formerly ClearPractice, is banking on. A little more than a year after ClearPractice launched its signature mobile EHR, which is tailored to the iPad, the company has changed its name and direction. One of its goals is to create products that help physicians improve mobile coordination. “Our strategy has changed a little bit, really, around accountable care,” says Andersen. “For accountable care to work, you’re going to need to engage physicians in new ways so they can do a better job of coordinating care for patients, or episodes of care for a specific patient.” As such, Lumeris’s latest product, still in production, is a “physician engagement solution” that combines the company’s signature EHR with tools to collect and share data/ information from across the continuum of care. Though Lumeris is primarily targeting hospitals because they are leading the formation of ACOs, the product is designed to be compatible with most major EHRs used by practices. “It’s a system that takes information from all these disparate systems to create what we call a ‘single version of the truth,’” says Andersen. “It’s an intelligent health information exchange … an integrated platform as a service that includes specifications to decode and exchange information in a meaningful way.” CareCloud also has a stake in the mobile EHR game, and is developing products to help facilitate mobile care coordination — but not just for doctors to communicate with each other. “There will be physician-patient collaboration in all this,” says Santalo. “You’ll be able to do video, voice, chat, sharing of records, and stuff like that.” WWW.PHYSICIANSPRACTICE.COM
3/20/12 1:22 PM
PhysiciansPractice.com/coding.
HOW DO YOUR PAYERS RANK?
Each year, PHYSICIANS PRACTICE ranks the payers in a report called PayerView.SM How well does your payer treat physicians? Find out by searching Payerview at tablets being of patients, PhysiciansPractice.com..
Santalo sees mobile especially helpful to mental health professionals, who will be able to talk to patients in different care settings, such as schools or prisons, from their office or another location. Potential Considerations
more aptly coordinate ancillary service offerings,” says Andersen. “Physician-to-physician communication around a unified medical record, that’s the holy grail, where one doctor and another doctor can coordinate the transition of care from one doctor to another.” n
CLICK AND LISTEN
Our monthly podcasts cover everything from RVUs to meaningful use to training staff in informative interviews with experts. Listen now at PhysiciansPractice.com/podcasts.
Mobile collaboration’s benefits — making life easier and less stressMarisa Torrieri is an associate editor ful and allowing physicians to do MORE THAN of Physicians Practice. She can be a better job of caring for patients PRINT reached at marisa.torrieri@ubm.com. because they can coordinateJUST care The Physicians Practice Buyers anytime, anywhere — aren’t Guide costis more than a print and consideration free. directory! Our online version allows you to browse our A number of issues need to be electronic listings by category, compare products addressed by providers looking to do and services side-by-side, anything mobile, from accessing their and email vendors with a click. it at PhysiciansPractice.com. EHRs to collaborating withSee physicians at off-hours. For starters, there’s the compatibility issue. Applications used by Physician A have to support whatever smartphone platform is being used by Physician B. And some older EHR technology isn’t readymade for all mobile platforms. We offer six credits a year. Then, there are the security issues. Read our articles and take a SIGN UP FOR Per HIPAA, personal health informaquiz to earn free CME credits. POPULAR tion that is digitized mustOUR be encryptVisit www.cmellc.com/ PracticeManagement. E-NEWSLETTERS ed or otherwise secured before it is “I sometimes sent across the airwaves. In addition,feel isolated in my practice without a barometer to you have to make sure checks and the practical balances are in place so the wrong aspects of business. Your e-newsletter is a huge help.” user can’t access given data. – Allish Hayes, MD, Boston, Massachusetts “It’s one thing to set up an appAT PHYSICIANS REGISTER to allow physicians and PRACTICE.COM other caregivers to access the data, but you have to restrict what data and what data elements the user(s) can see,” says healthcare technology consultant Marion Jenkins. “So you MicroMD® PM + EMR software would have to manage and authenticate users and their devices.” Successfully secure CMS EHR incentives with ONCFinally, don’t forget to consider ATCB certified MicroMD EMR and profitably manage the cost. billing operations with MicroMD PM. Henry Schein Media tablets run upward of $500 MicroMD provides simple yet powerful EMR and upfront, plus additional data-plan practice management solutions that facilitate the charges depending on how you will delivery of superior patient care, automate incentive use the device to go online: A wireless and quality reporting activities and streamline operator’s data plan can run $25 per operations for today’s busy providers. month and up. The same goes for MicroMD EMR Version 7.6 smartphones: Even with a two-year CC-1112-524956-3 Schedule your look at MicroMD PM + EMR contract, a smartphone can cost $200 www.micromd.com/certified or more a month, and that doesn’t include monthly service charges. 800-624-8832 However, having mobility could www.micromd.com/simplify be well worth the money if you value certain benefits. “Mobile devices allow you to manage admission and discharge
LOOKING FOR FREE CME?
SIMPLE TOOLS. POWERFUL RESULTS.
BY CCHIT ®
www.physicianspractice.com
PPJ_04012012.indd 35
April 2012 | Physicians Practice |
35
3/20/12 1:22 PM
Coding
Coding Questions? Answers
We’ve Got the
Family planning modifier; NPP billing; coding concerned patients; modifiers and bundled codes By Bill Dacey
FAMILY PLANNING MODIFIER
We get denials when we use the 96372 code for the administration of Depo-Provera. Can we just use a 99211 instead? A You could be getting denials on these because you are not using the family planning modifier, which is required by some payers. The provider manual for one payer states that “CPT procedure code 96372 (therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular) was a new code effective with date of service January 1, 2009. The FP (family planning) modifier is allowed with this code. However, some claims have been denied with a denial code that states ‘Claim includes family planning diagnosis and no family planning procedure.’ Please resubmit with family planning procedure/modifier or correct the diagnosis.” Watch those Level II HCPCS modifiers. NPP BILLING
Q If a NPP sees a new problem on one Medicare patient and bills under the NPP’s own ID, then continues management on the next visit following the physician’s plan outlined in the previous visit, would the billing be incident-to in the second visit but not the first visit? Is it OK to go back and forth depending on the situation on the same day? A Yes. Although the regulatory side would not express it that way, (that it’s OK to go back and forth on the same day), that is what the regulations come down to if you have the requisite oversight in the incident-to version. For a new problem, use the NPP NPI and direct bill. For an established problem with oversight, use the physician NPI and bill in the physician’s name. Good distinction! There has been discussion among carriers and regulators that once a NPP is using his own number, they should not have to pay for the incident-to version, but as long as the incident-to policy is in effect, what you describe is allowed. CODING CONCERNED PATIENTS
Q When I bill an E&M visit along with an AWV, I have been getting some patient complaints about the two charges — even though Medicare patients don’t pay anything on the AWV. Complaints worsen when I bill a regular 99395 or 99396 to a commercial insurer in addition to an E&M office visit. I thought this was allowed. What am I missing here? I’m really getting some upset patients. A If you are billing two codes because you are performing two distinct services then you are doing this correctly. But don’t forget to include the patient in the discussion. 36
| Physicians Practice | April 2012
PPJ_04012012.indd 36
It is really most efficient to combine an AWV for a Medicare patient with a scheduled chronic disease follow-up visit. In fact, some Medicare patients seem disturbed when they show up for an AWV and discover that there is no exam component. Patients like to have someone “kick all the tires” every once in a while. But to avoid any confusion, be sure to state upfront what the nature of the visit is. State that two services are being provided. Tell the patient, “You are here today for the AWV and management/assessment of X.” You will of course document the history, exam, and decision making associated with the problem and outline the elements addressed for the AWV. If you communicate this well during the encounter you will have fewer problems later. Some practices design work flows so that office or nursing staff participates in “prepping” the patient for the “what we are doing today” conversation. But in the end, the provider really should confirm or restate the services that will be provided. This can be more difficult for commercial plans when using the 9938199397 preventive codes along with an E&M. Not all plans cover both codes on the same day and this will surely get a rise out of patients. In this case, it is more important to check the patient’s coverage when the visit seems likely to be one in which multiple services will be provided. But again, the key to avoiding the phone calls and upsets www.physicianspractice.com
3/20/12 1:09 PM
is communicating along the way what you are doing. The trickiest visit of this sort is when it starts as a well visit only, and a finding is made either on examination or as a result of the ROS which then requires significant problem management. In this case, a problem crops up unexpectedly and no one — neither you nor the patient — was expecting two types of codes. Once more, the best course is likely to communicate with the
system in a chart review? I have heard it described as cardiopulmonary. I get that, but isn’t it really a cardiopulmonary cause with a musculoskeletal manifestation? I was looking at the general multisystem examination. Under the musculoskeletal section, the second bullet point is “Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes).”
The better course is to have a flat cash fee for a “family conference.”
SANS PATIENT
patient that you need to account for the tests ordered and work done and that there will be a problem-management component to this visit. A best practice is to post a policy or guide to combination visits somewhere in the office where patients can see it. No surprises is the goal. MODIFIERS AND BUNDLED CODES
Q I recently started working at an orthopedic practice and I am working on denied claims. I have come across several claims that have been billed with CPT codes 29881 and 29877-59. Different payers are denying the claims stating the payment for 29877 is included with the primary code, even though modifier 59 was used. Is this correct? A The first place you should refer to is to CCI. You’ll see that 29887 is a Column II component of 29881. The modifier indicator is “0” — which tells you that no modifier will break the edit. The modifier you would likely have used is 59, but even that won’t work here. Modifier 59 will break bundling edits in some cases, when indicated by the CCI tables, but it isn’t fairy dust! CHART REVIEW
Q Is documentation of clubbing acceptable for the musculoskeletal www.physicianspractice.com
PPJ_04012012.indd 37
Wouldn’t that make it possible to use clubbing as an exam element for musculoskeletal? A Yes, the 1997 exam guidelines do indicate that clubbing and cyanosis are in the musculoskeletal system — and you can count them as such. But, the bigger issue is when the exam area is labeled as “extremities,” followed usually by the CCE comment. Although the finding is technically musculoskeletal as above — it doesn’t look like it — it looks more like a cardiorespiratory finding in an extremity and may not be counted as a separate system by federal or other auditors. FAMILY CONFERENCE/ PATIENT ABSENCe
Q If a patient does not come to the office, but a family member comes instead and wants to discuss the patient’s health conditions, can you bill for the consultation based on the history and decision-making parts (2 out of 3)? A Medicare requires that the beneficiary (patient) be present in the office in order to bill. So forget any of this for Medicare. The CPT manual states “patient and/or family” is relative to billing by counseling time on most E&M codes. Theoretically, unless a commercial payer has stated that the patient
needs to be present, you could use the looser CPT definition. But the better course is to have a flat cash fee for a “family conference.” PATIENTS PREVIOUSLY TREATED ELSEWHERE
Q I am a primary-care physician working in more than one organization. I have a family practice and unrelated employment in an urgentcare center with different provider numbers and tax ID numbers. I occasionally have patients from urgent care who decide to become established with my family practice. On multiple occasions, insurance payers have rejected the 99204 code submitted in the initial visit, stating that the patient is not new because I have treated him in the past three years. Should I be billing for new patients as if they are established in my family practice since I have seen them elsewhere? I have not been successful in appealing these denied claims. How can I make sure I’m getting paid for the work I am doing with patients new to the practice? A The rule is found on page four of the CPT 2011 Professional Edition. It states, “A new patient is one who has not received any professional services from the physician … within the last three years.” So your answer is yes, bill them as established. There is more language pertaining to tax ID and group in the definition, but your NPI number is showing up on all the claims and you are still you — no matter which hat you are wearing that day. I can see why you’d want to get paid for these patients as new — setting up the chart, working them up from scratch in the office rather than the urgent-care setting — but you are unlikely to prevail here. n Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com. April 2012 | Physicians Practice |
37
3/20/12 1:09 PM
Advertiser Index Co mpa ny
CEO UBM Medica Ltd, UK Henry Elkington CFO UBM Medica Ltd, UK Patrick McAleenan
W eb A ddress
Pag e
AltaPoint Data Systems
www.altapoint.com
5
American Academy of Physician Assistants
www.aapa.org
athenahealth
www.athenahealth.com IFC
CareCloud
www.carecloud.com 7
DSS Research
www.dssresearch.com
Emdeon
www.emdeon.com 2
GE Healthcare
www.gehealthcare.com
Greenway Medical Technologies, Inc.
www.greenwaymedical.com
Henry Schein Medical Systems
www.micromd.com
Keurig
www.keurig.com 17
Medical Protective
www.medpro.com
Moonlighting Solutions
www.moonlightingsolutions.com
27
Physicians Alliance, Inc.
www.physiciansalliance.com
25
Physicians Practice LIVE
www.physicianspractice.com/live
18
ZirMed
www.ZirMed.com 15
23
Group Publishing Director, Pharmacy, UK Phil Johnson Group Publishing Director, Medical, UK Mary McGregor CEO UBM Medica USA Sally Shankland Senior Vice President/ Finance Director, USA Steven Resnick Senior vice president, integrated media Amy Sklar Senior Vice President, Content and Strategy, USA Pamela L. Moore, PhD
IBC
Vice President, Technology, USA Morgan Kelsey Managing Director Asia Ben Yeo CEO Benelux Ben Houdmont CEO Eastern Europe Kerri McCartney CEO France Gérard Kouchner
BC
CEO Germany Uwe Richter General Manager, Iberia Javier Sanz CEO New Zealand/Pacific Colin Abercrombie
32, 33
Resou rces To Subscribe to Physicians Practice: Click the subscriber link at www.PhysiciansPractice.com. To Advertise: Please contact your sales representative listed below:
35
For Business Advertising: Group Director,
Business Development eric.temple-morris@ubm.com
Eric Temple-Morris 503 203 1060
National Sales Manager
Pamela Peterson 201 984 6246
National Sales Manager
Seth Geller 410 818 2716
pamela.peterson@ubm.com
seth.geller@ubm.com
For classified Advertising:
9
Heather Koitzsch | KERH Group LLC | 888 537 4858 hbk@kerhgroup.com
For Pharmaceutical Advertising: Group Director, Business Development
eric.temple-morris@ubm.com
Eric Temple-Morris 503 203 1060
hospital sales: Group Director, Hospital
Business Development steven.gottshall@ubm.com
Steve Gottshall 847 242 9552
HOSPITAL ACCOUNT MANAGER
Lindsay Moe 410 818 2713
CLIENT RELATIONS STRATEGIST
Taylor L. Hine 203 523 7024
lindsay.moe@ubm.com taylor.hine@ubm.com
for sales & production coordination: info@physicianspractice.com 800 781 2211 on the web: www.PhysiciansPractice.com to order reprints of articles or to reach us: info@physicianspractice.com 5523 Research Park Drive, Suite 220 Baltimore, MD 21228 Phone: 443 543 5100 Toll Free: 800 781 2211 Fax: 443 543 5170 www.physicianspractice.com
PPJ_04012012.indd 39
IBC= Inside Back Cover, BC = Back Cover, IFC = Inside Front Cover April 2012 | Physicians Practice |
39
3/20/12 1:09 PM
2
easy
PLEA PLEASERS
How can you ensure your patients leave your practice feeling healthier and happier? We asked 10 patients for their tips.
1
PERSONAL NATURE
“I appreciate when nurses and the doctor treat you like an individual, not just another patient filing through the office for an appointment. Asking some personal questions and genuinely taking interest in what’s going on with me goes a long way.”
GOOD TIMES “I
like doctors’ offices that have Wi-Fi, sports magazines, and beer — though I know that last one isn’t possible.”
A SENSE OF HUMOR “Unless you’re telling me that I have cancer or that mole on my shoulder is a rare African flesheating virus, lighten up for a change! Too many doctors carry the weight of the world on their shoulders while probing whether I eat enough leafy vegetables or if I’m doing enough cardio (I am).”
9
GOOD READS
“I like when doctors actually listen to and repeat back my concerns to me before acting. They’re supposed to do this with every patient, but many do not.” THOUGHTFUL REACTIONS
PLEASERS | PHYSICIANS PRACTICE | APRIL 2012
PPJ_04012012.indd 40
SOOTHING ATMOSPHERE
“If the exam room is painted in a color rather than stark white walls, I always feel calmer.”
SUSTENANCE
Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com. 40
4
“One thing that makes my visits to my doctor more enjoyable is that her waiting room has a coffee machine with different types of coffee, and a little fridge filled with small water bottles available to anyone who’s waiting.”
10
5
“I was a bit nervous about a dental procedure I had to have done, and when I called the office to ask questions, the periodontist gave me her cell phone number and was able to talk with me later that day to provide some answers. It’s great when doctors go out of their way to be accessible!”
7
“I enjoy a waiting room with decent magazines of interest to wide audiences.”
3
ACCESSIBILITY
8
6
DISTRACTIONS “I love the pictures on the ceiling at the [OBGYN].”
COLORFUL CLOTHES “I like when the nurses and aides are dressed in cheerful, colorful uniforms — it makes me feel happy and not stressed.”
Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com. WWW.PHYSICIANSPRACTICE.COM
3/20/12 1:09 PM
